Tagged Nursing Homes

How To Find And Use New Federal Ratings For Rehab Services At Nursing Homes

For the first time, the federal government is shining a spotlight on the quality of rehabilitation care at nursing homes — services used by nearly 2 million older adults each year.

Medicare’s Nursing Home Compare website now includes a “star rating” (a composite measure of quality) for rehab services — skilled nursing care and physical, occupational or speech therapy for people recovering from a hospitalization. The site also breaks out 13 measures of the quality of rehab care, offering a more robust view of facilities’ performance.

Independent experts and industry representatives welcomed the changes, saying they could help seniors make better decisions about where to seek care after a hospital stay. This matters because high-quality care can help older adults regain the ability to live independently, while low-quality care can compromise seniors’ recovery.

“It’s a very positive move,” said David Grabowski, a professor of health care policy at Harvard Medical School. He noted that previous ratings haven’t distinguished between two groups in nursing homes with different characteristics and needs — temporary residents getting short-term rehabilitation and permanent residents too ill or frail to live independently.

Temporary residents are trying to regain the ability to care for themselves and return home as soon as possible, he noted. By contrast, permanent residents aren’t expecting improvements: Their goal is to maintain the best quality of life.

Three separate ratings for the quality of residents’ care now appear on the Nursing Home Compare website: one for overall quality (a composite measure); another one for “short-stay” patients (people who reside in facilities for 100 days or less, getting skilled nursing services and physical, occupational or speech therapy) and a third for “long-stay” patients (people who reside in facilities for more than 100 days).

Ratings for short-stay patients — available for 13,799 nursing homes — vary considerably, according to a Kaiser Health News analysis of data published by the government in late April. Nationally, 30% of nursing homes with a rating received five stars, the highest possible. Another 21% got a four-star rating, signifying above-average care. Twenty percent got three stars, an average performance. Seventeen percent got two stars, a worse-than-average score. And 13% got one star, a bottom-of-the-barrel score. (Altogether, 1,764 nursing homes did not receive ratings for short-stay patients.)

Here’s information about how to find and use the new Nursing Home Compare data, as well as insights from Kaiser Health News’ analysis:

Finding data about rehabilitation. Enter your geographic location on Nursing Home Compare’s home page, and a list of facilities will come up. You can select three at a time to review. Once you’ve done so, hit the “compare now” button at the top of the list. (To see more facilities, you’ll need to repeat the process.)

A new page will appear with several tabs. Click on the one marked “quality of resident care.” The three overall star ratings described above will appear for the facilities you’ve selected.

Below this information, two options are listed on the left side: “short-stay residents” and “long-stay residents.” Click on “short-stay residents.” Now you’ll see 13 measures with actual numbers included (most but not all of the time), as well as state and national averages.

Understanding the star rating. Six measures are used to calculate star ratings for the quality of rehab care for short-stay patients. Two of them concern emergency room visits and rehospitalizations, potential indicators of problematic care. Another two examine how well pain was controlled and bedsores were managed. One measure looks at how many patients became better able to move around on their own, an important element of recovery. Yet another examines the rate at which antipsychotic medications were newly prescribed. (These drugs can have significant side effects and are not recommended for older adults with dementia.)

One measure of great interest to seniors is the percentage of residents who return successfully home after a short nursing home stay. But actual numbers aren’t available on the Nursing Home Compare website this time around: Instead, facilities are listed as below average, average or above average. The national average, reported in April, was 48.6%, indicating room for improvement.

Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.

For instance, the nursing home at Westminster Village, a high-end continuing care retirement community in Scottsdale, Ariz., had the highest score for rehospitalizations — 39.9% — out of 68 facilities in and around Phoenix. (By contrast, the lowest score in the Phoenix area was 15.4% and the state average was 23.5%.) It also had the highest rate of helping residents improve their ability to move around on their own — 88.6%. (The lowest score was 37.6% and the state average was 63.6%.)

In an email, Lesley Midkiff, marketing director at Westminster Village, said that the facility’s staff is vigilant about sending residents back to the hospital if health issues arise. At the same time, she said, staffers “push the residents just enough to regain independence and recover quickly from their short term stays.” Both priorities have the “residents’ best interest” in mind, she said.

If a facility has an average or low quality score, Dr. David Gifford, a senior vice president at the American Health Care Association, a nursing home industry group, recommended that people look closely at various measures and try to figure out where the institution fell short. Call the facility and ask them to explain, he said. Also, review Nursing Home Compare’s information about staffing and health inspections, Gifford suggested, and visit the facility if possible.

Variations within nursing homes. The newly published Nursing Home Compare data also shows that institutions aren’t always equally adept at caring for short-stay and long-stay residents.

Disparities in facilities’ ratings for short- and long-stay patients are common. Of 13,351 nursing homes that received both ratings, 32% received the same star ratings for the quality of care received by short-stay and long-stay residents. Another 32% of facilities received higher star ratings for short-stay residents, while 36% got higher ratings for long-stay residents. About one-third of the time, these rating categories were one star apart, but in another third of cases, they varied by two or more stars — a significant discrepancy. (This analysis does not include 2,212 nursing homes for which data was missing.)

In Phoenix, Desert Terrace Healthcare Center, which bills itself on its website as the city’s “premier location for short-term rehabilitation and long-term care,” is one such facility. Its quality-of-care rating for short-term residents was two stars, while its rating for long-term residents was five stars. Notably, hospital admissions and ER visits for short-stay patients were higher than the state average, while the portion of short-stay residents whose mobility improved was lower than average.

In an email, Jeremy Bowen, the facility’s administrator, wrote that the facility had a good record of managing pain and bedsores and limiting antipsychotic prescriptions for short-stay patients. Factors such as hospital readmissions depend on community resources and patients’ understanding of their health needs, which are difficult to control, he noted.

Sierra Winds, part of a continuing care community in Peoria, Ariz., has a similar split in quality ratings (two stars for short-stay residents, five stars for long-stay residents). On four of six measures used to calculate star ratings for short-stay residents, it performed worse than the state average.

“Sierra Winds remains committed to providing the highest quality care and services to its residents,” wrote Shannon Brown, the facility’s executive director, in an email. “We are proud of our 4-star rating with CMS [the Centers for Medicare & Medicaid Services].”

That’s the facility’s overall rating (this includes data about staffing and health inspections). But it doesn’t address the split in scores for short-stay and long-stay patients, which raises a red flag and should certainly cause seniors and their families to ask follow-up questions.

“If I’m a patient looking for a place for a short-term rehab stay, I really want to know how patients who look like me did,” said Dr. Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a quality-measurement expert.

KHN senior correspondent Jordan Rau contributed to this report.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Readers And Tweeters Parse Ideas — From Snakebites To Senior Suicide

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


Could ‘Aid-In-Dying’ Stem Tide Of Senior Suicide?

Lethal Plans: When Seniors Turn To Suicide In Long-Term Care” (April 9), by Melissa Bailey and JoNel Aleccia, was a significant, interesting, thoughtful article with wonderful stories and solid information. However, the emphasis seems to be on the role of caregivers and various involved institutions to create “safer” environments to foster prevention of elder suicides through better assessment, better trained and more empathetic caregivers, and stronger monitoring and/or oversight.

To me, assessment is the vital piece of the puzzle. If the suicide drive is triggered by depression or other mental health issue, then treatment, well-trained personnel, monitoring, etc. are all on point, with the hope that the suicide ideation will subside as life improves.

However, if loving, thoughtful and professional interactions with the elder reveal that physical or emotional suffering has become unbearable subsequent to a serious, life-threatening illness, the issues involved are very different. They should now be addressed in a patient-centric manner in keeping with the underlying principle of self-determination.

In the article, these issues are only vaguely alluded to, as if medical aid-in-dying is an insubstantial fad or a “rare” policy exception. On the contrary, almost 20% of the U.S. population has legal access to aid-in-dying now that New Jersey’s new aid-in-dying law will take effect Aug. 1.

I wonder about the differences in elder suicide rates in Oregon and Washington, where medical aid-in-dying has been legal for decades. And I wonder if candid, loving discussions about advance care planning and sharing among loved ones about the value of longevity vs. quality of life, etc. are part of the solution. At least it would keep suicide survivors from unending questions, recriminations and flat-out guilt that may be undeserved.

So, my challenge to the incredibly capable and terrific authors is to try and tie these threads together and make the focus about informed decision-making, advance care planning, policies that maximize options (including medical aid-in-dying) and the inevitability of death for the elderly. We all die. Thanks for caring so much.

— Barak Wolff, NM End of Life Options Coalition, Santa Fe, N.M.


Elaborating on her tweet, reader Sharon Moon told KHN: “This is going to become more and more pressing as baby boomers age. I was in risk management in hospitals. In my view, hospitals err on the side of not reporting things. There is a huge culture of retaliation and seeking to sweep problems under the rug. … I can only imagine the way it is in nursing homes that are largely for-profit and without as many M.D.’s to speak out for patients.”

— Sharon Moon, Yardley Borough, Pa.


Is There A ‘Dr.’ In The House Style?

Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care” was an interesting and informative piece on a topic that deserves more public exposure. Thank you for writing it. But would it be possible for KHN to change its style and use the “Dr.” honorific when referring to psychologists? There are many people who describe themselves as psychologists without having a doctorate. And there are other mental health practitioners who are not psychologists at all — social workers and counselors, for example — who are frequently referred to in news accounts as “therapists,” just as a doctoral-level psychologist might be. You may not be aware that psychologists must complete seven years of education, plus post-doctoral work, and that practitioners must go through state licensing. The level of training is on par with doctors of dental surgery, M.D.’s, doctors of optometry, doctors of osteopathic medicine, doctors of podiatric medicine and doctors of veterinary medicine — all of whom are routinely accorded the “Dr.” honorific.

— Kim I. Mills, American Psychological Association, Washington, D.C.


I appreciated Melissa Bailey and JoNel Aleccia’s piece on long-term care suicide. But unclear why you refer to physicians as “Dr.” and not psychologists? Is that KHN editorial policy? Perpetuates stigma.

— Benjamin A. Bensadon, Ed.M., Ph.D., associate professor, University of Florida College of Medicine, Gainesville, Fla.

[Editor’s note: KHN follows Associated Press style for titles and honorifics. Its guideline on medical doctors — with our blanket apologies to Ph.D.’s — reads: “Use Dr. in first reference as a formal title before the name of an individual who holds a doctor of dental surgery, doctor of medicine, doctor of optometry, doctor of osteopathic medicine, doctor of podiatric medicine or doctor of veterinary medicine. … Do not use Dr. before the names of individuals who hold other types of doctoral degrees.”]


After Snakebite, Swift Action (And Taylor Swift) — But Skip Tourniquet

I am the director of The Rattlesnake Conservancy. We are thrilled that you are covering snakebites and educating people without fear-mongering (“Bill Of The Month: Summer Bummer: A Young Camper’s $142,938 Snakebite,” April 30). However, I am concerned that in the radio report on NPR your team mentioned the young lady used a tourniquet and did not mention how dangerous that can be. Many snakebite experts agree that using a tourniquet is dangerous, leading to potentially life-threatening consequences when the tourniquet is removed. Absent loss of life, it also leads to venom accumulation in the limb and significant tissue damage. The best course of action is immobilizing the affected limb and emergency care as soon as possible. No snakebite kits, tourniquets or other devices will help. The only effective treatment for snakebite is antivenom.

The Facebook group “National Snakebite Support” is a crucial tool for anyone who may have been envenomated. The group is staffed by the United States’ top venom specialists and snakebite medical doctors. Their team quickly responds to patients and will communicate with hospital staff on behalf of a patient as needed.

That being said, remember that venom has saved more lives than it has taken. Many medications, including several for blood pressure, arterial clotting and experimental medications, are developed from venomous snakes. For more information, check out our website.

— Anthony Daly-Crews, Buckeye, Ariz.


A hunter weighs in with advice on Twitter:

— Mark Frye, Ash, N.C.


Re: your 9-year-old girl snakebite story: Where was your question about why the girl was wearing open-toed sandals in the woods? Why do you not cover the personal responsibility angle: What did the girl learn? Will she be wearing more protective gear on her return visit this summer?

— Dick Crawford, Anaheim, Calif.


Nothing Like A Good Blood Boiling With My Morning Coffee

I just wanted to convey to the editors of KHN and NPR’s Shots that the “Bill of the Month” series is amazing and I appreciate your work. Normally something I read that gets my blood boiling this easily in the morning is not something I would seek out. However, I appreciate the intent of these articles to call out the ridiculousness of health care charges. What is even more infuriating is the majority of these articles seem to cover individuals who have some sort of health insurance. The reader can only infer what someone without any sort of health coverage would be dealing with!

— Mike Morse, Grand Junction, Colo.


Further Steps To Guard Against ‘Shameful’ Amputations

Thank you for drawing much-needed attention to disparities in unnecessary limb amputations for communities of color (“Diabetic Amputations A ‘Shameful Metric’ Of Inadequate Care,” May 1). While I applaud your article’s focus on diabetes, understanding related diseases like peripheral artery disease (PAD) is just as important.

As a limb salvage specialist in the Mississippi Delta, I know firsthand that African American patients with diabetes are over three times more likely to have their limbs surgically removed — with even higher rates in Mississippi. Sadly, a majority of the estimated 200,000 annual non-traumatic amputations —many stemming from PAD, a complication of diabetes –– can be avoided with the proper care.

Tragically, even though PAD is as serious as cancer, more than 90% of the amputees I have met have never had a diagnostic test for PAD or an appropriate vascular evaluation to salvage their limbs. Most have never even heard of PAD until it is too late.

To stop these troubling trends in my community, I created a team to aggressively screen, diagnose and treat each one of our 10,000 patients early and often. With no institutional or outside financial support, our practice was able to decrease PAD-related amputation rates in the region by 87.5%.

More must be done on the federal level to address America’s “amputation lottery.” The United States Preventive Services Task Force (USPSTF), for example, should change its recommendation for screening at-risk patients including racial and ethnic minorities and low socioeconomic populations who have a disproportionately higher prevalence of PAD and amputation rates. The current recommendation makes the USPSTF complicit in perpetuating current PAD-related amputation disparities in treatment and outcomes.

There also needs to be broad adoption of non-amputation treatment measures such as revascularization in all algorithms for wounds to heal properly before amputation is ever needed. Finally, policymakers should advance a comprehensive strategy that combines increased public awareness, robust screening and better access to multidisciplinary care for at-risk populations. Together, these steps could go far in reducing limb loss, especially among minority communities.

— Dr. Foluso Fakorede, co-chair of the PAD Initiative for the Association of Black Cardiologists and CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Miss.


— Jazzmin Williams, San Francisco


I am 69, Caucasian and was diagnosed with Type 1 diabetes 57 years ago. Both of my legs were amputated above the knee in 2014. My overall health has deteriorated since about 2000: heart disease, heart attack, quad bypass, pacemaker, peripheral circulatory disease. Eyes and kidneys are good.

Types 1 and 2 are vastly different, and while the ultimate goal is the same — normalizing blood sugar — Type 1 must be totally controlled with food, injections and exercise. A change in any one changes the others, often drastically. I am a retired engineer and know how to control my diabetes well, but life is tough. I cannot leave home without wheelchair-access transportation. I eat one meal a day, a casserole of sorts of beaten eggs, green beans and a small can of chicken breast. Every day.

My injection sites are badly worn, from 20 years of porcine insulin, and I must choose sites I formerly avoided, to get consistent uptake. One must roll the dice with every injection, particularly the fast insulins. Knowledge and extreme discipline are the keys to longevity.

— Mike Kemp, McComb, Miss.


— Keirsten Brager, Houston


Models Of Superbug Warfare

Reading “How To Fight ‘Scary’ Superbugs? Cooperation — And A Special Soap” (April 12), I wondered: What about other nations? How are they dealing with MRSA and the like? I’ve read that northern European nations and the Department of Veterans Affairs have made excellent progress in decreasing MRSA, or methicillin-resistant Staphylococcus aureus, infections and death rates by screening, isolation and disinfection, while most U.S. health care facilities have not. What is it that other nations (and the VA) are doing to exercise control? Seems they’ve been a lot less freehanded with handing out antibiotics and using antibiotics in low doses in stock animals (chickens, steers in feedlots, etc.). Let’s hear how the rest of the world’s health care systems are dealing with the problem — the U.S. might learn something. Just as we’d do well to adopt a system for providing health care from at least one of 10 other nations, who get better results with less expenditure/capital than the U.S. does.

— Susan Hogg, Newport, Ore.


— Gary Lindsay, Bellingham, Wash.


Crossing Paths: A Baby and His Grandfather

Photo

Credit Josephine Sittenfeld and Thad Russell

In a photo essay, Thad Russell and Josephine Sittenfeld chronicle the end of life of a beloved father and the beginning of life of their new baby.

Nov. 20 – Thad

I’ve left my very pregnant wife, Jo, and our little daughter, Polly, to drive up to northern Vermont to retrieve my 86-year-old father and bring him back to Providence.

But when I get there, Dad is hunched over in his chair in the living room. He looks thin and tired, unshaven, confused, cold, short of breath.

In a weak voice he says that his lungs aren’t working and he can’t get enough air. With his arm hanging limply over my shoulder I move him toward his bedroom. I take off his shoes and glasses, turn off his light, and kiss him goodnight. I go to bed shaken to the core.

Dad grew up on a farm, played football in high school, went to M.I.T. to study engineering and architecture, and had a long career designing and building houses.

He became an expert skier back in the 1950s when downhill skiing was rebellious and dangerous.

And now, maybe for the first time ever, he doesn’t want to get out of bed.

I call my friend Bill, an emergency room doctor. He tells me quietly and firmly, “Call 911 and get him to a hospital ASAP. Don’t think about it. Just do it.”

This is the last time my father will ever see his land or be in his own house or sleep in his own bed. In fact, it is the last time he will sleep in any bed that isn’t in a hospital or nursing home. It’s the last time he will live without the assistance of a walker or a wheelchair, a professional caregiver or an adult diaper.

At the hospital, Dad’s cardiologist puts it bluntly. “Your father needs a new heart, and he’s not going to get one. I’ve used up my bag of tricks. Have you thought about hospice?”

Photo

Credit Josephine Sittenfeld and Thad Russell

Jo

That tiny, rapidly fluttering shape amid the gray static — even though I’ve been through ultrasounds before with my first child, the evidence of the life inside me is still awe-inspiring. I feel excited and tearful.

Nov. 28 – Thad

Dad’s vital signs are bad. He has trouble breathing and now needs oxygen full-time. It’s Thanksgiving morning, and Dad is taken by ambulance from the nursing home to the Miriam Hospital. I meet him in the emergency room, abandoning Jo to cook her first turkey and prepare for a house full of in-laws. The emergency room staff does a battery of tests and confirms what we already know: Dad is suffering from late-stage heart failure.

But after a few hours, he’s released, and I bring him home for Thanksgiving dinner.

Dec. 25 – Thad

Amazingly, Dad is able to be at our house on Christmas Day. He doesn’t believe in Santa Claus, or even Jesus for that matter. But he does like a good turkey dinner.

Photo

Credit Josephine Sittenfeld and Thad Russell

Jan. 9 – Jo

I wake up at exactly midnight with contractions. Around 6 a.m. the contractions get closer together. Polly wakes up and thinks it’s funny that I’m mooing like a cow. Thad and I take Polly to a neighbor’s house and head to the hospital.

I have another killer contraction in the lobby. I’m on all fours on the floor, moaning. People are staring.

Once we finally get to the room, I get into the tub. It feels good to be in the water, but the contractions are painful and intense — after the tub I’m on a ball, then on the bed, then standing, then on the toilet, then back on the bed.

Thad is on the phone in the next room trying to coordinate a urology appointment for his dad when all of a sudden things intensify. The baby’s head starts crowning, and it burns like hell. The nurse runs out to get Thad. And with a few more pushes our baby is out.

When they hand him to me, he’s big and grayish, but pretty quickly turns pink.

It’s intense and beautiful and crazy and amazing.

Baby Curtis lies on my chest, still connected through the umbilical cord, and Thad and I just take him in.

Photo

Credit Josephine Sittenfeld and Thad Russell

Jan. 13 – Thad

Dad is excited to meet his first grandson  —  and a little confused. He keeps calling him Matt, and asks when we have to give him back.

Photo

Credit Josephine Sittenfeld and Thad Russell

Jan. 24 – Thad

A nurse calls to tell me that Dad has fallen. I meet him in the E.R., again. He looks pretty beat up and has a big gash on the top of his head.

The test results worry the doctors.

And yet he survives  —  for days, then weeks, then months.

I visit Dad as often as I can and for as long as I can. I pick him up and we go on little field trips: to doctors’ appointments, to get new eyeglasses, to get his hearing aids cleaned, or to our house for dinner.

Photo

Credit Josephine Sittenfeld and Thad Russell

Occasionally, I find Dad asleep in his room, his face lit by the light of CNN Headline News. Some nights I stay with him for quite a while, rubbing his feet, watching him breathe and wondering what he is dreaming about.

I feel conflicted  —  it’s not that I want Dad to die, but I sometimes wonder if this is the way he ever wanted to live.

Dad can’t walk, get dressed or complete most basic daily routines without assistance, but his spirits are good.

In July, Dad has a bad fall, spends another week in the hospital. I call my siblings and tell them it’s time. We’re going to start hospice.

Photo

Credit Josephine Sittenfeld and Thad Russell

Aug. 8 – Jo and Thad

Dear Family & Friends –

We are sad to report that Sam died Friday evening. He was 87 years old.

For the past year, Dad continually impressed us with his dignity, toughness and overriding will to live. He  —  and we  —  were rewarded with some distinctly good days that we will never forget.

But last week, he and his heart decided it was time. He retired early one evening, declaring that his bed felt “wonderful,” and started his long sleep.

In the end, he passed quietly and gracefully, surrounded by his family (including his bouncy and bubbly baby grandson Curtis, who played happily at the foot of his bed), and a wonderfully compassionate team of rotating attendants and nurses.

Ever the solar animal, he waited until just after sunset to pass.

With love and thanks,

Thad & Jo

Photo

Credit Josephine Sittenfeld and Thad Russell


Thad Russell and Josephine Sittenfeld are photographers who live in Providence, R.I., and teach at the Rhode Island School of Design. More of their work can be found at thadrussell.com and josittenfeld.com.

Finding Ways to Keep Patients at Home

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Credit Getty Images

My patient was a proudly elegant woman in her 70s who lived alone. Her Parkinson’s disease had so severely restricted her ability to move that it would take her hours to get dressed in the morning. And leaving the house was virtually impossible, so she had to rely on neighbors and friends from her church community for help with shopping.

She was adamant that she wouldn’t want aggressive treatment to keep her alive. She’d been hospitalized many times, and she told me she wouldn’t want to take a hospital bed that would be better used for someone else. So she dutifully completed an advance directive that made her wishes clear. It said that she would not want to be kept alive on a breathing machine, and that she wouldn’t want cardiopulmonary resuscitation if her heart stopped. She also wouldn’t want to be fed through a tube if she was no longer able to eat. What was most important to her, though, was staying at home and avoiding a nursing home.

As a palliative care physician, I always urge my patients to complete advance directives. These are legal documents that tell doctors and family members what treatment they do and don’t want if they’re ever unable to make decisions for themselves. That’s important, because if I don’t know what my patients want, the default is to do everything to keep them alive, which typically results in unnecessary and costly treatment. Indeed, one of the most often-cited arguments for advance directives is the fact that 25 percent of Medicare spending is for people in the last year of life.

When my patient developed a cough and a fever, likely a result of pneumonia, she became too confused to make decisions for herself. Thanks to her advance directive, her family knew that she didn’t want aggressive treatment, and we knew that she wanted to stay home. So we arranged for short-term daily nursing visits and enough support so that, with additional help from her family, she was able to remain at home as she wanted.

I thought that she would get worse without aggressive treatment in the hospital, and that we would enroll her in hospice, so I was surprised when she began to improve. Soon she was able to make decisions for herself and even returned to the same level of independence that she’d had before she became sick. That’s when it became obvious to me that advance directives have their limits.

My patient lived, as many people with chronic, serious illnesses do, on a thin ledge of independence. The smallest nudge — a few missed medication doses, the loss of just a little support — left her entirely vulnerable. In my patient’s case, that nudge came two months later, when her neighbors ran into financial problems and their daughter, who had been doing the grocery shopping for my patient, had to take an after-school job. My patient valued her independence more than anything, so whenever her neighbors and her out-of-state family checked on her, or when we called her, she told us all that she was fine.

For three weeks, my patient subsisted on nothing but white rice, because that was all she had in the house. When her grand niece called us and asked us to check on her, we sent a social worker and a nurse to visit her. We found her housebound, surrounded by garbage, with no clean laundry and no toilet paper.

Despite our best efforts, we couldn’t do enough to keep her safe at home, so she went to live in a nursing home, where she spent the last two months of her life. An advance directive had helped her stay out of the hospital, as she had wanted. And perhaps it even made a bed available for someone who needed it more, as she’d hoped. But that piece of paper didn’t help her to live out her final months with the sort of comfort and dignity that she deserved.

When we talk about advance directives and reducing costly and unnecessary treatment at the end of life, we should also be talking about ways we can provide more support. We need to make sure that people like my patient have access to the kinds of care that can help them remain safely and comfortably at home.

Now when I help my patients complete an advance directive that defines the treatment they don’t want, we also discuss what support they’ll need in the future. I talk with my patients and their families about what’s going to be necessary to keep them safe and comfortable in their homes today, and next month and — if they’re lucky — for the next few years.

Those sorts of discussions are essential, but they’re not enough. We also need to revise the way we think about advance directives. Advance directives help reduce health care costs at the end of life by avoiding aggressive treatment, but that’s not the most compelling argument for them. It’s not enough to reduce what we spend on aggressive treatment at the end of life; we also need to spend those resources in better ways.

For someone around my patient’s age, the average cost of a hospitalization is about $13,000. So Medicare should have been willing to spend $13,000 to keep her safe and comfortable at home. That sum would have been more than enough to pay for a visiting nurse to continue to check on her after she recovered from pneumonia and a home health aide to help her with bathing and dressing. And it could have paid the girl next door to do her grocery shopping so a frail elderly woman didn’t need to subsist on white rice because it was the only food she had.

We should have been able to provide all of that help. My patient was adamant that she didn’t want to spend her last days of life in a hospital, taking up a bed that someone else could use. Let’s make sure that when people like her forgo costly treatment at the end of life, they get something in return.

Dr. David Casarett is a professor at the University of Pennsylvania Perelman School of Medicine and the author of “Stoned: A Doctor’s Case for Medical Marijuana.”

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Using the Arts to Promote Healthy Aging

Photo

Credit Paul Rogers

Throughout the country, the arts are pumping new life into the bodies and minds of the elderly.

Two summers ago, a remarkable documentary called “Alive Inside” showed how much music can do for the most vulnerable older Americans, especially those whose memories and personalities are dimmed by dementia.

The film opens with a 90-year-old African-American woman living in a nursing home being asked about her life growing up in the South. All she could say in response to specific questions was, “I’m sorry, I don’t remember.”

But once she was fitted with an iPod that played the music she had enjoyed in her youth, her smile grew wide and her eyes sparkled as vivid memories flooded her consciousness. She was now able to describe in detail the music and dances she had relished with her young friends.

At another nursing home, a man named George with advanced dementia refused to speak or even raise his head when asked his name. He too was outfitted with an iPod, and suddenly George came back to life, talking freely, wiggling to the music in his wheelchair and singing along with the songs he once loved.

The Music and Memory project that provided the iPods was the inspiration of a volunteer music lover named Dan Cohen, and has since spread to many nursing homes and facilities for the aged around the country. Alas, not nearly enough of them. Medicaid, which fully covers the cost of potent drugs that can turn old people into virtual zombies, has no policy that would pay for far less expensive music players. So the vast majority of nursing home residents who might benefit are deprived of this joyous experience.

Nonetheless, across the country, the arts in their myriad forms are enhancing the lives and health of older people — and not just those with dementia— helping to keep many men and women out of nursing homes and living independently. With grants from organizations like the National Endowment for the Arts and the National Institute on Aging, incredibly dedicated individuals with backgrounds in the arts have established programs that utilize activities as diverse as music, dance, painting, quilting, singing, poetry writing and storytelling to add meaning, joy and a vibrant sense of well-being to the lives of older people.

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Walter Hurlburt, 90, decorates rooms at the Burbank Senior Artists Colony, a retirement facility where he lives.

Walter Hurlburt, 90, decorates rooms at the Burbank Senior Artists Colony, a retirement facility where he lives.Credit

Through a program called EngAGE in Southern California, 90-year-old Walter Hurlburt, who once made a living as a sign painter, now decorates rooms at the Burbank Senior Artists Colony, a retirement facility where he lives, with lovely oil paintings he creates from pictures he finds in magazines and books. Mr. Hurlburt regularly attends classes on various art forms at the residence where, he told me, “I’m always learning something new.”

His buddy at the residence, Sally Connors, an 82-year-old former schoolteacher, surprised herself by writing and directing a screenplay that was performed by fellow residents. Then, with Dolly Brittan, 79, a former early childhood educator, they both surprised themselves by writing their life stories in rap and performing their rap memoirs on a stage for at-risk teenagers they were mentoring.

Both she and Ms. Connors said their newfound involvement with the arts has made them feel decades younger.

Tim Carpenter, the executive director of EngAGE, is now working to expand this approach to senior living in other cities, including Minneapolis, Portland, Ore., and Raleigh, N.C. His goal is to create a nationwide network of programs for seniors that keep them healthy, happy and active through lifelong learning in every conceivable art form, enabling them to live independently as long as possible.

As in Burbank, Mr. Carpenter is promoting the development of arts colonies in senior residences where residents can study and create art in all its forms and where they can see their artistic creations come to life on a stage.

Dr. Gene D. Cohen, a gerontologist at George Washington University who died in 2009, was a staunch advocate for the mental and physical benefits of creativity for the elderly. He directed the Creativity and Aging Study, a controlled study sponsored by the National Endowment for the Arts at three sites, including Elders Share the Arts in Brooklyn, N.Y., that showed after only a year that the health of elders in the cultural groups stabilized or improved in contrast to a decline among those in the control groups.

In a film called “Do Not Go Gently,” Dr. Cohen, who founded the Creativity Discovery Corps, featured an architect who, at age 96, submitted a plan for redeveloping the World Trade Center site. Dr. Cohen pointed out that creativity challenges the mind and results in the formation of new dendrites, the brain’s communication channels.

At 26 different facilities in the Washington, D.C., area, 15 teaching artists work with seniors in centers where they live or visit regularly. Janine Tursini, director of Arts for the Aging in Rockville, Md., seeks to “get at what best jazzes up older adults.” Groups of about 20 older adults get involved in what she calls “art making” — music, dance, painting or storytelling.

Ms. Tursini said the N.E.A.-sponsored study showed that when older people become involved in culturally enriching programs, they experience a decline in depression, are less likely to fall and pay fewer visits to the doctor. In another study among people with Alzheimer’s disease, a sculpting program improved the participants’ mood and decreased their agitation even after the program ended.

“The arts open people up, giving them new vehicles for self-expression, a chance to tell their stories,” Ms. Tursini said. “The programs capitalize on assets that remain, not on what’s been lost.”

Naomi Goldberg Haas created the Dances for a Variable Population program to get older adults dancing. People who haven’t moved in years, even those who can no longer stand, can participate. Young professionals and older dancers go to various sites — libraries, churches, senior centers — where elders gather and encourage them to “move more.”

“Movement enriches the quality of their lives,” Ms. Haas said. “It’s absolutely healing. Balance, mobility, strength — everything improves.”

Social engagement, which nearly all these programs provide, has been repeatedly found in major population studies to prolong life and enhance healthy aging. Clinically, the programs have been linked to lowered blood pressure, reduced levels of stress hormones, and increased levels of the “happiness hormones” that are responsible for a runner’s high.

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