When patients with dementia become combative, there’s often nowhere to go but a state psych ward
By MARIE ALBIGES AUG 14, 2019 | 2:17 PM Cindy Piccirilli was out of options. The Chesapeake assisted living facility where her spouse, 57-year-old Catherine Wright, had been living for nearly three months could no longer handle her violent outbursts and aggressive demeanor. Wright, whose cognition had been steadily declining since she was diagnosed with early-onset Alzheimer's disease five years earlier, periodically had what Piccirilli called violent, random episodes — she would hit other residents and staff, and push and throw furniture around. The former Virginia Beach public school teacher was younger than most residents in the memory care unit, and more able-bodied. It often took four staff members to bathe her. When Wright became aggressive, staff at the assisted living facility, Commonwealth Senior Living at Georgian Manor, said Wright needed to go to a psychiatric facility, where her medications would be adjusted to deal with her dementia symptoms. So one day in March 2018 after Wright had a particularly difficult weekend, Piccirilli finally agreed, hoping someone at a psych facility would figure out what was triggering the aggressive behavior and find a way to calm Wright down. Piccirilli didn't realize it would end with her wife — who she described as usually calm and mild mannered — strapped to a gurney with her wrists chained to her ankles, screaming and crying, "You're hurting me!" as law-enforcement officers wheeled her out of a hospital emergency room and into a medical transport vehicle that would take her to a state psychiatric hospital 70 miles away, where she would develop a bowel infection and never walk again. Health officials and experts agree this never should've happened. They acknowledge a state psychiatric hospital like Eastern State in Williamsburg wasn't the appropriate place for people like Wright, who become combative as a result of their dementia. But a state law allows Wright and countless others living with dementia to be placed into involuntary hospitalization if they are in a psychiatric crisis and are deemed a threat to themselves or others. Called a temporary detention order, or TDO, it's normally reserved for mentally ill individuals, but it's being used on people like Wright because there simply isn't anywhere else for them to go in Virginia for treatment. —- There are a few factors that contribute to people like Wright ending up in state psychiatric hospitals, said John Oliver, who worked in the Chesapeake city attorney's office for 31 years and now represents people held under involuntary commitments. First, there's an increasing number of people with behavioral and mental health issues that need medical attention, and a growing number of people with dementia. According to the Alzheimer's Association, by 2025, more than 190,000 Virginians who are at least 65 years old will have some form of Alzheimer's. And an estimated 200,000 people already have early-onset Alzheimer's, which can often affect people who are younger than 65. Second, there's a limited number of facilities that are set up to manage the challenges of dementia, including the aggressive behavior, which can happen when a patient has a medical issue — like a urinary tract infection — but can't articulate it. There aren't a lot of options for private inpatient hospitalization or crisis stabilization services close to home. Third, there's a staffing shortfall. It's hard to retain people to work in those environments for low pay, and hard to find people properly trained to handle aggressive patients, Oliver said. "When you reach that kind of situation, the state psychiatric hospitals are the backstop and they end up with these patients, ready or not," he said. Ready or not, because state psychiatric hospitals aren't equipped to treat complex physical illnesses — they often lack oxygen tanks or supplies for ulcers — and don't have enough beds to treat everyone coming through the doors. Virginia's "bed of last resort" law — passed in 2014 following the suicide of State Sen. Creigh Deeds' son after a psychiatric bed wasn't available for him — says the state psychiatric hospitals have to admit patients in a mental health crisis if no private facility will take them. Since that law was implemented, state hospital TDO admissions have risen by 294%, and many of the hospitals are at or near capacity. Private hospitals aren't required to admit those patients, and many of their beds are taken by an increasing number of people voluntarily committing themselves for psychiatric treatment. State hospitals were traditionally designed for mentally ill patients who were having trouble getting their illness under control and were typically admitted for longer. But now, many of the TDO patients stay less than a week, according to the Department of Behavioral Health and Developmental Services. Dr. Daniel Herr, the department's deputy commissioner for facility services, estimates 38% to 40% of people admitted to state psychiatric hospitals under a TDO require specialized care beyond mental health treatment. —-- Rick Jackson, a member of the state's Alzheimer's Disease and Related Disorder Commission, said there's been a debate happening for years in Virginia around the best place for someone with dementia whose behavior puts themselves or others at risk. "We as a society have been struggling with this for decades," said Jackson, who's the executive director of the Riverside Center for Excellence in Aging and Lifelong Health. Some, he said, argue the state should be responsible for their care. Others say that task should be handled by community-based for-profit and nonprofit facilities like nursing homes and assisted living facilities with memory care units. But assisted living facilities have to balance caring for those with behavioral issues with protecting their other clients, Jackson said. Often, like in Wright's case, the combative patients are sent to the emergency room, where doctors can try to treat the short-term issue causing the behavior — if they can identify it. If they can't, and the assisted living facility is reluctant to take them back, the only other option is usually a state psychiatric hospital, Jackson said. Cindy Piccirilli stands with her wife, Catherine Wright, in their home Thursday afternoon May 16, 2019. Wright has early-onset Alzheimer's and after an outburst at an assisted living facility was issued a temporary detention order. (Jonathon Gruenke) Cindy Piccirilli reflects while discussing her wife, Catherine Wright, Thursday afternoon May 16, 2019. Wright has early-onset Alzheimer's and after an outburst at an assisted living facility was issued a temporary detention order. (Jonathon Gruenke)Wright moved into the memory care unit at Georgian Manor on Jan. 9, 2018, and over the next 10 weeks, staff struggled to bathe and feed her. "Very combative when we changed her. It took four staffs to change her," read one entry in Wright's medical chart, a copy of which Piccirilli provided to The Virginian-Pilot. "She really fights. All four staff helped together to changed (sic) her," another entry states. In the 10 weeks she lived at Georgian Manor, staff recorded at least 11 instances where Wright was labeled as "combative" or attacking staff members who tried to change her. Piccirillli said she noticed bruises on Wright's arms from where she suspected staff members gripped her to bathe her. She also didn't eat much, Piccirilli said. Even though she was paying for three meals a day, she mostly ate chocolate nutritional drinks. By the end of her stay, Piccirilli said Wright had lost 30 pounds. On that March day, she was originally sent to Chesapeake Regional Medical Center for medical clearance before being voluntarily admitted — through Piccirilli's medical power of attorney — to The Pavilion at Williamsburg Place, a private inpatient psychiatric facility. Nearly 18 hours into their stay at Chesapeake Regional, with the medical evaluation done, the Pavilion said it could no longer accept Wright as a patient. Mike Post, Pavilion's CEO, would not discuss Wright's case but said there are several reasons why the facility would turn someone away. It could be full; it could lack the resources to treat a medically complex patient, like someone who has cancer or needs dialysis; or the patient doesn't fit the population the Pavilion serves — for example, it doesn't admit children under 18. In Wright's case, her medical records show she wasn't admitted because there appeared to be something wrong with her EKG. So, like so many others in her situation, her next stop was Eastern State Hospital on a TDO. —- TDOs, signed by a magistrate, involuntarily commit people experiencing a mental health crisis who might harm themselves or others to a hospital for up to 72 hours. After that, a judge can order further treatment if it's still needed. More than 25,500 TDOs were issued in fiscal 2018 according to the state behavioral health department. The region that includes Hampton Roads had the second-highest number after Southwest Virginia. That day in the ER was the first time Piccirilli — herself a retired Navy neurosurgeon — had ever heard the term temporary detention order. She didn't know it involved a social worker calling around to different hospitals to see if they could admit her wife. She didn't understand why, after the eight-hour limit to find a bed mandated by state law, the only option was Eastern State Hospital, a place she'd been told by Chesapeake Regional staff to avoid if possible. Piccirilli wasn't told a TDO meant armed officers would show up and take her wife to Eastern State in handcuffs, even though she said Wright was medicated and calm at that point. And she didn't understand why her medical power of attorney — which she and Wright had obtained before Wright's cognitive decline — was powerless to stop it. Patients under a TDO are usually taken to the psych facility in a police car, though a new state alternative transportation program is trying to make that less common. Wright couldn't get out of bed, so a medical transport vehicle was called, and Piccirilli followed it and a police car up Interstate 64 to Williamsburg in the middle of the night. "Catherine was a frightened child, being arrested and chained," Piccirilli said. —-- Similar ordeals are happening more frequently in Virginia, Herr said in a phone interview. In fiscal 2013, 16 people with a primary diagnosis of dementia were admitted to the state's psychiatric hospitals under a TDO, according to the state behavioral health department. By this year, that number had risen to 115. The state code section around TDOs doesn't have any exceptions for people with dementia who are experiencing behavioral changes because of underlying medical issues. In Wright's case, that issue was extreme constipation. At Chesapeake Regional, a test showed no medicine in her system, despite what had been prescribed to her at Georgian Manor. And a week into her stay at Eastern State, she developed bed sores and a fever and was taken to Sentara Williamsburg Regional Medical Center, where doctors discovered a bowel infection. But the state code is clear — if a person is in a crisis and is deemed a threat to themselves or others, the only place for them is at a psychiatric hospital. And often that means handcuffs and a police car. Someone with a chronic condition like dementia needs different treatment than a person in the midst of a psychiatric crisis. But in the eyes of the law, Herr said, they both meet the definition of someone who should be temporarily detained. Larry Fitch, a professor of mental health law at the University of Maryland law school, studies involuntary commitment proceedings and said situations like Wright's happen all over the country. He said some states have found ways to prevent people with dementia from being involuntarily committed. In Wisconsin, the state Supreme Court ruled in 2012 that someone suffering exclusively from Alzheimer's disease couldn't be subject to Wisconsin's version of a TDO. Instead, they are appointed a guardian ad litem, who can place them somewhere other than a psychiatric facility. In Kansas, the state Department of Aging and Disability Services and the Alzheimer's Association partnered to create the Kansas Dementia Bridge Project, which provides crisis support to dementia patients and tries to avoid hospitalization at all costs. Coordinators work with families to provide direct support, counseling, and advocacy in crisis situations at home, the hospital, at the doctor's office or during transitions to facilities. Researchers found the Bridge Project significantly reduced patient anxiety, depression, resistance to care, impulsive behavior, verbal outbursts and wandering. Patients also were hospitalized less frequently, and people living at home were able to hold off on being placed in nursing homes. In Virginia, a state-mandated work group consisting of mental health advocates, the private hospital system, law enforcement and state health officials wants to tackle one part of the temporary detention order cycle: reducing the number of people admitted involuntarily to the state's psychiatric hospitals, as Wright was. Members are considering extending the eight-hour window Community Services Board workers have to evaluate the patient and find them a bed in a psychiatric facility. That could be key, because finding a facility that's also equipped to address the patient's physical issues often takes longer. And if the time window is extended, a follow-up assessment could lead to a CSB worker deciding a TDO isn't necessary and placing them in a more appropriate setting, like a geropsychiatric facility. The problem remains, however, that more appropriate settings are pretty slim, Herr said. "Virginia doesn't have that in any consistent kind of way," he said. -- Piccirilli still can't believe Wright's experience under a TDO was legal. "The state treated her worse than a dog, and like a common criminal, because she has dementia," she said. "It was immoral, it was medically inappropriate —- they hurt her — and it was so inhumane." After safely returning Wright home — she didn't want to bring her back to Georgian Manor — and hiring 24-hour help, Piccirilli finally had some time to think. She wrote a letter to Commonwealth Senior Living, and the state department that regulates assisted living facilities. The department sent an inspector to investigate the claims, and found instances where medications weren't being administered according to physician's instructions, according to the Department of Social Services inspection report. The inspector also found the facility "failed to ensure" that it not admit or retain clients "presenting an imminent physical threat or danger to self or others." Bernie Cavis, who oversees residence programs at five Commonwealth Senior Living facilities in Hampton Roads including Georgian Manor, said the facility thoroughly assesses each potential new resident to determine their needs and appropriate level of care. But sometimes, especially if the resident becomes violent, her staff doesn't have the capacity to restrain them and aren't able to safely calm them down, so hospitalization is inevitable. "It's a process we avoid at all costs," she said. Piccirilli drafted a letter to Gov. Ralph Northam — a pediatric neurologist — but never sent it. She read it over it once, and realized it was filled with raw emotion. She spoke with a former Virginian-Pilot reporter who wrote about a case similar to Wright's four years ago. She commiserated with another caregiver who wrote about her experience losing her husband to early-onset Alzheimer's. More than a year later, she's still grappling with who to hold accountable, and what to tell her elected representatives. She wants to write to members of Virginia's congressional delegation and Deeds, the state senator whose son died. "I don't know why the legislature keeps lumping dementia with psychiatric illness," she said. She wants to see staffing standards put in place at assisted living facilities. She wants to see a facility that can give individualized care to people living with dementia, with physicians available to detect and treat underlying symptoms that cause aggressive behavior. Six years into being officially diagnosed, Wright needs less intensive care as her condition has worsened. She sleeps more, and when the aides aren't there, Piccirilli sits with her, occasionally listening to the Carpenters. Piccirilli often thinks about what Wright would've wanted if she'd hadn't gotten sick. She regrets taking Wright out of their home in Great Bridge, but the one positive outcome of the TDO ordeal was that Wright got to come home. Now, Piccirilli's goal is to ensure her spouse has a dignified, peaceful death at home. Correction: This article has been updated to reflect John Oliver worked for the Chesapeake city attorney's office, not the Commonwealth Attorney's office. Marie Albiges, 757-247-4962, malbiges@dailypress.com
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Uber Taps Lucrative Medicare Business With Logistics Deal
Bruce Japsen Senior Contributor I write about healthcare business and policy ASSOCIATED PRESS Uber has signed a contract with a key medical transportation company that has relationships with some of the nation’s biggest health insurers. Uber Health, the healthcare business of the ride-sharing giant, said it is partnering with American Logistics Company in “the rideshare company’s first national collaboration with a healthcare transportation management company.” Financial terms of the partnership weren’t disclosed. Uber’s partnership with American Logistics offers another glimpse into the expanding and lucrative opportunities for ride sharing companies including rival Lyft as well as other startups and new entrants like Ford Motor Company’s GoRide Health invest into expansion for non-emergency medical transportation services. “The combination of Uber's vast driver-partner network and American Logistics' full-service, turnkey transportation solution delivers an unmatched level of access to millions of healthcare plan members,” Uber Health said in a statement. “Healthcare plans and organizations can now provide smarter patient pickup and drop off, scheduling, real-time GPS tracking, and messaging through one unified platform.” To be sure, American Logistics contracts with Caremore, a unit of Anthem, the nation’s second-largest health insurance company with more than 40 million health plan members. Anthem’s CareMore contracts with American Logistics to provide patients with transportation to their doctor’s offices and other medical appointments, which is a goal of health insurers to try to make sure their health plan enrollees are getting primary care upfront before they get sick and end up in a more expensive care setting like a hospital. As health insurers like Anthem move away from fee-for-service medicine to value-based care and population health models that make sure patients are getting quality care in the right place and at the right time, ride-sharing companies say they can have a key role. CareMore is an integrated delivery system that provides care to about 150,000 patients enrolled in Caremore or Anthem Medicare Advantage plans as well as Medicaid health plan subscribers depending on the state. Medicaid patients suffer multiple chronic conditions and are known to have difficulty accessing medical care services so insurers and Medicaid programs see ride-share as a potential solution to making sure they get to their doctor’s appointments. And seniors are flocking to Medicare Advantage plans, which are increasingly covering more supplement health benefits thanks to rule changes by the Centers for Medicare & Medicaid Services. “Transportation touches many aspects of a person’s life and reliable transportation is fundamental to healthy communities,” Dan Trigub, head of Uber Health said. “As we find more ways for Uber to help Medicare and Medicaid beneficiaries, partnerships with organizations like American Logistics are critical to our success. Uber Health along with American Logistics will reduce barriers to care for our most vulnerable populations, including the elderly and low-income patients.” Trigub said American Logistics’ integration with Uber’s application programming interface (API) “creates a single-platform solution that, coupled with our dedicated team of healthcare professionals, will drive significant value." For Uber, the American Logistics partnership shows a commitment to the healthcare space, Uber executives said. Landing more deals with health insurance companies and medical providers could also be a boon to Uber as the ride-sharing company is trying to boost sales and become profitable. “Our Uber Health platform that helps improve access to healthcare organizations grew at over 400% year-on-year this quarter,” Uber CEO Dara Khosrowshahi told analysts last week during the company’s second-quarter earnings call. Follow me on Twitter or LinkedIn. Check out my website or some of my other work here. https://www.forbes.com/sites/amandalauren/2019/07/28/building-and-designing-homes-for-people-with-disabilities/#7ff428487dd4
News Release 15-Aug-2019Financial abuse of older adults by family members more common than scams by strangersAnalysis of resource line calls identifies various types of elder abuse reported, along with relationship to alleged perpetrators
University of Southern California - Health Sciences Share Print E-Mail IMAGE: This is Duke Han, PhD, associate professor of family medicine, Keck School of Medicine of USC. view more Credit: Ricardo Carrasco III LOS ANGELES — Despite numerous telephone, mail and internet scams directed toward older adults, relatives may perpetrate more financial elder abuse than strangers, suggests a new study by experts at the Keck School of Medicine of USC. Using a unique source of frontline data — instances of elder abuse reported to the National Center on Elder Abuse (NCEA) resource line, Keck School researchers were able to identify the most common types of elder abuse reported and profile the alleged perpetrators. The NCEA resource line is a source for individuals seeking information regarding how to identify or report elder abuse. Of the nearly 2,000 calls logged for the study, more than 42% (818 calls) alleged abuse. Financial abuse was the most commonly reported at nearly 55% (449 calls). Family members were the most frequently identified perpetrators of alleged abuse at nearly 48% of calls in which relationship could be determined. The most common abuse perpetrated by family was financial abuse (61.8%), followed by emotional abuse (35%), neglect (20.1%), physical abuse (12%) and sexual abuse (0.3%). Of the calls that alleged abuse by a family member, more than 32% reported more than one abuse type. "We expected to find that financial abuse was the most common abuse reported," says Gali Weissberger, PhD, lead author of the study, and postdoctoral scholar in the Han Research Lab at the Keck School. "But despite the high rates of financial exploitation perpetrated by scammers targeting older adults, we found that family members were the most commonly alleged perpetrators of financial abuse. In fact, across all abuse types, with the exception of sexual abuse and self-neglect, abuse by a family member was the most commonly reported." Elder abuse affects an estimated one in 10 older adults annually, but is often underreported. Aside from its physical, psychological and social impact on victims, their families and society, elder abuse attributes to more than $5.3 billion in U.S. annual health care costs. "This is the first study to characterize elder abuse from calls made to the NCEA resource line, which serves as a public access point for people seeking information and resources about elder abuse," says Duke Han, PhD, associate professor of family medicine at the Keck School and corresponding author of the study. "Our findings highlight the importance of resource lines for those seeking information on elder abuse, as many calls were made to understand whether certain situations reflected abuse." The researchers coded nearly 2,000 calls, emails or messages logged on the NCEA hotline between August 2014 and June 2017, reviewing for any mention of abuse. They categorized type of abuse alleged, whether multiple types of abuse occurred and who perpetrated the alleged abuse. The researchers add that it is important to incorporate diverse data sources when collecting information regarding alleged abuse. The study was limited by selection bias, as the data was from individuals proactively calling the NCEA line. "The results highlight the importance of developing effective strategies to prevent future abuse," says Weissberger. "Our next step is to conduct more studies targeting high-risk individuals and to better understand additional risk factors." 3,268 viewsAug 15, 2019, 04:19pmElderly Bankruptcy Is On The Rise -- Here's Why
Teresa Ghilarducci Contributor Retirement I am an economics professor focusing on retirement security and jobs. GettyThis week, the U.K.’s Financial Times covered an important and overlooked aspect of how the U.S. treats its elders: bankruptcy. Stories of seniors filing for bankruptcy are heartbreaking and uncomfortable, so I am not surprised that it took a correspondent paid by a foreign newspaper (Patti Waldmeir) to tell this American story from the lobbies of our bankruptcy courts. Like every good story, there are complicated victims and more than one perpetrator. Everyone has a role in the “crime.” Victims In Elder Bankruptcies Bankruptcy in the United States has undergone a rapid “graying” over the past few decades. In 1991, elders made up 2% of the bankruptcy relief claims; now the share is 12%. Those stark numbers come from a recent Indiana Legal Studies research paper, “Graying of U.S. Bankruptcy: Fallout from Life in a Risk Society,” cowritten by professors Deborah Thorne of the University of Idaho, Pamela Foohey of Indiana University Bloomington, Robert M. Lawless of the University of Illinois, and Katherine M. Porter of the University of California, Irvine. The leap in elder filers means about 98,000 families or about 133,000 elders out of 51 million people over 65 file for bankruptcy to get relief from all debt, excluding nondischargeable student debt (which is often incurred by co-signing the student loans of children or grandchildren). In most cases, those filing for bankruptcy come from the lower end of the income ladder. Of elder households that filed for bankruptcy in 2016, 78% made less than median total income. Explaining Elder Bankruptcy Several overlapping factors have contributed to the rise in elder financial distress. Big impersonal forces are one set of reasons more elders are filing for bankruptcy. In the last 40 years, trade unions have weakened, real wages have stagnated, and good pensions have eroded—trends that catch up with people as they age. Companies have offloaded longevity and pension risk onto employees by eliminating pension plans or switching from defined-benefit plans to less-certain 401(k)-type options.Another big impersonal force is the rise in medical costs, which has coincided with political decisions to have Medicare pay for a smaller share of elder health care. The longer people live, the higher the medical costs. It's always tempting to cite bad decisions on the part of the poor as a reason for a victim’s woes. The Financial Times mentions that some researchers blame aging boomers for diverging from their Depression-era parents who, unlike their aging sons and daughters, were averse to debt. Yet it is difficult in this case to separate the consumer side from the industry that markets to borrowers—it is unlikely that humans have changed as much as banks’ business model for credit cards. Perpetrators and predators are another source causing bankruptcy risk among the elderly. Banks hype low-interest credit cards, even to elders who have just filed for bankruptcy. According to the Federal Reserve’s Survey of Consumer Finances, 60% of senior households had debt in 2016 and 29% of senior households owed money on mortgages or other housing debt. These rates represent a roughly 50% increase in the share of senior households holding debt over the last 25 years. The Financial Times reporter also notes that positive psychological effects of bankruptcy may explain why people go to the unnecessary trouble of discharging debt in court. An advisor quoted in the story suggests elderly people file for bankruptcy not because they need to but because creditors—who can’t garnish their Social Security checks or squeeze “blood from a turnip”—will simply stop harassing them. A Broken System Whatever the role that personal psychology plays in the rise of elder bankruptcy, it is clear that America’s evolving labor markets and crumbling retirement system play a central role. Many older workers in their 50s are faced with superannuation. Discarded from the labor market, they can’t find decent work and can’t afford to contribute to their 401(k)s. The do-it-yourself 401(k)-based retirement system requires a great deal of luck: 40 years of steady employment and steady contributions. Waldmeir, the Financial Times correspondent, did a great job in not blaming the victim. America has embarked on a 40-year economic experiment of do-it-yourself pensions, the breaking of unions, real wage stagnation, the common practice of discarding workers in their 50s, and cutting Social Security benefits by raising the retirement age. The effects of that experiment are now coming home to roost in bankruptcy courts across the nation and, more broadly, in the form of personal misery among aging boomers. Maybe now it is time for an American news outlet to investigate the financial health of British elders. The elder poverty rates in the U.S. and U.K. both exceed the OECD average of mostly rich and developed countries, and both have faced sharply rising bankruptcies among their older population. Nearly 21% of elderly Americans face poverty compared to nearly 14% in the U.K. Whatever is the cause of the crisis in elder finances, it isn’t limited to the U.S. |
AuthorJeff Sodoma, MPA, Esq. is a lawyer based in Virginia Beach, Virginia Blog!Hello, there! Welcome to my blog. I will use this blog as a platform for my writing. I will write about topics in the legal world, certainly, as well as everything else under the sun, because I have many interests (and viewpoints). All views expressed in this blog, unless otherwise noted, are mine alone. One of my interests is music--my wife believes that I should go on "Beat Shazam" because I know so many songs--and I will be, from time to time, analyzing song lyrics and how they relate to the legal world.
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