Dramatic Increase In Patients Going From Hospitals To Home Care

The number of patients who needed home health care after being discharged from hospitals surged by about 70 percent (2.3 million to 4 million) from 1997 to 2008, according to the latest News and Numbers from the Agency for Healthcare Research and Quality.


In contrast, the number of patients routinely discharged to their homes without the need for additional care grew by less than 8 percent, from 27 million to 29 million patients, during the period.


The federal agency also found during 1997-2008:


- Some 5 million hospital patients were discharged to nursing homes and other long-term care facilities - an increase of 35 percent (from 3.7 million to 5 million).


- There was a 40 percent increase in the number of patients (264,000 to 370,000) who left the hospital against medical advice.


- Hospitals transferred an additional 4 percent of patients to other hospitals (846,000 to 878,000 )


- Fewer patients died in the hospital - a decrease of 5 percent (from 852,000 to 811,000).


This AHRQ News and Numbers summary is based on Exhibit 1.5 in HCUP Facts and Figures 2008, which provides highlights of the latest data from the 2008 Nationwide Inpatient Sample, a part of AHRQ's Healthcare Cost and Utilization Project.

Home Health Advance Beneficiary Notice (HHABN) Being Revised - Again, USA

Home health agencies will recall that a revised Home Health Advance Beneficiary Notice (HHABN) was slated to go into effect on May 1, but it ran into a roadblock. This came in the form of agencies' comments on the revised form and challenges to CMS's estimate of how much of a burden it would create for providers. So CMS has gone back and revised the HHABN once more, this time with comments due on July 24, with the intent of requiring home health agencies to use only this form as of September 1. In the meantime, providers should continue to use the current HHABN. CMS is seeking Office of Management and Budget approval of its new form, in a clearance package that you can access through aahomecare (go to Advocacy and Government Relations by clicking on the button on left of homepage and see Home Health heading on the Advocacy page).



Agencies must issue an HHABN in cases where they believe that items and/or services will not be reimbursed by Medicare (Option 1), they will no longer provide care for financial or business reasons (Option 2), or a beneficiary's homecare services are being reduced as a result of physician's orders (Option 3). CMS has simplified the language on the notices, which are in both English and Spanish, and has provided a much more realistic estimate of the frequency of issuance and burden on providers. Medicare estimates that 87.9 percent of HHABNs will fall into the Option 3 category and that agencies will issue an average of 2.12 notices during an episode of care.



You may want to provide input to CMS and OMB after reviewing CMS's six-document clearance package. If you have any comments please also e-mail them to Ann Howard at ahowardaahomecare by July 17 so that we can incorporate your input into AAHomecare's comments. In addition to the OMB clearance documents, HHAs will want to review 26 new Q&As that CMS posted on its beneficiary notices website on June 20. (See Advocacy and Government Relations at aahomecare by clicking on the button on left of homepage and see Home Health heading on the Advocacy page).


American Association for Homecare

625 Slaters Lane

Suite 200

Alexandria

VA 22314

USA

(703) 836-6263.

aahomecare

Caregivers And Physicians Need Education About Battery Ingestion In Children

Ten years of case studies at a pediatric hospital and a thorough literature review have shown that it is not uncommon for children to ingest small "button" batteries, either through swallowing or inserting the batteries into their noses.



In a paper presented at the 2009 American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Annual Meeting & OTO EXPO in San Diego, researchers revealed that a significant lack of knowledge about the dangers of button batteries exists in the lay population and in healthcare providers.



Button batteries are miniature disc batteries that are typically used to power hearing aids, watches, calculators, and many commonly used items, including small toys and musical greeting cards. Each year, more than 3,000 people of all ages in the U.S. unintentionally swallow these batteries, according to the National Capital Poison Center in Washington, DC. Sixty-two percent of battery ingestions involve children under the age of 5, with a peak incidence in 1- and 2-year-olds.



While many children who ingest button batteries recover with few long-term health issues, some develop long-term complications that significantly deteriorate quality of life, such as tracheostomy-tube or gastrostomy-tube dependence, vocal paralysis, and septal perforation with saddle nose deformity. The authors say expeditious identification and treatment of button battery ingestion is crucial, for which continuing education must be provided to pediatricians, primary care, urgent care, and emergency room care providers, and otolaryngologists.



The authors also concluded that increased public awareness is necessary to diminish the incidence of such ingestions. Industry changes, including improved packaging and button battery markings, will also be fundamental to this process.



Title: Button battery ingestion in the pediatric population

Presenters: Dale Amanda Tylor, MD and Seth Pransky, MD

Louisiana Nursing Home Owners Likely To File Lawsuit Against State For Lower Medicaid Rate Increase In 2009, Health Official Says

Louisiana Department of Health and Hospitals Secretary Alan Levine on Friday said that the state likely would face a lawsuit from nursing home owners if Medicaid cuts approved by the state House are not restored, the New Orleans Times-Picayune reports (Moller, New Orleans Times-Picayune, 5/24). The House this month approved a $30 billion state budget for fiscal year 2009 that is $240 million less than Gov. Bobby Jindal's (R) proposed budget.

Jindal's original budget called for a $600 million increase in Medicaid funding, including about $21 million for new initiatives. The House Appropriations Committee cut the spending increase by $183 million but did not specify where the reductions would come from. In a letter to House and Senate leaders last week, Levine wrote that the cuts would affect a wide range of health care providers, and the biggest reductions would be for hospitals, nursing homes and pharmacies.

Levine said that implementing the Medicaid cuts would include $38.6 million in payment cuts to nursing homes (Kaiser Daily Health Policy Report, 5/22). On Friday during a state Senate Finance Committee hearing, Levine said nursing homes are entitled by law to receive a rate increase that would cost the state about $69 million.

Commissioner of Administration Angele Davis has asked lawmakers to restore the health care cuts. Doing so, however, could bring the proposed budget near the constitutional cap on state spending, according to the Times-Picayune (New Orleans Times-Picayune, 5/24).


Reprinted with kind permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation.

© 2008 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Chronic Disease Care Poorer In Nursing And Residential Homes Under GP Target Scheme, UK

The quality of chronic disease care under the GP pay for performance system is poorer for residents of care homes than those living in the community, according to a study published on bmj today.


The Quality and Outcomes Framework (QOF) for general practice is a voluntary system of financial incentives, which has been in place since 2004. Part of the programme includes specific targets for GPs to demonstrate high quality care for patients with chronic diseases.


The study found that, although pay for performance systems do not invariably disadvantage residents of care homes, GPs are much more likely to exclude them from quality targets, which may compromise their care.



The authors, led by Dr Sunil Shah from St George's, University of London, say that pay for performance systems should include measures relevant to care home residents to improve chronic disease care in this often vulnerable group.


Dr Shah and his team studied data from The Health Improvement Network (THIN), a large database of primary care records from 326 UK general practices, to assess the quality of chronic disease care for care home and community residents.


They identified 10,387 care home and 403,259 community residents aged 65 to 104 years who were registered for 90 or more days with their general practitioner.


Even after adjusting for age, sex and dementia diagnosis, they found that attainment of quality targets was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators suitable for older people in care homes.


The largest differences were for prescribing in heart disease and monitoring of diabetes. Smaller differences were seen for use of antiplatelet therapy and monitoring of blood pressure.


Residents of care homes were also more likely to be excluded from all QOF targets for a condition. For example, 34% of patients with stroke in care homes were excluded compared with 17% in the community, and 35% compared with 9% for diabetes.


This difference persisted even after taking account of patients with dementia or with limited life expectancy.


This is the first study to examine quality of care for residents in care home since the introduction of pay for performance in the primary care contract and shows a need to improve care for chronic diseases among older people in care homes, say the authors.


They acknowledge that, for some interventions, lower attainment of quality indicators may be appropriate, but argue that "high disease wide exceptions suggest a less individualised approach and may act as a disincentive to good disease management."


They conclude: "Our current findings support enhancement of pay for performance systems to include measures that are particularly relevant to residents of care homes and vulnerable older people in the community, such as pain management, falls and continence care."


Link to paper


Source
British Medical Journal

Study Reveals Cultural Differences In Attitudes Towards Caring For People With Dementia

People of south Asian or Black Caribbean origin are far more likely to hold a 'traditional' view of caregiving than White British people, new research shows.



The study, published in the September issue of the British Journal of Psychiatry, found that south Asian and Black Caribbean carers of people with dementia are more likely to perceive their caring role as natural, expected and virtuous.



In contrast, White British people are more likely to hold a 'non-traditional' caregiving ideology, deriving little or no reward from such a relationship and believing their own lives are put 'on hold' while they perform caring duties.



In the UK, around two-thirds of older people with dementia are supported in the community, and family members are the most important source of dementia care. This is particularly true among ethnic minority populations, who are less likely to access specialist healthcare of social care services.



Researchers at the Institute of Psychiatry, King's College London carried out in-depth qualitative interviews with 32 carers of people with dementia: 10 were Black Caribbean (9 women, 1 man), 10 south Asian (5 women, 5 men) and 12 White British (11 women, 1 man). The participants were recruited from four socially and ethnically diverse south London boroughs - Lambeth, Southwark, Lewisham and Croydon.



Carers fell into one of two groups (traditional and non-traditional) according to whether they held three core interrelated beliefs: that caregiving is natural, expected and virtuous. The majority of the south Asian, half of the Black Caribbean and only a minority of White British participants were found to possess a traditional ideology.



Most south Asian and Black Caribbean carers with traditional ideologies possessed strong religious values. For them, providing care was consistent with being a 'good' Hindu or Christian and was therefore the normal thing to do.



Others felt a natural inclination towards caregiving. For example, a high proportion of Black Caribbean carers had experience in the nursing profession, and felt this equipped them to deal with the caregiving role.



Many traditional caregivers viewed their role as a natural part of their life course, either as the spouse or the child of someone with dementia. One south Asian son said: "You know, as Indians, we always look after our parents??¦my father looked after me when I was young and he has done lots and lots of things for me so it's my turn to look after him."



Sons and daughters of south Asian and Black Caribbean origin with traditional ideologies viewed caring less as a necessity and more as an opportunity to reciprocate parental support. One daughter, born in the Caribbean, reflected on how her attitude towards caregiving differed from that of her British-born siblings: "It's something I want to do and I'm glad I can do it. It's almost a privilege to do, but then, you know, I??¦as I said I grow up in Jamaica and it's probably a cultural thing. Whereas my younger siblings don't have quite the same dedication, they'll do it because it's Dad but it's not their duty."
















Having a traditional caregiving ideology was found to help carers derive rewards from the relationship and feel that their lives, although changed, were ongoing. This contrasts sharply with those with non-traditional ideologies, for whom caregiving often signified the end of their relationship and, to a large extent, their lives.



For example, one White British woman with a non-traditional ideology caring for her mother said: "In a way she's not my Mum anymore, that's the hard bit, she's just sometimes??¦she can be a difficult old lady that you have to keep your eye on."



The researchers found that caregiving had a negative impact on carer health across all participants - both traditional and non-traditional. Many felt that they were constantly battling exhaustion and were sleep-deprived.



Overall, caregivers with a traditional ideology were more likely to be satisfied with the support they received from professional health and social care services. Conversely, some carers with non-traditional ideologies were eager to relinquish their caregiving responsibility, were more demanding of services and more likely to feel their needs were not being met.



The study's authors make recommendations of ways in which carers with both traditional and non-traditional ideologies can be better supported.



For those with traditional ideologies, professional care staff should reassure carers that it is both natural and necessary to take time for themselves. Significantly, some south Asian carers saw asking for professional help as a failure to fulfil their responsibilities. Therefore, services might be considered more acceptable if they communicated their commitment to supporting - rather than substituting - family members in the caregiving role.



Carers with non-traditional ideologies may benefit from a change in governmental policy and the benefits system to directly support and promote the role of family carers. Specific grants or targeted benefits would help legitimise the caregiving role as well as directly help those who care.



Reference:


"Attitudes and support needs of Black Caribbean, south Asian and White British carers of people with dementia in the UK."
Lawrence V, Murray J, Samsi K and Banerjee S (2008)
British Journal of Psychiatry, 193: 240-246


Royal College of Psychiatrists


The Royal College of Psychiatrists is the professional and educational body for psychiatrists in the United Kingdom and the Republic of Ireland. We promote mental health by:


- Setting standards and promoting excellence in mental health care

- Improving understanding through research and education

- Leading, representing, training and supporting psychiatrists

- Working with patients, carers and their organisations


Royal College of Psychiatrists

Death At Home Less Distressing For Cancer Patients And Families

Cancer patients who die in the hospital or an intensive care unit have worse quality of life at the end-of-life, compared to patients who die at home with hospice services, and their caregivers are at higher risk for developing psychiatric illnesses during bereavement, according to a study by researchers at Dana-Farber Cancer Institute.


One striking finding of the study, reported in the September 13th issue of the Journal of Clinical Oncology, was that bereaved caregivers of patients who died in an intensive care unit (ICU) were five times more likely to be diagnosed with Posttraumatic Stress Disorder (PTSD), compared with caregivers of patients who died at home with hospice services.


"This is the first study to show that caregivers of patients who die in ICUs are at a heightened risk for developing PTSD," wrote the authors, led by Alexi Wright, MD, a medical oncologist and outcomes researcher at Dana-Farber. The American Medical Association Glossary defines PTSD as "feelings of anxiety experienced after a particularly frightening or stressful event, which include recurring dreams, difficulty sleeping, and a feeling of isolation."


In addition, families and loved ones of patients who died in the hospital, though not in an ICU, were at higher risk of developing Prolonged Grief Disorder (PGD), an intense and disabling form of grief which lasts more than 6 months.


The report comes at a time of growing concern over the appropriateness of aggressive, hospital-based end-of-life care for terminal cancer patients. The authors noted that although most cancer patients would prefer to spend their last days at home, 36 percent die in a hospital and 8 percent in an ICU and may be subjected to invasive and painful procedures at the end of life.


In contrast to home or hospice care that emphasizes alleviating pain and discomfort and providing a peaceful death, ICU care can be traumatic for patients and their family and caregivers, said Wright.


The report, whose senior author is Holly Prigerson, PhD, director of Dana-Farber's Center for Psycho-oncology & Palliative Care Research, contains findings from a prospective, longitudinal study of advanced cancer patients recruited at seven cancer centers from 2002 to 2008. Patients and caregivers mainly family members were interviewed at the beginning of the study. Their medical charts were reviewed at that point and after the patients died, on average 4.5 months later. Within two weeks of the death, researchers interviewed the caregiver most closely involved with the patient's care during the last week of life; they interviewed the caregiver again six months later.


In the interviews, the researchers asked the caregivers to assess the patients' quality of life and physical and psychological stress during the last week of life. The researchers also evaluated the caregivers' own mental health at the beginning of the study to uncover any pre-existing psychiatric illnesses and again six months after the patient's death.


After analyzing the data on 342 patient-caregiver pairs, the investigators found that patients who had died in the hospital or an ICU experienced more physical and emotional distress and worse quality of life than those dying at home. Among the caregivers, they determined that 4 of 19 caregivers (21 percent) of patients dying in an ICU developed PTSD, compared with 6 of 137 (4.4 percent) when death occurred in the home/hospice setting. A similar elevated risk of prolonged grief disorder was found in caregivers when patients died in the hospital, but not in an ICU.


These findings are important for both patients and physicians, said Wright. "If patients are aware that more-aggressive care may affect not only their quality of life, but also their loved ones after their death, they may make different choices."


In addition to Wright and Prigerson, the paper's other authors are Tracy Balboni, MD, Ursula Matulonis, MD, and Susan Block, MD, of Dana-Farber, and Nancy L. Keating, MD, of Harvard Medical School.


The research was supported by grants from the National Institute of Mental Health and the National Cancer Institute.

Medicare Reimbursement for Home Inhalation Drug Therapies Must Rise Dramatically

A study of inhalation drug therapy services provided to Medicare beneficiaries in their homes found the new 2005 Medicare reimbursement formula based on average sales price (ASP formula) would under-reimburse the actual cost of providing two key drug therapies by $68.10 per monthly supply.



The study, the largest of its kind, conducted for the American Association for Homecare (AAHomecare) by Muse and Associates, surveyed 109 pharmacies that represent 2,448 branch locations providing inhalation drug therapy services to 337,348 Medicare beneficiaries per month - or 61 percent of all Medicare inhalation drug therapy patients. AAHomecare is sharing the study with the Centers for Medicare and Medicaid Services (CMS) and the Government Accountability Office.



"This objective assessment of the cost of inhalation therapies in the home reveals a serious gap between what will be paid under the new 2005 reimbursement formula and the reality of what it costs to deliver these therapies to Medicare beneficiaries," said Kay Cox, president and CEO of the American Association for Homecare. "The ability to provide these therapies and patient access to these therapies will both suffer if we don't close this reimbursement gap."



In a notice of proposed rule making for the 2005 Medicare physician fee schedule issued last month, CMS proposed 89 percent reimbursement cuts, using the ASP formula, for albuterol sulfate and ipratropium bromide. The two drugs, covered under Medicare Part B, are commonly prescribed to treat diseases such as chronic obstructive pulmonary disease (COPD), which afflicts more than 14 million Americans. However, because of the numerous patient-management, pharmacy, compounding, delivery, and administrative costs, these drug therapies cannot be provided to Medicare patients at the ASP mandated formula without a substantial service or dispensing fee, says AAHomecare.



Among suppliers responding to the survey, nearly nine out of ten (89 percent) said that they would discontinue providing inhalation drugs to Medicare beneficiaries under the ASP formula if no other Medicare reimbursement were available to offset their substantial, additional costs. The study was supervised by Don Muse, Ph.D., president of Muse and Associates which specializes in analysis of Medicare and Medicaid statutes and regulations.



"We will file the study as part of our comments to CMS and look forward to cooperating closely with CMS to ensure that beneficiaries continue to have access to critical inhalation therapies," said Cox.



To see the executive summary of the study, visit aahomecare and click on Newsroom.



Homecare provides tremendous value for Americans' healthcare dollar. AAHomecare is the only national association that represents every line of service in the homecare community, including home health and home medical equipment providers, respiratory and infusion therapy, telemedicine, and re/hab and assistive technology. Representing more than 3,000 member locations nationwide, AAHomecare is dedicated to advancing the value and practice of quality, cost-effective health care services where consumers prefer them - at home.




Michael Reinemer

Director, Communications

American Association for Homecare

625 Slaters Lane, Suite 200

Alexandria, VA 22314-1171

703-535-1881

aahomecare

Mental Health Therapy For Children Traumatized By Hurricane Katrina

After a successful pilot run, the LSU School of Social Work received $100,000 from the AmeriCares Mental Health Grant Program to continue its study, "Weathering the Storm: Wellness Groups for Children and Caregivers."



The grant enables clinically licensed social workers to offer psycho-educational help by using group interventions in Baton Rouge area schools. The groups are expected to reduce the long-term consequences of post-hurricane trauma and relocation of elementary school-aged children.



Officials estimate that more than 46,000 public school elementary students relocated to Baton Rouge following Hurricane Katrina. Many of these children and their caregivers not only lost their physical homes, they also lost their communities and their sense of normalcy. With priorities focused on regaining basic needs, children's mental and emotional health can easily become neglected.



In response to the need for counseling, Daphne Cain, LSU social work professor, requested her co-workers' help in providing a program to teach parents the normal reactions to disaster regression behavior. This approach enables parents to help their own children to cope with the traumatic loss.



Cain, who has research experience in parenting interventions, is the study's primary investigator. Carol Plummer, assistant professor in LSU's School of Social Work, has research experience with trauma and children's studies. Toni Bankston, LSU adjunct professor, and Tangela Colson, a local social work practitioner, are also participating in the study.



Bankston developed a six-week program based on a one-hour session each week to go with the book, "After Hurricane Katrina: Helping Children Cope with Traumatic Loss" by Marge Heegaard. The book helps child trauma victims to understand and express their emotions in the form of drawings. Heegaard is a registered art therapist and social worker in Minneapolis.



The team provides caregivers with information about the group therapy provided for the children, including handouts with explanations of the differences between common and severe reactions. The term caregivers refers to parents or other legal guardians. The team can provide caregivers with referrals for additional services for children showing severe reactions. Caregivers can also receive more information, ask questions and participate with their children during the drop-in sessions, which occur during two of the six therapy sessions.



Group leaders help children to cope better with their emotions and reactions to the trauma caused by Hurricane Katrina, making the children less likely to have behavior problems at school. Group leaders will use positive channels including art, dialogue and play activities to release anxiety and other negative feelings associated with the disaster.



Cain said that the best assistance she can offer is to employ interventions known to be effective in offsetting trauma exposure in other disaster situations. Many post-disaster studies of children have documented elevated levels of post-traumatic stress disorder. The long-term effects and mental health consequences for children who survived Katrina are still unknown. The LSU Health Sciences Center screened children affected by Katrina and found several common symptoms. These include medical symptoms, nightmares, flashbacks, increased anxiety, bed-wetting, behavior problems and depression.
















Topics covered in the groups include: change as a part of life, learning about feelings and difficult feelings about Katrina. Other topics are: soothing painful feelings, changing negative thoughts, and moving on and getting stronger.






The groups are being offered through area schools, which are able to distribute informed consent forms for parents to enroll their children. The team is currently working in Glen Oaks Park Elementary and Scottlandville Middle schools. All school-age children displaced by Hurricane Katrina who have relocated to the Baton Rouge and Baker areas are invited to participate in the groups. The groups meet for one hour each week. Participation is free.



LSU's School of Social Work is working with the Big Buddy Program, East Baton Rouge Truancy Assessment and Services Center and a number of health-care facilities. The grant is through the AmeriCares Foundation in collaboration with the Baton Rouge Area Foundation.



AmeriCares is a non-profit disaster relief and humanitarian aid organization that provides immediate response to emergency medical needs and supports long-term humanitarian assistance programs.



"After being in the Gulf region early on in the disaster, we recognized that the long-term efforts were going to be just as important as the immediate relief needs," said Trish Tweedley, vice president of the AmeriCares Hurricane Relief Program.



As part of AmeriCares longer-term recovery effort, the organization has partnered with the Baton Rouge Area Foundation to develop a funding mechanism to support local mental health providers in recovery efforts in their own communities.



"Funding from AmeriCares will not only provide relief for the people in the affected areas but also for the agencies that have been stretched by the shift in population to Baton Rouge and other communities," said John Davies, president and CEO of the Baton Rouge Area Foundation.



Contact: Melissa Prescott


Louisiana State University

Strategies Evolving As Retractable Safety Syringe Suppliers Strive For Traction

Following the lead of the Needlestick Safety and Prevention Act in the U.S., government regulations regarding syringe needle handling and disposal continue to proliferate worldwide, fostering increased demand in the use of safety syringes. Retractable syringes represent the most elegant approach to addressing the caregiver sharps risk issue by lowering the risk of user error and de-emphasizing the need for a separate sharps disposal step.


New retractable designs address caregiver preferences while reducing part counts and manufacturing steps. These refinements are helping to close the price gap with naked disposable syringes and non-retractable safety devices, and this development will help retractable syringe manufacturers and their distribution partners make a stronger sales case with the healthcare buying groups that account for the vast majority of syringe purchases.


Historical retractable syringe unit growth continues to be modest, hovering in the single digits. While price points remain the single most important factor limiting market penetration, several unrelated issues are slowing the market acceptance of retractable syringes. Many participants in this sector are undercapitalized and unprepared for the lengthy development, approval and sales cycle steps required to establish a foothold against entrenched devices, user habits, buying cycles and competitors. Patent and IP challenges are another risk area that has impacted and in some cases derailed the product plans of aspiring market entrants, while draining the financial resources of others.


Several sector companies are evolving their business strategies to focus on niche opportunities for which retractable safety syringes present strong business and use cases. These developments, long overdue, signify a willingness on the part of syringe developers to accept the role of retractable syringes as a specialty device.


Source

Greystone Associates

Children's Stress Affected By Child Care Providers' Behavior

A new study on preschoolers attending full-day child care in licensed day care homes has found increases in cortisol, a stress hormone, when the children are in child care that exceeds their levels at home. The increases were larger in day care homes where providers were intrusive or overcontrolling.



The study, in the May/June 2010 issue of the journal Child Development, was conducted by researchers at the University of Minnesota, Georgetown University, and the Oregon Social Learning Center.



The researchers looked at about 150 mostly White, largely middle-class 3- and 4-year-olds in 110 different family child care homes, observing the children's behavior at child care as well as the behavior of their care providers, and sampling saliva to measure cortisol levels. Cortisol is a hormone that helps individuals adapt to challenges and stretches their coping skills.



The study found that about 40 percent of the children showed elevations in cortisol that were large enough to indicate that their bodies were stressed. It also found that cortisol increases over the day were larger in settings where care providers were intrusive or overcontrolling. In such settings, children moved frequently between activities, were given relatively little time for free play, and spent long periods of time in structured activities led by the providers. While many of these structured activities seemed designed to help the preschoolers learn letters, numbers, and colors, the activities weren't carried out in a way that allowed the children to learn actively through play, but rather in a rote fashion that required the little ones to sit quietly and respond when called on.



The larger elevations in cortisol meant different things for girls and boys in terms of behavior. Girls with larger increases in the hormone acted more anxious and vigilant at child care, while boys acted more angry and aggressive.



"These findings indicate that the behavior of the care provider is associated with both how well children function at child care, and how much their cortisol is elevated," according to Megan R. Gunnar, Regents Professor of Child Development at the University of Minnesota, who led the study. "They add to our understanding of how children process stressors in child care, highlighting differences between boys and girls in how they express being more physiologically stressed."



The study was supported by the National Institute of Mental Health.

For Children From Disadvantaged Homes The Quality Of Child Care Could Be Key

Decades of research have demonstrated the importance of the resources in children's homes and the benefits of high-quality interactions with parents in supporting healthy development. High-quality child care plays a similar, albeit less powerful, role. Children who come from more difficult home environments and have lower-quality child care have more social and emotional problems, but high-quality child care may help make up for their home environments.



Those are the findings of a new study by researchers at the University of Denver, Georgetown University, American University, Harvard University, and Auburn University. The research is published in the January/February issue of the journal, Child Development.



Researchers used information from a large-scale longitudinal study carried out under the auspices of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The Study of Early Child Care and Youth Development followed children from birth through the middle-school years.



This research looked at the double jeopardy of children at ages 2, 3, and 4-1/2 who come from more difficult home environments and have lower-quality child care. Difficult family environments were characterized by fewer resources, fewer learning opportunities, and less sensitivity and acceptance of the child as rated by trained observers in the home. Lower-quality child care was characterized by fewer observed learning opportunities, caregivers who used negative or neutral facial expressions and tone of voice, as well as insensitive responses, as rated by trained observers in the care environment. The study also assessed the child's age, gender, race, and ethnicity; the family's resources in the child's first 6 months of life and at each assessment age; the age the child started child care; and how many hours per week the child spent in nonmaternal care.



The study found that children in difficult home and child care environments had more social-emotional problems - such as being anxious or fearful; behaving disruptively or aggressively; or being less helpful, friendly, and open to peers - than children who attended lower-quality care but were raised in more advantaged and supportive homes.



It also found that when children who grow up in homes that lack important influences are enrolled in high-quality child care, the child care may compensate for the children's challenging home environments. The researchers posit that experiencing high-quality child care may offer children models of positive ways to express themselves and interact with the world, and provide a safe emotional space to grow and learn. In so doing, children may be protected from developing anxious, fearful, aggressive, or unfriendly behaviors.



"This pattern of findings is consistent with existing evidence that the quality of child care that young children experience may matter more for those from more disadvantaged home environments," according to Sarah Enos Watamura, assistant professor of psychology at the University of Denver, who directed the investigation.



"The study also confirms the importance of integrating early intervention strategies and policies across home and child care environments."

The Emotional Cost Of Nursing

What are the costs of caring? A new project in the School of Psychology explores nurses' experience of distress and aims to determine if empathy with patients is associated with traumatic experience in nurses.


Researcher Jenny Watts said nurses can develop symptoms such as flashbacks, sleeping difficulty and emotional detachment which can have serious consequences for both their personal and professional lives.


She will be presenting her research at the Festival of Postgraduate Research which is taking place on Thursday 25th June in the Belvoir Suite, Charles Wilson Building at the University of Leicester between 11.30am and 1pm.


Miss Watts said: "What is apparent is that nurses who identify with the patient and experience empathy appear to be most vulnerable to distress.


"Nursing is a diverse specialty and patient condition and contact will vary greatly between different wards. Currently the research focuses upon surgery, accident and emergency and children's wards

.
"Nurses caring for patients with dementia and other age related illnesses have shown anxiety and depression following patient deterioration and death.


"Further knowledge about nurse distress is required to shape interventions, reduce staff turnover, improve morale and maintain a high quality of care.


"This knowledge will be applied to shape suitable prevention and intervention strategies."


Miss Watts added that with a growing number of patients aged over 70, it was important to ensure that the nursing force remains healthy, compassionate and able to provide high quality care for older adults,



Miss Watts studied BSc psychology at the University of Stirling, in Scotland. After work experience gained within the National Health Service and Social Services she became intrigued by positive psychology and specifically research aiming to enhance the wellbeing of health professionals.

Philadelphia Inquirer Series Examines Lack Of Health Insurance Among Home Health Aides

The Philadelphia Inquirer on Monday as part of a series titled "Falling Through: Casualties of the Heath Insurance Crisis" examined the lack of health insurance among many home health aides.

The article profiled a 51-year-old home health aide in Pennsylvania who lacks health insurance and receives through her employer a plan that costs $20 to $30 weekly and provides limited benefits. The woman has a hernia that could block her intestine or cause an infection without treatment. In addition, she has interstitial cystitis, a painful bladder condition. In late 2006, the woman, who has an annual income of $28,000, experienced shortness of breath and underwent a stress test that cost $3,500. Her hospital established a payment plan of $25 monthly to cover the cost, but the woman could not afford to make the payments. The woman twice has applied for medical assistance from Pennsylvania, but the state has rejected her application because she does not meet annual income requirements.

According to surveys conducted by the Paraprofessional Healthcare Institute, two-fifths of the estimated 100,000 home health aides in Pennsylvania lack health insurance (Vitez, Philadelphia Inquirer, 10/6).


Reprinted with kind permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation.

© 2008 Advisory Board Company and Kaiser Family Foundation.?  All rights reserved.

American Association For Homecare Takes Issue With CMS Competitive Bidding Claims

The American Association for Homecare (AAHomecare) expressed concerns about the proposed rule for competitive bidding published in the Federal Register on Monday, May 1. The Centers for Medicare and Medicaid Services (CMS) issued the notice of proposed rulemaking (NPRM) for competitive bidding for durable home medical equipment, which is mandated by the Medicare Modernization Act of 2003.



AAHomecare is concerned about patient access to quality care, the impact on small providers, and the Association disputes the claim that competitive bidding will save significant dollars for Medicare.



"Competitive bidding will limit patient choice," said Tom Ryan, AAHomecare Chair and CEO of Homecare Concepts. "Dissatisfied beneficiaries or referral sources can currently choose another provider if they are not satisfied with their service - but the number of choices will be reduced under the national competitive bidding program."



The American Association for Homecare disputes CMS's claim that a national competitive bidding program will save Medicare a significant sum of money in light of the numerous cuts to homecare reimbursement in recent years and the administrative costs of implementing the new contracting system.



Ryan stated, "Homecare providers have seen double-digit percentage cuts from the Medicare Modernization Act of 2003, a freeze on CPI increases until 2008, and institution of a new rent-to-purchase policy for oxygen under the Deficit Reduction Act of 2005. These cuts, freezes, and restrictions come at a time when skilled labor, operational, and fuel costs for delivery of homecare continue to rise at unprecedented rates."



"The reality is some durable medical equipment items have already been set by the government at a price below what the market would set. If a provider cannot bid above a mandated below-market fee ceiling, how does that accomplish the wonders that CMS advertises, which is to 'harness marketplace dynamics to create incentives for suppliers to provide quality items'? The touted cost savings and market-driven benefits of this restrictive contracting program are unrealistic."



AAHomecare believes that managing costs and promoting competition are important goals for homecare under the Medicare program, but these goals must be pursued in a way that protects patients' choice as well as access to quality care. Beneficiaries should at least have the option to opt out of the national competitive bidding program - otherwise, it will serve as a closed-panel HMO.



"It's extremely important to get this program right," Ryan said. "There are many important issues that remain. Much is at stake for Medicare beneficiaries and providers so this program should be rolled out very cautiously."



The American Association for Homecare continues to aggressively support the Hobson-Tanner bill which would amend MMA to add important protections for patients (requiring implementation of quality standards before the bid process begins), exempt rural areas, and allow small providers to continue to participate in Medicare if they meet the competitive price. The bill, introduced by Reps. David Hobson (R-Ohio) and John S. Tanner (D-Tenn.), has more than 100 cosponsors with strong bi-partisan support.



The proposed rule addresses some key aspects of competitive bidding implementation, but many issues, such as the products and metropolitan statistical areas (MSAs) that will be subject to competitive bidding will be determined by CMS at a future date. See aahomecare for AAHomecare's updated summary highlighting key elements of the proposed rule and other documents including the proposed rule itself.




American Association for Homecare

625 Slaters Lane, Suite 200

Alexandria, VA 22314-1171 703-535-1881

aahomecare

Financial, Health Challenges Faced By Nursing Assistant Workforce

A pioneering study of certified nursing assistants (CNAs) in nursing homes reveals that more than half of them incurred at least one work-related injury in the previous year. One in three received some kind of means-tested public assistance, and nearly half of those without medical insurance claimed they could not afford their employer-sponsored plan.



These statistics, gathered from the first-ever National Nursing Assistant Survey (NNAS), are presented in an article appearing in the latest issue of The Gerontologist (Vol. 49, No. 2). The lead author is Senior Policy Analyst Marie Squillace, PhD, of the Office of the Assistant Secretary for Planning and Evaluation within the U.S. Department of Health and Human Services.



"The care of 1.5 million elderly and chronically ill persons in the United States is largely in the hands of nursing assistants - the individuals who provide eight out of every ten hours of care residents receive in nursing homes. Turnover of these direct care workers is high, which profoundly decreases the quality of life and care of the residents," Squillace said.



Many reports - most prominently the Institute of Medicine's 2008 "Retooling for an Aging America: Building the Health Care Workforce" - project there will be a shortage of CNAs in coming years. The federally-funded NNAS can be used to develop a strong evidence base for policy, practice, and research initiatives to improve nursing assistant recruitment and retention efforts.



"The NNAS is useful for improving data quality and bridging knowledge gaps. As the only national database on CNAs in nursing homes, the NNAS will improve our current understanding of a vital job," states Squillace's team of researchers. Previous studies had only examined local or regional samples that were not representative of the country as a whole.



The survey results are based on the responses of 3,017 nursing-home based CNAs. To be eligible to participate in the NNAS, a nursing assistant had to be employed by a nursing home (and not as a contract worker); be certified by the state to provide Medicare/Medicaid reimbursable service; be a speaker of English or Spanish; and be employed more than 16 hours per week.



Slightly more than half (56 percent) reported they were injured on the job at least once in the previous year. Of those who were injured, almost one quarter were unable to work for at least one day as a result.



Approximately 16 percent had no health insurance; 42 percent of that group cited cost as the reason. Years of experience did not translate into higher wages among CNAs. Those with ten or more years of experience averaged just $2 per hour more than aides who started working in the field less than one year ago. The reported median hourly wage was $10.04.



As many as 40 percent of CNAs had at some point in their lives received public benefits (e.g., food stamps, rental subsidies, or Temporary Assistance for Needy Families); almost one third were currently receiving this type of aid at the time of the survey. Additionally, the vast majority of the survey respondents (92 percent) were female.



"These and other forthcoming results will figure prominently in federal and state labor, welfare, and health policy discussions on expanding the pool of workers and on reimbursement policy, regulation policy, and program design," Squillace said. "Ultimately, this will lead to improvements in the quality of life and care of older Americans in U.S. nursing homes."

U.S. Supreme Court Rules Home Health Care Workers Not Entitled To Minimum Wage, Overtime Pay

The Supreme Court on Monday in a 9-0 decision ruled that federal minimum wage and overtime laws do not apply to home care workers, the AP/Lincoln Journal Star reports (Yost, AP/Lincoln Journal Star, 5/11). In the case, Evelyn Coke, a 73-year-old immigrant from Jamaica, filed a lawsuit against New York-based Long Island Care at Home to challenge Department of Labor regulations that exempt home care workers from the laws. The Supreme Court agreed to hear the case after the U.S. 2nd Circuit Court of Appeals overturned the regulations, which the court said conflicted with congressional intent.

Congress in 1974 amended the Fair Labor Standards Act to extend federal minimum wage and overtime laws to household workers but exempted baby sitters and "companions" for the elderly and those with illnesses. In 1975, DOL proposed regulations to implement the revisions to the law that exempted home care workers. In a brief, Long Island Care argued that the regulations were consistent with congressional intent because some lawmakers had raised concerns about the need to reduce costs. According to the brief, "The need to restrain costs in the case of third-party employees has only become more acute as agencies provide an increasing amount of needed care."

However, attorney Craig Becker, who represents Coke, argued that the "exemption for baby sitters and companions Congress had in mind the quintessential neighbor-to-neighbor relations," adding, "Increasingly, this is not a casual form of work akin to baby-sitting but a full-time regular type of employment." The case applies only to home health care workers employed by agencies (Kaiser Daily Health Policy Report, 4/17).

Decision Details
The Supreme Court overturned the appeals court decision and ruled that Congress must amend the Fair Labor Standards Act to extend federal minimum wage and overtime laws to home care workers (Savage, Los Angeles Times, 6/12). In the decision, Justice Stephen Breyer wrote that DOL had the authority to exempt home care workers from federal minimum wage and overtime laws and that "courts should defer to the department's rule" (AP/Lincoln Journal Star, 6/11).

According to the Los Angeles Times, the "impact of the ruling will vary by state" because many states -- including Colorado, Illinois, Kansas, Michigan, Minnesota, Nevada, Pennsylvania, Washington and Wisconsin -- have separate minimum wage and overtime laws that apply to home care workers (Los Angeles Times, 6/12).

Comments
Becker said, "This decision is bad public policy. There's a growing demand for home care workers." He added, "This decision will surely only worsen that shortage." Gerry Hudson -- vice president of the Service Employees International Union, which represents an estimated one million home care workers -- said, "Today's Supreme Court decision is a serious blow to efforts to ensure quality home care in America and underscores how unprepared we are to care for the millions of seniors who will want to live at home instead of institutions" (Johnson, CongressDaily, 6/12).














Nancy Duff Campbell, co-president of the National Women's Law Center, said that the decision is "another blow to struggling, low-wage women." Under the decision, "profit-making companies can legally choose to pay home care workers deplorably low wages or deny them just compensation for overtime," she said (Los Angeles Times, 6/12).

However, Joe Hafkenschiel, president of the California Association for Health Services at Home, said, "This is a very significant ruling and a very good thing. The exemption from overtime is in the public's interest because it keeps prices for these important home care services reasonably priced" (Morrill, Contra Costa Times, 6/12).

"Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Planning Ahead Can Help Caregivers

Caring for a loved one can be a rewarding experience, but it can oftentimes be challenging and stressful work. Taking steps to plan ahead can make a significant difference in relieving stress and help to lighten the caregiver's load.


Most Americans will face the challenges of caregiving at some point in their life. According to the Office on Women's Health, a division of the U.S. Department of Health and Human Services, more than 44 million Americans are already providing unpaid care to an elderly or disabled person 18 years or older in any given year.


"As a company that specializes in the retirement market, we know that people want to live on their own for as long as possible," explains Scott Perry, president of Bankers Life and Casualty Company, a national health and life insurer. "Thanks to the selflessness of their caregivers, many are able to fulfill that wish."


Family Caregiving 101, a Web site launched by the National Family Caregivers Association (NFCA) and the National Alliance for Caregiving (NAC), advises potential care providers to start by learning about eldercare issues such as Medicare, living wills and powers of attorney.


"Caregivers should also make it a point to know who their loved one's physicians are, the medications they take and why, and details about their condition," said Perry. "This information can better prepare them for unusual situations that may be encountered when caring for someone. It can also help plan future care needs."


Many national and local associations provide comprehensive support for specific conditions. The Alzheimer's Association, which Bankers Life and Casualty Company supports with an annual fundraiser, offers programs and services that help those affected by Alzheimer's. These include a toll-free help line available 24/7: (800-272-3900); an informative Web site (alz); and local services including information and referral, education, and support groups.


For more topics of interest to seniors, visit bankers and click Senior Resources.

Source
National Family Caregivers Association

Effectiveness Of Advance Directives Compromised By Legal Restrictions

Current legal restrictions significantly compromise the clinical effectiveness of advance directives, according to a study by researchers at the University of California, San Francisco.



Advance directives allow patients to designate health care decision-makers and specify health care preferences for future medical needs. However, "the legal requirements and restrictions necessary to execute a legally valid directive prohibit many individuals from effectively documenting their end-of-life wishes," said lead author Lesley S. Castillo, BA, a geriatrics research assistant in the UCSF Department of Medicine.



The authors suggest that advance directive law and advance care planning evolve from what they call a current "legal-transactional approach" into a "flexible, relationship-and communication-based model," in which any type of advance care planning tool or discussion, including advance directives, can help guide clinical care.



Currently, tension exists between advance directive law and what occurs in clinical practice, noted principal investigator Rebecca Sudore, MD, an assistant professor of medicine at UCSF. In the clinical setting, she said, "advance directives often are just one piece of information among many that are used as guidelines when determining a patient's wishes and health care preferences." Conversely, said Sudore, advance directive law "takes a much more rigid approach to advance care planning - one that is more akin to signing a will than having a conversation between physicians and family members."



Castillo and her co-authors list a number of legal barriers to the clinical effectiveness of advance directives, including requirements that certain legal terms be used, regardless of the patient's reading comprehension level or native language; restrictions on who may serve as a patient's health care agent or surrogate, such as anyone who works for a clinician including a case manager; and technical hurdles such as not allowing oral advance directives and requiring a witness's or notary signature for advance directives to be legally valid.



Other barriers include lack of reciprocity from state to state, lack of attention to religious, social and cultural preferences - for example, allowing family instead of an individual to serve as the surrogate, and encouraging documentation of specific death rituals.



"Vulnerable populations are most likely to be affected by these barriers," said Castillo. "These include patients with limited literacy levels and limited English proficiency, same-sex or domestic partners, and patients who are isolated and without friends."



To improve the clinical efficacy of advance directives, the researchers suggest doing away with mandatory legal language to improve readability; relaxing health care agent and surrogate limitations to expand the potential pool of medical decision-makers, including non-medical professionals who may be close to unbefriended adults; promoting universal acceptance of oral advance directives; and eliminating witness and notary requirements.



They also recommend that all states adopt nonrestrictive reciprocity laws for directives from other states, regardless of the location or type of advance care planning tool used, and urge that patients be allowed to document their religious, social, and cultural values and preferences for end-of-life care.


Notes:


The study, which surveys medical and legal literature from across the United States, appears in the January 18, 2010 issue of the Annals of Internal Medicine.



Co-authors include Brie A. Williams, MD, of UCSF; Sarah M. Hooper, JD, of UC Hastings College of Law; Charles P. Sabatino, JD, of the American Bar Association; and Lois A. Weithorn, PhD, JD, of UCHCL.



The research was supported by funds from a Pfizer Fellowship in Clear Health Communication, UC Hastings College of Law, and the Department of Veterans Affairs.



UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.

Alzheimer's Society Comment On Care Homes, The Human Rights Act And Department Of Health Announcement On Elder Abuse Research, UK

Two thirds of the country's care home residents are living with dementia.


This hat-trick of announcements will play an important part in tackling the abuse and neglect of people with this devastating condition and help ensure failing homes are forced to improve standards.


Human rights are not privileges, but rights, which are now guaranteed for many more care home residents with dementia due to amendments to the Health and Social Care bill. The welcomed closure of this legal loophole will provide an important safety net for both them and their families.


Too many people with dementia are still being subjected to abuse or neglect in residential care. This important new research into the dignity and safety of older people in institutional settings will help us understand the scale of the problem and the reality of what happens behind the horror stories.


People with dementia must be able to report concerns about their treatment regardless of how they pay for residential care. It will be interesting to see how the role of an independent adjudicator to support residents funding their own care will be developed by the government later this year.


Note


- Alzheimer's Society is the leading care and research charity for people with all forms dementia and their carers. It provides information and education, support for carers, and quality day and home care. It funds medical and scientific research and campaigns for improved health and social services and greater public understanding of dementia.


- The Alzheimer's Society provides a national help line on 0845 3000 336 and website alzheimers.uk. Please include this information in any publication that uses these comments.

Alzheimer's Society

Smoothing TheTransition From Care Of Pediatric Disease To Adult Care

Growing pains can mean one thing for a typical adolescent and quite another to an older teen with cerebral palsy attempting independence in an adult world. A unique program, the Indiana University School of Medicine Center for Youth and Adults with Conditions of Childhood (CYACC) is helping these youths spread their wings and live more independently.



IU pediatricians at Riley Hospital for Children have been at the forefront of innovative care for patients, including advances that over the past three decades have created new challenges for patients with special needs and their caregivers. Now, Riley physicians are leading the way to providing a solution.



CYACC provides interdisciplinary consultation in a health-care setting to specifically address transition and adult life issues regardless of the youth or adult's diagnosis.



"Twenty to 30 years ago it was not unusual for children with serious congenital or developmental conditions to die before reaching adult life," said Mary Ciccarelli, M.D., an assistant professor of clinical medicine and pediatrics at the IU School of Medicine and medical director of CYACC. "Today, the life expectancy of many of these children reaches well into adulthood yet there are few programs available to help them transition to independent lives with both the best health status and the fullest participation in their communities."



Nationally, there are only a handful of programs that are beginning to address the need, Dr. Ciccarelli said. It is estimated that 4,000 Indiana youth with special health-care needs experience transition into adult life each year.



CYACC patients, who are between the ages of 11 and 22 years, are seen at the Wishard Primary Care Center on the IU Medical Center campus. Frequent diagnoses of patients served by the CYACC team are cerebral palsy, Down syndrome, autism, diabetes, rheumatologic disorders and spina bifida. Resources in many specialties and disciplines are involved to successfully integrating youth with chronic conditions into the adult world.



Psychosocial, educational, vocational and medical needs of the adolescents are addressed by the interdisciplinary team of physicians, nurses, social workers and community organization liaisons. Health-care coverage options and applications are made available. Family support and education are provided. While increasing numbers of community programs provide resources or accommodations for those with disabilities, many families are not aware of these opportunities in their communities. Collaboration is tailored for each individual with schools, employers, and agencies that can provide services for youth and their families.



Coordination of medical care also is one of the key issues the team addresses. With more than 300 unusual chronic conditions with onset in childhood, adult practitioners often have never provided care for individuals with the majority of these conditions. Pediatric doctors are trained to care for youth with childhood diseases but are not routinely familiar with addressing issues such as reproduction and other health issues common in adult life.



The team approach provides hands-on learning opportunities for IU School of Medicine physician residents in training. By involving the young physicians, CYACC extends its mission; these residents will take with them an awareness of the comprehensive medical, social and educational needs of this group of patients as they begin their careers in Indiana or elsewhere.







CYACC is currently funded by the Indiana State Department of Health and the Indiana State Division of Disability, Aging and Rehabilitative Services.

8 Out Of 10 People Who Care For A Relative Suffer From Anxiety And Stress, According To A Study

Conducted at the Department of Developmental and Educational Psychology from the University of Granada, the research reveals that the negative effects on the caregiver's physical, psychological and social development are highly associated with previous life history between caregiver and care receiver. To carry out this work, researchers applied a questionnaire to a population of 203 subjects whose only requirement was to be the informal caregiver of a dependent elderly person.


8 out of 10 people in charge of caring for a relative suffer from anxiety and stress, regardless of their socio-demographic variables. Families, and particularly daughters, assume the "informal care" of dependent elderly people in most of the cases. This follows an investigation carried out by Ruth M ?? Calero P?©rez and directed by professor Jos?© M?? Roa Venegas at the Department of Developmental and Educational Psychology at the University of Granada.


The work in the UGR shows that in some cases this care in the family creates inappropriate behaviour in the relationship, and that the negative effects on the physical, psychological and social caregiver are highly related to the previous life history between caregiver and care recipient, social isolation felt by the caregiver, and the feeling of loneliness in the relationship with the care recipient.


To carry out this work, the researchers applied a questionnaire to a population of 203 subjects whose only requirement was to be the informal caregiver of a dependent elderly person.


Family and institutional support


Results reveal that both positive and negative cognitive variables (thoughts and assessments) used by the caregiver have a decisive influence on how caregiver and care receiver relate to each other. These variables include family support and institutional support, and modulate the relationship between caregiver and care receiver.


In addition, cultural variables such as parenting patterns and styles of education received, have clear implications in the way of being and acting of informal carers, which will impact on the work of caring.


Researchers from the UGR intend to monitor all these variables as a first step towards government intervention in order to improve the quality of life of this group, and consider that this action "should use a psychoeducational approach and, somehow, ensure a better quality of life for dependent elderly people's carers.


The fact is that the relationship between informal caregiver and care recipient, the authors note, "it is not an innocuous relationship, but it is full of effects, sometimes harmful, for the caregiver's physical and psychological health. Effects of stress, anxiety, stress, etc., are known to affect the informal caregiver. But we believe these variables are insufficient to explain the variability that occurs in the conduct of the caretaker in his relationship with the care receiver. Therefore, it seemed interesting to us to introduce variables of a cognitive and (rather less studied) socio-cultural nature, in order to clarify that variability as far as possible."

A Breath Of Fresh Air: New National Guideline Will Provide Clarity On Emergency Oxygen Use In Adults, UK

The first national guideline for the emergency use of oxygen in adults has been published, with the aim of simplifying oxygen delivery and better protecting acutely ill patients. Developed by a working party and led by the British Thoracic Society (BTS), the guideline is published in the October 2008 issue of Thorax1, the journal of the BTS, and is supported by 22 professional societies and institutions.



Until now, most healthcare professionals have followed their own institution's customary practice when administering oxygen therapy, and it is this lack of consistency and clear guidance that the BTS' guideline aims to correct.



Oxygen is one of the most widely used drugs, and is used across the whole range of healthcare specialities. Oxygen is an extremely important drug because hypoxaemia can cause death during many medical emergencies and it is essential to protect patients from this risk by the rapid recognition of acute illness and hypoxaemia followed by the immediate provision of oxygen to hypoxaemic and critically ill patients.



The guideline recommends that oxygen is administered to patients whose oxygen saturation falls below the target saturation ranges (94-98% for most acutely ill patients and 88-92% for those at risk of type 2 respiratory failure with raised carbon dioxide level in the blood), and that those who administer oxygen therapy should monitor the patient and keep within those specified target saturation ranges.



Dr Ronan O'Driscoll, of the Department of Respiratory Medicine, Salford Royal University Hospital, one of the respiratory physicians who led the development of the guideline said: "The development of this landmark guideline is a vital step in the recognition of oxygen as a carefully targeted therapeutic agent. For the first time, delivery of oxygen will be controlled and monitored in accordance with the best available evidence, allowing patients to receive better, more effective care."



The BTS' Standards of Care Committee established a working party, in association with 21 other Societies and Colleges, to produce an evidence-based, up-to-date guideline for the UK. BTS President Prof Martyn Partridge said: "This guideline is a welcome step forward in the delivery of oxygen in many different settings, which should translate into even better care for acutely ill patients."



Despite a widespread belief amongst medical staff, and patients, that oxygen relieves breathlessness, there is no evidence that oxygen has an effect on breathlessness if the blood oxygen level is normal. The guideline group advised that too much oxygen can prove harmful in patients with chronic lung diseases such as chronic obstructive pulmonary disease (COPD), and 'blind' oxygen therapy outside of critical illness might actually delay recognition of a patient's deterioration by providing a false sense of reassurance based on high oximetry measurements.



Historically, oxygen therapy has been delivered via complex protocols, involving either unreliable clinical examination or taking blood from the arteries. The widespread use of oximeters, in both hospital and community settings, makes the controlled, adjustable use of oxygen and reliable monitoring of oxygen saturation levels possible for the first time. The guideline also recommends that pulse oximetry should be available in all locations where emergency oxygen is used.
















The biggest changes that people will notice are as follows:


- Oxygen therapy will be adjusted to achieve target saturations rather than giving a fixed dose to all patients with the same disease.


- Nurses will make these adjustments without requiring a change to the prescription on each occasion.


- Most oxygen therapy will be from nasal cannulae rather than masks.


- Oxygen will not be given to patients who are not hypoxaemic (except during critical illness)


- Pulse oximetry must be available at all locations where emergency oxygen therapy is used.


- Oxygen will require a prescription in all situations except for the immediate management of critical illness.



To ensure widespread and accurate take-up of the guidelines, the BTS has taken the innovative step of identifying 'oxygen champions' in every hospital in the UK. The 'oxygen champions' will facilitate training and will disseminate the supportive educational materials and new standardised documentation for the prescription and monitoring of emergency oxygen use, which have also been developed. This aims to reduce the existing confusion around oxygen prescription and use in emergency settings and cut through the often-conflicting advice given in training and practice.



More information and an abbreviated copy of the BTS Guideline for Emergency Oxygen Use in Adult Patients for download are available on brit-thoracic.uk.



The British Thoracic Society is the UK's professional body of respiratory specialists.



Reference:


1. Thorax 2008;63(Suppl VI):vi1-vi68.

British Thoracic Society

Child Care Linked To Assertive, Noncompliant, and Aggressive Behaviors

Vast Majority of Children Within Normal Range


The more time children spent in child care from birth to age four-and-a-half, the more adults tended to rate them, both at age four-and-a-half and at kindergarten, as less likely to get along with others, as more assertive, as disobedient, and as aggressive, according to a study appearing in the July/August issue of Child Development.


However, the researchers cautioned that for the vast majority of children, the levels of the behaviors reported were well within the normal range.



In fact, a mother's sensitivity to her child was a better indicator of reported problem behaviors than was time in child care, with more sensitive mothering being linked to less problem behaviors. Higher maternal education and family income also predicted lower levels of children's problem behaviors.



The findings are from the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development.



'It's important to put these findings in perspective,' said Duane Alexander, M.D., Director of the NICHD. 'The amount of time in child care is one of several family and child care factors linked to children's behaviors, both positive and negative.'



The NICHD launched the study of early child care in 1991. The 27 researchers conducting the study have been following the development of more than 1000 children from across the United States.


The children were enrolled in the study at birth and come from an ethnically and economically diverse sample of families.


In addition to focusing on time in child care, the current article focused on several other aspects of the child care experience: the quality of the child care arrangement, the proportion of time that the child was in a child care center, the proportion of time that the child was cared for in a group setting, and the number of times that the mother reported that the child started a new child care arrangement.



In the current article, the researchers describe how child care experiences in the first four-and-a-half years of the children's lives relate to children's social competence and behavior problems, when the children were four-and-a-half years old, and later, when they reached kindergarten.



The study measured children's social behavior by having mothers, child care providers and teachers complete standardized ratings of children's behavior problems and social competence - their ability to get along with children and adults and their ability to follow social rules. Information about the number of hours the children were in child care was obtained from the mothers every 3-4 months.



The link between time in child care and problem behavior was greater than the link between infant temperament and problem behavior or maternal depression and problem behavior. This link between time in child care and problem behavior was also greater for children in center-based care than for children in other types of care.
















The study authors noted that, of the children who displayed problem behaviors, the majority were well within the normal range. A small proportion of children showed levels of problem behavior that should be monitored to see if they developed into more serious problems.

The proportion of children showing these higher levels of problem behavior is commensurate with the proportion of children in the U.S. population as a whole who also display these problems.



The link between time in child care and problem behavior occurred across all family backgrounds and all types and quality of care. The authors added that the time in child care during infancy did not appear to have a greater bearing on the children's behavior than did the time they spent in care after infancy.


The researchers also found evidence that children who experienced better quality child care - in which caregivers provided intellectual stimulation and were warm, positive, and sensitive to child behavior-had fewer child caregiver/teacher - reported problem behaviors and conflict than did children who experienced lower quality care.

The researchers noted, however, that high quality child care did not eliminate the link between hours in care and behavior problems.



The researchers could find no threshold of child-care hours above which problem behaviors were especially likely to emerge.



To illustrate the reported findings that were based on the information from the group as a whole, the researchers classified the children into four groups, based on the amount of time they spent in child care:



16 percent of children were in child care an average of 0-9 hours a week


38 percent for 10-29 hours


36 percent for 30-45 hours

10 percent for more than 45 hours a week.



In each of these groups, a minority of the children had a high score on behavior problems. However, the percent of children with high scores increased with the increase in the number of hours children spent in child care.



Children were rated by mothers and teachers on items such as: child demands a lot of attention; argues a lot; bragging and boasting; cruelty, bullying or meanness to others; destroys things belonging to others; disobedient at home; disobedient at school; gets into many fights; lying or cheating; screams a lot.



One of the important findings of this study is that the strongest predictor of how well a child behaves was a feature of maternal parenting that the researchers described as sensitivity - how attuned a mother is to a child's wants and needs.

The behaviors of the sensitive mother are child centered; the sensitive mother is aware of the child's needs, moods, interests, and capabilities. She allows this awareness to guide her interactions with her child. Children of more sensitive mothers were more competent socially, less likely to engage in disruptive behavior, and less likely to be involved in conflicts with their caregivers and teachers.



Similarly, children whose parents had higher incomes and who were more highly educated also were more socially competent and less likely to engage in problem behaviors.



The study authors noted that their study was not designed to prove a cause and effect relationship. That is, the study cannot prove whether spending more time in child care causes children to have more problem behaviors. The behavior problems the researchers documented might be due to some other characteristic of the children or of their environment.

Accompanying editorials in the July/August issue of Child Development offer possible explanations.



Findings previously reported from the NICHD Study of Early Child Care and Youth Development showed that more time in care predicted more problem behavior among two-year olds, but not among three-year olds; less sensitive maternal behavior and less harmonious mother-child interaction when children were 6-36 months of age; as well as higher rates of insecure attachment to the mother if the mother's parenting was relatively insensitive.



Preliminary findings pertaining to the research questions posed and answered by the current article were presented at the meeting of the Society for Research in Child Development in April of 2001. In the future, the researchers plan to focus on the relation between hours spent in child care and children's behavior during the school years.



The NICHD is part of the National Institutes of Health (NIH), the biomedical research arm of the federal government. NIH is an agency of the U.S. Department of Health and Human Services. The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. NICHD publications, as well as information about the Institute, are available from the NICHD Web site, nichd.nih, or from the NICHD Information Resource Center, 1-800-370-2943; e-mail NICHInformationResourceCentermail.nih.

Rubber Gloves: "Born" And Now Banished

William Stewart Halsted, The Johns Hopkins Hospital's first surgeon in chief, is widely credited as the first to develop and introduce rubber surgical gloves in the United States. That was in 1894, five years after the institution opened.


Now, in an effort to make medical care safer for patients and health care workers, The Johns Hopkins Hospital has become the first major medical institution to become "latex safe" by ending all use of latex gloves and almost all medical latex products.


"Latex hospital gloves were invented here, so it's only fitting that Johns Hopkins takes the initiative to promoting alternatives," says Johns Hopkins anesthesiologist Robert H. Brown, M.D., M.P.H., the chair of the John Hopkins Hospital Latex Task Force and one of many Hopkins faculty and staff members who have contributed to making the hospital latex-safe.


It was at Hopkins that immunologists Robert Hamilton, Ph.D., and Franklin Adkinson, M.D., conducted early key research related to the problems of natural rubber latex as an allergen. Furthermore, Brown points out, the nurses and other frontline hospital workers have been instrumental in implementing the latex-safe policy and educating the staff. Studies show that roughly 6 percent of the general population and up to 15 percent of health care works are allergic to latex, with the higher rate among medical personnel due to longer periods of contact with natural rubber. In addition to surgical gloves, latex is used in numerous medical devices such as tourniquets, blood pressure cuffs and stethoscope tubes. The anaphylactic reactions, similar to those caused by foods such as peanuts or by bee sting allergies, can include a drop in blood pressure, an irregular heartbeat, swelling in the hands and feet and constriction of the airways. In extreme cases, anaphylactic shock, which can occur minutes after the exposure, can lead to death.


Allergic reactions generally result from exposure to natural proteins, in this case proteins specific to natural rubber latex, a product from rubber trees.


Currently available replacement gloves are made of one of three synthetic products -- neoprene, polyisoprene or vinyl, none of which contain natural plant proteins.


Johns Hopkins is now using sterile neoprene and polyisoprene gloves in the operating room because they have a more sensitive feel.


"The sensitivity and fit of the new gloves are the same as what you get with latex gloves," says Julie Freischlag, M.D., professor and chair of surgery. "Unless someone told you, you wouldn't know the difference. The only down side is that they are a little more expensive."


Sterile neoprene and polyisoprene gloves cost 30 percent to 50 percent more than latex gloves. Nonsterile neoprene and vinyl examine gloves cost approximately the same as those made from latex. Johns Hopkins uses mostly neoprene gloves for all nonsterile procedures that require glove protection.
Dr. Brown says the risk of developing an allergic reaction to latex is higher if contact is made with broken skin or mucous membranes such as when hands are raw from multiple scrubbings or when health care workers breathe in the powder that makes the gloves easier to put on. Patients for whom latex medical products are commonly used for treatment such as children with conditions such as bladder exstrophy or spinal bifida can have as high as an 80 percent chance of developing an allergic reaction to the natural rubber latex.


Halsted is reported to have developed the latex glove to protect the hands of his scrub nurse from the harsh antiseptics in widespread use as disinfectants. By 1966, disposable latex gloves were the norm in operating rooms nationwide, and in the 1980s, the need for "universal precautions," prompted by the AIDS epidemic, increased their use outside the operating room and among health care workers everywhere. As glove use proliferated, so did the rate of allergic reactions, and by the mid-1990s, latex allergies were considered a major health issue. Dr. Brown says he prefers the term "latex safe" to "latex free" because removing all sources of natural rubber remains a bit of a challenge.


"We are still searching the hospital for the few remaining medical latex products that we might have overlooked, although we can safely say that all major latex products that are a clear risk to health care workers and patients have been eliminated," he says.


Johns Hopkins Medicine

901 S. Bond St., Ste 550

Baltimore, MD 21231

United States

hopkinsmedicine

Intel Launches Online Community To Connect Family Carers And Nurses In The UK

With a goal to assist carers in the United Kingdom, Intel Corporation unveiled ConnectingForCare.co.uk, the first online community of its kind for family carers, community and district nurses, healthcare assistants, social care workers and others to share information and provide emotional support to one another, filling a void in today's healthcare system.


Developed by Intel, in collaboration with Counsel and Care, The Princess Royal Trust for Carers and The Queen's Nursing Institute, ConnectingForCare.co.uk uses the Internet to build a sense of community among carers through interactive forums, personal profiles and links to the latest research or treatments. The forums will allow carers to engage with one another at any time, ultimately leading to better coordination of care between the various groups.


Stephen Burke, Chief Executive of Counsel and Care said: "The growing number of carers in the UK need more support, guidance, information and resources to help them continue in their caring role. Too many carers go without the support they are entitled to, or risk their own health because they cannot access the essential support they need. ConnectingforCare.co.uk links unpaid carers with professional carers, giving them an opportunity to develop new coping skills, and helping them to become more effective in their role."


"Community nurses have always considered patients, their families and informal carers to be essential partners in their work," Rosemary Cook, Director of The Queen's Nursing Institute said. "Without this shared endeavour, many patients would find it much harder, and sometimes impossible, to cope. So we are very pleased to support this initiative to enable everyone involved in care in the community to share experience, expertise and support."


The Princess Royal Trust for Carers estimates that there are 6 million carers in the UK and that 13 million people can expect to become carers in the next decade.


British actress Pam Ferris (best known for her roles as Ma Larkin from the TV series "The Darling Buds of May" and more recently Aunt Marge in the Harry Potter films), Vice President of The Princess Royal Trust for Carers, knows from personal experience the challenges faced by carers. "Most caring experiences are borne out of crisis. You find yourself thrust into a whole new world which can be very demanding, draining and isolating," she said. "Being able to connect with not only other family carers but also healthcare professionals for advice and support during those difficult moments is invaluable. The Connecting for Care website offers a place for the exchange of experiences, expertise and knowledge and is a welcomed addition to the carer community."


The Carers Week survey results announced this week revealed that 77 percent feel their health is worse as a result of the strain of caring, and well over half have not had a chance to discuss their concerns about their mental or physical health with someone else, either a friend or healthcare professional. ConnectingForCare.co.uk offers a gateway for communication with other carers which may help alleviate the isolation that many carers experience on a daily basis.















ConnectingForCare.co.uk is part of Intel's commitment to finding new and innovative ways to apply technology to support today's carer population and improve health outcomes. Since 1999, Intel has focused on research-driven solutions for improving the care of aging and chronically ill individuals in home and clinical settings. This research continues to drive a variety of product offerings, aimed to assist those with various conditions as well as members of the care team. For example, the Intel Mobile Clinical Assistant (MCA) platform was designed to enable nurses to access patient records at the point of care, helping them spend more time with patients, remain connected while on the move and manage the administration of medications.


Intel shares a vision with healthcare leaders of using technology to enhance the healthcare experience, increase quality of care and reduce the burden on the healthcare system. This campaign is a natural outgrowth of Intel's focus on people-centred innovation, providing a way to not only improve the quality of healthcare and reduce the burden of caring, but also a way to connect people and build a sense of community.


"Intel respects and honours the important work of carers around the world," said Louis Burns, vice president and general manager of Intel's Digital Health Group. "By developing ConnectingForCare.co.uk we hope to not only celebrate this dedication, but also to use our expertise in technology as a tool to support and encourage the community to share information and ultimately improve the quality of life for both the patients and the carers."


ConnectingForCare.co.uk provides various ways for carers to interact with one another. Highlights include:


- My Connections: a page where carers can create a personal profile and join a variety of networks based on their specific needs and interests. Carers can directly connect with others within their networks to share stories, tips and support.


- Forums and message boards where carers can discuss issues or concerns and pose questions to the community - linking carers to each other in an active dialogue 24 hours a day.


- Information centres on a range of chronic diseases and conditions where carers can search for information and connect on health-specific topics. Within these centres, users can add comments and link to the latest research and resources on caring for individuals with specific conditions, including Alzheimer's, Parkinson's, diabetes, COPD and heart failure.


- Spotlight on: a section where users can publicly honour carers who have touched their lives. Patients, loved ones and fellow carers can use this feature to recognise carers and share their stories.


About Intel


Intel, the world leader in silicon innovation, develops technologies, products and initiatives to continually advance how people work and live.

intel

UNISON Appeals For Urgent Action Over Care Worker Deportations, UK

UNISON, the UK's largest public sector union, is calling for urgent Government action, to stop the wholesale deportation of much needed, highly skilled senior care workers. The union is making representations to the government as a result of a growing number of pleas for help from care workers across the UK. The complaints come from workers who currently care for the elderly in residential care homes and in the community but face deportation because of unfair changes to the immigration rules.


The union is also exploring the possibility of mounting a legal challenge to the Home Office's revised policy decision not to issue any more new or renew any existing work permits for senior care workers.


Heather Wakefield, UNISON's Head of Local Government, said:


"These senior care workers are a tried and tested workforce who, day in day out, deliver high quality care to the elderly. This is a real vocation and we simply cannot afford to lose this skilled and dedicated workforce.


"These are the people who make such a difference to the comfort and security of elderly residents in care homes across the country. They also provide home care services that give the support needed to elderly people, to allow them to stay in their own homes, instead of being forced into residential care.


"UNISON will be doing all it can and adding its weight to the growing number of voices protesting at this unfair change in policy."


UNISON is also sending out urgent guidelines to staff in its regions to help them respond to the growing number of requests for help from members threatened with deportation.


Heather Wakefield went on to say: "We have to move quickly or it may be too late for some members who have already been refused new work permits. We are also working with employers on this issue and issuing advice about steps to take if their staff are refused permits."

unison.uk

Antipsychotics In Older Adults With Dementia Associated With Serious Adverse Events And Death

Short term courses of antipsychotic medications, when given to older
adults with dimentia, are associated with a greater risk of
hospitalization and death, according to a report released on May 26,
2008 in the Archives of Internal Medicine, one of
the JAMA/Archives journals.



Antipsychotic drugs are used to treat various psychotic disorders --
some conventional examples include haloperidol or loxaprine. The
authors point out that a new generation of these drugs has been
released, but the effects of short term prescription have not yet been
ascertained. "Newer antipsychotic drugs (olanzapine, quetiapine
fumarate and
risperidone) have been on the market for more than a decade and are
commonly used to treat the behavioral and psychological symptoms of
dementia," they say. "Antipsychotic drugs are often used for short
periods to treat agitation
in clinical practice. They are frequently prescribed around the time of
nursing home admission." Approximately 17% of nursing home admission
begin a regimen of antipsychotic medications, with only 10% on a single
prescription. Given this information, they say, it is important to
evaluate the effects of short term regimens on patients.



To investigate this issue, Paula A. Rochon, M.D., M.P.H., F.R.C.P.C.,
of the Institute for Clinical Evaluative Sciences (ICES), Ontario, and
colleagues examined older adults living with dementia in the community
and in nursing homes between 1997 and 2004. In each setting, three
separate groups of equal size were identified, each differing only in
their exposure to antipsychotic medications. One group had not received
antipsychcotics, one group had been prescribed atypical or newer
antipsychotics, and the last group was prescribed conventional
psychotics. For older adults in the community, 6,894 were in each group
for a total or 20,682 patients. In the older adults with dementia
living in nursing homes, each group had 6,853 for a total of 20,559
subjects.



The medical records of each participant were examined, and hospital
admissions and death within 30 days of the initiation of therapy were
noted as serious adverse events. The team found that, in the general
community, those prescribed with nonconventional antipsychotic drugs
were more likely to experience adverse events, while those on
conventional antipsychotic drugs were even more likely. "Relative to
community-dwelling older adults with dementia who did not
receive a prescription for antipsychotic drugs, similar older adults
who did receive atypical antipsychotic drugs were three times more
likely and those who received a conventional antipsychotic drug were
almost four times more likely to experience a serious adverse event
within 30 days of starting therapy." The authors continue, noting a
similar but less pronounced trend in the nursing room group: "Relative
to nursing home residents in the control group, individuals in
the conventional antipsychotic therapy group were 2.4 times more likely
to experience a serious adverse event leading to an acute care hospital
admission or death. Those in the atypical antipsychotic group were 1.9
times more likely to experience a serious adverse event during 30 days
of follow-up."



The precise number of adverse events may be underestimated in this
study, because the length of follow-up was so short, according to the
authors. Also, often, the serious events experienced by nursing home
residents are taken care of within the facility, without hospital
admission. Additionally, when physicians notice signs of a problem
early, they may take patients off of antipsychotics. This could avoid
more serious consequences. The authors indicate that this only cements
the need for further research to this end. "Our results exploring
serious adverse events likely identify only the 'tip of the iceberg',"
they say. "Antipsychotic drugs should be prescribed with caution even
for short-term therapy."



Antipsychotic Therapy and Short-term Serious Events in Older Adults
With Dementia

Paula A. Rochon; Sharon-Lise Normand; Tara Gomes; Sudeep S. Gill;
Geoffrey M. Anderson; Magda Melo; Kathy Sykora; Lorraine Lipscombe;
Chaim M. Bell; Jerry H. Gurwitz

Arch Intern Med. 2008;168(10):1090-1096.

Click Here For
Journal



Written by Anna Sophia McKenney