(Reprinted From Mcknights LTC News) I left long-term care in 2016. One day, I sat across a long conference room table and was awestruck by the decimation I observed before me.  This woman — once a spry, inspired, vibrant young single mom of 4 — had prepared to give all to the nursing profession. Before me was someone whose empty spirit couldn't be camouflaged by the fake passion she tried to muster up. She was the most brilliant DONs I had met in my 25-year career as a nursing home administrator and regional director of operations. Stunningly smart. Amazingly intuitive. Someone I had relied on, not only for my career, but for the moment-by-moment, exemplary care she had given to each of the patients that we had the opportunity to care for together.  But, do you know what I saw today as I sat and watched her at a final job interview? I saw a dried-up, beaten-up spirit. I saw a woman who was kicked around by surveyors. She had been vomited on, not by patients, but by the corporation she had worked tirelessly for. She was bruised from the Immediate Jeopardy baseball bat hitting her head. I saw the pain from the punch in the gut when she swore she thought of absolutely everything to avoid a citation. And I saw the lungs deflate as this long-term care system slowly, methodically sucked the joy of life, the joy of giving, and the joy of being a nurse out of her once energetic body.  She was a shell of a woman.  You know what else I saw? Desperation. I have seen that look in her eye before. I have felt it in her spirit when we knew above all else we did the right thing. We made the right decisions. We completed every single line on that investigation and yet, it was not good enough. It never seemed to be good enough.  Not for the state surveyor. And not for the COO. It. Was. Never. Ever. Good. Enough. The DON wanted out of long-term care. I could feel it palpitating through her veins. She caught a glimpse of escape through me. I had escaped, as if fleeing from an abusive cult. I was the one that got out. She had followed me before. Many times. But, despite knowing in my soul of souls what this woman is capable of, what determination, grit, tenacity and just damn straight up brilliance resided in her small stature, as I watched her, I knew she was not shining. She was not plump and shiny and vibrant. She was the puppy that was left behind; the runt of the litter.  This is what long-term care did to this woman, and so many others of us. Over and over, day in and day out, tearing us apart. You left us empty shells. How dare you?  Long-term care company: How did you not commit to building up your talent? To keeping them plush and pliable so they are bursting with that initial joy and desire to help others. Do you remember how joyful and young and vibrant they looked that day you interviewed prospects? It was obvious they were the pick of the litter. You thought to yourself: “I'm going to get tons of mileage out of this one.” Yeah. You sure as hell did.  This nurse isn't the only one. There are so many of us leaving long term care. We are LEAVING the industry.  We are leaving with our experience. We are leaving with the tips and tricks to get YOUR Company out of a lawsuit. We are packing our bags and leaving you with our full understanding of the regulations that you so strongly cling to for your operational success. We are leaving you.  Companies like this should be ashamed. Ashamed for not taking better care of its leaders. There will be no one left to care for these priceless, precious patients that we still so desperately love. The patients that no family comes to see. We made a difference to these patients, even when you didn't see it or care to acknowledge it. We loved them.  But no one took care of us. Many of us who have left long-term care have healed, rebuilt our spirits and are ready to take action. We are coming for this woman. We will rescue her and love her for the leader, the woman, the nurturer, the warrior that she is. It's just a matter of time.  That's unless the industry changes. It's up to the presidents, CEOs and COOS. I'm talking to you. How are you building up the life of your leaders? How are you supporting them? How are you acknowledging their expertise at keeping your company away from CMP's, IJ's and substandard care? Do you realize how much you rely on their actions? I know you do.  Treat employees like this woman as if they are priceless gems. Acknowledge them. Educate them. Praise them. Support them when DSHS is unrelenting and impossible. Give them the tools, freedom and ability to make their own decisions. Invest in their future. Invest in their education and training. Good grief, give them some time off! I mean, real time off. Time off with no calls, no texts, no conference calls. When they won't even get called if state walks in. That's how important their recuperation time should be.  Limit their hours each week. Send them home without a bundle of work to do that night. Care. Care about them and their families. Not just what they can do for you and your bottom line.  Keep your word. Without these leaders, you have nothing. I implore you to look at your administrators, your directors of nurses, and regional teams. Look at them with a new set of eyes. Look at who is ready to leave. Who is working to the bone for your company. Decide to make a change.  If you do,  patient care and your company will flourish. Wake up. Open your eyes. Make a difference. Your priceless patients, and your employees, are counting on you. Buffy Howard, MBA, BA, NHA, was a regional director of operations and a nursing home administrator for 15 years. She works as an operator in the healthcare industry, but left long-term care in 2016.
Do you have any regrets? Most people do. But it appears our regrets gain a lot of weight as we approach the end of our lives. For many years, Bronnie Ware – an Australian nurse and counselor – worked in palliative care; taking care of terminally ill people, most of whom had less than 12 weeks to live. Her patients were typically old people with very serious illnesses, waiting to die. And a lot of her work involved providing counseling and relief from the physical and mental stresses that come naturally when a human being comes face to face with their mortality. Death is not a comfortable subject for most people. We prefer to not think or talk about it. But the sad truth is, all of us will die someday. Knowing you are going to die in a few weeks is a very bitter pill to swallow. And Bronnie noticed as her patients experienced a range of emotions that usually started with denial, and then fear, anger, remorse, more denial, and eventually, acceptance. As part of therapy, Bronnie would ask about any regrets they had about their lives, and anything they would do differently if life gave them a second chance. Of all the responses she got from her patients, she noticed there were 5 regrets that stood out. These were the most common regrets her patients wished they hadn’t made as they coursed through life. But the regrets of the dying can be sound and invaluable advice for the living. And that’s why it’s a really good thing you’re reading this article. One of the key revelations from Bronnie’s study is that we often take our lives for granted because we are healthy . Health affords us boundless freedom very few realise, until we no longer have it. But while her dying patients were helpless in the face of their regrets, you and I still have time to do something about our regrets, before it’s too late. Let’s now look at each of the 5 most common regrets Bronnie observed: 1)    I wish I pursued my dreams and aspirations, and not the life others expected of me According to Bronnie, this was by far the most common regret of all. When people realise their life is coming to an end, it becomes easier to look back and see all those dreams they had but didn’t have the courage to pursue. In many cases, their failure to pursue those dreams were often due to fitting into the expectations of others – usually family, friends and society. One of her dying patients, Grace, made Bronnie promise that she would pursue all her dreams and live her life to its fullest potential without ever considering what others would say. According to Bronnie, Grace was in a long but unhappy marriage. And after her husband was put in a nursing home, she was diagnosed with a terminal illness. And Grace’s biggest regret was that she never was able to pursue all the dreams she put on hold. I think the biggest lesson from this regret is, if you know what really makes you happy, do it! It appears that our unfulfilled dreams and aspirations have a way of silently stalking us, and eventually haunt our memories in our dying days. And if you’re afraid of what people will say about your choices, remember that their voices will not matter to you in your dying days. 2)   I wish I didn’t work so hard This one makes me feel guilty. According to Bronnie, this regret came from every male patient she nursed. And a few female patients too. As breadwinners, their lives were taken over by work, making a living, and pursuing a career. While this role was important, these patients regretted that they allowed work to take over their lives causing them to spend less time with their loved ones. Their regrets were usually about missing out on the lives of their children and the companionship of their spouse. When asked what they would do differently if given a second chance, the response was quite surprising. Most of them believed that by simplifying our lifestyle and making better choices, we may not need all that money we’re chasing. That way, we can create more space in our lives for happiness and spend more time with the people who mean the most to us. 3)   I wish I had the courage to express my feelings and speak my mind This one just made me so much bolder. :) According to Bronnie, many of her dying patients believed they suppressed their true feelings and didn’t speak their mind when they should have, because they wanted to keep peace with others. Most of them chose not to confront difficult situations and people, even when it offended them. By suppressing their anger, they built up a lot of bitterness and resentment which ultimately affected their health. Worse still, harbouring bitterness can cripple you emotionally and stand in the way of fulfilling your true potential. To avoid this type of regret later in life, it’s important to understand that honesty and confrontation are a necessary part of healthy relationships. There is a common misconception that confrontation is bad for relationships and can only create division. Not all the time. In reality, when confrontation is kind, honest and constructive, it helps to deepen mutual respect and understanding and can take the relationship to a healthier level. By speaking our minds, we express our true feelings and reduce the risks of building up unhealthy stores of bitterness that ultimately hurt us. 4)   I wish I had stayed in touch with my friends This one is a regret many of us struggle with. Bronnie found that her patients missed their old friends and regretted they didn’t give those friendships the investment of time and effort they deserved. Everyone misses their friends when they’re dying. It appears that when health and youth have faded, and death is looming, people realise that some friendships hold more value than all their wealth and achievements. According to Bronnie, it all comes down to love and relationships in the end. Nothing else mattered to her patients in the last few weeks of their lives but love and relationships. We live in a busy world these days. And the pressures and demands of work, city life and trying to raise a family can take its toll on some golden relationships. Knowing this now, what would you do differently? 5)   I wish I had let myself be happier This is a very humbling one, really. Many of her patients didn’t realise until the end of their lives that happiness is a choice. They wished they had known that happiness isn’t something to be chased and acquired through wealth, social acceptance and the trappings of life. In their deathbeds, these patients realized they could have chosen to be happy, regardless of their circumstances in life – rich or poor. To me, this regret is the most touching. Throughout our active lives, we often focus too much on acquiring the things we would like to have – wealth, status, power and achievement. We often (wrongly) believe that these things hold the keys to our happiness. When asked what they could have done differently, here’s the key message those dying folks shared: Learn to relax and appreciate the good things in your life. That’s the only way to find real happiness. Happiness is a choice. Is it possible to live a life without regrets? This is the big question I’ve been asking myself. As no human being is perfect, and I doubt there’s anything like a “perfect life”, I expect all of us would have some regret(s) in our dying days. But I think the key is to have as few regrets as possible. And the best way to die with very few regrets is to live life as if we would die today. After all, almost nobody knows exactly when they’ll die. By living our lives as if the end is nigh, we would realise that we really don’t have all the time in the world. As a result, we would procrastinate less , and pursue our truest desires, dreams and aspirations. Also, to live a life of few regrets, we have to focus on and accommodate ONLY those things and people that make us happy. Because if we try to conform to the expectations of others and hide our true feelings, the regrets could haunt us later in life. If you’re reading this article and you’re alive and healthy, you still have a choice.
No Place Like Home: Nursing homes struggle with too few nurses, aides for growing elderly population      In the typical American nursing home, too many residents are waiting too long for too little assistance on the good days. And on the bad days, something tragic happens.  In the good homes, tens of thousands of well-intentioned but underpaid, undertrained workers struggle to care for patients who arrive far sicker than residents did years ago. In the bad places, residents endure unanswered call buttons, cold meals, festering pressure sores, inexplicable medication errors and worse results of inattention. Such incidents can recur in the same facilities for years with minimal repercussions for their operators. While the quality of care in nursing homes has been criticized for years, the magnitude of the problem in 2002 dwarfs that of prior years, a joint Pittsburgh Post-Gazette/KDKA investigation has concluded. The nation's 85-and-over population will double by 2030, swelling the ranks of Americans living with their bodies and minds in disrepair and requiring skilled nursing care. Presently, more than 1.5 million people reside in 17,000 nursing homes nationally. The pool of younger females who traditionally have served that group of elderly, meanwhile, is stagnant. A lack of manpower -- or more accurately, womanpower -- is already used often by the industry's defenders to explain its shortcomings. A recent government study found that fewer than one in 10 homes employs the optimum number of nurses and aides. Few facilities are ever cited for understaffing, however, because minimum government standards are set far below the levels needed to help assure high quality care. A succession of federal reports also has highlighted neglect, abuse and enforcement problems. At the state level, only one of every nine Pennsylvania nursing homes went through 2001 free of violations on the regular mandated inspections and complaint investigations conducted at the more than 760 facilities, according to the Health Department. Industry representatives argue that many of the deficiencies are minor, considering the thousands of regulations with which they must comply. Still, 18 percent of the homes were cited in a serious category of "actual harm" to residents. That's but one indication that problems are wide-ranging rather than limited to the relatively few homes that receive state and federal sanctions each year, said Robyn Stone, a former assistant secretary of aging in the Clinton administration. "The major problem is mediocrity, because it's so difficult to do good work in this area because of a convergence of conditions -- complex medical problems, the low pay, the fact that society doesn't value this work very much," said Stone, who now heads the research institute of the American Association of Homes and Services for the Aging. "I do not believe that most people doing this work are ill-intended," she said, "but that does not mean they're doing a great job, either." Avoidable deaths Mabel Taylor's death on Oct. 26, 2001, led to the type of nursing home investigation not seen locally for years, if ever. Taylor, an 88-year-old Alzheimer's patient at the Atrium I Nursing and Rehabilitation Center in Robinson (the facility has since added Ronald Reagan to its name), died of heart disease aggravated by cold after she was locked outdoors in a fenced courtyard on a 40-degree night. An inquest included testimony that Taylor's body was moved indoors in an apparent attempt to deceive her family about the circumstances of her death. Allegheny County Coroner Dr. Cyril H. Wecht recommended that criminal charges be brought against Atrium administrator Martha Bell, and the county district attorney and federal authorities are conducting separate investigations.  Atrium has one of the worst performance records on inspections of any nursing home in the state, but it's not the only facility where such problems occur. State investigators have identified at least five Allegheny County nursing home deaths since Taylor's that could have been avoided: At the Wilkins House in Wilkinsburg on Dec. 1, Esther Hopkins suffocated when her upper chest slid under a waist belt that had been used to tie her to her wheelchair. At the Wightman Center for Nursing and Rehabilitation in Squirrel Hill on Dec. 30, former Braddock Hills council president Russell Blystone choked to death on his food. He was given eggs and toast by an aide from a temporary agency who did not recognize that he was supposed to receive nourishment only by feeding tube, because he had had a tracheotomy. At the John J. Kane Regional Nursing Center in Glen Hazel on March 13, James Quinlan also was supposed to receive no solid foods, but he was asphyxiated by a piece stuck in his feeding tube. The morning of March 20 at the Shadyside Nursing & Rehabilitation Center, William Walker was found dead on the bedroom floor, unable to breathe, his neck wedged into the bed's side rail. The state's report on the incident said the staff failed to monitor him as it was supposed to, considering his history of falls.  In another death at the Wightman Center, a ventilator assisting the breathing of Evalee Tab, 51, of Beltzhoover, became disconnected July 13. Restraints supposed to be applied to her wrists to help keep her from detaching the ventilator were not in place. All five deaths resulted in state fines but no evident criminal investigations. Law enforcement agencies rarely prosecute nursing home deaths considered "accidental" from human error, without evidence of willful neglect or abuse. And in Quinlan's death at the Kane-Glen Hazel, the state's imposition of a $4,250 fine and provisional license was not for the feeding tube error, but because it found the staff mishandled attempts to revive the resident. The federal government has imposed a $117,000 fine, which like the state's, has been appealed by the county. Family members have difficulty excusing such incidents. "He had no plans to check out," Rose E. Quinlan of Greenfield said of her father, 84, a widowed railroad laborer with dementia. "They decided his checkout time for him, and that's not right." An analysis of Pennsylvania Health Department data found that for-profit homes are far more likely than others to be cited for numerous deficiencies, but the premature deaths show how troubles arise in all types of homes. The Glen Hazel facility is one of the four Kanes owned and operated by Allegheny County, which generally have an excellent survey history. Wightman Center is nonprofit. The for-profit Wilkins House is locally owned, while Shadyside Nursing & Rehabilitation Center is part of one of the nation's biggest investor-owned chains, HCR Manor Care. That chain has had numerous problems in recent years among its 47 homes in Pennsylvania. Frustrated families It doesn't take death to bring families to rage over the care of loved ones. Bert Spontak and his sister, Madelin Ruffner, spent two years frustrated by treatment of Bert's wife, Shirlie Spontak, at the Friendship Ridge facility owned by Beaver County before moving her in July. They said the staff failed to respond for at least four days in late March when Shirlie Spontak, a former artist with an intestinal disorder and dementia, became uncharacteristically lethargic, constantly sleeping while failing to eat or drink. The family pressured Friendship Ridge to have her evaluated April 1 at a hospital, where they said Spontak was finally diagnosed as having had a stroke an uncertain number of days before. Bert Spontak and Ruffner said they had complained repeatedly to staff and administrators about care, to the point that Friendship Ridge officials subsequently suggested in writing that they consider using another facility. The family members didn't feel their concerns about her lethargy were taken seriously, perhaps because of the sour relationship with the staff. "If the resident's family is the one that has to bring the issue to this point, to me there's something wrong with the system," said Ruffner, who's more pleased with her sister-in-law's care at Passavant Retirement and Health Center in Zelienople. Friendship Ridge administrator Bill Jubeck said he was not permitted to discuss specifics about Shirlie Spontak, but he is confident that the nurses of the 613-bed facility -- Western Pennsylvania's largest nursing home -- promptly bring changes in any patient's condition to the attention of physicians. "I can assure you we have not been found to provide substandard care in any respect," Jubeck said of Friendship Ridge, formerly the Beaver Valley Geriatric Center, which was renamed last year to soften its image. Relatives of Hasim Icagic and Lois Dowdell felt frustrated after the two residents of Wightman Center died a week apart in April. Separately, the families concluded the staff there couldn't be relied upon to offer therapeutic help, provide liquids or dispense medications appropriately. Fatima Icagic, daughter of the Bosnian immigrant who fled war in his homeland, said there were repeated problems with her father's feeding tube, and a lack of food and water led to hospitalization before his death April 8. By that time, she had complained often about Hasim Icagic's care on trips here from Germany, where she lives. "I know my father was very, very sick, and I said to the head nurse, 'I want just one thing -- in the few months he has to live, let him live as a human, and not as an animal,' " Fatima Icagic said. Her impression was that her father's needs were ignored if not for her occasional presence. Wightman Center administrator Michael Annichiarico said he was limited by confidentiality requirements in discussing specific care issues of Icagic or Dowdell, but "their deaths at area hospitals were clearly unrelated to the care they received earlier at Wightman. It's also important to note that neither case resulted in action by the Pennsylvania Department of Health." Annichiarico said Wightman Center specializes more than other homes in caring for the neediest patients, such as those dependent on ventilators for breathing, like Icagic and Tab, the woman who died in July. Annichiarico acknowledged that an unusual number of problems have occurred in recent months, however, and said Wightman Center has responded with significant steps, including hiring an outside consultant to review operations. It is the day-to-day difficulties of obtaining satisfactory care -- not sporadic cases of headline-grabbing, horrific abuse -- that represent the true hardship for nursing home residents and their families, said Janet Wells, director of public policy for the National Citizens Coalition for Nursing Home Reform. "The criminal attacks are more the exception than the day-to-day rough treatment and neglect," said Wells, whose prominent advocacy group is based in Washington, D.C. "What people experience on an average day mostly is poor care, like somebody getting a bed sore that's so painful as to destroy their quality of life," Wells said. "We sit here and get calls every day from families having incredible struggles getting decent care for somebody they love, and it's hard to find the problems we hear about justifiable." In business as usual The majority of nursing homes could not be characterized as terrible places, from what appears on their inspection reports. Most residents receive at least some basic daily hygiene, nutrition and activities, in a way that family members are unable or unwilling to provide. But many officials both inside and outside the industry agree that too little is done to ensure homes with repeated serious flaws correct them. The state has not forced a facility to shut down since 1998. "Twenty percent of the facilities cause 80 percent of the problems -- I really believe that," said state Health Department Deputy Secretary Richard Lee. Industry spokesmen tend to estimate the problem homes at more like 10 percent, and they commonly proclaim they would like to see the bad apples more closely monitored -- even put out of business. In the long run, such attrition would improve the field's battered image. "If you clearly have a bad actor, it strikes me that government should be able to move more rapidly than it currently can to make sure residents are adequately protected," said Alan Rosenbloom, president of the Pennsylvania Health Care Association, which represents for-profit nursing homes. But state officials are loath to take the most severe action against homes -- even those that fare worst on the comprehensive inspections -- because they don't want to disrupt the lives of frail residents by forcibly relocating them. Their counterparts in most states and with the federal government share that reluctance. "Our objective is not to put nursing homes out of business," Lee told a recent gathering of nursing home administrators. "We want to achieve compliance." The state uses a system of fines and other penalties to attempt that. The federal Centers for Medicare & Medicaid Services oversees the enforcement by states, since tens of billions of federal dollars are invested in patient care. The federal agency supplements state actions with its own penalties. Still, many of the same homes that are penalized return to non-compliance after temporary improvements. "Ironically, [sanctions are] taken very seriously by the provider trying to do a good job to begin with, and not by providers who are trying to skirt the regulations and not provide decent care," said Ron Barth, president of PANPHA, the state trade association made up primarily of nonprofit homes. Since opening in late 1995, the Atrium facility has had five provisional licenses for failing inspections, four state fines, a ban on admissions and federal denial of reimbursements for new Medicare-Medicaid admissions. Even after 40 visits to the nonprofit facility in the past two years by state inspectors, Atrium is one of only three Pennsylvania facilities carrying Provisional II licenses, which connote persistent problems but do not prevent a nursing home from operating. Wightman Center is the only other Provisional II home currently in Western Pennsylvania. The only home with a worse licensing status is operated by Manor Care in Harrisburg. It is on its fourth consecutive provisional license, the maximum allowed before shutdown proceedings. The staffing issue To some, the issue of nursing home quality revolves first and foremost around staffing. Various studies have drawn correlations between staff size and quality of care. Yet no national ratio of staff to residents exists. The federal government mandates only that a home have "sufficient nursing staff to ... maintain the highest practicable level of physical, mental and psychosocial well-being of each resident." States may apply their own staffing requirements. In Pennsylvania, a nursing home must maintain a complement of nurses and nursing aides sufficient to provide a combined 2.7 hours of care per day per resident. The number of staff on duty varies according to the three shifts of the day, but the brunt of work falls on the certified nursing aides. They perform the hands-on tasks needed by residents for an average of less than $10 an hour, and the way those direct-care workers approach their jobs makes all the difference in the satisfaction of patients and families. "There are many good aides and many good nurses," Ruffner said, "and then you have the ones either fed up or tired or just not made for the job, and I've run into them and had an encounter, and that just makes it miserable." Jo Ann Stroud, who worked for 12 years as a nursing aide at Mercy Senior Care: St. Joseph's, a century-old facility in Garfield that is closing Nov. 1, said the demands of the job make it hard to give residents the attention they deserve. In a typical nursing home, an aide might care for 12 residents at a time, and on some shifts, it's much worse. "It was like having the residents on an assembly line. You never felt you could really sit down and talk to them," said Stroud, who switched to a clerical position after suffering tendinitis in both arms, which she attributed to constant lifting. Many of those inside and outside the industry say the state's 2.7-hour requirement does not reflect the change for the worse in the health status of the nursing home population. Residents with some medical problems but still capable of helping themselves have increasingly turned to assisted-living options in place of nursing homes, if they can afford it. Hospitals, meanwhile, are discharging their sick patients quicker than they used to, because of reimbursement limitations. Those individuals, and their severe medical conditions, thus become the responsibility of nursing homes more so than in the past. That leaves nursing homes with a population in which nine of every 10 residents need help bathing, eight of 10 need assistance using the toilet and more than four of 10 have dementia, according to one national study. There is no evidence that nursing homes have increased staff to keep up with the challenges. Many facilities ask -- or order -- employees to work double shifts and use temporary agency employees who don't know the patients they're caring for. "You can put in a different enforcement system, but it won't get the job done because of the staffing problems," said Charlene Harrington, professor of sociology and nursing at the University of California-San Franciso. "Unless we're going to finance the money to pay for the staff, and make sure the nursing homes spend the money to hire the staff, we're going to continue to have the problems," said Harrington, who has studied the staffing issues for 20 years. Funding complaints Industry representatives say they can't afford to hire more staffers or pay them more. Financial turmoil reigned in the once-profitable industry after Congress in 1997 enacted changes in the Medicare reimbursement system. Instead of being paid afterward for all services rendered to patients, homes receive flat payments according to the condition of each patient. Revenues sank in the late 1990s, a setback especially for operators accustomed to hefty reimbursements for therapeutic services. Many had taken on excessive debt by acquiring numerous facilities. In 1999, five of the nation's largest nursing home chains filed for bankruptcy. Congress restored some funding to Medicare in 2000 and 2001, which has helped all but one of the chains return to solvency. But those restorations were temporary, and unless Congress acts by Oct. 1, Medicare payments to nursing homes are projected to drop by about 10 percent. "These are not wildly profitable enterprises," said Jerry Doctrow, managing director in equity research for Legg Mason Wood Walker Inc., a financial analyst firm. "For most companies, we see them much less profitable but able to survive" the Medicare cuts. But nursing home owners and administrators also complain about poor reimbursements from Medicaid. The combined federal-state program pays for care of about two-thirds of the nation's nursing home patients, those who are either poor or have spent down their assets. Medicare pays for up to 100 days of medical and rehabilitative care, usually for those coming out of hospitals and eventually headed home. Studies conducted for industry associations contend that while Medicare is profitable for nursing homes, Medicaid underfunds the actual cost of care by $9 to $14 a day per patient. Medicare and private-pay patients make up the difference in homes able to attract the right mix of residents. It's hard to erase criticisms over staffing or care quality, industry spokesmen and some others say, in the face of the low Medicaid rates, escalating payroll costs to compete for workers, and soaring liability insurance rates due to court cases against nursing homes elsewhere in the nation. "What you've got in the nursing home industry is very high expectations and standards for care in terms of the regulatory function, and a constant struggle to make sure you've got adequate payment for that," said Doctrow, the Wall Street analyst. Tom Scully, director of the Centers for Medicare & Medicaid Services, said the nation needs a new financing system for long-term care, such as increasing the use of private insurance. Medicaid was never intended to pay for two-thirds of the nursing home population, he noted, and state and federal budget limits prevent any huge payment increases. In the meantime, Scully said, nursing home operators had better not be using funding limitations to excuse any problems with care. The federal government is planning a publicity campaign in November to educate consumers about each nursing home's ability to prevent bed sores, weight loss and other patient problems. Scully believes public perception and accountability can do more than enforcement actions to improve nursing homes, and he said industry leaders seem willing to accept that as an alternative to stiffer penalties. "The image of the industry is terrible, and they understand it," he said. "If you want to get more money from Harrisburg or Washington, like they are usually talking about, you sure have to be making some improvements."
The most valuable part of any skilled nursing facility is their employees … human capital.  We also know that the best way to identify your company’s future talent is through an effective and thorough interview process.  Well then why is it that most organizations are okay with a sub-par process and interviews that are “good enough?” Perhaps it’s because everyone is so busy that they don’t feel they have time to prepare, or because there is a mentality of the candidate being responsible to “wow” the interviewer.  The reality is that the company is being evaluated by the candidate just as much as the candidate is being evaluated by the company.   The Top 5 Traits of a Master Interviewer: They know what they are looking for: Just because you know the position title and you are looking at a job description, does not mean you know what you are really looking for.  In advance of the interview, it is crucial to clarify the job functions and desired output from this new hire, which will determine success for this role. You want to converse with colleagues and other company leaders to ensure that you are all on the same page regarding the job description for this position and how it will serve and benefit the organization.  Do not make assumptions about what someone else’s perceptions are.   Just because you and your counterpart agree you need a new “Receptionist” does not mean you know exactly what that means ; not to be cliché, but the devil is in the details. They PREPARE: Take time to review the resume of the candidate prior to meeting them.  It is important to thoroughly look through the resume and highlight areas of intrigue or concern.  You can then develop a series of specific questions based on the details contained in their information.   Take the time to prepare the staff and others at the facility, so that the candidate can have a positive, welcoming experience.  Prepare your meeting space and ensure it is clean and comfortable.  When interviewing a candidate, you are hosting them, so be a host.    Don’t forget to research your candidate, much like the candidate should research the company.  With today’s technology, information is at your fingertips. They prep the candidate: Keep in mind that the candidate is evaluating your opportunity and your company from the moment they receive their first call from you.  Their impression starts immediately. No one likes surprises and everyone can appreciate a company and a person who has their act together.  Ensure that the candidate has all of the necessary information about their meeting.  Send an email, Providing them with arrival instructions & a contact # in the event of a last minute need.  Also, make sure you ask them to email back to confirm receipt.  Just because you send an email, doesn’t mean it was received.     Think Red Carpet treatment from the very beginning! They get ready for a good conversation: Most perceive an interview to be a line-up of question after question after question.  Then at the end, the interviewer asks the candidate if they have any questions.  There is nothing fluid about that style.  It creates an un-easy, nervous interaction.  Instead, be comfortable! Remember the interview is a meeting.  Focus on a conversation.  You know the ground you want to cover and the areas you are preparing to inquire about, so now have a conversation.  Allow the candidate to talk and then you can learn to ask questions based off of their responses, rather than jumping to the next question on your list.  When the candidate is relaxed, you will get a clearer glimpse into who they are and you will be able to feel their energy.  In addition, when people are relaxed, they share … they talk … they open up.  Aha! They provide next step expectations to each candidate and FOLLOW THROUGH: Upon completion of your meeting, you should always advise the candidate of the next steps.  And extra bonus tip … walk them out! Provide your contact information should they have thoughts or questions afterwards (which often happens). Everyone wants to know what they can expect next, it is just human nature. If something changes, contact them as soon as possible, as a courtesy to the candidate.  Not only does that provide them with clarity, it continues to bode well for the image and reputation of your organization.   Always close the loop.  Even if the call is to say that you have chosen someone else, call.  Don’t email, don’t text, don’t LinkedIn message them, CALL!  They are a person, you are a person.  Every person likes to know where they stand and have closure.    By adopting these positive habits as your own you will always create a positive meeting experience for you and for the candidate.  Whether the end result is an immediate hire, a future hire for a different role or simply a meeting between people, these habits will always create a feel-good experience and an extremely positive, professional impression of your organization.  
Per Mcknights, Pay rates for registered nurses working in skilled nursing facilities rallied in 2016, with employers awarding raises at levels not seen in years. It's a reflection of the competitive market for RNs, believes Rosanne Zabka, director of reports for Hospital & Healthcare Compensation Service, which annually conducts the largest annual nursing home survey of its kind. “With RNs, we saw a lot of increases, up to 10%,” Zabka told McKnight's on Monday. “We saw a lot of 4%, 5% and 6%. It's been years since we've seen a four. “They leveled themselves out when it got to the average (2.86%). But a lot of employers were striving to be competitive, ahead of their competition. They are increasing salaries to attract, or keep, RNs.” The Nursing Home Salary & Benefits Report 2016-2017 was released Friday by HCS, which produces the annual publication in cooperation with LeadingAge and support from the American Health Care Association. It includes data from more than 155,300 employees of 2,076 participating nursing homes The average pay hikes for RNs in 2014 and 2015 were just 1.27% and 2.27%, well below this year's mark of 2.86%. The jump comes amid rising turnover rates among RNs, according to HCS. RN turnover was pegged at 27.55% in 2014; 29.0% in 2015; and 31.17% in 2016. Average hourly pay for RN staff nurses rose from $26.43 to $27.19 among facilities that took part in both the 2015 and 2016 surveys. The national average for staff RNs among all facilities taking part was $27.62 (gauged at the 50th percentile). Other averages at the 50th percentile for all facilities nationwide were: Charge Staff Nurses (RN level) — $26.97; Practical Nurses (LPN) — $21.42; Charge Staff Nurses (LPN) — $20.70; and Certified Nurse Aides — $12.33.
In the twenty-first century, nursing homes have become a standard form of care for the most aged and incapacitated persons. Nearly 6 percent of older adults are sheltered in residential facilities that provide a wide range of care. Yet such institutions have not always existed; rather, their history and development reflect relatively recent demographic and political realities that shape the experience of growing old. Before the nineteenth century, no age-restricted institutions existed for long-term care. Rather, elderly individuals who needed shelter because of incapacity, impoverishment, or family isolation often ended their days in an almshouse. Placed alongside the insane, the inebriated, or the homeless, they were simply categorized as part of the community's most needy recipients. In the beginning of the nineteenth century, women's and church groups began to establish special homes for the elderly persons. Often concerned that worthy individuals of their own ethnic or religious background might end their days alongside the most despised society, they established—as the founder of Boston's Home for Aged Women (1850), explained—a haven for those who were "bone of our bone, and flesh of our flesh". Advocates for these asylums contrasted their benevolent care with the horrors of those who were relegated to the almshouse. "We were grateful," wrote the organizers of Philadelphia's Indigent Widows' and Single Women's Society, one of the nation's earliest old age homes, in 1823, "that through the indulgence of Divine Providence, our efforts have, in some degree, been successful, and have preserved many who once lived respectfully from becoming residents of the Alms House". Although designed for those without substantial familial support, these early homes still generally required substantial entrance fees and certificates of good character. Through these policies, the founders strove to separate their own needy poor from, as the Boston founder explained, foreigners who "have taken possession of the public charities. . .as they have of the houses where our less privileged classes formerly resided". Not surprisingly, perhaps, throughout the nineteenth century the numbers of elderly people who found shelter in these institutions was rather limited. In 1910 the state of Massachusetts, reported that 2,598 persons resided in such asylums. The great majority of these individuals were widowed and single women who had lived their entire lives, or at least a great proportion, as citizens of the state. Although the institutions were hardly palatial, the amount spent on each resident was far greater than the allocation for each almshouse resident. Much as their founders had hoped, the nineteenth-century old-age home operated to differentiate the "worthy" old of a particular religion or ethnic group from the most needy and desperate of the aged population. As a result, for the most impoverished individuals, the almshouse still served as the last refuge in their old age. Throughout the nineteenth century, in fact, this institution appeared to play an increasingly important part in the long-term care of the old. Some states, such as Pennsylvania, periodically revoked outdoor relief in the form of money, wood, or clothes, demanding that those in need either struggle on their own or enter an almshouse. Moreover, as charity advocates removed other, younger paupers to institutions organized to specific needs—such as orphanages, work homes, hospitals, or insane asylum—elderly persons became the dominant almshouse residents. Thus, although the proportion of the elderly population that was institutionalized remained stable at about 2 percent, the percentage of elderly within almshouses soared. In 1880, 33 percent of the national alms-house population was composed of elderly individuals, but by 1923 the proportion had increased to 67 percent. Many of the superintendents of state and local institutions responded to the changing nature of their residents by altering the names of their asylums. In New York City, in 1903, the Charity Board renamed its public almshouse the Home for the Aged and Infirm. The city of Charleston followed suit in 1913, transforming their almshouse into the Charleston Home. In these institutions, their managers claimed, the old could find everything they needed in their last days. Despite the name changes and the rosy descriptions that filled the institutions' annual reports, most people hardly looked upon the almshouse as a satisfactory solution to the demands for long-term care for the elderly. Throughout the early twentieth century, the institution remained a symbol of failure and despair. Poorhouse, according to early twentieth-century social analyst Harry C. Evans, was "a word of hate and loathing, for it includes the composite horrors of poverty, disgrace, loneliness, humiliation, abandonment, and degradation" (Epstein, p. 218). Often pointing to the rising percentage of aged individuals within these institutions as proof of increased dependency, pension advocates such as Abraham Epstein repeatedly argued that such institutions clearly revealed the inability of elderly persons to succeed in the industrial world. The almshouse, Epstein wrote in 1929, "stands as a threatening symbol of the deepest humiliation and degradation before all wage-earners after the prime of life" (p. 128). By the 1930s, government officials accepted the argument that the rising proportion of elderly persons in almshouses was a sign that older people could no longer compete in the modern world. According to a government study in the 1930s, "the predominance of the aged in the almshouse is a sign of their increasing dependency" (United States Social Security Board). Despite the fact that the percentage of aged individuals who required such care appeared rather stable, both the tangible horrors of the almshouse and the rising percentage of aged individuals within such institutions convinced officials that radical measures needed to be taken. Moreover, many were sure that the almshouse had become a costly solution to the needs of the old. Assuming that all elderly individuals would eventually need support, they argued that small pensions were a less expensive solution. In the movement to establish the Social Security program, therefore, concerns about the almshouse's central function in providing long-term care played an essential role. Hoping to eliminate the institution entirely, pension advocates barred any almshouse resident from receiving old-age support. "We were," wrote Pennsylvania's deputy secretary of public assistance, "rather enthusiastic to empty the poorhouses" (Thomas, p. 97). Although individuals who resided in a privately funded institution could be beneficiaries of pensions, almshouse residents were barred from such payments. This proviso was essential for establishing both the popularity and legitimacy of Social Security legislation. In asserting the constitutionality of the Social Security Act (1935), Supreme Court Justice Benjamin Cardozo, writing for the majority, proclaimed that "the hope behind this statute is to save men and women from the rigors of the poorhouse as well as the haunting fear that such a lot awaits them when the journey's end is near" (Haber and Gratton, p. 139). To a large degree, many of the pension advocates had overestimated the impact of pensions on the lives of the needy elderly. Most had simply assumed that, with monthly annuities, individuals could live independently. They saw little reason to reform the poorhouse or support it with financial resources. A few, however, such as aging advocate Homer Folks, argued that only about 15 percent of the almshouse population were in the institution because of strict financial need. "The others," he explained, "are physically infirm and sick, and have various kinds of ailments that require personal attention of the kind that you could not get in an individual home; [they] require nursing or medical attention . . . in some sort of institution" (Thomas, p. 40). Nonetheless, the symbol of the almshouse was so powerful that Folks's argument had little public support. Despite its relatively small inmate population, the almshouse stood as a tangible sign of a despised welfare system. There seemed little doubt that it needed to be eliminated. In eradicating the almshouse, therefore, pension legislation had an unforeseen consequence. By barring almshouse inmates from payments, aged individuals in need of long-term care were forced to seek shelter in private institutions. In Charleston, for example, while some of the almshouse residents were able to leave the institution and, with the support of pensions, live on their own, many were compelled to enter private, often unregulated, sanitariums. In some cases, such a move was more a change in name than in place. In Kansas, for example, immediately following the enactment of Social Security, officials transferred well-established county homes into private control, although neither the residence nor its supervisors changed. Most importantly, however, the inmates could now be classified as recipients of private care, and the institution was able to receive residents' monthly annuities. By the 1950s, the intent of policymakers to destroy the hated almshouse had clearly succeeded. Most poorhouses had disappeared from the landscape, unable to survive once their inmates no longer received federal annuities. As a result, and due to the lobbying of public hospital associations, Congress amended Social Security to allow federal support to individuals in public facilities. New legislation, including with the Medical Facilities Survey and Construction Act of 1954, allowed for the development of public institutions for the most needy older adults. For the first time, both public and private nursing-home residents were granted federal support for their assistance. As Homer Folks had predicted, not all elderly individuals could be supported in their own homes with monthly pensions; many incapacitated older adults required long-term care. In 1965, the passage of Medicare and Medicaid provided additional impetus to the growth of the nursing-home industry, which, while it had been increasingly steadily since the passage of Social Security, grew dramatically. Between 1960 and 1976, the number of nursing homes grew by 140 percent, nursing-home beds increased by 302 percent, and the revenues received by the industry rose 2,000 percent. To a great extent, this growth was stimulated by private industry. By 1979, despite the ability of government homes to provide care, 79 percent of all institutionalized elderly persons resided in commercially run homes. According to investigations of the industry in the 1970s, many of these institutions provided substandard care. Lacking the required medical care, food, and attendants, they were labeled "warehouses" for the old and "junkyards" for the dying by numerous critics. The majority of them, proclaimed Representative David Pryor in his attempt to initiate legislative reform in 1970, were "halfway houses between society and the cemetery" (Butler, p. 263). And, like the almshouses of old, people feared ending their days in the wards of these institutions and relatives felt guilty for abandoning their elders to nursing-home care. Beginning in 1971, therefore, policymakers began to enact numerous government regulations in order to control the quality of long-term care. In 1971 the Office of Nursing Home Affairs provided a structure to oversee numerous agencies responsible for nursing-home standards. In 1972, reforms of Social Security established a single set of requirements for facilities supported by Medicare and for skilled-nursing homes that received Medicaid. Although this limited the ability of most individuals to enter skillednursing facilities, it increased the demand for intermediate-care facilities. Other amendments to the Older American Acts in 1973 and 1987 provided and strengthened statewide nursing home ombudsman programs. Nursing homes residents and their families now had a secure way of voicing any institutional complaints. These policies, however, did not uniformly raise the standards of all nursing homes, nor did they eliminate the fear expressed by many of the older adults who faced nursinghome admission with dread. Yet, as the percentage of the population over eighty-five has continued to grow, nursing home care has become an increasing reality for many of the nation's oldest old. By 2000, nursing homes had become a 100 billion dollar industry, paid largely by Medicaid, Medicare, and out-of-pocket expenses; and although only 2 percent of all elderly individuals between sixty-five and seventy-four reside in such institutions, the proportion of those over eighty-five increased to 25 percent. While these aging individuals no longer face the horrors of the almshouse, the development of the modern-day industry reflects its historical roots. In establishing monthly annuities for the old and disqualifying all residents of public institutions, the creators of Social Security took direct aim at the despised poorhouse. In their initial policies, New Dealers were anxious to sever the connection between old age and pauperism. In barring all residents of public institutions from receiving pensions, however, they clearly underestimated the proportion of elderly persons who required residential support. As a result, they did not initially provide for public asylums or regulate the quality of private care. Although recent legislation has attempted to control nursing homes, and federal funds such as Medicaid contribute to their assistance, the problems that face long-term care for older adults are clearly tied to their historical development. In shutting the almshouse door, policymakers gave birth to the modern nursing-home industry.
On July 23, our photographers captured the Day in a Life of a Caregiver, the joy and the struggles by Michael Anft, Meghan Bogardus, Christina Ianzito, Brennen Jensen and Austin Keating, AARP The Magazine ,  November is National Family Caregivers Month. In the United States, about 40 million people provide unpaid care to an ill or disabled adult. One-quarter of those caregivers have been in their roles for five years or longer. Sometimes it starts small: Maybe Mom needs a little help with her checkbook or a hand with the housework. Other times, it arrives like a thunderclap, with a catastrophic injury or shocking diagnosis. But however an illness or disability arrives, the person who steps up to assist a stricken loved one earns a title: That person becomes a caregiver . Many caregivers don't even recognize themselves in that word, though. To them, helping family is simply what you do. Their contributions are quiet and often overlooked. But caregivers are legion. In the United States, about 40 million people provide unpaid care to an ill or disabled adult . One-quarter of those caregivers have been in their roles for five years or longer. And these loving helpers often go it alone. Only half of family caregivers say they get unpaid help from another family member or friend. On one day this past summer, we visited caregivers across the nation to talk about their joys and challenges. Together, they showed us the meaning of devotion. Wanna talk? Need to vent? Need advice? Chat online with other caregivers in the same situation. Cyndie Rhodes dancing with her father who uses a wheelchair — Ackerman + Gruber 24 Hours, 8 Families 8:51 a.m. / Manitowoc, Wis. Her parents have been divorced for more than 40 years. But when Cyndie Rhodes' dad, George Fix, 91, and mom, Katherine Gibble, 86, needed care, both moved in. "They hadn't seen or spoken to each other in all those years," recalls Rhodes, 61. Fix, who uses a wheelchair, has lived with Rhodes since 2008. Gibble arrived the following year and stayed until 2011, when she moved to a nearby residential facility . Still, Rhodes visits often. "It has been a period of forgiveness and healing," she says. "They kid around together and play cards." Fix loves to play old records; his daughter adds: "He always wants to polka with me." Estelle Sandler assists her partner, Angie DiPrinzio — Randy Harris 10:30 a.m. / Palm Springs, Calif. Angie DiPrinzio, 66, was a personal trainer and extreme athlete when, in 2008, she suffered a stroke . The cause: a routine root canal that allowed bacteria to get into her bloodstream. DiPrinzio still has short-term memory loss and struggles with language and dexterity, says her partner, Estelle Sandler, 68. "I live with a child some days," says Sandler. "But some days, she has a better idea than me." The New York residents travel regularly to California for therapy. "I'm the tour director," Sandler says. "Angie doesn't know what to do until I give her something to do." Share your story about a special caregiver .  Enter the Random Acts of Kindness contest and you could win up to $2500. Ends 3/15/16. Official rules Leah Davidson caring for friend Scott Shettleroe — Erika Larsen 1:11 p.m. / Boca Raton, Fla. Leah Davidson first met Scott Shettleroe in 1981, when he briefly rented a room from her. A choreographer by trade, Shettleroe became a close friend. "My husband wanted to adopt him so we could write him off on our income tax," jokes Davidson, 75. Two years ago, after Davidson's husband died and Shettleroe, 57, became ill with COPD, the choreographer moved in with his pal. "He's here to keep me company, and I'm here to take care of him," she says. Anita Raghavan cares for her son Tavrik, who has Down syndrome — Allison Joyce 3:36 p.m. / Gurgaon, India "People are surprised that I take vacations with my son," says Wichita, Kan., resident Anita Raghavan, 48. "It would take more energy for me to figure out how not to do this." Raghavan's son, Tavrick Lawless, 19, has Down syndrome and needs steady supervision to stay safe. "He knows there are bad things out there," says Raghavan. "But he doesn't recognize that they can happen to him." In July, the two visited relatives in India. After Raghavan's husband died in 2012, she resolved to guard her health. "I need to be an extremely feisty 80-year-old," she says. "I can't get tired of caretaking . That is not an option." Marcus Waller assisting his mother who has rheumatoid arthritis — Taylor Glascock 4:22 p.m. / Chicago Melida Butler, 83, was always a "fiery, hardworking, upbeat Caribbean woman," recalls her son Marcus Waller. But by 2001, Butler was so disabled by rheumatoid arthritis and a spinal infection that Waller, 56, moved home. He works full time as a mail handler, then helps his mom exercise, eat and bathe. "For me to not be able to lift my mother's spirits is just one of the most disheartening things that I've ever had to endure," he says. Learn "11 Fall Vacations You Never Thought Of" and more in the next AARP Webletter Peter Rosenberger experiences the joys of caring for his wife, Gracie — Ben Sklar 5:02 p.m. / Nashville When Peter Rosenberger met his wife in college, he noticed that she walked with a limp. "But I just saw the courage, saw the beauty," he recalls. Gracie had been in a car crash, and the pain from her injuries has never gone away. To ease it, she has had dozens of operations, including two leg amputations. In search of balance, Peter, 52, took up the martial art of hapkido. Caring for Gracie, 49, means embracing happiness in the midst of pain, he says: "Even while you have tears on your cheeks, you can experience deep levels of joy. You're not cut off from life. This is life." Alice Arnold cares for her husband, Army Chief Warrant Officer Douglas “D.W.” Huggins, who was injured in Iraq — Matt Eich 6:23 p.m. / Outer Banks, N.C. In 2005, Alice Arnold's husband, D.W., was injured in a mortar attack in Iraq. The Army chief warrant officer broke one of his knees, both of his ankles and seven disks in his spine. The explosion also caused a traumatic brain injury that has gradually led to confusion and short-term memory loss. Alice, 69, helps keep him on track. A hot tub soothes her arthritis as well as his pain. D.W., 65, can get aggravated by his limitations. "I see him struggling," says Alice. "He used to run every day — three, four, five miles — and now just walking can be a challenge." Melissa Lee travels between New Orleans and California to care for her father — Mark Peterson/Redux 11:04 p.m. / New Orleans to Los Angeles Melissa Lee lives in New Orleans; her widowed father, Joseph, stayed in the California home where she grew up. But a heart attack last year led to a cascade of health crises for Joseph, 79. Now Melissa, 42, shuttles back and forth to see to her father's care. "He's always taken amazing care of me," she says. "Now it's my turn." In hospitals, part of her role is to "represent who he is as a human being," she says. "To say, 'This is a man, and here are his wishes.' " Kindnesses from friends and relatives help her to endure the emotional stress, she says: "Just sitting with you. Or picking up your mail while you're gone. It goes a long way." Caregiving Facts 16.6% of Americans provide unpaid care to an adult 7% of caregivers live more than two hours from the person they help One-quarter of care recipients have problems with memory 40% of caregivers are men 56% of caregivers work full time 2 million Americans are caring for their own adult children 13% of caregivers are assisting a friend or neighbor
A shout-out for the caregivers, some 40 million strong, who lend a hand to loved ones by Robert Love , AARP The Magazine ,  Anita Raghavan cares for her son Tavrick Lawless — Allison Joyce Bear with me. I have been thinking lofty thoughts lately — about what it means to be noble in this ignoble, me-first, selfie-stick age. The word "noble" originally meant "highborn," and — as we have learned from five seasons of Downton Abbey — this derivation describes the English upper classes who live in castles, where they are served night and day by loyal servants with different accents. But over a century of days and an ocean's distance from Old England, I would like to employ another meaning of the word: something or someone "of high moral principles and ideals." This line of thinking came to me as I was reading Bill O'Reilly's new book, Killing Reagan , which is excerpted in this issue. O'Reilly, an AARP member for 10 years, dedicates the book to "all those who are caring for an elderly person" — inspired, he told me, by Nancy Reagan, who cared for her husband during his 10-year descent into Alzheimer's disease. The book's dedication closes with three surprising words: "You are noble." Wanna talk? Need to vent? Need advice? Chat online with other caregivers in the same situation. And I thought to myself: It's true. We humans show our nobility when we put ourselves aside and care for those in need: elderly or young, wounded, ill or scarred in any of the 10,000 ways that life chips away at us. At AARP, we think quite a bit about people who take care of their vulnerable loved ones. We maintain a resource center with tools, tips and advice for such caregivers ( ). And we're encouraging readers to lift caregivers' spirits through random acts of kindness. Rake a lawn, pick up groceries, drop by with a movie and popcorn. If your act of kindness is especially creative, enter our contest (starting Oct. 15) and tell us about it —   Medication Confusion? Scan and manage your meds with the new AARP RX app It's a rare family that hasn't known the joys and pain of caregiving. Our Public Policy Institute recently conducted a study that found that 39.8 million Americans — 16.6 percent of the population — are providing unpaid care to an adult. We also learned that 56 percent of caregivers are working full time while putting in all those hours.
CMS finalized Medicare payment increases and policy changes for  skilled-nursing facilities  (SNF),  inpatient rehabilitation facilities  (IRF), and  hospices  last Friday.  The changes,  proposed  in April, will continue the push toward paying providers for value rather than the quantity of services provided with several new quality measures.  Failure to submit the required quality data under CMS' reporting programs will result in a 2 percentage point reduction to their payments, according to the agency. Dive Insight: The administration's  timeline  for tying Medicare payments to quality of care in its shift away from the traditional fee-for-service (FFS) is ahead of schedule. As of this March, 30% of Medicare payments are  tied  to alternative payments models (APMs) though HHS intended to meet that goal by year's end. The final rules for SNFs and IRFs, scheduled to be published on August 5 in the Federal Register, adopt four quality measures - three to measure resource use and one for medication reconciliation.  The new quality measures for SNFs and IRFs are: Medicare Spending Per Beneficiary - Post-Acute Care (PAC)  Discharge to Community – PAC  Potentially Preventable 30-Day Post-Discharge Readmission Drug Regimen Review Conducted with Follow-Up for Identified Issues The rule for IRFs adopts one additional measure for FY 2018 - “Potentially Preventable within Stay Readmission for IRFs.” CMS will begin reporting IRF quality data this fall.  In addition, the value-based purchasing program for SNFs, which is required by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT), adopts a performance scoring methodology, provides feedback reports, and establishes performance standards as well as a baseline and performance periods.  “In many areas, we believe these are important changes aimed at advancing quality via the IMPACT Act and other new law,” American Health Care Association President and CEO Mark Parkinson  told  McKnight's. “In others, we wish a different outcome had occurred,” Parkinson added. Under the updates, aggregate payments to skilled-nursing facilities (SNFs) are projected to increase by $920 million (2.4%) once the rule becomes effective on October 1. Inpatient rehabilitation facilities (IRFs) will see an increase of about $145 million (1.9%). Payments to hospices for FY 2017 will increase by $350 million (2.1%). The cap amount for 2017, which ends on September 30, will be $28,404.99. In 2016, the cap amount was $27,820.75. Hospices will be required to regularly collect survey data from January to December of CY 2017 for FY 2019 annual payments updates (APU) and from January to December of CY 2018 for FY 2020 APU. CMS wants hospice care to adopt two new measures - one for assessing staff visits to patients and caregivers (Hospice Visits When Death is Imminent), and one for evaluating "the percentage of hospice patients who received care processes consistent with guidelines" (Hospice and Palliative Care Composite Process Measure). The second measure will be based on the existing seven measures under the Hospice Quality Reporting Program: Pain screening, pain assessment, dyspnea screening, dyspnea treatment, patients treated with an opioid who are given a bowel regimen, treatment preferences and beliefs/values addressed.  
It can be difficult to know which strategy will work best for attracting new clients to your home care business. Finding a strategy that works for you and your business is often a trial and error process, testing various strategies until you find one that works for you.  Healthcare Success Strategies  calls this important process “testing, tracking and adjusting.” For example, a home care owner places an ad in the local newspaper to test whether or not the ad will attract new clients. Over a certain time period, she tracks how many new clients mention seeing the ad. Next, she weighs the profit they’ve made from those new clients versus the overall cost of running the ad. Was it worth it? Through this process she might also make adjustments to the ad, move the ad to a different section or have it print on a different day. She’ll again track the results and adjust if necessary. In the end, they’ve either discovered a successful marketing strategy for their business, and they continue on with it, or they’ve discovered it just doesn’t work, and they abandon that strategy and try something else. Depending on your marketing budget, this could be easier said than done. Make sure you have a realistic marketing budget, one that allows you—as much as possible—to aggressively market your business to consumers. Be aware of where your marketing dollars are being spent, and be diligent at tracking and adjusting your spending. If you determine that a certain strategy isn’t producing enough new income for your business, stop spending your marketing budget on it. Move on and try something new. When it comes to the money you spend on marketing,  Forbes  says, “Spending the right money in the right places can drive the success of your business.” So, where do you begin? Which places are the right places for a home care business to advertise? Here are some ideas, according to the “ 2014 Private Duty Benchmarking Study ,” that many home care businesses use for consumer marketing: Search Engine Optimization (SEO) Corporate web leads (such as a franchisor website) Company website Listing in local telephone directory Google Ad Words (pay per click) Newspaper ads/local community paper/senior newspaper Ads in senior directories Flyers/brochures in public places Public speaking/giving presentations (at churches, senior centers, etc.) Sponsorships (sponsor a community/charity event) Internet lead sites (such as Exhibiting at health fairs Open houses Facebook/Twitter/LinkedIn Email campaign to consumer Postcards mailed to consumers Local press releases As you select a marketing strategy to test, think of the community you serve. What will people respond to? What will grab their attention and help them to remember your business?  With this in mind, become involved where you can and design a marketing strategy that you think will work best. Then test, track and adjust! According to , “Advertising is an art, not a science.” If you look at marketing from that perspective, you realize how certain strategies work for some businesses but not for others. Every situation is different. Every community is different. Think creatively and use your imagination. Be unique in your approach, and don’t just think about introducing your home care business to your community. Try to understand how your community will receive your company, based on your marketing efforts.