Wall Street Journal Looks at Home Care Aide Crisis

Readers know that the shortage of in-home workers and elders’ vulnerability to abuse by criminal caregivers has long been a concern of mine. So I was delighted with Phil Shiskin’s in-depth article on the subject that appeared in today’s Wall Street Journal. It focuses on California and mentions Napa's effort to develop a local screening program. Check it out at Caregiver Abuse.

For more on the topic and some of the initiatives cited in the article, see the Elder Abuse By Paid Caregivers page of my Web site.

Luring Health Care Providers into Geriatrics

Supporters of loan forgiveness programs aimed at encouraging health care providers to specialize in geriatrics got a boost from a report issued last month by the Institute of Medicine (IOM). Retooling for an Aging America: Building the Health Care Workforce is based on the findings of an ad hoc committee that looked at the health care needs of the 78 million baby boomers who’ll soon be turning 65. The group estimates that there are currently only about 7,100 doctors certified in geriatrics in the US, one for every 2,500 older Americans, a shortage they attribute to a lack of training programs and low Medicare reimbursement rates for geriatricians compared to other specialists. The report comes just as the government prepares to cut Medicare physician payments this July. The group has called for increased reimbursement rates, loan forgiveness programs, and student scholarships.

I was pleased to see that the report also addressed the need for more direct-care workers, including nurse aides, home health aides, and personal care aides. Unlike geriatricians, who have high job satisfaction rates (the highest, in fact, of any specialty), these hands-on workers are generally dissatisfied and have high rates of turnover due to low pay and working conditions, high rates of on-the-job injury, and few opportunities for advancement. Turnover among nurse aides, for example, averages 71% annually, and 90% of home health aides leave their jobs within the first two years. In response, the committee is calling for more opportunities for career growth, higher pay, and access to fringe benefits. They also recommend that all health care workers be trained in basic geriatric care and treating older patients.

As I've said many times before, we can screen and regulate all we want to prevent worker abuse and neglect, but it’s not going to do much good until we make these jobs tenable and have an adequate pool of workers for seniors to choose from.

At the national level, Senator Boxer’s Caring for an Aging America Act of 2008 (S. 2708) would amend the Public Health Service Act to attract professionals and direct care workers by earmarking $130 million for a loan forgiveness program. Those covered include physicians, physician assistants, advance practice nurses, social workers, and psychologists. The legislation would also create the Health and Long-Term Care Workforce Advisory Panel for an Aging America to advise the Secretary of Health and Human Services, the Secretary of Labor, and Congress on workforce issues related to elder healthcare. The bill has bipartisan support and counts among its supporters the American Geriatrics Society, the National Council on Aging, the Alzheimer's Association, AARP, American Academy of Physician Assistants, American College of Nurse Practitioners, American Psychological Association, Coalition of Geriatric Nursing Organizations, and the National Association of Social Workers.

Here in California, our loan forgiveness program is also making headway. AB 2543, which was developed by the California Senior Legislature under the leadership of Shirley Krohn and introduced by Assembly member Patty Berg, is called the California Geriatric and Gerontology Workforce Expansion Act of 2008. To qualify, loan recipients would have to commit to a minimum of three years of service in geriatric care settings. Covered under the bill are physicians, dentists, psychologists, registered nurses, and social workers.

I thought I’d end with an excerpt from the terrific New Yorker article "The Way We Age Now," by surgeon Atul Gawande, which I cited in a posting last fall (see Geriatricians, Angry and Otherwise):

Several years ago, researchers in St. Paul, Minnesota, identified five hundred and sixty-eight men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric specialists. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, ten per cent of the patients in both groups had died. But the patients who had seen a geriatrics team were a third less likely to become disabled and half as likely to develop depression. They were forty per cent less likely to require home health services.

Little of what the geriatricians had done was high-tech medicine: they didn’t do lung biopsies or back surgery or PET scans. Instead, they simplified medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

How do we reward this kind of work? Chad Boult, who was the lead investigator of the St. Paul study and a geriatrician at the University of Minnesota, can tell you. A few months after he published his study, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

“The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he is now a professor at the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a twenty-five-thousand-dollar pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs.

Seems to me that the need for more geriatric training is pretty much a no-brainer.

Guardianship, Reverse Mortgage Fraud, and Politicians Posing as Health Care Workers

Advocacy Update
There’s lots happening on the advocacy front, and I’m a bit behind. But here goes:

Guardianship Reform: The National Scene
Last week, Senator Gordon H. Smith (R-OR) released Guardianship for the Elderly: Protecting the Rights and Welfare of Seniors with Reduced Capacity, a report on the role of the feds in overseeing the guardianship system. The report was based on responses to a call for papers Smith issued following a 2006 Senate Special Committee on Aging hearing. The hearing had followed a flurry of negative reports about guardianship, including the findings of a GAO report and a scathing 2005 Los Angeles Times series that exposed blatant abuses by professional conservators (California parlance for guardians) and negligence by courts in monitoring them. Widespread media coverage about philanthropist and socialite Brooke Astor, whose son was charged with looting her estate while acting as her guardian, had also brought additional attention to the problem.

According to the report, federal actions that warrant consideration include uniform federal standards for guardianship and an enforcement mechanism; a national guardianship office, possibly administered through the Department of Justice, to promote best practices, training standards, data collection, and oversight; increased coordination among the multiple government agencies that are involved including the Social Security Administration, Department of Justice, and Department of Health and Human Services; an infusion of federal funds to boost local court supervision programs; a national system of data collection and research; improved regulation and oversight of private and professional guardianship entities; and greater attention to guaranteeing the safety and due process rights of incapacitated seniors under guardianship. Specific areas of need include ensuring the right to counsel, independent medical and physical examinations, and the right to petition the court for guardianship termination. A full copy of the report is available at www.aging.senate.gov/minority or by calling 202-228-5862.

Smith’s report was released in conjunction with the publication of Guarding the Guardians: Promising Practices for Court Monitoring by Naomi Karp of the AARP Public Policy Institute and Erica Wood of the ABA’s Commission on Law and Aging. This resource for courts and policy-makers is a follow-up to Guardianship Monitoring: A National Survey of Court Practices, a 2006 report by Karp and Wood. The first report highlighted the results of a 2005 national survey of judges, court managers, guardians, elder law attorneys, and advocates. It called for better reporting by guardians (including prospective, or forward-looking, plans to show how they will manage the affairs of those they supervise); improved verification of reports; the use of technology for greater efficiency; and more resources devoted to monitoring. Part 1 is available at AARP's Web site.

The follow-up report (also available online on AARP's Web site), showcases specific practices, examples of which include:

• Ramsey County, MN has an e-filing system, which not only allows guardians to file their annual accountings online, but has built-in red flags to identify irregularities that bear further investigation

• Maricopa County, AZ uses fiduciary arrest warrants when necessary. Arizona’s guardianship certification program also performs intensive random audits of professional guardians.

• Suffolk County, NY has adopted a “problem-solving restorative jurisprudence approach to guardianship,” which includes mediation, a resource coordinator, volunteer advocates and the ability to integrate all pending cases involving the incapacitated person, including divorces, evictions and other matters.

The follow-up report even provides tips on how to spot “guardianships going bad"; examples of how courts handle specific situations like guardians’ failure to file reports; and ideas for how to raise and leverage funds for court monitoring.

According to Naomi Karp, “Their innovations show that effective oversight is more a matter of will than of money. It's not really rocket science and it's not really expensive. In all cases, there's at least one person who's a real visionary who is dedicated to getting it done."

And, In California:
As described in an earlier post (see Feel Good Laws or Real Reform?), the LA Times expose’ on private professional conservators prompted California last year to enact a package of laws to reform guardianship. Although courts were promised new funds to implement the provisions, with some having already hired additional staff to do so, the promised funding never came. Courts are doing their best to make due in the meantime and are hopeful that the state will honor its commitment next year.

Reverse Mortgages
In an email with the subject line “Mr. Cole Goes to Washington,” Shawna Reeves Nourzaie of the Fair Lending Project for Seniors of the Council on Aging Silicon Valley alerted me to the December 12 Senate Special Committee on Aging hearing “Reverse Mortgages: Polishing not Tarnishing the Golden Years.” Mr. Cole is our very own Prescott Cole of the San Francisco-based California Advocates for Nursing Home Reform, who was the lead witness. The hearing was prompted at least in part by lawsuits filed against "reverse mortgage specialist" company Financial Freedom. Although invited, Financial Freedom was not represented.

In a bizarre twist, Financial Freedom has since announced that the company did not make the loan that was the subject of damning testimony by panel witness Carol Anthony, who claimed that the company had wheedled her elderly mother into an expensive and inappropriate loan. Rather, Financial Freedom reps claim that the company simply purchased the loan after it had been closed by the original lender, Senior Freedom Corporation Funding. They blamed the confusion on the similarity of the names. But, as Shawna points out, even so, one might wonder what responsibility loan purchasers have in making sure that the loans they buy were not procured by fraud.

Also during the hearing, AARP unveiled its in-depth study of the Reverse Mortgage industry, highlighting many of the sales practice abuses directed towards seniors. You can view a webcast of the hearing, which was chaired by Committee Member, Claire McCaskill (D-MO), at http://aging.senate.gov/

Candidates Learn from Health Care Workers
Congressional and presidential hopefuls got a chance to experience first hand (well, sort of) what life is like for home care workers, nursing home aides, and other health workers as part of the “Walk a Day in My Shoes” campaign sponsored by the Service Employees International Union (SEIU). The campaign is “about making sure politicians truly know what the real world is like for the rest of us.” You can watch Hillary walk in the shoes of a registered nurse, Obama walk in the shoes of a home care worker, and Edwards walk in the shoes of a nursing home worker. Also shown walking the halls of a nursing home is U.S. Senate candidate Al Franken, who’s career I’ve been following since well before his Saturday Night Live days when my sister and I took a filmmaking class with him in the 60s. Footage of the candidates’ visits is available at SEIU’s Web site. (The Nerenberg/Franken productions were lost or destroyed by our mom.)

Looking for a Stocking Stuffer?
Springer Publishing has agreed to provide my blog and Web site readers with a 30% discount on my book, Elder Abuse Prevention: Emerging Issues and Promising Strategies, from tomorrow through the end of the year. They tell me the book will be released "any second." To get the discount, click on the icon that appears on the right or from my Web site at http://lisanerenberg.com/.

Happy Holidays
At the rate I’m going, this may be my last posting for 2007. So, Happy New Year to all and keep up the terrific work!

Follow-up on Government-Subsidized Elder Abuse

Although I welcome feedback, apparently my blog doesn’t. Seems it’s been rejecting comments. I’m exploring how to fix the problem, but in the meantime, I wanted to pass along an item from Lori Delagrammatikas, program coordinator of Project Master at San Diego State University’s School of Social Work:

Riverside County (California) convinced an IHSS administrative hearing judge to deny a client the right to continue to use an abusive independent provider using the argument that the purpose of the IHSS program is to maintain the client safely at home. (Clients who have complaints about state benefits and services can request hearings, which are presided over by administrative law judges from the California Department of Social Services. Clients [and their advocates] and representatives from their counties present their sides.)

This was a domestic violence case and the boyfriend was not only the IP but also the client's authorized representative. He was very violent, and when he came to the hearing, he was verbally abusive to the hearing judge! It was obvious that paying this particular provider caused the client to be "unsafe" at home, undermining the purpose of the IHSS program. Unfortunately, the judge's ruling was for this individual case and did not set a precedent for other cases.

I’d be interested in hearing about what’s happening in other states.

Georgia Anetzberger, assistant professor at Cleveland State University, wrote suggesting the need for an in-depth article on this topic and more research. Georgia, by the way, did some of the seminal research on family abusers and has continued to do cutting edge work for over two decades. I fully agree about the need for research, especially studies to help identify high-risk IPs, which could serve to educate administrative hearing judges (and others) and alert consumers to risks.

I’ve also received many positive comments about the blog, suggestions for publicizing it, and ideas for future topics. Thank you all, and I’ll make every effort to oblige. Also, feel free to comment and let me know if you have problems doing so.
Lisa

Consumer Choice or Government-Subsidized Elder Abuse?

Years ago, San Francisco’s multidisciplinary team was discussing a case involving flagrant abuse by a chore worker. When the group learned that the worker was being paid with public funds through the state’s In-Home Support Services program, we turned to Mary Counihan, supervisor of our APS and IHSS units, and chimed in unison “Fire him!”

It wasn’t that simple, Mary explained. Under IHSS, clients can either be provided with workers through licensed agencies, or they have the option of hiring and supervising their own “independent providers,” including family members, with IHSS funds. In our case, the abuser was an IP, and the victim refused to fire him. Mary went on to explain that it was younger adults with disabilities who’d advocated for allowing IHSS “consumers” to take a more active role in managing their own services, which included making hiring and firing decision. It was a matter of client autonomy.

But autonomy was our mantra too, we complained. Still, paying abusers with public funds didn’t sit well with many of us.

The county eventually exercised its option to change the “mode of service,” which meant requiring the client to accept services from a licensed agency. But for many of us, the case was our first exposure to the incipient “consumer choice” movement. Flash forward ten or so years. The movement has flourished, fueled by the 1999 Olmstead decision, a Supreme Court case brought on behalf of two developmentally disabled women who’d been living in an institution but wanted to live in the community. Their lawyers successfully argued that the state had an obligation, under the Americans with Disabilities Act, to reasonably accommodate the women in the community. In essence, Olmstead framed community-based, long-term care as a human rights issue. It further got translated to mean that states had to offer consumers more options.

Since then, many in the aging services community have joined the disability community in support of consumer choice. Prominent organizations like The National Council on the Aging have been among the foremost supporters, and the Robert Wood Johnson Foundation has funded projects to increase opportunities for consumer choice.

In the meantime, APS and IHSS programs have continued to struggle to protect clients from abusive chore workers. It hasn’t been easy. Over 90% of IHSS clients choose the IP option and half hire family members. In California, repeated attempts by counties to change the mode of service of clients whose workers have abused them have been successfully challenged. Counties have challenged the challenges, but it seems to be a losing battle. According to Mary, there’s widespread agreement around the state that if clients want to keep their abusive IHSS workers, there’s little counties can do.

Okay, those of us in elder abuse prevention are jaded. It’s hard not to be when we hear about rampant abuse by chore workers and know that elders hire troubled offspring who can’t find better jobs. And then there’s the critical shortage of workers, the lack of screening, and recent studies showing disturbingly high rates of chore workers with serious criminal histories. Not to mention the rumors that probation and parole officers are actually encouraging their clients to become chore workers. And while consumer choice advocates acknowledge that some workers abuse, they seem to shrug off the risks and point to the “safety net” of APS and the elder abuse prevention network.

For example, the NCOA publication Myths and Realities and Consumer Choice includes as Myth 2: Consumer-directed services are not appropriate for elderly persons with disabilities or for individuals with cognitive impairments. The authors counter the “myth” with “Studies have shown that many elderly individuals with disabilities and persons with cognitive impairments can express daily preferences.” It’s true that many cognitively impaired consumers can express preferences, but that’s not what has me worried. It’s their ability to screen workers, detect exploitation, seek shelter, and withstand undue influence. The same publication lists as Myth 4, “Consumer-direction places older adults at greater risk,” and goes on to point out that “There is no evidence that the consumer direction model of service delivery is inherently “riskier” than professionally-managed services.” I have trouble with this one too. Studies I’ve read that compare abuse rates by IPs with agency-managed workers do suggest lower rates of some forms of abuse by IPs, especially family IPs, but they rely on elderly consumers’ perceptions of whether or not they’d been abused, which, as we know, is by no means a perfect indicator. Many victims don’t know they’ve been abused, are afraid to say so, are manipulated by their workers, or are more concerned with seeing troubled kids get jobs than their own safety.

I’m not against consumer choice. In fact, I’m a firm believer that responsible family caregivers should be compensated for the enormous contributions they make. What’s troubling to me is that the “safety net” isn’t working and members or our network have not, to my knowledge, been involved in state and federal policy discussions about consumer choice. Dealing with abuse by IPs is tricky business, which has gotten trickier in the age of identity theft and worker shortages. And then there are the unanswered questions about capacity. How do you define capacity to screen, supervise and fire workers? Since cleaning up messes is harder than avoiding them in the first place, shouldn’t we be involved in policy discussions about consumer choice, building relationships with the consumer choice network, explaining the barriers we face, and figuring out how to make consumer choice programs as safe as possible? I think so.