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

2. Why is this an Issue Now? 10,000 new Medicare beneficiaries daily Then
Average life expectancy – 47.0 (1900)
Average life expectancy—78.2
Families close together
Families dispersed
Women as stay-at-home caregivers
Women in the workforce
Short period of illness and infirmity, then death
Old age and frailty, in need of almost constant care for months/years
In need of a hot meal and loving attention
In need of catheter care, oxygen, tube feeding, many medications, etc.
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: generation

4. Talk, Talk, Talk Issues: Guiding principles:
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

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
House Calls
1997
2012
Follow-up
$59.37
$131.38
New
$101.62
$188.35
Assisted Living
2005
2012
Follow-up
$48.30
$137.38
New
$75.00
$191.51

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
Medicare Spending
% of Total
Mean
Top Quartile
85%
$24,800
Second Quartile
11%
$3,290
Bottom Half 4%
$550
Total
100%
$7,310
Medicare Spending
% of Total
Mean
Top 5%
43.1%
$63,030
Top 6-10%
18.4%
$26,900
Top 11-25%
23.5%
$11,430
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
$103,502,088
Before HBPC
During HBPC
Change
Total Cost of VA Care
$38,168
$29,036*
-$9,123
Hospital
$18,868
$7,026
-63%
Nursing Home
$10,382
$1,382
-87%
Outpatient
$6,490
$7,140
+10%
All home care
$2,488
$13,588*
+460%
* 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 ●