Monday, October 16, 2017

Personal Blog #3 ... "Living With Alzheimer's Conference"

“What is it like to be in an Alzheimer’s caregiver’s shoes and, given that experience, what advice do I have for students about to enter the medical profession.”

I was invited to make a presentation to 2nd year medical students at the "Living With Alzheimer's Conference" Northwell School of Medicine at Hofstra University on 2/14/17.  Since I didn’t post Personal Blogs on my website at that time, I never posted a copy of that address anywhere.  So, below is a slightly edited copy of my remarks made at that conference:

Good morning ... it’s a pleasure to be here today.  Let me begin with some brief background.  My wife, Clare, died 10 months ago, one month shy of her 70th birthday, and 2 months shy of our 49th anniversary.  She battled Alzheimer’s disease for nearly 10 years.  I was her 24/7 caregiver at home for 6 years and then was Clare’s part-time caregiver when she was in assisted living, a psychiatric hospital, regular hospital, and nursing home.  I started writing for publication out of frustration while watching Clare being treated first for stress, then anxiety, and then depression when I was pretty sure that she was already in early stage Alzheimer’s.  I wrote to try to effect change in how doctors diagnose and treat people with Alzheimer’s, and their caregivers, and also to help other caregivers.  To date I’ve had 46 articles about Alzheimer’s published in medical journals, caregiver magazines, and major newspapers, and 35 Alzheimer’s columns published in The Huffington Post. 

I was asked to address two questions with you today:  What is it like to be in an Alzheimer’s caregiver’s shoes and, given that experience, what advice do I have for students about to enter the medical profession.  Here goes: 

What is it like to be in an Alzheimer’s caregiver’s shoes?  The answer is both simple and complex.  The simple answer is that life as a caregiver is one of non-stop daily stress, with much sadness and anxiety, often accompanied by periods of mild and/or serious depression.  Feelings of doubt, guilt, frustration, and many other emotions result in many caregivers taking anti-anxiety or anti-depressant medication, meeting regularly with therapists, taking sleeping pills, or experiencing weight gain or loss.  Stress drove me to my comfort foods and I gained nearly 100 pounds during the past 10 years and it’s only in the last 6 months that I’ve been able to start taking off that weight.

Helping a loved one with Alzheimer’s just with activities of daily living ... basic hygiene, dressing, eating, etc. ... becomes progressively difficult.  Caring for a loved one who is confused, no longer remembers your name or who you are, or can occasionally become aggressive, is emotionally painful.  When Clare was in a facility my role morphed from primary caregiver to primary care advocate.  But meeting regularly with staff to insure proper care was also very stressful because many staff members were not sufficiently motivated, educated, or trained to consistently provide proper care for those with Alzheimer’s.  

And then there is the financial stress faced by most caregivers.  Unless one qualifies for Medicaid, is very wealthy, or lucky enough to have goldenlong term health care insurance and prescription drug coverage, caregiving costs can be astronomical.  For someone with Alzheimer’s here on Long Island, assisted living facilities run around $7-$10,000 per month and nursing homes about $15-$18000 per month.  24/7 home health aides ... about $15,000 per month.  Caregiving costs can drain not just the patient’s bank account, but can also wipe out the entire retirement life savings of the surviving caregiver. 

And once Clare went into assisted living I had to deal with the daily loneliness, and the enormous life style changes.  Going to sleep all alone in bed those first few nights after placement was painful beyond words, and learning to live alone for the first time after many years of marriage brought incredible sadness.  I often referred to myself as being both married and widowed at the same time.  One person in my support group referred to those last 3 or 4 years as grief on the installment plan.  It is no surprise to me that research reports caregiver stress as a significant factor contributing to caregiver mortality. 

So ... that’s an overview of how it felt to be in my shoes.  As for the second question, advice for students about to enter the medical profession, I would suggest the following:

1.  Listen very carefully to caregivers.
When Clare first demonstrated possible Alzheimer’s symptoms, I started logging them and presented written summaries to doctors at each visit.  But unless Clare exhibited those same symptoms in the presence of her doctors, my observations were routinely ignored.  I’d try to discuss concerns ... e.g., Clare getting lost while driving to familiar locations, experiencing aphasia or agnosia, whatever ... but for 2 years neither her primary care physician, neurologist, nor cognitive psychologist took the time to listen to what I wanted to tell them or to read my logs.  Page 28 of last month’s AARP Bulletin noted studies showing that doctors only listen for 23 seconds before interrupting patients, but then cited a recent South Carolina study that doctors listened to patients for only 12 seconds before cutting them off.  12 seconds ... how sad is that??

I eventually did learn that early Alzheimer’s symptoms can be easily misinterpreted as signs of stress, anxiety, and/or depression.  But that just makes it even more important for doctors to listen to caregivers who observe behaviors 24/7 that may not be present in a quick office visit or demonstrated on a brief cognitive screening test.  So ... please listen very carefully to caregivers!

2. Use effective screening tools to try to diagnose possible Alzheimer’s.
The Mini-Mental State Examination, or MMSE, continues to be the most frequently used cognitive screening test, even though it was never designed to screen for Alzheimer’s.  But doctors use this test because it can be administered in 3 minutes.  Please, when you start your practice, learn about other more modern brief screening tests that are more effective.  A study just published in the December issue of Journal of Alzheimer's Disease confirmed the effectiveness of the “Sniffin' Sticks Odor Identification Test” where subjects try to identify 16 different odors.... and I can attest to Clare’s rapidly changing sense of taste and smell.  Anyway, to quote from their study: "Results suggest that a simple odor identification test can be a useful supplementary tool for clinically categorizing MCI and Alzheimer's.  Prompted by prior studies that have linked a weakening sense of smell to Alzheimer's, doctors in a few larger dementia clinics have already begun using smell tests in their assessments.  Part of the reason the practice has not yet become common, however, is that the tests take too long to administer.  We're hoping to shorten the Sniffin' Sticks test, which normally takes 5 to 8 minutes, down to 3 minutes or so -- we think that will encourage more neurology clinics to do this type of screening.”  Is this not another sad commentary?

There’s also another very valuable screening test that definitely takes only 2- 3 minutes to administer and is also more effective than the MMSE ... the “AD-8 Screening Interview,” which was developed by researchers at Washington University in St. Louis. The AD-8 consists of 8 questions given to family/friends of individuals being screened.  When compared to results of the MMSE, the AD-8 "was superior to conventional testing in its ability to detect early signs of dementia.  It (AD-8) can't tell us whether the dementia is caused by Alzheimer's or other disorders, but it lets us know when there's a need for more extensive evaluation to answer that question."   Please ... do not use the MMSE to screen your patients for possible AD!

3. Please be honest when speaking with Alzheimer’s patients and their caregivers.
A survey reported in Time Magazine on March 24, 2015 found that as many as 66% of doctors do not share an AD diagnosis with their patients because of "fear of causing emotional distress in their patients" due to lack of effective treatment or cure, and "lack of time and resources to fully explain the diagnosis."  But Alzheimer’s patients and their caregivers need as much time as possible to plan accordingly ... to possibly enjoy some final trips or activities, and to discuss end-of-life planning decisions and documents ... will, living will, health care proxy, durable power of attorney ... and time to discuss future plans for care before cognitive impairment prevents such discussions.  So, please, don’t withhold a diagnosis!

4. Provide a brief handout to Alzheimer’s caregivers at or shortly after diagnosis.
Information on the stages of the disease, local support groups, and some informative online sources would be extremely helpful.  Of the 15 people in my LIAF support group, only one was referred there by a doctor.  How sad is that?  Doctors need to be more aware of local support groups because that is where
caregivers can discuss common needs, learn and share helpful caregiving strategies and techniques, and find emotional support from others walking in similar shoes. 

5.  Please tell Alzheimer’s patients not to drive.
When to take away the car keys is an extremely difficult emotional decision that often leads to very strong heated arguments.  People with Alzheimer’s rightfully fear losing their independence and accepting that they no longer can drive safely.  But their caregivers worry about them getting lost, causing an accident or, worse, causing a death.  Even if some people with Alzheimer’s can continue to drive safely for a while, an Alzheimer’s diagnosis, by definition, means cognitive impairment that will worsen over time and, sooner or later, impaired judgment and inability to process information can easily lead to an accident.  So if caregivers have observed their loved one having driving issues and ask you to tell their loved ones not to drive anymore, please help remove a major cause of caregiver stress while also making our roads safer.  And please don’t refer people with Alzheimer’s to driving test facilities because a person with Alzheimer’s may do very well at the particular moment of the test but not an hour before or after that test.

6. Educate yourselves about Alzheimer’s meds before prescribing them.
You will eventually learn that none of the currently FDA-approved meds have proven to have any long term positive effects.  Clinical trial data show that they MAY be able to delay disease progression ... BUT only for up to 6 months to a year ... AND only for about half the people who take them.  Yet many doctors keep renewing these expensive prescriptions year after year to give their patients hope.  I’ve written about these meds as “expensive bottles of hope” because these thousands of dollars spent on totally ineffective meds could be much better spent on day care programs, personal aides, etc.  Before initially prescribing or renewing Alzheimer’s medication, please read the clinical trial data research!

7.  If you plan to work in a hospital, especially in the Emergency Department.
If the caregiver is present, please direct your questions to the caregiver and not to the patient.  Examine and treat Alzheimer’s patients as if they were non-verbal.  If not given information on why the patient was admitted and where the pain is, place your hands gently on the patient’s chest, back, stomach, etc. and press lightly.  Trust me, when touching a sore spot the patient will let you know where it hurts.  But asking them for reliable information is almost always fruitless. 

More importantly, doctors must understand how upsetting it is for an Alzheimer’s patient to be in the ER ... an unfamiliar setting, forced to be undressed and have their Depends removed to put on hospital diapers and paper gown, placed on a hard surface gurney, seeing all those bright overhead lights, hearing all those strange machine sounds, having strangers poking them here and there while painful needles are placed in their arms. Also, many Alzheimer’s patients “sundown” as the day goes on, becoming increasingly confused, much more anxious, and some even very aggressive.  Withholding a patient’s medication and food until testing is completed may be sound medical practice, but withholding anxiety medication and food for up to 9 hours, as happened twice with Clare, is almost akin to medical malpractice.  Clare was screaming louder and louder, ripping IVs out of her arm, constantly trying to get up, refusing to use a bed pan and soiling her clothing as we waited and waited for her to either be admitted or discharged so she could be given meds and food!  Doctors must consider Alzheimer’s patients as high triage priorities in the ER!

In my opinion, there is a lot that doctors can do to improve the ways they diagnose people who may have with Alzheimer’s, and how they treat Alzheimer’s patients and caregivers.  I appreciate this opportunity to share my personal views with you this morning and look forward to answering any questions you may have. 


Thank you ... and good luck with your future careers!

Tuesday, September 12, 2017

Discussing Brain Donation With Dementia Residents


Although the topic of organ donation, brain donation specifically, is not the most appealing topic to bring up to patients or families of patients with Alzheimer disease (AD) and dementia, having this conversation is important nonetheless, especially as the number of older adults living longer with AD grows.  
The Harvard Brain Tissue Resource Center at McLean Hospital near Boston, MA, is one of the largest brain banks in the world. Their focus is on research to learn more about diseases using brain tissue. CNN interviewed researchers at that facility and reported the following: “According to Dr Kerry Ressler, the chief scientific officer at McLean Hospital, new treatments for many mental and neurological diseases are within the grasp of the research community. However, he says, it is the lack of brain tissue that is holding back their development. Scientists at McLean Hospital and at brain banks across the world do not have enough specimens for the research community.”
Perhaps due to the sensitivity of the topic, many long-term care facilities (LTCFs) may not have protocols in place for how to educate residents and families on donation. Thankfully, I had a positive experience in relation to this topic, but others have had less helpful experiences.  
My late wife, Clare, was diagnosed with AD at a major New York City hospital, the Mount Sinai School of Medicine (MSSM). MSSM is an Alzheimer’s Disease Research Center (ADRC), one of 33 ADRCs in the United States receiving special funding from the National Institutes of Health in order to “translate research advances into improved diagnosis and care for people with Alzheimer’s disease while focusing on the program’s long-term goal—finding a way to cure and possibly prevent Alzheimer’s.
Over the course of Clare’s many visits to MSSM for periodic testing and evaluation, and to monitor her participation in a clinical trial, doctors periodically discussed MSSM’s brain tissue donation program with us. MSSM’s website describes its brain tissue donation program as follows: “The Alzheimer’s Disease Research Center (ADRC) is committed to fighting Alzheimer’s disease and other neurodegenerative diseases by understanding causes, identifying genetic components, developing new treatments, and seeking a cure. One critical part of this fight is what we learn from brain tissue donation research.”
During our discussions, doctors reviewed additional information about brain donation; we were told: “Examining the brain after death is the only way to obtain a definitive diagnosis of AD or other dementias. The more often we can confirm (or refute) the diagnosis, the better able physicians will be to accurately identify the disease in living patients. Results from brain donation research have led to important advances in current treatments for AD. And the only way to obtain the brain tissue necessary for both diagnostic and research purposes is through donations.”
We were also given papers to review about Clare’s possible participation in a national AD brain donor program. After several discussions, Clare and I agreed upon the importance of contributing to future research that may help others dealing with AD, so she signed (and I co-signed) a form giving permission for her brain to be donated post-mortem for scientific research. And, upon my wife’s death, that was done.
Because of the coordination and support that MSSM had in place regarding brain tissue donation education, Clare and I were able to make an informed decision that will hopefully lead to new advances in AD research. Although Clare had to go through the experience of living with AD, at least we could take this practical step in perhaps helping others in the future.
Unfortunately, many AD family caregivers report that their doctors never discussed the possibility or importance of brain tissue donation with them or their loved ones. And if the matter is ever brought up, it may not always be discussed properly. One member of my former AD spouse support group recently told me what happened when she brought up brain donation with her husband’s neurologist:
“The doctor’s reaction was tepid, and the recommendations and instructions were vague, unsupportive, and complicated. At that time, I didn’t need complicated. I just needed the information. I was made to feel like I was offering to donate an old sofa, instead of a brain that might have something valuable to offer to those doing research on neurological diseases.”
This woman had wanted to do her part to further AD research, yet she was met with indifference and a lack of compassion, despite the need for brain tissue donations.
It may be helpful to make information on brain donation part of the intake procedure for all AD residents and/or patients in LTCFs. Caregivers could be asked if they have made brain tissue donation provisions for their loved ones. If yes, then that information should be recorded for the future, and the caregiver should be told to bring in a copy of the signed brain tissue donation form for their records. If not, LTC personnel could provide brain tissue donation information and facilitate the donation process for caregivers if asked to do so.
Brain tissue donation is one practical way to allow researchers to learn more about AD that may one day result in new knowledge leading to an effective means of prevention, treatment, or cure.
It would not take much time or effort for a LTC administrator, social worker, physician, or nurse to be responsible for coordinating such an effort in every LTC setting.
__________________________________________________________
Dr Vann writes a monthly Commentary blog column for the Annals of Long-Term Care journal, which is one of the brands housed on the Managed Health Care Connect website. He has also written frequently for caregiver magazines, other medical journals, and major newspapers. After his wife, Clare, was diagnosed with early onset Alzheimer’s disease, Dr Vann made it a point to increase public awareness of Alzheimer’s and to help fellow caregivers. You can read more than 90 of his other articles about Alzheimer's at www.allansvann.blogspot.com. If you would like Dr Vann to respond to questions or comments about this article, please email him directly at acvann@optonline.net.


Published in Annals of Long-Term Care, September 12, 2017.  Access online only at 
http://www.managedhealthcareconnect.com/blog/discussing-brain-donation-dementia-residents


Wednesday, August 9, 2017

Coordinating Private Aides For LTC residents With Dementia

Assisted-living facilities (ALFs) in New York (NY) can hold one or a combination of different types of licensure and certification: basic, enhanced, and/or special needs. According to NY Health Department regulations, ALFs with enhanced certification can provide “aging in place by admitting and retaining residents who desire to continue to age in place…able to provide skilled nursing services and to accommodate residents who exceed the retention standards” that are found in ALFs with only basic certification.
ALFs with a “special needs” certification are authorized “to provide services to residents with special needs, most commonly Alzheimer’s disease [AD], dementia, or cognitive impairment. In addition, the assisted living operator may choose to be dually certified to provide enhanced and special needs services, thereby further allowing residents to age in place.”But there will be times when residents with AD may require additional care, even in ALFs with both enhanced and special needs certification.
My late wife, Clare, was a resident with AD in a dually certified ALF in NY. However, at a certain point, the ALF required me to hire personal “home health” aides to be with her in order to remain there to age in place. (Even if care is given in ALFs and not in private homes, these aides are still referred to as home health aides.) According to NY regulations, “Personal care tasks that exceed the approved scope of tasks in which an assisted living resident aide is trained must be performed by trained home health aides.
Regulations governing enhanced ALFs also state: “A resident shall be permitted to…continue to reside and age in place…provided the operator, the resident’s physician, and, if applicable, the resident’s licensed or certified home care agency agree that the additional needs of the resident can be safely and appropriately met at the residence.”
According to the National Center for Assisted Living, ALFs are responsible for providing “coordination of services by outside health care providers.” But what exactly does this responsibility imply? What is meant by “coordination,” and what procedures should ALFs implement to provide this coordination?
Below are some experiences I had when my wife was a resident in an ALF, demonstrating the many instances where care coordination in long-term care facilities needs improvement.
  • When my wife needed services provided by an outside health care provider, the ALF chose the agency. As the caregiver, I had no input. After observing and reporting negligent care and/or shoddy work habits of outside aides assigned to care for Clare, the AD unit supervisor told me I should contact the care provider. To their credit, new aides were assigned each time I complained to the care provider. But why didn’t the facility complain to the outside care agency to ensure that Clare was receiving proper care?
  • My daughter and I spent time with each new agency aide to provide specific instructions for my wife’s care regarding food, clothing, personal hygiene, etc. But too often a different aide would be assigned the following day, an aide who had no knowledge of the specific instructions for my wife. When I would find out, my daughter and I would meet with the new aide, but why didn’t the AD unit supervisor communicate those specific instructions to new aides initially?
  • I visited my wife on a daily basis, and several times I noticed aides arriving late or leaving early.  But no one at the facility ever informed me of when an aide arrived late or left early. Shouldn’t outside aide arrival and departure time be monitored by facilities? 
  • When I received statements from the outside care provider detailing charges already billed to my credit card, I sometimes noticed billing for hours when the aide was not there, or overtime charges without advance notice that overtime rates would apply. But I could never be sure that aides worked for all hours billed when I was not personally there to verify such hours, and again, no one from the facility had recorded their presence. Shouldn’t outside care agencies submit their statements first to facilities for verification?
  • It would be very helpful for already stressed caregivers if care facilities took more responsibility for supervising and coordinating personal aides hired by caregivers to allow their loved ones to age in place.
_____________________________________________________
Dr Vann is a frequent writer in caregiver magazines, medical journals, and in major newspapers. After his wife, Clare, was diagnosed with early onset Alzheimer’s disease, Dr Vann made it a point to increase public awareness of Alzheimer’s and to help fellow caregivers. You can read his other pieces at www.allansvann.blogspot.com. If you would like Dr Vann to respond to questions or comments about this article, please email him directly at acvann@optonline.net
© Copyright 20
Published in Annals of Long-Term Care, August 7, 2017.  Access online only at:



Thursday, August 3, 2017

Personal Blog #2 ... The Truth About Alzheimer’s Disease Through the Eyes of a Home Caregiver

Although I had no editorial control over what was printed, Angels Homecare, a Chicago based organization, invited me to share some thoughts about caregiving for a forthcoming online article. That organization published its online piece today, 8/3/17, giving the perspectives of four Alzheimer's caregivers that readers may find interesting.  I am one of the four caregivers cited.

There is no way I can reproduce the pictures and graphics accompanying the online article to do it justice, but readers may go to their website page if interested in reading the complete article.  Cut/copy and paste this address into your browser:
myangelshomecare.com/the-truth-about-alzheimers/


Friday, July 28, 2017

Personal Blog #1 ... 15 Months as an Alzheimer's Widower

        
It’s been 15 months since Clare passed away, but despite “moving on” with the rest of my life I still sometimes find myself dealing with mild depression.  I had expected to occasionally feel very emotional at times when viewing certain scenes in movies or on television, or when listening to certain music.  But I had not expected to continue to occasionally experience brief but very intense feelings of painful loss and weepiness.  Obviously, I was wrong.  

I attended several “recently widowed” support group meetings but felt that I had little in common with the others in my group.  Perhaps it is because many widowed Alzheimer’s disease (AD) spouses have already gone through years of “anticipatory grief” while watching their loved ones slowly die before their eyes.  Others in my group were dealing with their spouse’s unexpected death, but I had already felt widowed in many ways during the 3 years when Clare was living in an assisted living facility and nursing home prior to her death.

When Clare had been in early to moderate stages of AD, I had participated in a very helpful weekly support group exclusively for AD spouses.  Unfortunately, no support groups exclusively for widowed AD spouses seem to exist.  I cannot say with certainty that such a group would have been, or would now be, helpful to me ... but I wish I had the opportunity to find out.

It’s not that I have become a social recluse.  I socialize with others in three weekly bowling leagues, I exercise several times each week at a local Y, and I usually go out to eat at least twice a week with family or friends.  But I think I would be further ahead in my “moving on” and suffer fewer periods of mild depression if I could meet someone with whom I could enjoy a more special relationship several times a month. 

I suppose that I could try online dating to increase my chances of meeting a special someone, but I just don’t want to do that.  I did go to several social mixers and activities for "sociable seniors," but too many women my age (70) or younger seemed to be looking for serious relationships and I’m not looking for that.  After living alone for four years, I have come to enjoy my ability to do what I want when I want. 

What I really want, I suppose, is a “friend with benefits” ... a woman to enjoy being with as a friend while also enjoying a physical relationship.  But I do not want a FWB to be with me every day or even several days a week.  I just don’t want that serious a relationship.  However, if I could be with someone truly special a few times a month, that would be perfect.

Some surviving AD spouses have been helped by therapists to deal with their grief.  For me, writing has always been my therapy.  I found it very helpful to maintain a journal for nearly 10 years while dealing with Clare’s AD, so I thought that writing about my current feelings would be helpful. 

When I finished this journal entry, I thought that maybe other widowed AD spouses with similar feelings might find some comfort just by knowing that they are not the only ones who feel as they do.  So I decided to post this journal entry today just on my own site as Personal Blog #1.  Whether or not there will be a Personal Blog #2, or any additional personal blogs, remains to be seen.
 

If you’d like to comment on this blog post and have me reply, please email me directly at acvann@optonline.net and write “AD blog” in the subject line.  I truly hope that someone out there may be helped by reading this blog as I was helped by writing it. 

Tuesday, June 20, 2017

Dementia Resident Care Transition Strategies

My late wife, Clare, had Alzheimer’s disease and spent two and a half years in the lockdown dementia wing of an assisted-living facility (ALF) and two months in a nursing home (NH). New facilities meant new faces and establishing a new protocol for communication between myself, Clare’s caregiver, and staff routinely responsible for Clare’s care. These experiences showed me that a few small changes in facilities could make these transitions much easier for new residents and their caregivers.
1.  Issue a staff list to caregivers
When I first met with ALF and NH admissions staff, I was given a folder with lots of helpful information. However, after Clare was admitted, I never received a list of the specific personnel responsible for Clare’s care. While I was introduced to the social workers in both facilities, the dementia unit director in her ALF, and the supervising nurse in the NH dementia unit during the intake assessment, I was never given direct-line phone numbers and email addresses in the event that I may need to contact them. Having a list of Clare’s aides in each facility and names of the other nurses in her NH unit would have also been helpful. 
With this additional information, I could have more easily familiarized myself with the names and faces of those responsible for Clare’s care and known who to speak to about concerns. I eventually obtained most of this information without any assistance from management at either facility but only after investing much personal time and effort. I never did receive information on how to contact Clare’s NH doctor directly, forcing me to repeatedly leave messages for the doctor at the front desk. Providing caregivers with names and contact information will help reduce caregiver stress and also improve patient care.
2.  Provide highly visible name badges for personnel
Many ALFs and NHs provide personnel with badges where the name of the facility is very prominent, but the name of the individual is typed in comparatively small font size; the employee’s title is often even smaller. Now I have 20/20 vision but, in order to read names and titles clearly for most personnel, I had to get very close to each person, almost violating their personal space. I know that ALFs and NHs are proud of their names and want to market their names, but what is important to caregivers is the name and title of the people working with their loved ones, not the name of the facility. 
3.  Provide removable name badges for residents
ALFs should consider supplying name badges for residents in their dementia units. Prior to her entrance into her ALF, Clare attended social day care programs at various sites. Upon arrival at each site, she and all the other participants were given name badges that were then collected at the conclusion of their program. This was very helpful for Clare because even though at this stage of her cognitive decline she could no longer remember names, she could still read the names (first names only!) on those badges and interact with fellow participants by name. Name badges would have allowed Clare to know who she was interacting with and allowed me to readily identify and interact with her friends during my daily visits.
4.  Establish a monthly meeting schedule with caregivers
When I worked as an elementary school principal, busy parents always knew that they had the opportunity to ask me questions at the monthly PTA meetings. I can understand the reluctance of ALF/NH administrators to add more meetings to their busy schedules. However, dementia unit administrators should provide a monthly opportunity for caregivers to meet with them to discuss general concerns or offer suggestions for improvement with respect to routines, activities, medication protocols, etc. More communication between caregivers and ALF/NH administrators can only be more helpful.
_________________________________________________________________
Dr Vann is a frequent writer in caregiver magazines, medical journals, and in major newspapers. After his wife, Clare, was diagnosed with early onset Alzheimer’s disease, Dr Vann made it a point to increase public awareness of Alzheimer’s and to help fellow caregivers. You can read his other pieces at www.allansvann.blogspot.com. If you would like Dr Vann to respond to questions or comments about this article, please email him directly at acvann@optonline.net

Published in Annals of Long-term Care, June 20, 2017.  Access online only at: 
http://www.managedhealthcareconnect.com/blog/4-tips-enhance-dementia-resident-care-transitions

Wednesday, May 10, 2017

Is Your NH Visitation Policy in Compliance with Federal Law?


“What are your daily visiting hours?” was one of the many questions I asked the intake person in a New York (NY) nursing home (NH) office last year before my late wife was admitted. I was told that I could visit each day between 10:30 a.m. and 8:30 p.m. I was also given several booklets explaining patient rights, administrative policies, and various NH routines, but nothing in any booklet discussed visiting hours. Those same visiting hours, 10:30 a.m-8:30 p.m., were also posted by the entrance desk where visitors had to sign in and out. Twice I came at around 10:15 a.m. and each time I was asked to wait in the lobby until 10:30 because I was “too early.”

Imagine my surprise when I recently learned that I should have been told that I could visit my wife anytime, day or night, as long as she wanted me to be there. Every NH in the United States that accepts Medicare/Medicaid funding, I now know, must allow immediate family members 24/7 access to visit residents.

Section 483.10 (j) (1), subsection vii of the Federal Nursing Home Reform Act of 1987 guarantees visitation rights at any time for immediate family members of NH residents. Whereas the law does state that non-immediate family visits may be subject to “reasonable” restrictions, "immediate family or other relatives are not subject to visiting hour limitations or other restrictions not imposed by the resident."

In 2009, The Center for Medicare and Medicaid services (CMS) attempted to clarify the meaning of subsection vii of Section 483.10 (j) (1) in “Guidance to Surveyors of Long Term Care Facilities.” CMS provided “Interpretive Guidelines,” emphasizing that “Immediate family or other relatives are not subject to visiting hour limitations or other restrictions not imposed by the resident." CMS further provided one question that NHs must be able to answer in the affirmative to be in compliance with federal law: “Do residents and family members know that they are able to visit 24-hours a day?"

CMS also provided revised guidelines that became effective in November 2016 that broadened NH visitation policies. They said, in addition to the provision allowing unrestricted access by immediate family members, NH residents now also have the right to “have visitors at any time, as long as you want to see them, and as long as the visit doesn't interfere with the provision of care and privacy rights of other residents." Similarly, the “Visitors” section of Medicare’s “Skilled nursing facility rights” document now states: “You have the right to spend private time with visitors at any reasonable hour. The SNF must permit your family to visit you at any time, as long as you want to see them.”

New York State NH Regulations
Once I learned about federal law pertaining to 24/7 access to residents by immediate family members, I went online to access the New York State Department of Health regulations for NHs. Surely, I thought, NY had sought a waiver from federal law as it pertains to family visits in NHs; otherwise, why would I have been told to restrict my visits (at one of the best NHs in our state) to between the hours of 10:30 a.m. to 8:30 p.m.

What I discovered was alarming. NY Health Department regulations mirror the federal visitation guidelines in all but one respect: there is absolutely no mention that NHs must provide immediate unrestricted access for immediate family members. The NY visitation regulation states that residents may have visitors, with their consent, “subject to reasonable restrictions and [their] right to deny or withdraw consent at any time.”

The NY Health Department issues a document, “What to Look For When Visiting a Nursing Home,” to help consumers select a good NH for their loved ones. In the section, “Following is a list of some policies to check,” visitation rights are only mentioned in one phrase: “visiting hours should cover a 10-hour period including 2 meal times,” but there is no mention of checking to ensure that the NH provides unrestricted access by immediate family members.

I then contacted the Commissioner’s office of the NY Health Department to ask one question: Has NY sought a waiver from the federal government regarding NH visitation rights, or is NY simply out of compliance with federal law?

I ended up being referred to and speaking with thirteen different individuals in the NY Health Department before one official was finally able to answer my question. She said, “of course NY is in compliance with federal law.” When I noted that the subsection on unrestricted visitation rights by immediate family members does not appear in the state guidelines, I was again assured that the state was in compliance despite no mention of unrestricted access.

When I then related my personal experience, I was told that I could file a complaint! When I asked if the official thought a clarification should be added to the Health Department guidelines, she said that was unnecessary. Incredulously, to me at least, she said that NHs should make visitation guidelines clear but there is no state regulation requiring them to do so, and there is no state requirement for NHs to have anything about unrestricted visitation rights in writing.

Telephone Survey of 10% of NHs in NY
I then decided to contact NHs directly to find out if the situation at my late wife’s NH was unique or if many other NY NHs were also not informing consumers of their right to unrestricted access for family members. I went online again at the NY Health Department website to find a list of all 624 NHs in New York.

I called every tenth NH on each list, 63 NHs altogether, providing me with a good sample size of 10% of all the NHs in NY. (I actually ended up calling 70 NHs because 7 NHs did not answer, even though all calls were made on Saturday or Sunday afternoons between noon and 4 p.m.). I also made sure that each NH was Medicare/Medicaid certified and therefore subject to the Federal Nursing Home Act regulations allowing unrestricted visitations for immediate family of residents.

I asked one question at each NH, and if not given complete information I asked a second question. My first question was, “Can you please tell me your visiting hours?” If told that the NH didn’t have any set hours, hours were 24/7, I can come anytime, or a similar response, I simply said “terrific” or “that’s excellent,” said thank you, and hung up the phone. If given a set time for visits, eg, from 8 a.m. to 8 p.m., I then waited several seconds to see if they would say something like, “unless you are an immediate family member.” None asked me that question, but a few did hang up and I had to call them back! After that pause, or call back, I asked a second question: “If I place my mother at your NH, can I visit her on the way to work an hour before visiting hours begin (whatever time they gave me, I’d pick an hour earlier; so if they said visiting hours begin at 8, I’d ask if I could visit at 7.) I asked the same about visiting on my way home from work at an hour after the limit time they provided.

Survey Results
Results were very disappointing. Given pre-existing federal law and recent updates, every Medicare/Medicaid eligible NH in every state in 2017 should respond the same way when asked about visiting hours for residents. The policy in every NH should be that there are no set times to visit; all visitors may come anytime, 24/7. Immediate family members should face no restrictions, but all other visitors may be asked to wait temporarily if a provision of care or privacy rights of other residents should apply at that time.

Of the 63 NHs I contacted, only 24 responded correctly to my first question by saying that I can visit anytime. When I asked my second question at the other 39 NHs, responses were of five types: ignorant, encouraging, discouraging, very discouraging, or absolutely out of compliance.

Ignorant responses were variations of “I’m not sure” and when asked to check they would return to the phone and continue to say they weren’t sure. Encouraging responses were like this: “Yes, but the doors are locked before and after those times, so just ring the bell and someone will let you in.”

Discouraging responses were often like this: “You can try to get permission from a social worker or a supervising nurse; if we have that permission on file, then someone will come to open the locked door at those times.” Or, “We try to avoid that, but usually we’ll usually let you in.”

Very discouraging responses were often like this: “Our doors are locked and the person with the keys is at a fixed station and doesn’t walk around that much. So you can ring the bell but it may take a long time before anyone comes to let you in.”

However, 5 responses were completely non-compliant with federal law, all variations of “no” such as ... “I’m sorry, but our doors are locked before _ a.m. and after _ p.m.” Or, “No, you must come between those times.”

Obviously, NHs in NY have not yet gotten the message that since 1987 immediate family have been allowed to visit with their loved ones whenever they want, and now other visitors may also visit at any time, albeit subject to some possible restrictions due to resident privacy and care issues. Posting limited visitation hours is not in accordance with federal law, unless those posted visiting hours say 24/7 or “come visit your loved ones anytime.”

For immediate family members and relatives of loved ones placed in NHs in New York, it is both outrageous and sad that so many NHs are actively violating the law and illegally restricting and/or discouraging visits from caring family members.

So, is your facility in compliance with federal law?
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Dr Vann is a frequent writer in caregiver magazines, medical journals, and in major newspapers. After his wife, Clare, was diagnosed with early onset Alzheimer’s disease, Dr Vann made it a point to increase public awareness of Alzheimer’s and to help fellow caregivers. You can read his other pieces at www.allansvann.blogspot.com. If you would like Dr Vann to respond to questions or comments about this article, please email him directly at acvann@optonline.net

Published in Annals of Long-Term Care, May 9, 2017.  Access online only.  Access at: http://www.managedhealthcareconnect.com/blog/your-nh-visitation-policy-compliance-federal-law

Note:  Direct links to all sources quoted in this article appear in my blog at the Annals access site.