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.