Friday, December 11, 2009

I Prefer Honeycrisps

OK, you're probably wondering what the title means. Honeycrisps are my new favorite apple. They are crisp, with just the right balance of sweet and tart. I figure since I'm starting my teaching career soon, some might want to know what kind of apple I like.

Yes, I'm starting my teaching career soon. In January I will begin teaching a graduate level social work class at the University of Texas at Arlington School of Social Work. The class title is Direct Practice in Aging, kind of a specialty of mine.

I was pretty pleased to even learn such a class was being offered--I have long been frustrated that most schools of social work have dragged their feet on offering coursework on aging issues. I was even more pleased to be approached about teaching this course.

You can imagine that my Christmas vacation will now be spent reading the textbook and preparing lectures. My mind is already swirling with all the things I want to talk about; I just now need to start getting it all on PowerPoint!

This is a great opportunity to help teach others about the joy of working with older adults, and with luck some of these students will go on to provide services to older adults in our community. I will be pleased to see that happen.

Wednesday, November 25, 2009

Happy Thanksgiving

Turkey Day is tomorrow, and I'm pondering the rituals of Thanksgiving.

When I worked at the Osteopathic Medical Center of Texas (The O), we always had a Thanksgiving dinner for the staff and patients. Staff would bring things, but we also had the patients help prepare parts of the dinner--this was a rehab unit, after all. I often offered to make, or help make, the turkey and dressing.

I have to admit that this offer was selfishly motivated, because I happen to think that my dressing is the best dressing around.

I remember one year we had a patient, an older African-American lady, and she and I had several conversations about dressing. We compared recipes, which were very similar, and we both believed that we made the best dressing ever.

When the day of our dinner rolled around, I made the turkey and dressing as usual. After the dinner, this lady made a point of telling me that my dressing was almost as good as hers--high praise, indeed!

Now, I also have to admit that my dressing isn't really my dressing. I learned at my Mother's side, she learned at her Mother's get the picture. I owe a debt to all the women in my family who preceded me. And in my generation, it's not just the women who owe this debt. All of my brothers are good cooks, and some are even better cooks than I. They just can't make better dressing.

Wednesday, October 28, 2009

The Mystery of Medicare

I've been thinking a lot about Medicare lately, partly because Medicare and the possibility of cuts have been in the news. I am certainly no expert on health care; smarter people than I are stymied by how to reform health care, including Medicare.

So I'm not going to talk about that.

I'm going to talk about what I know.

Open enrollment begins on November 15. For those of you not on Medicare, this means that this is the time when people on Medicare can change their Medicare Part D plans or their Medicare Advantage plans.

This is important because with my own mother we have been able to save money every year by switching her Medicare D plan. Each year the insurance companies change their formularies (lists of covered medications) and they can raise premiums or deductibles.

The easiest way to compare plans is to go to the Medicare website. You will need a list of prescription medications in order to get the best information. Once you enter the medication information, you will get the lengthy list (over 50 providers in North Texas) of different plans available. It is possible to even choose your preferred pharmacy and compare prices at different pharmacies.

There are some things you need to watch for.
  • If you have a Medicare Advantage plan that you like, DO NOT change your part D plan. If you choose a part D plan, you be dropped from your Advantage Plan. All Advantage plans have prescription drug benefits built into the plan.
  • If you have Tricare for Life, you probably don't need a part D plan, because you already have coverage with Tricare.
  • If you have coverage through a retirement plan, read your new options carefully. Some companies are only offering Advantage plans, and you might not want to sign up for one of those plans, because your doctors may not be providers.
  • If you are just now eligible for Medicare A and/or B, be sure to sign up for a part D plan. If you wait too long you might be penalized.
All of this information is available in Medicare and You 2010 publication.

Monday, October 5, 2009

Guess Who I'm Letting in My Home

One of the most difficult decisions many older adults make is to allow caregivers into their home. But as hard as this decision is, I am beginning to think that choosing the right caregiver agency is even harder.

There are so many things to consider when choosing an agency. Cost is obviously a huge factor. Any way you look at it, paying for care is expensive. In the Fort Worth area, you can count on paying anywhere from $16-$24 an hour, and that is often with a four hour minimum. Some agencies will consider shorter minimums, but they might charge a higher hourly rate.

If round the clock care is needed, live-in care could be an option. Many agencies define live-in care based on whether the caregiver can sleep or not. If the caregiver can sleep, even getting up 3-4 times a night to provide assistance, this might qualify as live-in care. Of course, you then have to have a place for the caregiver to sleep, which in some situations might not be available. Live-in care is less expensive, usually in the $10-$12 dollar per hour range. Many times these caregivers are in the home for several days at a time, which can result in fewer caregivers.

If the caregiver is not able to get adequate sleep, the agency is probably going to insist on 24-hour care, which will usually be billed at the regular rate. You can expect however that the night time caregiver is awake all night long, and ready to provide assistance. Many agencies will try to have teams of 4-5 people on the care team in this situation, to minimize the number of people providing care.

In addition to having good, well-trained caregivers, it is also important to have a good relationship with the agency owner/administrator and other office staff. You are paying a lot of money for care, and it is reasonable to expect that when you call the office with a problem, you will get a quick response.

When choosing an agency, here are some questions you may want to consider asking:
  • Are the caregivers certified?
  • What kind of orientation and ongoing training do the caregivers receive?
  • How are problems resolved?
  • What kind of background checks are done?
  • How many clients do you have?
  • How many caregivers do you have?
Another source of information about caregiver agencies is the Department of Aging and Disability Services (DADS). They have a Long Term Care Quality Reporting System. At this website you can view information on recent complaints, not only for home care agencies but also for nursing homes and assisted living communities.

And finally, don't ignore your gut reaction. If you have a bad feeling after meeting with an agency owner or representative, pay attention. It might not be scientific, but these are people you will be dealing with on a regular basis, and if you don't like them, the relationship will probably not be a good one. There are enough other agencies out there that you should be able to find a good fit.

Wednesday, September 16, 2009

Outstanding Person and Ideas

I had the good fortune to attend a dinner last night hosted by Senior Citizens Services of Greater Tarrant County. One of the many things Senior Citizens Services does is administer many of our local senior centers. One thing I learned at the dinner last night was that they served 260,000 congregate meals to older adults in Tarrant County last year.

The purpose of last night's dinner was to present the "Outstanding Citizen for Seniors" award. This year's honoree was Bob Schieffer, the CBS News Chief Washington Correspondent. For those of you who don't know, he is a fellow Texan, attended college here in Fort Worth at TCU, and worked for the Fort Worth Star-Telegram.

Mr. Schieffer has obviously attended many of these events, because he kept his remarks very short, but he made several important points that I wanted to share.

He talked about how things have changed since 9/11: that eight years ago, there was truly a feeling of bipartisanship in the nation's capital, and that as Americans we all came together in a time of need.

He talked about how in a 40 year career in Washington, DC he has never seen the level of acrimony as high as it is now. He very eloquently expressed my own feelings that guns at public rallies are inappropriate (at best); that signs calling our President a Nazi or worse are absolutely uncalled for; and that what we need is civil debate. Not name calling, not shouting each other down, not elected officials calling other elected officials liars.

Last night I was proud to be a Texan, and proud to be an American.

Monday, September 14, 2009

Fire! (Not)

I had an exciting experience yesterday. I was in Chicago for a conference, staying in a nice hotel. I woke up a few minutes before 6:00 am to use the restroom. Before I got to the bathroom, some pretty loud beeping started, and I thought to myself, "Wow, that person has a really loud alarm in their room". Almost immediately I heard voices, which I thought was said person's really loud radio. After a couple of seconds when it didn't go off (because I figured if I could hear it, said person surely would and would have turned it off), I listened more closely, to hear this: "This is a fire emergency, please evacuate".

Not the way I wanted to start my day.

I poked my hea
d out the door, as did a few others; we all looked at each other and said "Guess we need to go".

I threw on some clothes, grabbed my purse, my cell phone, and my laptop and headed down the stairs.

We all ended up staying outside for about 25 minutes.

The experience has made me think about a few things.

First, I'm glad I was only on the 3rd floor. I hate to think how the evacuation would have been if my mother, with her 2 bad knees had been traveling with me, and
especially if we had been on the 12th floor. From now on, when traveling with Mom, I'm going to request the lowest floor possible. We never think this is going to happen, and despite all my years of emergency training in the hospital, I just never thought it would happen.

But I'm glad for all my years working in hospitals, because I knew what to do in a "fire emergency". I knew not to go to the elevator. While I did take a moment to change, it was only because my clothes for the day were already laid out. I only grabbed the laptop because it was stowed in it's bag and I could easily carry it, and I did these things because I had assessed the situation and did not smell any smoke on my floor.

Now, I learned today that there really wasn't a fire emergency. The person who sounded the alarm needed an ambulance, and thought that pulling the fire alarm would result in a quicker response. It may have, but I'm glad I'm not the one responsible for forcing a few hundred people to needlessly evacuate a hotel at 6:00 am.

I hope that everyone will take a few moments and think about their own disaster plans when traveling. It only takes a few minutes to review the fire evacuation maps posted in every hotel room. And if you ever wondered if a fire alarm would be taken seriously, I can tell you that it is in Chicago!

Wednesday, August 26, 2009

The Health Care Debate

I read an interesting article this morning on the internet. The article is attributed to The headline read Health Care Debate Based on Total Lack of Logic, so of course I had to read it.

The crux of the article is that we are illogical (Mr. Spock has known that for 40 years). In the case of health care reform, each side starts with a conclusion, then works backward to find facts and data to support the conclusion. I know this to be true, because that's how I wrote an awful lot of my papers in graduate school. I'd write the paper, then go back to all the reference books to find supporting documentation to support my theory or hypothesis, instead of doing the research first. Today all you have to do is watch FOX or MSNBC to see this in action.

The article also made the point that the town hall meetings can promote even more rigid beliefs. Why? Because changing your mind about an idea can affect your sense of identity and sense of being part of a community.

So with that in mind, I think it might be helpful if we all take a step back, take a deep breath, and try to listen to the other side. Certainly each side of the debate has valid concerns and valid points that deserve to be heard.

Monday, August 24, 2009

Working With Older Adults

One of my soap boxes, as anyone who knows me will tell you, is that there aren't enough people specializing in aging issues, whether they are social workers, doctors, or even home builders. Over the years I've been to a lot of seminars lamenting this fact; I've even given a few of those seminars.

Go into any social work/nursing/medical school class and ask students what they plan to specialize in, and almost unanimously the answer is families/children/pediatrics/babies. I have yet speak to any class of college students where someone admits they want to work with older adults.

And I was the same way when I was in graduate school. I was going to work with teenagers, and my first job out of graduate school was with Child Protective Services. The strange thing is, I'm not a "kid" person, and never have been.

My colleagues and I have all tried to figure out how we can make working with older adults more appealing, going so far as to offer paid stipends to social work interns, with some limited success. The research that has been done on the subject has shown that students who have had positive experiences with older adults are more likely to consider working with older adults. So I was intrigued to read this article in the New York Times today.

It's about a program where medical students actually live in a nursing home for a short period of time. The students are given a "diagnosis" and they are expected to receive care just as if they actually had the diagnosis. The students interviewed for the piece talked about how they came away with a much better understanding of the needs and experiences of nursing home residents, but they also feel they interact differently with all patients.

This sounds like a unique program, and one that would benefit all kinds of health care professionals and students.

Monday, August 3, 2009

Health Care Reform

Much has been written lately about the proposed health care legislation, and I decided it was my turn to weigh in on the subject.

I will tell you up front that I have not read the entire 1000+ page bill. I have read one little part of it, and what I know from reading that part is that older adults will NOT be encouraged or forced to commit suicide. Neither will care be withheld from people at the end of their lives.

Let me explain what the bill does allow and encourage, and I'll use some examples.

In the last hospital where I worked, I worked in the intensive care unit. The patients there were really sick, and many died. There was one gentleman, who was only in his 60's, but with very serious end stage lung disease. He was on a ventilator, but he was alert and oriented. He knew he was not going to get better, and he knew the chances of coming off the ventilator were small. Sadly, no doctor was really forthcoming with this information; he just knew it to be true. When he did raise the issue with his doctors, they did at least confirm his suspicions. He then made the decision to stop the ventilator. I can't imaging how difficult a decision this was for him, but he had the courage to face the reality of his condition.

Conversely, there was another patient with the same diagnosis, although not as advanced. She was able to come off the ventilator, but she was actually told by her doctors that each time she went on the ventilator she risked not being able to come off of it. She refused to consider hospice, but she had no one to help care for her at home. She did not want to go to a nursing home. She was completely unrealistic about the course of her disease, despite having doctors who were very honest and realistic about her prognosis. She ended up going home, only to be re-hospitalized soon after and placed back on the ventilator. I heard that she died during that last hospitalization; I don't know if she ever came off the ventilator or not.

What do these two people have to do with health care reform? What the bill will do is require doctors to talk to their patients about advance directives. This is a good thing. The bill will also require doctors to talk to people with end stage diseases about hospice and palliative care; also a good thing.

Back in the early 1990s federal law began requiring hospitals to provide information to people about advance directives. Think about the last time you went to the hospital: a clerk probably gave you a brochure that told you about advance directives, and you probably threw it away. This is all the law requires currently.

Making serious end of life decisions is a conversation that we all need to have with our families and our doctors. When was the last time your doctor talked to you about what you want at the end of your life? I've never had a doctor talk to me about it.

Think back to the two patients I told you about. If their doctors had been having meaningful conversations with them about their disease process all along, perhaps if they had been encouraged by their doctors to talk to their families about end of life decisions, they might have both made different choices that would have allowed for more dignity and comfort at the very end of their lives.

Friday, June 12, 2009

Buyer Beware

A colleague recently handed me a flyer she had received and asked if I knew anything about the service. Here are some of the claims made in the flyer:

Important Elder Law Update
Congress has passed legislation that standardizes entitlement provisions for persons 60 and over. These laws provide the following benefits:

Seniors may apply to completely avoid all probate and estate taxes
I don't even know what that means. The way it reads, it implies that there are probate taxes. There are not. If they mean that you can "apply" to avoid probate, they are wrong. You can't "apply" to avoid probate. You can plan to avoid probate.

In 2009, unless your estate is over 3 million dollars, there won't be any estate taxes anyway. Again, there is no "application" to complete to avoid estate taxes. If you have to pay estate taxes, you may be able to minimize the tax liability through proper planning.

Exempt assets from collection by government or nursing home if ill (with no need for nursing home insurance!)
I assume they are talking about paying for nursing home care. The government does not collect assets. Neither will the nursing home.

If you do not have long term care insurance and you need nursing home care, you can either pay privately for your care, or you can apply for Medicaid assistance. If you apply for Medicaid assistance, certain assets, like a homestead up to a certain value or one vehicle of any value are considered "exempt" (This is the rule in Texas. Medicaid rules vary from state to state). If the state pays for your nursing home care, they do have the right to recover expenses from your estate, this is the Medicaid estate recovery program. With proper planning, it may be possible to avoid estate recovery. Even so, the state isn't going to take your assets. They will file a claim against your probate estate, just like any other creditor.

The key is proper planning, done by qualified professionals. Many elder law attorneys are well versed in Medicaid laws, as well as estate tax planning. You would probably not let an electrician work on your plumbing system, so why would you let a someone with no credentials or questionable credentials give you tax planning or Medicaid planning advice?

I would also be cautious getting advice from someone whose main business appears to be selling financial products. Sometimes annuities are a perfectly fine financial product, but if an annuity won't mature until you're 114 years old (I have seen this, really), then it may not be the best product for you.

When I went to the website listed on the flyer, annuities figured prominently, as well as other financial products. There was no information on the "advisors", so there was no way to tell if they were Certified Financial Planners or if they held any other certification or designation.

I just don't think you can be too cautious when it comes to doing research on the folks who are going to help you plan for your retirement. If you need an elder law attorney, you can find one at If you need a financial planner, you can find one at Another resource for a financial planner is the National Association of Personal Financial Planners.

It may be hard spending a little money for the right advice, but in the long run it could save you a bundle.

Thursday, June 4, 2009

To Keep or Not to Keep

Writing and keeping up with a blog is hard work. I find more often than not that I'll get an idea, even think about it for a bit, then just never get around to actually writing anything. I've been re-inspired this week, thanks to the daughter of a former client. She and I have had several emails about the blog, and networking, our facebook page, and networking, our website, and networking. But the thing she said that inspired me the most is that she feels the information I provide is easy to understand about practical topics.

Now that I'm inspired to write, what to write about...

...So, I'm going to muse a little bit about the issue of hoarding, because it's on my mind a lot lately, for more than one reason.

I learned a couple of years ago from my childhood best friend (I'll call her Ann) that her mother had become a hoarder. At the same time I also learned from Ann that her mother had been diagnosed with a rare form of cancer, and was not expected to live much longer. As we talked, I learned that Ann's mother, in an effort to control vermin, sprinkled Sevin dust everywhere in her house. Now, Sevin dust is a dangerous pesticide, and according to Ann, it was not possible to go anywhere in the home without coming into contact with Sevin dust, and her mother lived in it. It was no surprise to learn that the type of cancer her mother had has a strong correlation to chemical exposure. While no doctor had suggested the Sevin exposure caused the cancer, Ann, being in health care, firmly believed the exposure caused the cancer.

Around the same time I found out that a former neighbor also had a problem with hoarding. When her son went in and cleared out more than 20 trash bags full of her stuff, she basically disowned him. By her son's report, there wasn't even room on her bed for her to sleep, and her husband had all but left her.

I am currently working with a gentleman with similar issues, and his friends and family are struggling to help him deal with making the decision to move, which means sorting through a lifetime of belongings, and deciding what stays and what goes.

What I know about hoarding is that not enough is known about it. I went to a very informative presentation on hoarding at the American Society on Aging conference in March. The speakers reported that while hoarding has been commonly understood to be related to obsessive compulsive disorder, current research is finding a strong link to depression and dementia. Some researchers now believe that the changes in the brain that come with depression and dementia make it difficult for people to distinguish between "important" stuff and trash, so they just keep it all. Of course this is a major simplification, but it does make sense.

The other thing I learned is that for family to go in and just toss stuff out is often the worst way to deal with the problem, as my neighbor's son found out. Hoarders are often very attached to their stuff, even things that are obviously trash to the rest of us. When all that stuff is gone, the hoarder grieves, and I have heard of instances where psychiatric treatment was required, although that rarely repairs the damage done to the family relationships. We saw a film clip from the movie My Mother's Garden, which is a very poignant documentary about a family's struggle with this problem.

So how do you deal with it? It seems that often the best way to deal with the issue is to use a "good cop/bad cop" type of strategy.

The good cops are family members, friends, mental health professionals and other support systems. The bad cops can be code enforcement, law enforcement or Adult Protective Services (APS). Basically, the bad cops spell out why things need to be cleaned up and what will happen if it doesn't happen. The good cops then provide support, encouragement and assistance to help the hoarder maintain control of the situation while they clean things up. This is certainly a very labor intensive method, as my client's family and support system knows, but it can work.

Monday, May 4, 2009

Medicaid Unplugged

No, I don't know all the answers you might have about Medicaid. I'm just way more tuned into Medicaid now because I'm doing more with Medicaid right now. I'm actually helping clients with their applications (for readers who are these clients, don't fret, I have LOTS of supervision).

Even though I've been listening in on Medicaid consultations for over 2 years, like anything else, you don't really pay attention until you actually need the information. Like now. And Medicaid is really complicated.

I'm also looking at my own family's situation in a new light. I know my Mom is getting really tired of me telling her "If you ever have to apply for Medicaid...", but what I know is that I don't want to have to do her Medicaid application. It will be one of those hard ones, and not just because it's Mom.

I marvel at some of the families I work with when they get the list of all of the documentation that's needed: months worth of bank statements, sometimes from years ago, copies of checks, copies of legal documents, copies of life insurance policies, etc., and then they actually send it to me. I'm not sure I could find all that documentation for myself, much less for my Mom.

Mom announced over the weekend that she had old bank statements that she needed to shred, and I told her "Keep at least 5 year's worth, in case you need to apply for Medicaid". She's keeping 7 year's worth for the IRS; who cares about the IRS?

I guess my point is, Medicaid is such a complicated animal, that if you or a loved one has even an inkling that Medicaid might be needed in the future, it's worth a visit to your friendly, neighborhood Medicaid specialist to learn a little bit about it. I'm thick in the middle of Medicaid every day, and the thought of being on the client side of the table makes my head hurt, and I know about this stuff!

If Katten & Benson is too far away or too difficult to get to, call us anyway, because we can refer you to someone more convenient who we know will do a good job for you.

Happy sorting and filing!

Thursday, April 9, 2009

Medication Reminders

Keeping track of medications can be hard, especially when you are on multiple medications, like so many older adults are. I wanted to make a couple of resources that I've learned about recently available.

For a lot of folks, pill minders aren't an option, because there isn't anyone to set the box up each week. I learned about this service, called DailyMedRx. They package all medications, including over the counter medications into pre-sorted into single dose packs. Each pack is then printed with the date and time the medication is to be taken. Now, I have not personally used the service, but it sounds like it could be a really great service for a lot of people.

Another useful site is e-pill Medication Reminders. They carry several different reminders, including ones that talk or vibrate. Again, these are great, but only as long as there is someone who can load them every week.

When choosing a medication reminder it's important to think about who will be using it. Someone told me recently about their client who had one of the really fancy ones, that's all computerized and has all the bells and whistles. This gentleman, who had dementia, had been an engineer, so of course he took the very expensive device apart, to see how it worked, and then he couldn't put it back together! I don't know what they ended up doing, but sometimes simpler is better.

There are also services that can provide monitoring, usually tied in with an emergency response system. One thing to remember with these is that you might know that the device opened at the proper time, and that the person even took the medications out, but you have no way of knowing that they actually took them.

These devices can be helpful for people in early stages of dementia, but as the dementia progresses they can often forget the purpose of the device. It's important to monitor how the person is understanding and using the reminder. I've actually seen a person take the pills out, say that they need to be taken, then put them on the table and forget about them.

Some of these products can be very helpful and can keep a person independent longer, just don't ever expect a device like these to be a substitute for real, live person.

Tuesday, March 31, 2009

Medically Complex Patients

There was a great article today in the New York Times, The article talks about some of the issues involved in treating patients with multiple medical conditions, many of whom are age 65 or older.

One of the basic issues, which I had not really thought of before, is that almost no research has been done on medications. Lots of research is done on, say, diabetes medications, when diabetes is the only medical condition being treated. There is little to know research on diabetes medications when they are taken along with medications for heart disease, Alzheimer's disease, blood pressure, and high cholesterol.

What we know is that the more medications a patient takes, the greater the possibility of serious side effects, and the higher the risk of serious drug interactions. The way our health delivery system is fragmented, there are many patients who have a cardiologist prescribing one set of drugs, an internist prescribing other drugs, and then maybe an endocrinologist or a gastroenterologist also prescribing drugs. This often means that no one doctor is looking at the patient as a whole. This is further complicated by the fact that so few doctors are trained in geriatric issues.

The article suggests that at this point, patients are pretty much on their own, and must take responsibility themselves to stay informed about their medications and be proactive when talking to their doctors.

Monday, March 2, 2009

Little Known Facts About Medical Scans

There was an interesting article in the New York Times today about medical scans. It seems that radiology centers are not required to be accredited, so there are no standards governing the quality of the scans being done.

According to the article, there is a great deal of discrepancy between good scans and bad scans, but insurers, including Medicare, pay the same price regardless of quality. In an example from the article, a woman had an MRI of her knee that was so bad the radiologist could not read it, but she went ahead and had surgery. The surgeon found no damage, and she still has knee pain. Her insurance company paid for the initial scan, but would not pay for a follow-up scan, and they paid for the unnecessary surgery.

Imaging centers can choose to be accredited by the American College of Radiology, which does requires that technicians be certified and provides standards for physicians. A new Medicare law was passed recently that will only allow Medicare to pay for scans at accredited centers, but this law does not go into effect until 2012.

Until there is more regulation, there is little for a health care consumer to do. The article does suggest however that consumers ask why the scan is needed, ask about the center's accreditation, ask about the technician's credentials, and ask how old the scanner is. Scanners more than 10 years old are much more likely to produce poor quality scans, because the technology has improved so much in the past 10 years.

Saturday, February 28, 2009

Oops, Lost Again

I had to go see a client in the hospital earlier this week, and even for me it was a somewhat daunting experience. The hospital is in Dallas, and it's large. Now on this particular trip I did go right to the hospital, thanks to my GPS. In the past I can see it; it's really big, then I can't see it, turn down a one way street; oh, there it is, but it's behind me, I have to turn, finally there! So, anyway, I got there without incident this week.

It's a large complex, with multiple buildings, but I did at least know which building I was going to. I actually found a parking lot, with empty spaces, right across the street. The signs to the parking lot were OK, not great. My big issue was with the signs at street level. Why do they put the names of buildings 40 feet up on the top or side of the building? OK, I know it's so you can see it from the car, but what about when you are on the sidewalk? While I knew I was right across the street from the correct building, the only entrance that looked promising had a big sign that said "Physician Referral Service Only/No Hospital Entrance", so I kept walking. The next building was definitely not the building I needed (signage 40 feet up, but readable), so I backtracked, and went in the Physician Referral door to ask how to get to the hospital. Well, guess what? In the foyer of the Physician Referral office was an elevator guessed it...the Hospital!

I found my client fairly easily from there, although once I got to the unit, which seemed circular in design, there were no signs at the entrance to tell which way the numbering went, so I pretty much made the circle looking for the room.

On the way in, I had observed that there was a skywalk from the hospital to the building across the street, which was adjacent to the parking lot where I had parked. In the elevator the floor with the skywalk was labeled, so I decided to go that way. Big mistake. I got off on the right floor, saw a sign with an arrow to the skywalk--but then never saw another sign and never found the skywalk. I could see it....Anyway, I walked from one area that was clearly patient rooms, then into an area that looked like it should be off limits to the likes of me. All gray walls and office doors and people in lab coats, but no one stopped me, and then ahead I saw more patient rooms, so I just kept going. I finally found some more elevators, got to the ground floor and out of the building, and saw I was on the other side of the building. So I had to go back in, go through the lobby, then finally out the way I came in.

As I was doing all this traipsing around, I kept thinking about my client's 80-something year old husband, who takes himself there every day to be with his wife. I'm sure he parks in the same place every day and follows the route that he knows will get him to his wife. But what if that parking lot is full? What if that particular elevator is out of service? What if they move her? I'm pretty comfortable wandering around hospitals, and I can read small, ambiguous signs and usally figure them out, but not every 65 year old, or 85 year old can. I only had one hospital employee ask me if I needed help, even though I passed dozens.

It's not just the emergency room that needs to be redesigned to accommodate older adults. Hospitals are often huge complexes, with remote parking lots, and as our population continues to age, they are going to have to be more proactive in serving this older population. I didn't see much being done about it when I worked in hospitals, and I don't see much evidence of it now when I go to hospitals.

In a few weeks I'm going with some friends and colleagues to Las Vegas, where we are doing a presentation at the American Society on Aging conference. We are going to teach people how to teach age sensitivity to others. This is just a first step. I hope some of you will consider joining me on this trip toward better accessibility for everyone.

Thursday, February 19, 2009

ER Follow-Up

Here is a comment I received from a colleague regarding my last post about the cutting edge ER in Maryland:

I spent Saturday morning in the emergency room at "Memorial Hospital" (the name has been changed to protect the guilty) because my ward had fallen and had cut her head. The nurse was awful insisting that she “settle down” so they could do the stitches. I kept telling the nurse that she has dementia and that her agitated stage was normal. I asked if they could give her something to sedate her. The nurse said they did not sedate patients for stitches and that she was just going to have to relax otherwise they would not be able to do anything. What an experience. Fortunately, the doctor came in, saw what was going on, had her sedated, an stitched her up. When we got her back to the nursing home, we discovered her hip was very swollen and bruised – something they did not see in the emergency room. Wish they had an emergency room like the one in the article she could have gone to.

One of the many things that is upsetting about this story is that my colleague is a social worker; she is someone who knows how to be an advocate, someone who "knows the system", and yet in this case had no influence at all with the nurse. If she can't get the professional in this instance to do what is right and best, how can someone without her skills and knowledge advocate for a loved one in a similar situation?

My initial response to my colleague was that this is the very reason I think all nurses and social workers, and really all health care workers, need mandatory training in geriatric issues. The nurse appears to have been more concerned with protocol than with listening to the patient or to the patient's guardian. This nurse's actions seemingly fly in the face of one of the basic tenets of medical ethics: Do no harm. Luckily for the patient, the ER doctor was able to place her needs ahead of protocol, and did what was necessary to make a frightening experience less so.

A Cutting Edge Emergency Room

I was driving to work this morning, listening to NPR like I usually do, when a most interesting story came on. It was about an emergency room built especially for seniors, so of course I listened with extra interest ( you can find the text of the story at

This ER is at Holy Cross Hospital in Silver Spring, MD. One reason the hospital decided to build this special ER is because according to a federal survey, only infants go to emergency rooms at a higher rate than those over age 75. This was a new statistic to me, but not surprising. I do know that people over age 65 use other health care services at a much higher rate than the rest of us, so it only stands to reason that this is true of emergency rooms.

One quote from the story that had me cheering was made by geriatrician Bill Thomas, who helped design the ER. He said, "Good care for older people teaches us how to take good care of everybody." I could not agree more!

Friday, February 13, 2009

Where Shall We Go for Dinner?

I am fortunate that my mother is still living; in fact, she lives with me. As she has gotten older, I see that certain things have become more difficult or challenging for her, and often times for me as well. And lest you think that because I work in the field of aging I cope with her changes any better than the rest of you, think again! It doesn't matter what your job is; if it involves your family, your knowledge and professionalism often just disappear.

One thing that we both enjoy is going out to eat, but it is also an activity that can be incredibly frustrating. Let me illustrate with a recent experience:

We got to the restaurant, and there were actually some handicapped parking spaces available, so we parked. The parking lot had something of an uphill slope, and we had to walk to the end of the walkway to get to the ramp, than up a steep ramp to enter the restaurant. Mom has bad knees, so she had to hang on while we negotiated all this.

Once inside the restaurant, the hostess started to take us all the way to the back of the restaurant, so she obviously did not notice Mom's trouble with mobility. I had to ask if we could sit some place closer to the front, and she was able to accommodate this; not all hostesses will. We received our menus, but the combination of dark, romantic lighting and small print made the menus difficult to read. There was of course music playing, but I can't really say that it was background music. It was front and center music, and because Mom is hard of hearing, it made conversation difficult. I'm not sure when restaurants decided that diners don't need to talk to each other, but I think it coincided with the prevalence of cell phones and blue tooth technology.

The practical result is that there are some restaurants we just don't go to anymore. Many are simply too loud to allow an enjoyable experience. Some only have booths, which are difficult for Mom to slide in and out of. Dining out should be a pleasant experience, but I find it frustrating when I have to analyze every potential restaurant for barriers.

I have a brother who manages a restaurant, and he tells me that he is constantly struggling with the owner over lighting and music volume. I think until we all start doing our part to educate restaurant managers and owners of these issues, and on a constant basis, we won't see much change.

Friday, February 6, 2009

Life Care Planning

I am approaching my second anniversary with Katten & Benson, an elder law firm in Fort Worth. When I came to work here, I had never heard of life care planning in the context of an elder law firm.

Life care planning as I knew it was a concept I was more familiar with in rehabilitation settings. An example is the young person who suffers a spinal cord injury in a car accident. Depending on the exact injury, there are certain medical issues that can be anticipated, such as recurrent urinary tract infections, possible skin breakdown, or shoulder problems if the person is able to transfer independently. There are also known equipment needs: a custom wheelchair and seating system, catheter supplies, a wheelchair van, etc. Even durable equipment like the wheelchair or van will have to be replaced every few years due to normal wear and tear. The life care planner considers all these needs and helps the client manage the settlement so that the goods and services required are paid for by the settlement, for the rest of the client's lifetime.

Life care planning in an elder law firm, it turned out, is not much different. Rather than working with people who have had traumatic injuries, we are working with people who have chronic medical conditions, such as dementia, Parkinson's, diabetes or heart disease, and we try to anticipate the needs and get goods and services in place.

Now, let's think about everything that might happen if you are diagnosed with Alzheimer's disease. From a legal standpoint, you certainly want to make sure your estate planning is in order. If you've done estate planning, we review it to make sure it's what you want. Powers of attorney are particularly important , because you want to make sure you have identified the people you want to handle financial and medical decisions. You might even want to take the additional step of designating a potential guardian, in the event guardianship is needed as the disease progresses.

A good financial review and Medicaid planning might also be needed. If you have limited income or assets, it's a good idea to know what will need to be done in order to qualify for Medicaid. Medicaid is complicated, and an attorney will best be able to advise you about issues like gifting, estate recovery, and protecting assets for a community spouse.

As an Elder Care Coordinator it's not my job to provide care, but it is my job to help you get care. The options can be overwhelming: Do I need help at home? What kind of help is available, and who pays for it? When do I need to consider assisted living? What will happen to my spouse? Is the doctor listening to me, and do I really understand what the doctor is telling me? These are all things I can help with.

It can be reassuring to know that you have someone you can call and talk to about a variety of topics. Sometimes I'm going to validate your thinking, and other times I will have to tell you it's time to consider something different. And sometimes I'll just sit with you and be supportive, so you know that you're not alone.

Tuesday, January 27, 2009

It's Never Too Early to Plan

Back in the early '90's I went on a wonderful sailing vacation in the British Virgin Islands with a group of friends. We spent time researching charter companies, we researched the islands themselves, we planned menus and even took groceries with us. Once there, we shopped again for provisions, we read maps and charts, and we plotted the course for our two weeks in the islands. Before we ever got there, we knew we wanted to go to Foxy's on Jost Van Dyke, Cane Garden Bay, made famous by Jimmy Buffett, and the Baths on Virgin Gorda.

All in all, we probably spent more time planning for and anticipating this vacation than we actually spent on the vacation. I suspect many of you have had similar experiences, whether it's a vacation trip to Disney World or a camping trip to Big Bend.

I bring this up because I heard somewhere recently that many people spend more time planning a vacation than they spend either on planning for retirement, for later life health issues, or how to manage finances in later life.

This was something I had never thought of before, but as I have been thinking about it, I'm sure there is a lot of truth to the statement. One thing I have learned is that it is never too early to plan for anything, especially something as important as retirement, which has a huge impact on quality of life. Another thing I have learned is to plan for the worst, and hope for the best.

As part of a Life Care Planning Law Firm, this is what I help people do. The Life Care Planning concept is designed to help the older adult with a chronic disease process plan for the future. Traditionally, we have dealt with chronic illness as a series of reactions. We feel bad, the doctor prescribes medicine, we get worse, we go to the hospital, maybe we have surgery, maybe we go home; and the cycle starts over again. Too often the patient is a passive participant in this process, with little input or decision making capacity. My goal is to help people take responsibility for their health and health care needs, and to become a more active participant in the decision-making process.

In future posts I'll give some examples of how this new way of planning has been able to help people.

Tuesday, January 20, 2009

The American Way

There was an article in the New York Times today titled "A Front-Row Seat as a Health Care System Goes Awry" ( The article is an interview with Dr. Robert L. Martensen, a former ER doctor. Dr. Martensen has written a book called “A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era.” I have not read the book yet, but I will be interested to see what his reflections are.

One thing he does talk about in this interview is the American way of dying. I have seen what he talks about far too many times, and I'm glad to see that at least one doctor recognizes the disservice that happens too often as patients and families face end of life issues. Dr. Martensen talks in the interview about doing ethics consults where there is no hope of recovery, and yet the doctors involved are reluctant to tell families this, in the name of keeping hope alive.

I will never forget the family I worked with some years ago. I don't even remember the initial problem that brought their mother to the hospital, but by the time she reached my unit she had several systems failing. This was shortly after HIPAA was enacted, and up to that point no one had talked to the family at all about what their mother's condition or prognosis was. When I took the intiative and talked to them about her condition, they were so relieved that someone was finally talking to them they didn't even care it was bad news.

A few days later, the physician agreed that a hospice referral was for the best, and I ended up having to talk to family about this over the telephone. While the way I had to deliver the information was less than ideal, the family was just glad that someone was finally telling them what to expect and what needed to happen next. I was able to get her transferred to an inpatient hospice unit, and as happens so often, she died just a few hours after getting there.

Dr. Martensen feels that doctors should be realistic, and I agree completely. I have seen 91 year old people put on dialysis, and people with end stage lung disease put on ventilators. I know that it is hard to tell people that there is nothing more than can be done, other than comfort measures; I've had to do it. I have also seen how hospice can be a tremendous support for patients and families, and how it can allow people to have the good death that Dr. Mortensen talks about.

It is my hope that as we start looking at ways to repair our broken health care system, we can work to make sure that more people have the option of a good death made available to them.

Sunday, January 18, 2009

There's No Place Like Home

One of the hardest things I do is help people make the decision to leave home and move to a nursing home, assisted living or retirement community. "Home" is obviously so much more than the roof over our heads. For some, home is where families were raised, with all the good and bad times that families go through. For others, home is where a husband or wife died, and the surviving spouse fears they will lose memories if they leave the house. Home is where all our stuff is; where we know which floor boards creak and how long the water has to run before it gets hot.

I've wondered before if this decision will be easier for people like me, who lived in a dorm, then went on to live in multiple apartments and living situations while in college and graduate school; but I guess deep down I don't really think it will be. I work with people who were career military and lived in barracks as well as all over the world, and they all struggle with the idea of leaving wherever home is now.

I do think that familiarity will make most changes a little easier. I and many of my colleagues are familiar with retirement and assisted living, so we may have a little easier time choosing that if and when the time comes. I was only half joking when I told my college roommate the next move was to assisted living!

I think the best thing we can do when we are helping an older adult with this decision is to try and help with the fear. Offer to take them to visit communities before they need to move. Most communities offer free lunch, and many will even let the prospective resident stay in a guest room for a few days to see what it's like. Encourage them to talk about the fears, and understand that they will experience grief at giving up their home and all that it represents. And always recognize that the decision is hard. It usually means a loss of independence or control, which is never easy. If possible, start the conversation before the move is even needed. It's a difficult conversation to start, but it will make the decision a bit easier when the time comes.

Friday, January 16, 2009

Greetings from Cowtown

To quote a friend of a friend, I never thought I'd be hip enough or cool enough to start my own blog. But here I am, starting my own blog. It seems that things have been guiding to me do this, so I finally decided to take the plunge and get started.

I am a social worker, and for almost two years I have worked for Katten & Benson, a law firm in Fort Worth specializing in elder issues. Now, a social worker in a law firm is a rare thing, indeed, but Steve Katten is a pretty rare lawyer. He is one of two Certified Elder Law Attorneys (CELA) in Tarrant County, and as he tells it, he realized some time ago that many of his clients needed more than the legal services he could provide, and that's where I come in.

While I have a title, Elder Care Coordinator, all you social workers out there know that titles in our business don't really mean anything. We do it all, or at least it feels that way many days! I have regular clients that I see through our Life Care Planning program, and I will talk more about that concept in the future. I also field questions from many other clients on issues like choosing nursing homes, or understanding their Medicare benefits.

One of my passions as long as I have worked with older adults is education, and helping people have the knowledge they need to make the best and most well-informed decisions possible, and that's why I decided to start blogging. I hope that as I run into situations and write about them, you will glean a little knowledge and understanding about growing older, caring for aging parents or loved ones, and navigating our crazy health care and public benefits systems. I don't know how often I'll post, but I hope that you'll check back often and see what's going on here in Cowtown.