Caregiver Series 4 Supplements 6 Friendship Line 8 Free Guides 8
Gray Matters A quarterly publication of Area 1 Agency on Aging
Hospital Admission: Inpatient or Observation? The Answer Could Mean Thousands of $$$$
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t’s been almost four years since his father died in a Eureka skilled nursing facility, but Mark Gatzke is still angry over a Medicare billing technicality that haunted his parents for his father’s final weeks, his mother for more than a year, and countless beneficiaries since then. The technicality has to do with whether a hospital patient is admitted as an inpatient or for observation. If admission is for observation, Medicare does not cover costs for a necessary following stay in a skilled nursing facility and only pays the hospital under Part B coverage. That meant McKinleyville’s Shirley Gatzke was looking at more than $30,000 in unexpected medical bills while her husband of 60 years spent the last weeks of his life in a hospital and nursing home. “He made jokes about it even dur-
ing the end, saying, ‘The best thing I can do is die,’” Mark Gatzke said by phone from his New Jersey home. “If it had gone on any longer, Mom would have lost her house and everything. As my Dad slowly died, they fought her over every penny.” “They” are Medicare, Mad River Community Hospital and Granada Healthcare and Rehabilitation Center, but none of the three deserve villain status in a story that involves misaligned payment incentives and unintended consequences. Even Mark Gatzke says he understands the multiple sides, but it’s hard not to want to label someone as the bad guy as his mother stressed about thousands of dollars in health care bills while watching her husband of 60 years slip away. Russell Gatzke died on Oct. 4, 2010 after a fall brought the Medi-
care-covered couple into Mad River Community Hospital for an Aug. 19-25 stay. “He had a private room. They were running tests,” Shirley Gatzke said last month. “Then they said he couldn’t come home, that he should go to Granada. They transported him by ambulance.” Shirley Gatzke believed the stay in the hospital and referral to a Medicare-covered skilled nursing facility meant Medicare would cover the costs for Granada. But according to a Sept. 8, 2010 notice signed by a Mad River representative, the hospital was “unable to find data that matched with Medicare’s guidelines for inpatient status.” Russell Gatzke stayed a week in the hospital for observation, not as an inpatient. It wasn’t until mid-September that Shirley Gatzke learned the nursing home bills were hers to pay as the administrator checked the box that said her husband did not meet the three-day inpatient stay mandated by Medicare for coverage. The Gatzke experience has been repeated by so many Medicare ben-
SUMMER 2014 eficiaries across the country that the Access to Medicare Coverage Act of 2011 was introduced, but is still winding its way through the legislative process, now as H.R. 1179/S. 569, the Improving Access to Medicare Coverage Act of 2013. The act seeks to count observation stays toward the three-day mandatory inpatient stay for Medicare coverage of skilled nursing facility services. “Over the last for years, I’ve had maybe one or two calls about this,” said Suzi Hendry, volunteer coordinator for the Health Insurance Counseling & Advocacy Program. “The last three months, I’ve had five phone calls about it. The floodgates have opened.” “It’s happening everywhere,” HICAP Program Manager Nancy Cloward said. “One of the big drivers is that hospitals are being dinged if they have too many readmissions. If patients are never admitted as an inpatient, they can’t get dinged.” A May 20, 2014 hearing on “Current Hospital Issues in the Medicare Program” was the first Congressional hearing to consider the impact of
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observation status on hospitalized Medicare patients. Testimony at the hearing included an example of a woman denied skilled nursing coverage after a 13-day hospitalization and a 90-year-old man denied coverage after his leg hematoma exploded, requiring emergency surgery and a four-day stay. In addition to avoiding readmission penalties, testimony at the hearing also said the drivers for observation status were an unintended consequence of a 2013 Medicare rule change around short stays, and the hospital’s desire for protection from denial of payment and audit by Medicare’s recovery audit contractors. Recovery auditors share a percentage of the savings achieved when they successfully challenge a hospital’s inpatient admission decision. “Hospitals are not doing anything wrong. Hospitals are simply responding to the incentives,” House Ways and Means Health Subcommittee Chairman Kevin Brady (Rep-TX) stated in his prepared remarks to open the May 20 hearing.
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Shirley Gatzke called HICAP (444-3000) for free assistance. “Martha Johnson was a lifesaver,” she said of the former HICAP program manager and Cloward’s predecessor. “She helped me understand my rights, helped me write the letters and pushed everyone to figure it out.” Gatzke said she was never reimbursed for $1,000 in prescription drugs, but she is not complaining as everything else was “taken care of.” She offers two recommendations for those in a similar situation. “Hold your ground and call HICAP.” Cloward adds, “With legislation pending in committee, we need more stories to document that this is an ongoing issue. Call us. We can help you, and we can forward your story to help get legislation passed that will correct the problem.” But unless the act passes or Medicare’s rules change, beneficiaries must be pro-active in gaining the inpatient designation (see sidebar).
Admission Status: What You Can Do Find Out Your Admission Status
Don’t be fooled by appearances. A night in a hospital room and a barrage of tests doesn’t mean a patient has been admitted as an inpatient. The admission could be for observation. Ask the treating physician. If the physician is unclear about the status, speak to the case management department.
Try to Get Your Status Changed
Changing admission status from observation to inpatient is hard to do. Asking your community doctor to intervene on your behalf is your best chance for success. A patient admitted for observation rather than as an inpatient will be responsible for Medicare Part B cost sharing (Medicare pays under Part B for doctors’ services, outpatient hospital care and other services), the costs of self-administered medications during the stay and/or payment for care in a skilled nursing facility after leaving the hospital. Medicare covers those expenses under Part A hospital insurance only for inpatients.
Prepare for Discharge
If you are not successful changing the admission status, but need follow-up care, you face decisions.
As long as you can safely return home, are homebound (leaving home requires a taxing effort and occurs infrequently) and require skilled care (skilled nursing or physical or speech therapy), Medicare should pay for home health care. Have home health care set up for you by the hospital as part of your safe discharge plan, or ask your community physician to order it.
Understand that Medicare Will Not Pay for Nursing Home Care After Hospitalization on Observation Status
If you cannot return safely home, the discharge physician likely will order care in a skilled nursing facility. Check to see if the nursing home participates in Medicare. Since you were not admitted to the hospital as an inpatient, Medicare will not pay for the nursing home stay without significant effort. You might be able to appeal the denial of coverage for nursing home care if you spent three midnights in the hospital (not in the emergency room). But the appeal can take a year or longer to resolve and winning is difficult. Filing an appeal does not prevent the nursing home from requiring you to pay for your care pending the outcome of the appeal.
Understand What Skilled Nursing Is
Medicare will only pay for a nursing home if it includes daily skilled care (five days a week of therapy or seven days a week of skilled nursing). Skilled care is care that is so inherently complex that it must be done by a skilled professional. Skilled nursing and/or therapy can be to improve or maintain a patient’s condition. Medicare will not pay for nursing home care when it is only custodial; for example, administration of oral medications or help with bathing or toileting. Go to www.medicareadvocacy.org for more information about Medicare coverage of skilled nursing care and how to appeal a denial.
Call HICAP and/or go to the Center For Medicare Advocacy
HICAP (444-3000) is a good place to start when you receive Medicare Summary Notices that
show Medicare denied payment to the nursing home because you did not have a three-day qualifying stay or that the hospital inappropriately billed your stay to Part B. HICAP’s trained staff and volunteers provide free assistance — and that includes advocacy. Remember: you have only 120 days from the date of a notice to file an appeal. Another option: The Center for Medicare Advocacy (www.medicareadvocacy.org) posts a complete Self Help Packet for Medicare “Observation Status” online. The step-by-step process includes information on appeals, gathering records, requesting redetermination, reconsideration and an administrative law judge hearing. The last, the Center says, is where appeals are “often successful.” Source: Excerpted from Center for Medicare Advocacy
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Free Caregiver Training Series Starts July 10
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ot Campbell and Camille Fellion know a good thing when they see it. On July 10, the two friends will start another session of the free Caregiver Training Series offered by Area 1 Agency on Aging. “I love the format,” Fellion said of the 32-hour, four-part series. An 8-hour block on four consecutive Thursdays alternates with two- or three-week breaks over the course of four to five months. Adult Day Health of Mad River hosts the four rounds starting July 10 in Arcata. A Fortuna series kicks off Jan. 8. “One night a week is the only way I can do it, and the break between each course gives you time to read all the stuff they give you,” Fellion said. “It’s not too intense, and it is very thorough. And you don‘t have to take them in order.” “I had enough experience to know what I didn’t know,” Campbell said. “When I went to that first class and saw the overview, I knew it would make a difference. I learned so much.” Neither Campbell, age 60, nor Fellion, 62, is a novice at caregiving. Fellion cares for a 26-year-old son with disabilities and a husband 14 years her senior who started a health decline a few years ago after suffering injuries in a motorized quadcycle
accident. “My son is pretty agreeable and will do what you want because he can’t do that much,” she said from her home in Piercy. “My husband is a little more challenging, so learning how to work with someone who is not wanting to be worked with is a major issue.” Blue Lake’s Campbell has moved into private caregiving after filling the role for her mother for one week a month for five years and then coordinating care from long distance for an aunt for another three years. “You don’t get any choice,” Campbell said of the family caregiver role that falls to many. “You rise to the occasion or you don’t.” Campbell said she “stumbled through it,” but by the time she was done she had “escorted two grand dames safely out of this world” and found a second career interest in endof-life care. “I learned a whole bunch as a volunteer about allowing people to die in their home or the way they choose,” Campbell said. But she had never dealt with catheters, transferring people from one place to another or medication management responsibilities as a paid provider. Fellion had little experience with wound and skin care or communicating with a spouse. Neither knew much about the array
of resources available to them. “Camille saw this class come up and told me I could use some training,” Campbell said. “I thought that wasn’t a bad idea. We turned it into a picnic and time together.” Area 1 Agency on Aging offers the series to improve the quality of care and family caregiver competency while at the same time reducing the level of caregiver stress. The series includes hands-on activities, professional presentations, educational videos and discussion. “The constant responsibility, the lack of knowledge regarding community resources and the lack of adequate training all contribute to frustration and stress among family caregivers, many of whom are often unprepared for what is being asked of them,” said Jeanie Ren, Manager of Information and Assistance and Caregiver Services at A1AA. “Stress threatens the health of the caregiver and, when mixed with other family dynamics, can sometimes lead to unintended abuse or neglect of the person who needs the care.” Thirty-seven people enrolled in the Caregiver Series and all but five participated. “The response shows that family caregivers are looking for training and support,” Ren said. Attendance in one four-week session is not a prerequisite for future segments, but participants are encouraged to attend all four classes in any series. “We like the group to get to know
each other,” Ren said. “A big benefit of taking a class is finding out there are others out there who are doing what you are doing.” Ren said caregiver support and stress management are a part of every series, but each series also has different focus areas. Part one will cover family caregiver support and stress management; communication skills and community resources; basic safety issues; and special challenges in family and informal caregiving. Space is limited and pre-registration required at 442-3763. Respite assistance is available.
CAREGIVER TRAINING SCHEDULE:
Pre-registration required Call 442-3763 to enroll
Arcata Schedule:
Site: Adult Day Health of Mad River, behind Mad River Community Hospital, 3800 Janes Road Thursdays, 5:30 p.m. to 7:30 p.m. Series 1: July 10-31 Series 2: Aug. 14 - Sept. 4 Series 3: Sept. 18 - Oct. 9 Series 4: Oct. 23 - Nov. 13
Fortuna Schedule
Site and Time: TBD Series 1: Jan. 8-29 Series 2: Feb. 19 – March 12 Series 3: April 2-23 Series 4: May 14 – June 4 SPECIAL INSERT TO THE NORTH COAST JOURNAL • THURSDAY, JULY 3, 2014
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Food First; Supplements Second
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itamin and mineral supplements can help an aging body stay healthy, but A1AA registered dietitian Debby Krzesni challenges the widely held belief that they are essential for healthy Americans. “You can do it without supplements – even women can – and you can save a whole lot of money in the process if you will just eat well,” Krzesni said. Krzesni provides nutrition education at senior dining sites throughout Humboldt and Del Norte counties. She said that at least half of adults age 65 and above take daily vitamins and supplements, but many may not need them. According to the executive summary of the Dietary Guidelines of Americans 2010, a daily multivitamin/mineral supplement “does not offer health benefits to healthy Americans,” but individual mineral/vitamin supplements “can benefit some population groups with known deficiencies, such as calcium and vitamin D supplements to reduce risk of osteoporosis or iron supplements among those with deficient iron intakes. “However, in some settings, mineral/vitamin supplements have been associated with
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harmful effect and should be pursued cautiously.” Krzesni said anyone taking supplements should discuss them with a physician. “We see too many people taking too many supplements and then we see people who don’t want to take anything like that but don’t eat well,” she said. “That’s bad either way.” Krzesni practices what she preaches. “I do one supplement a day and I’m about ready to dump that,” she said. “In most cases, you can do it with food.” Following is a Q & A pulled from some of her phone calls and visits to senior dining centers. What about B12? Krzesni: The Dietary Guidelines for Americans recommends people over age 50 should consume vitamin B12 in its crystalline form, which is how it appears in fortified foods like breakfast cereals, or as a supplement. B12 is a vitamin that helps the body metabolize correctly, but 10 to 30 percent of older adults are unable to absorb it, and anyone who is not eating animal byproducts may not be getting enough of it. Crystalline vitamin B12 is much more eas-
ily absorbed than naturally occurring B12. But if you are eating fortified cereals, something like Total, you are getting all of the vitamins and minerals you would get from most supplements, including B12. People who really have trouble absorbing B12 may need special treatment from their physician as low B12 levels can lead to symptoms that are mistaken for serious conditions, such as dementia. Isn’t it easier to take a multivitamin than to have to plan, shop, prepare and clean-up a meal? Krzesni: It may be easier, but it doesn’t fuel your body. If you take a vitamin and think you’re good, you’re not. Without food, you’re going to get skinny and die. And if you think you can eat whatever you want and then take a supplement to fix it, you’re wrong again. Multivitamins and supplements don’t replace everything you need. They don’t provide protein, calories, antioxidants, phytochemicals or fiber, to name a few of the hundreds of substances in food. If you don’t get amino acids from a balanced diet, you can’t build protein. You are what you eat, and one of the goals of our CalFresh partnership is to help people realize that eating better means living better. Food is always first. Aren’t calcium supplements something every post-menopausal woman should take? Krzesni: Men age 71 and older and women age 51 and older need 1200 mg a day of calcium to maintain strong bones. Milk, yogurt and cheese are the main food sources for calcium in the
U.S, and kale, broccoli and Chinese cabbage are good vegetable sources. A single cup of nonfat, calcium fortified milk has 504 mg of calcium. A cup of shredded mozzarella has 1086 and a cup of Total – one serving – has 1000 mg. Keep in mind that calcium supplements tend to constipate people. One person told me they took four calcium supplements a day. Are you kidding? You may never poop again, especially if you are not drinking enough water and eating fiber. Are supplements regulated? Krzesni: Dietary supplements are not reviewed by the FDA for safety or content prior to reaching the market, but the FDA has responsibility to take action against any unsafe dietary supplement product if there is a complaint after it reaches the market. If you are buying them you need to buy from a company you believe is reputable, but what does that mean? It’s a wide open industry. Nobody is checking to see that when you take the Vitamin D tablet, that’s what it really is. MedlinePlus is a good source of information. So is the NIH Office of Dietary Supplements. What’s the bottom line? Krzesni: If your budget is tight or you just want to save money, always buy healthy food before considering supplements. If you are 60 and older or disabled and struggling to eat well, call A1AA’s I&A staff at 442-3763 to see what kind of CalFresh nutrition assistance may be available to you.
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Free Telephone Community Calls Hit All-Time High
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he nation’s only 24-hour crisis hotline and emotional support warm line for older and disabled adults fielded an all-time high of 87 calls to and from Humboldt County in March and followed it up with 83 calls in April. The Friendship Line, based in San Francisco, posted 310 calls to or from Humboldt County for the first four months of 2014, more than six times the volume of the 50 calls posted in the same period in 2013. Ages spanned from 36 to 89, with half of callers between age 60 and 70. Del Norte calls jumped from 51 to 118 during the same four months, year over year. “It pretty much goes up every month, all the calls, and not just Humboldt and Del Norte,” said Natalie Schroeder, outreach coordinator for The Friendship Line. “We see individuals all over Northern California taking advantage of our service, especially where resources may be limited.” “Social connection can be a challenge for some of our older or disabled adults,” said Maggie Kraft, executive director of Area 1 Agency on Aging. “As
word spreads about what this telephone community has to offer, I expect the call numbers will continue to increase.” The call-in service features confidential discussions for people age 60 and older, younger disabled adults, and their caregivers who may be lonely, isolated, grieving, depressed, anxious and/or thinking about death or suicide. The call out service features phone calls to older adults for emotional support and well-being checks. “It’s that continual connection and engagement that keeps older adults feeling valued and supported,” Schroeder said. “Many of our clients come to rely on our calls and some have established meaningful relationships with our volunteers. This can go a long way for someone who is lonely or has limited social opportunities.” Loneliness and isolation impact nearly one in every four North Coast seniors, many of whom know little or nothing about The Friendship Line. It was founded by Patrick Arbore, director of the Center for Elderly Suicide Prevention and Grief-Re-
Free Resource Guides Available
The full color Senior Information Guide for Humboldt and Del Norte counties is available for free, as is the Humboldt County Food Resource Guide. The 92-page Senior Information Guide has been distributed to libraries, hospitals, and senior centers. Nicknamed SIG, the 2014-15 version directs people age 60 and older, people with disabilities, their families and caregivers to an array of services that support an active, independent and healthy lifestyle for residents of the North Coast. “That little booklet is an absolute wealth of resources,” Arcata’s Albert Drexel said. “I have it out on the counter
and thumb through it every other day.” The eight-page food resource guide identifies grocery delivery providers, farmers markets, food pantries, local and out-of-area doorstep delivery services, congregate meal sites, and home-delivered meal programs. The food guide also includes information about applying for CalFresh, a federally funded nutrition program that has seen local enrollment of people age 60 and older jump 46 percent in the past year. Both guides are available at the A1AA front desk at 434 Seventh Street in Eureka and online through a1aa.org. For more information, call A1AA at 442-3763.
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lated Services, a program of the Institute on Aging in San Francisco. “We provide contact, connection and compassion,” Arbore said. “We say to individuals that you matter and we care about you, and we do that daily, seven days a week, 24 hours a day, 365 days a year.” Schroeder said the staff handled 9,324 calls in May. She said expanded outreach to rural parts of California was the result of a three-year California Mental Health Services Act contract. Schroeder said CalMHSA is supporting a fourth year of the project, but at a reduced amount. “Our commitment to the northern counties will be unaffected,” she said. The toll-free number is 800-971-0016.
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211 5th Street, Eureka • 442-5399 Gray Matters is a quarterly publication of the Area 1 Agency on Aging. Maggie Kraft, Executive Director • mkraft@a1aa.org Carol Harrison, Editor • cah5@humboldt.edu AIAA is located at 434 Seventh Street in Eureka, 95501, across the street from Eureka Inn. Phone: 707-442-3763 Gray Matters is designed by graphic artist Amy Barnes of the NCJ and is posted on the NCJ website at www.northcoastjournal.com The next edition of Gray Matters is Thursday, October 2, 2014.