"You May Be Uncomfortable Providing This Type of Care"

There are many Caregiver manuals available on the internet that offer guidance on providing assistance with activities of daily living. For example, see "Family Caregiver Handbook," State of Washington, http://www.dshs.wa.gov/pdf/Publications/22-277.pdf.

It is not uncommon to find this phrase, "You may be uncomfortable providing this type of care" only in the section addressing toileting assistance. Speaks volumes about the "yuk" factor associated with toileting? Yet another indication that improvements in toileting caregiving/carereceiving are long past due.

Unique Collaborations Needed to Improve Home Med Equipment

Seeking Alpha (seekingalpha.com) reports on July 29th: Novartis (Pharma), Medtronic (Med Device), Oracle (Software) and Kaiser Permanente (Health System) among those providing Proteus Digital Health with $172M to develop "a 'smart pill' that a patient swallows. It records data on the internal milieu and transmits it externally via a patch on the abdomen. Reactions with stomach juices provide the power."

Hopefully, companies will grow in their willingness "to play with others" to get cross-cutting improvements in healthcare interventions to market. No longer do the solutions sit within the domain of any one sector!

Toileting Assistance: 2ND MOST FREQUENT MOVEMENT TASK

In a report sponsored by the National Alliance for Caregiving to identify ways technology can support family members and friends who help sustain elderly, disabled, sick and recovering patients, a panel of national experts and government officials used a "task matrix" to understand the frequency of demand for assistance with movement. HELP TO/FROM THE TOILET was the SECOND MOST FREQUENT TASK, only behind "Help in/out of bed/chair." Perhaps another indication of the need to improve the bedside commode, a common toilet substitute for the mobility impaired? Catalyzing Technology to Support Family Caregiving, http://www.caregiving.org/wp-content/uploads/2010/01/Catalyzing-Technology-to-Support-Family-Caregiving_FINAL.pdf

Will Worker Compensation Costs Decrease if Home Med Equip Design Is Improved?

In 2010, nursing aides, orderlies and attendants suffered 249 incidences per 10,000 workers [versus 34 for all U.S. workers] of musculoskeletal (MS) disorders, such as back injuries due to lifting. "High rate of health care worker injuries worries employers and insurers," posted on: Aug. 25, 2013 6:00 AM CST by Roberto Ceniceros, Business Insurance.

In a study of 13 years of worker compensation costs in a large tertiary hospital and affiliated community hospital setting, "patient-handling injuries (n=1543) were responsible for 72% of MS injuries and 53% of compensation costs among patient care staff. Mean costs per claim were 5 times higher for those over age 45 than those <25 years of age. Physical and occupational therapy aides had the highest cost rates ($578/FTE) followed by nursing aides ($347/FTE) and patient transporters ($185/FTE). There was an immediate, marked decline in mean costs per claim and costs per FTE following the policy change and delivery of lift equipment." Evaluation of direct workers' compensation costs for musculoskeletal injuries surrounding interventions to reduce patient lifting. Lipscomb HJ1, Schoenfisch AL, Myers DJ. http://www.ncbi.nlm.nih.gov/pubmed/22199366

A 2009 review of the published literature on use of lifting equipment found "16 individual and 45 environmental barriers and facilitators . . . The most important environmental categories were 'convenience and easy accessibility' (56%),'supportive management climate' (18%) and 'patient-related factors' (11%). An important individual category was motivation (63%)." Determinants of implementation of primary preventive interventions on patient handling in healthcare: a systematic review. Koppelaar E1, Knibbe JJ, Miedema HS. http://www.ncbi.nlm.nih.gov/pubmed/19228679

As reported in the Herald Sun, Melbourne, Australia: "A graduate nurse who says she injured her back moving an obese patient is suing the hospital amid a raft of similar complaints, [charging that the] injuries [were] triggered by trying to shift the “unco-operative” ­patient in a faulty commode have left her unable to work. The suit comes as the nursing union warned that nurses and midwives were at serious risk of injury if hospitals failed to follow safe handling guidelines for obese patients. The nurse says her injury from the December 2008 incident was exacerbated after she slipped on a wet floor, as well as through other heavy and repetitive duties during her time at *** Hospital, [alleging that] the hospital was negligent because [she] wasn’t given any help or instruction on how to heave the patient on her own and wasn’t warned the person was ­stubborn. http://www.heraldsun.com.au/news/victoria/nurses-sue-hospitals-for-injuries-from-moving-patients/story-fni0fit3-1227003459175

MAYBE IT IS TIME TO DESIGN DEVICES THAT CAN BE SELF-MANAGED BY MORE CARE RECIPIENTS, REDUCING THE NEED TO LIFT SOME PATIENTS AT ALL? As with many challenges in healthcare, the big toileting issues will be addressed only through targeted sub-population interventions.

Dropping Caregiver Ratio: Who Will Provide all the Anticipated "Aging at Home" Care?

A new study released by the Bankers Life and Casualty Company Center for a Secure Retirement, "Retirement Care Planning: The Middle-Income Boomer Perspective," found that U.S. unpaid caregivers provide approximately $450 billion worth of care to someone who is ill, disabled or aged. Among middle-income Boomers, four in ten have been a caregiver to a parent or spouse. Among these caregivers, 77% cared for a parent, and nearly one-fourth (23%) cared for a spouse.

Although they primarily relied on doctors and nurses to perform medical caregiving, Boomer caregivers found themselves quite involved in personal caregiving needs, such as:

• Assistance with eating (79%)
• Assistance with getting in and out of bed (78%)
• Assistance with using the toilet (69%)
• Assistance with dressing (68%)
• Assistance with bathing (56%)

Our thanks to Grand Villa of Delray Beach East for making this information generally available via Twitter!

Insights into Measuring Activities of Daily Living

In his article, "Life and Death After Hip Fractures in Older Nursing Home Residents," Eric Widera describes how Activities of Daily Living (ADLs), which include eating, dressing, bathing, toileting, and mobility, are measured in a typical nursing home setting:

" . . . but when is someone independent or dependent in ADLs? In nursing homes, . . . locomotion on the nursing home unit, is described . . . as: “how the resident moves from place to place in the room or hall using whatever device is appropriate or needed.” The device can be a thing like a wheelchair, walker, cane, feet, prothesis, or scooter. So if the nursing home resident did the activity completely on their own without cueing or supervision, then they are described as “independent”. If they need just some oversight or cueing then they are described as needing “supervision”. More help than that is “limited assistance” where the staff do some of the activity, and more help than that is “extensive assistance” where the staff do most of the activity. Lastly, complete dependence is where staff do all of the activity for the nursing home resident.

The other important thing to know is that functional status in this study is based on self-performance as observed across all nursing shifts over a 7-day period. So a resident is independent in an ADL if the resident is able to perform that activity “without help or oversight or requiring help or oversight only 1 or 2 times over 7 days”. The same thing goes with total dependence, the resident needs to require staff to do all of the ADL for all 7 days to be described as dependent.

Why is all of this important? Although these definitions are standardized, a nursing home resident’s self-performance can change shift-to-shift, day-to-day, and week-to-week based on things like their mood, an acute illness, or even just their relationship to their nurse. So one week you may be “dependent” and another week you may be “limited assistance.”

http://www.geripal.org/2014/07/Outcomes-of-Hip-Fracture-in-nursing-homes.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+Geripal+%28GeriPal%29

Good article on reasons for low pay of home health aides

Our thanks to Robert Hiltonsmith for his analysis of the reasons for the low pay of home health workers. I would add that another reason might be the fact that the reference price for paid home health work may be the unpaid family caregiver. And that group won't be able, or won't be willing, to sustain the coming aging of the baby boomer generation as the caregiver ratio drops (AARP report, “The Aging of the Baby Boom and the Growing Care Gap.") http://www.demos.org/blog/7/22/14/how-home-health-care-aides-are-microcosm-jobs-crisis

The way it has been: TIME FOR A CHANGE??

Home medical equipment for many people needing toileting assistance consists of using a transfer board to move from wheelchair and/or bed to a commode and back again. Height cannot be adjusted, and the picture below depicts the design solution for keeping a transfer board from shifting. It does not appear that the average care recipient will be able to position this equipment without assistance from others.

Time for a change?

Innovating Home Medical Equipment: Who experiences the burden of poor design?

I've been struck by the fact that improving home medical equipment is not as easy as it would seem it should be. Have come to think that this might be partially explained by the fact that the world of HME falls into the domain of low-paid workers and unpaid family/friends, which means the burden of poor design is experienced by those with the functional limitations and their caregivers. Improving the design of HME has not been seen as yielding any value to a hospital or a physician's practice. That means that is it very hard to persuade existing HME companies to take on any risk for introducing such innovations.

Yet, seems like the environment is changing in ways very favorable to getting a toileting improvement to market.

The Accountable Care Act is changing the incentives for providers and health plans. The smart ones will realize that HME is their "last mile" for reaching patients to avoid unnecessary hospitalizations and ED visits, support telemedicine and remote patient monitoring, and keep the mobility challenged with chronic conditions well and at home. Improved HME design will also provide respite to both paid and unpaid caregivers as users are better able to manage their assistive devices for themselves. And there will be plenty of work to go around as we baby boomers age; in fact, we will need this type of self-managed equipment to be able to handle the growing demand for caregiving.

Over the next weeks and months, I'll be posting short reports of our progress. Stay tuned,