Reform Proposal #4

Hospice care is a specialized form of care given to terminally ill patients at the end stage of their life (National Cancer Institute, 2011). This care is designed to focus on comfort rather than cure. The goal of the care is to adequately attend to the patient’s physical pain and mental suffering. In order to better relieve their suffering, pain medication is often used. However, ethical issues behind the use of pain medications in both hospice and palliative care have been globally debated. According to Douglas, Kerridge, and Ankeny (2008) a major issue that persists is, “the fear that the use of analgesic or sedative medications will hasten death” (p. 166). This may include the overdose of patients, especially in the mentally or terminally ill patients, who cannot express the severity of their pain.

The exact administration of analgesics and sedatives that are given to relieve the suffering of terminally ill patients are often times hard to determine because these drugs have a “double effect” (LaDuke, 2006). This is when the medications that are meant to ease and relieve terminal pain cause deterioration of the vitals, speeding up the end of life. According to LaDuke (2006), “studies have found that many physicians have trouble on a moral level distinguishing between administering medications that might hasten death to giving drugs that hasten death” (P. 165). If unskilled, unlicensed, and uneducated providers are hired in long-term care facilities to distribute pain medications to hospice patients, not knowing the side effects or even the effects of the medication itself, they could end up hastening a patients death.

Over the years, long-term care and end-of-life care has become very expensive. In order to accommodate to the increase in price, facilities have found ways around state restrictions and regulations. In doing so, many facilities have hired unskilled men and women. These care providers don’t know the first thing about the medications they administer or the side effects and symptoms of the drugs. They also don’t know how to accurately assess pain. By hiring unprofessional and unskilled workers to care for our elder generation, in order to decrease expenses, has overall decreased the quality of long-term health care.

In order to improve the quality of long-term health care, I propose that the federal government passes a bill that increases the hours of training for all workers, especially those who provide care to terminally ill patients, before the administration of drugs and the assessment of pain. I believe that before any nurse, doctor, or other health care professional administers medication they should be properly educated about pain management and hospice care. They should also be properly educated on the different kinds of medication that are administered, and there side effects and symptoms. The increase in education and training will increase the quality of care. In addition, it will lower the cost spent on sending patients out of the facility and to hospitals because of medication overdoses or horrible side effects that unskilled workers are not catching (P. Beilfuss, personal communication, March 20, 2011). It will also increase the access for any terminally ill patient to receive picture-perfect care.

Anyone who needs long-term care or end-of-life care should feel confident that those who provide it have the required knowledge, training, and skills. I also propose that all states regulate all long-term care facilities in order to have appropriate oversight and leadership. These elderly men and women deserve to be able to easily access good quality end-of-life care. The Wisconsin Board on Aging and Long Term Care believe that long term care consumers have the right to be treated with respect and dignity (Board on Aging and Long Term Care). In addition according to Horazdovsky (2009), “these individuals have lived productive lives, defended our country, and raised today’s leaders. Yet they are, at worst, threatened to be left behind or forgotten.”

-Written By Amber Wesela

Resources

Board on Aging and Long Term Care. Advocating for Residents Rights. Retrieved from http://longtermcare.wi.gov/subcategory.asp?linksubcatid=3001&linkcatid=1953&linkid=1014&locid=123

DOUGLAS, C., KERRIDGE, I., & ANKENY, R. (2008). MANAGING INTENTIONS: THE END-OF-LIFE ADMINISTRATION OF ANALGESICS AND SEDATIVES, AND THE POSSIBILITY OF SLOW EUTHANASIA. Bioethics, 22(7), 388-396. doi:10.1111/j.1467-8519.2008.00661.x

Horazdovsky, D. J. (2009, June 23). Long-Term Care is Vital Aspect of Health Care Reform. Retrieved from http://www.rollcall.com/news/-36168-1.html.

LaDuke, S., 2006. Attending Death with Dignity. In F. Mullan & E. Ficklen (Eds.), Narrative Matters (pp. 161-167). Baltimore, Md: The Johns Hopkins University Press.

National Cancer Institute. (2011). Hospice Care. Retrieved from http://www.nlm.nih.gov/medlineplus/hospicecare.html.

Reform Proposal 3

According to the Wisconsin Board on Aging and Long Term Care, long term care consumers have the right to be…

…fully informed of their rights, services available and all charges prior to admission to a facility or enrollment into a program.

…given advance notice of transfer, discharge, disenrollment, termination, or charges in services (1).

Case management can be defined as “the process of matching client needs with available services that are likely to best address those needs” (4). I believe the rights outlined above affirm the importance of “case management.” The purpose of case management is to assess the special needs of older adults, to prepare a care plan to address those needs, to specify services that are most appropriate, to determine eligibility for services, to make referrals and coordinate delivery of care, to arrange for financing, to ensure that clients are receiving services, and reevaluate needs as circumstances change over time (4).

I propose that hospitals be more active in their patient’s care beyond the hospital setting into the long term care location. They should make a commitment to their patient in seeing them through all their care even after discharge to a long term care facility. Under this approach, hospital-based case managers would identify clients, assess their needs, develop care plans, coordinate service delivery, and monitor results (2). This kind of care would be an extension of the hospitals services since the care is given after the patient has been discharged.

Policy makers have been urging hospitals to be more active in their patients care beyond the hospital walls. This is because the hospitals have been failing to meet the post discharge needs of their elderly patients with chronic health problems (2).

The federal government should act on this and make an attempt to have case management a regular part of the care of the hospital to ensure continuity of service. A case manager should be assigned to the patient and assess the care from acute care to the long term care facility (5). A case manager could be a nurse or social worker hired to see through their case from start to finish. For this to work, the hospital should run the case manager program in whatever way they see fit as long as they follow the guidelines from the government. The social worker or nurse would be assigned to each patient based on need. They will be able to monitor and coordinate the services more closely than an independent case manager (4).

The ultimate goal of case management is to bridge the gap between the acute care received at the hospital and the long term care (2). Case management assists in decreasing nursing home care through increased supportive services (3). If case management is available to the patient, it is found to be extremely beneficial in preventing unnecessary costs on the patient and their family. With this new policy, readmission of Medicare patients to the hospitals could be reduced and that would improve hospital profit margins. Since the quality of care would increase with case management, more patients might be attracted to this specific hospital and profits would increase. The care provided would be more appealing than competing hospitals without that service.

Case management protects the patient by allowing them to receive the care they need through a needs assessment by the case manager. The quality of care for others in the facility increases since these specialists are more readily available for patients who actually need them.

Since long-term care services, eligibility requirements, and financing can be overwhelming for the patient and the family it is important for case management to be there to support these issues. Many patients or older individuals live far from their children, so these services are comforting to the family as a whole (4). The patient will have increased access to the care they need because they will be receiving a direct assessment of their needs from their case manager.

A potential problem to this case management is that the patients might not find it necessary to spend the time with their case manager. The problem might arise with cooperation from the patient. The multiple consultations and time commitment with case managers could be a burden.

The funding for the case managers could be an issue. Depending on the type of patients referred to the case manager, the cost could come from within the hospital or vary based on insurance coverage.

1. Board on aging and long term care (n.d.). History. Retrieved February 16, 2011, from http://longtermcare.wi.gov/subcategory.asp?linksubcatid=3001&linkcatid=1953&linkid=1014&locid=123

2. Christianson, J., Warrick, L, Netting, F., Williams, F., Read, W. et al. Hospital case management: bridging acute and long-term care Health Affairs, 10, no.2 (1991):173-184

3. Cress, Cathy. (2007). Handbook of geriatric care management. Jones & Bartlett Publishers: Sudbury, MA.

4. Shi, L., & Singh, D. A. (2008). Delivering health care in America: A systems approach (4thed.). Boston: Jones and Bartlett.

5. Wilson, Margaret. (2011). Case management in long-term care: challenges, changes, and opportunities. The CBS Interactive Business Network. Retrieved March 2011, from http://findarticles.com/p/articles/mi_m0FSS/is_n1_v6/ai_n18607261/?tag=content;col1.

Reform Proposal 2

Long-term care is a variety of services including medical and non-medical care to people who have a chronic illness or disability (2). Long-term care assists patients to meet health or personal needs, primarily providing assistance with Activities of Daily Living (ADL’s) such as dressing, bathing, using the bathroom, and eating. Although long-term care may be needed at any age, it is especially prevalent among older adults. By 2020, 12 million older Americans will need long-term care (1).

Many people believe they can rely on Medicare to cover the costs of long-term care services that may be needed in the future. What people don’t know is that Medicare and private health insurance programs do not pay for the majority of long-term care services that most people need. In general, Medicare pays for about 20 percent of long-term care and will provide coverage only under specific circumstances. The majority of long-term care is covered by Medicaid. Eligibility for Medicaid and the services that are covered vary from state to state. Eligibility for long-term care coverage by Medicaid is primarily based upon the individual’s income level and personal resources. People with financial means do not qualify for Medicaid until they deplete those resources (1).

Purchasing long-term care insurance is another option for individuals. Long-term care insurance covers the costs of long-term care services including home assistance with Activities of Daily Living and care in a variety of facility and community settings (1). Long-term care insurance policies are very flexible, allowing the individual to choose from a range of care options and benefits. The cost of this insurance depends upon the type and amount of services chosen for coverage, age of the individual when they purchased insurance and any additional benefits they included in their plan.

Only 5 percent of Americans currently have private long-term care insurance (3). Most people are either unaware of this option or chose not to purchase long-term care insurance because they rather wait until Medicaid will cover their costs. In order for Medicaid to cover long-term care costs the patient first must deplete their own financial resources. If the patient has sufficient resources, Medicaid may never cover the costs, leaving the patient with extremely high expenses.

I propose that the federal government enact a bill in which long-term care insurance is offered by medical insurance plans. When individuals sit down to select a medical insurance plan, they should be provided with information regarding long-term care insurance. Long-term care insurance should be introduced as an option for all individuals. “A study by the U.S. Department of Health and Human Services says that people who reach age 65 will likely have a 40 percent chance of entering a nursing home” (2). Introducing long-term care insurance allows individuals to analyze their options and decide what would best suit them. It also provides them the opportunity to pay for long-term care over a period of time.

Purchasing long-term care insurance would initially raise individual costs by raising individual premiums. The individual would be required to pay pre-determined premiums. Payment of these premiums would allow the patient to access long-term care when they need it. Purchasing long-term care insurance at an early age insures the individual will receive care when needed later on in life, instead of being burdened with an extremely high cost after a catastrophe occurs. The cost of long-term care premiums can be reduced, if long-term care insurance is purchased early in life.

Although long-term care insurance would increase individual costs, it would reduce Medicare and Medicaid costs because government insurance companies would not be required to cover all long-term care costs. Legislation proposed by the late Ted Kennedy predicted that shifting long-term care costs from Medicaid to the individual would generate over 70 billion dollars in savings over a ten year period (3). As the number of individuals purchasing long-term care increases, the risk would be spread out among more individuals. This would lower the cost of individual premiums, thus making purchasing the insurance more affordable. As individuals become aware of the increasing likelihood of needing long- term care and the threat of only receiving services at the cost of their life’s savings, the value of long-term care insurance will be realized.

References

1. "Costs of Care." National Clearinghouse for Long Term Care. U.S. Department of Health and Human Services, 5 Dec. 2010. Web. 09 Mar. 2011. .

2. "Long-Term Care." Medicare.gov. 25 Mar. 2009. Web. 9 Mar. 2011.
.

3. Pickert, Kate. "Should Long-Term-Care Insurance Be Part of Health Reform?" TIME. Time
Inc., 8 Dec. 2009. Web. 13 Mar. 2011.
.

4. Shi, L., & Singh, D. A. (2008). Delivering health care in America: A systems approach
(4thed.). Boston: Jones and Bartlett.

5. Smith, MD, Michael W. "Medicare and Long-Term Care." WebMD. WebMD, LLC, 16 Aug.
2009. Web. 09 Mar. 2011. .