How to Care for Aging Parents Thomas Cornwell, MD

1. How to Care for Aging ParentsThomas Cornwell, MD How To Care For Aging Parents Thomas Cornwell, MD HomeCare Physicians

2. Why is this an Issue Now? • 10,000 new Medicare beneficiaries daily

3. Sandwich Generation • Nearly half of middle-aged adults are either raising a young child or financially supporting a grown child • About one in seven middle-aged adults is providing financial support to both an aging parent and a child Source: http://www.pewsocialtrends.org/2013/01/30/the-sandwich-generation

4. Talk, Talk, Talk • Issues: • Parenting your parent (Geriatric un-development) • Housing options (now and future) • Financial and legal • Healthcare • Death and funeral (“Honoring ceremony”) • Guiding principles: • Start with areas of agreement • Have entire family on the same page in regards to responsibilities and patient goals • Avoid highly charged and emotional words • Goal is to end all discussions peacefully and to not seek victory

5. Housing Options • Accessory (in-law) apartments • Shared and congregate housing • Shared apartments • Assisted living • Life care retirement communities • Nursing homes • Live-in caregivers • Guiding principles: • Try to discuss and plan before a crisis occurs • What are the options if/when you or your loved one declines?

6. Legal Issues • Living will • Durable power of attorney for healthcare and finances • Advanced directives • “Do not resuscitate” form/”POLST” form • Last will and testimony • National Academy of Elder Law Attorneys • Naela.com • 602.881.4005

7. Caring for the Caregiver • Set limits • Accept and enlist help • The Family and Medical Leave Act allows for 12 weeks of unpaid leave to care for family member • Emotional minefields: Guilt and helplessness • Maintain your physical, emotional and spiritual life

8. Preventive Care • Yearly flu shot • Pneumonia shot once, or twice five years apart, after age 65 • Tetanus shot every 10 years • Balanced diet • Exercise • Multivitamin • No smoking • Osteoporosis screening

9. Doctor Visits • Avoid ageism • Bring all medications to visit • Bring list of concerns

10. Medical Care • Yearly eye and dental exam (Audiologist if there is a hearing problem) • Medical alert system (e.g. Lifeline, Medical Alert) • Medications—the less the better • Ways to save money: • Ask pharmacist if there is a generic equivalent or a larger pill that can be broken in half • Pharmaceutical discount cards or indigent programs

11. Common Medical Problems • Falls—most common in bathroom • Pressure sore prevention: • Avoid same position for more than two hours • Pressure-reducing surfaces on hospital bed/wheel chairs • No donut cushion • Reduce friction • Signs of depression: • Depressed mood • Anger • Anxiety • Decreased motivation • Anhedonia • Loss of appetite • Trouble sleeping

12. Dementia • Descriptive diagnosis of abnormal memory loss and cognitive functioning • Greatest problem is short term memory loss is often not realized by patient (and sometimes family) • Agitation can be a major problem • Speak in a slow, calm voice • They are “always” right • Redirect when they are upset—they can only focus on one thing at a time • They use “cues” in their environment to orient themselves, and caregivers can take advantage of this (calendars, leaving messages, etc.) • Consider neuropsychiatric testing for more definitive diagnosis and coping strategies

13. Hospitalization • Elderly need to have an advocate • Discharge planning begins day one of hospitalization • Is going home an option? • Will rehabilitation be necessary/helpful?

14. Medicare/Medicaid Intermittent Home Health • Must be homebound • Must have a need for a skilled nurse, physical therapist or speech therapist • If above criteria are met, they can also get an occupational therapist, social worker and aide if necessary • Medicare and Medicaid do not pay for home health when only custodial care is needed

15. Quality Vs. Crisis End-of-Life Care “The death of a loved one will always be sorrowful, but it does not need to be a crisis. It tends to be a crisis in our country, because we avoid talking about it and planning for it.” - Dr. Thomas Cornwell

16. End-of-Life Care • “To whatever extent you are able, acknowledge this dying process and, in doing so, celebrate life.” • Start communicating preferably before he/she is sick • Responses to a terminal diagnosis: • Denial • Anger • Bargaining • Depression • Acceptance • Greatest fear of terminally ill: Suffering and abandonment—not death • Hospice care: • Life expectancy less than six months • Patient does not desire aggressive curative care but does want aggressive comfort care

17. Communication is Key • Hospice is a two-way evaluation • Hospice evaluates if the patient meets Medicare criteria • Patient/family evaluate if they would benefit from hospice • Hospice is an interdisciplinary home health service for patients whose prognosis is less than six months • Doctors and patients are poor at predicting when end-of-life will occur, which leads to: • 10% of hospice patients dying on day one • Over 50% of patients dying in the first two weeks • A good question to ask is, “Would you be surprised if the patient passed away in the next six months?”

18. Communication is Key (continued) • Patients/families need to know their options: • DNR (DNAR)/POLST • Hospitalization • Ventilator • Tube feedings • Dialysis • Antibiotics • Preferred site of death

19. Five Wishes Document • The person I want to make care decisions for me when I can’t • The kind of medical treatment I want or don’t want • How comfortable I want to be • How I want people to treat me • What I want my loved ones to know

20. Wish 1: The Person I Want to Make Health Care Decisions for Me When I Can’t Make Them for Myself • Picking the right person to be your healthcare agent: • Knows you well • Can make difficult decisions • Will stand up and advocate for you • Lives nearby • Must be at least 18 years old • Should not be your healthcare provider or employee of your healthcare provider • Communication your wishes with your healthcare agent: • What level of medical care is desired and for how long? • What level of psychiatric care is desired? • Release of medical records • Organ donation • Review financial information and insurance forms • Desired location to spend your last days/hours

21. Completing Five Wishes • Sign and fill in demographic information • Have two witnesses sign • No notarization required in Illinois • Distribute copies and discuss with POAHA, family, medical provider, nursing home, assisted living facility, etc. • Fill in Five Wishes Wallet Card and keep it with you to notify people where to locate the document

22. DNR (Do Not Attempt Resuscitation)/POLST Form • Only document paramedics can accept to not do CPR • Must be signed by patient, guardian, POA or healthcare surrogate • Must have a witness • Must be signed by a doctor • State of Illinois transitioning to POLST (Physician Orders for Life Sustaining Treatment) form

23. The “Honoring” Ceremony • The funeral/memorial service is our last chance to honor them, but we usually give ourselves only 3-4 days to prepare • It is never too early to start planning the “honoring” ceremony • When the time comes, you will know you are doing exactly what they wanted, and the time is much less stressful

24. Quality/Cost of End-of-Life Care • Nationally, only 25% of deaths occur at home, although more than 70% of Americans say that this is where they would prefer to die • The 75% of patients that die in hospitals and nursing homes often receive high-tech interventions and are in pain • 26% of Medicare funds are spend on care in the last year of life; 38% of this is spent in the last 30 days

25. HomeCare Physicians’ Mission • Improve the quality of life of homebound patients • Improve the quality of life of caregivers • Decrease healthcare costs by enabling patients to remain at home and avoid expensive emergency departments, hospitals and nursing homes

26. Three Reasons for the Decline of the House Call • Increased office/hospital-based technology • Fear of increased liability • Financial disincentives

27. House Call Decline: Financial Disincentives

28. Why Home Care Medicine’s Time Has Come • Demographics: The aging of society • Technology allows quality care in the home • Cost savings

29. 5/14/09—2/18/11 (1 year, 9 months) • 44 Emergency Department (ED) visits (average 16 days between visits) • 27 hospitalizations—over half required ICU days (average 25 days between stays) • HCP first visit 3/2/11 (365 days) • One ED visit and one hospitalization (May 2011) • Expected: 25 ED visits and 15 hospitalizations • One year cost savings: $188,000

30. High-Cost Medicare Beneficiary Spending Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services. Note: Spending reported in 2005 dollars

31. Costs of Care Before Vs. During HBPC for 2002 * Includes HBPC cost

32. Potential Savings • Illinois population = 12,869,257 • 12.7% > 65 = 1,634,396 • 3.4% ≥ 3 ADL deficiencies = 55,569 • VA saved $9,132 per HBPC patient • Total yearly savings = $507,460,233

33. Thank you • Thanks to legislative sponsors Senators Jim Oberweis and Linda Holmes and Representatives Linda Chapa LaVia, Mike Fortner and Kay Hatcher ●Thomas.Cornwell@nm.org ● http://rmg.nm.org/what-we-offer/specialized-care/home-care