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MGH Community News |
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MGH Community News |
| November 2018 | Volume 22 • Issue 11 |
Highlights
Sections Social Service staff may direct resource questions to the Community Resource Center, Elena Chace, 617-726-8182. Questions, comments about the newsletter? Contact Ellen Forman, 617-726-5807. |
Rest Homes in Mass. Keep Closing as Financial Pressures Mount On Dec. 1, the Somerville Home, the brick Colonial-style building perched on a hill, will become the 100th rest home in the state to close and displace its residents in the past two decades, according to the Massachusetts Association of Residential Care Homes. Seventy-three rest homes still operate across the state, but whether they can survive is an open question. Rest homes trace their roots to the 19th century, when fraternal, religious, and ethnic groups pooled their funds to furnish large Victorian homes to provide for needy widows in an era before Social Security. Those that endure remain a vital safety net for low-income older residents, many of whom have mental or behavioral disabilities. Nursing homes, a much larger sector, provide more intensive medical care. Assisted-living developments, which are typically newer, offer more independence but cater mostly to wealthier seniors who can afford higher rents. Rest homes, by contrast, provide room and board along with some services, such as dispensing medications and offering psychosocial support for residents with bipolar disorder, schizophrenia, or traumatic brain injuries. “It’s a great option for people who don’t have a lot of options,” said Elissa Sherman, president of Leading Age Massachusetts, which represents nonprofit housing and aging services for older adults. “Many of their residents would probably be homeless without the rest homes.”
But as new assisted-living complexes have opened, drawing more affluent residents, they’ve left the rest homes with a majority of residents on public assistance. At the same time, more resources have been funneled to helping older residents stay in their homes. As a result, the number of beds at Massachusetts rest homes has fallen 57 percent, from 7,000 to 3,000, since 1998. Alice Bonner, the Massachusetts secretary of elder affairs, said the Baker administration is committed to maintaining the state’s remaining 73 freestanding homes, along with 20 others housed within nursing homes. |
Toward that end, it boosted reimbursement rates 9 percent and raised the daily minimum to $74, effective Dec. 1. It also convened a cross-agency team to find ways to stabilize rest homes, and it hired a consultant to help plot a way forward. But the state’s reimbursement for rest home patients is still less than half of the daily per-patient rate for nursing homes, which receive a federal funding match, and many of which are owned by chains that have more clout on Beacon Hill. Most rest homes continue to be independently operated by small businesses, nonprofits, or religious groups. -See the full Boston Globe article.
John Jeffries House to Become a Luxury Boutique Hotel The John Jeffries house is currently closed for renovations (John Jeffries House Closing for Renovations, MGH Community News, October 2017). The Boston Business Journal is now reporting (and confirmed by the hotel’s website) that when the once moderately-priced lodging reopens in the spring of 2019 it will be as a luxury boutique hotel called The Whitney. -See the Boston Business Journal article (pay wall) or their website: John Jeffries House
Positive Changes to SNAP Overpayment Collections After extensive advocacy from MLRI, DTA has made some positive changes to how it handles Agency Error overpayments (overpayments that are DTA's fault). Background SNAP overpayments occur in three ways:
When DTA determines that there has been an overpayment, they are required by federal law to either collect repayment or waive the overpayment. States collect overpayments from current SNAP recipients by taking 10% or $10 of their monthly benefit, whichever is higher (20% or $20 for fraud overpayments). States can collect overpayments from former recipients in 2 core ways – through a repayment plan (client sends money to DTA) or, more often, through the federal Treasury Offset Program (TOP). TOP most often involves intercepting federal tax refunds or Social Security (up to 15%, but not on benefits below $750/mo and TOP cannot intercept SSI). Because of the amount of money intercepted, TOP recovery can be catastrophic for low income households. Changes
DTA does not currently have a policy to reduce non-Agency Error claims. DTA pursues all overpayments - agency error, recipient error, and fraud cases – that are over a certain amount. DTA will now not create an overpayment if the claim is for less than $600 for an AE case, or less than $125 for a UPV or IPV. DTA will also not pursue AE or UPV overpayments that happened over a year before DTA realized there was an overpayment. Resources and More Information
DTA Overpayment Issues - Please help fix issues by flagging cases! MLRI and their legal services partners have been looking into a number of issues with how DTA establishes (creates) overpayments, and how overpayments are calculated. If you work with any clients who have an overpayment that DTA is collecting on, or who are told by DTA that they have an overpayment, MLRI is asking you to let Vicky Negus from know - vnegus@mlri.org or 857 241 1715. -Adapted from FoodSNAPCoalition listserv post on behalf of Victoria Negus, MLRI, November 08, 2018.
State Cracks Down on Funeral Home Storing Bodies in South Boston Garage As reported previously (MGH Community News, September 2017), WCVB Channel 5 “5 Investigates” team had reported last year that Casper funeral home had been accused of storing bodies in an unlicensed garage and that the state was investigating. Now, according to a consent agreement reached between the state Board of Registration of Funeral Directors and Embalmers and Casper Funeral Home obtained by 5 Investigates, the funeral home has agreed to stop using the garage to store bodies after the funeral board found the company failed to hold bodies within a licensed funeral establishment. Casper also agreed to pay a $5,000 fine and it will be on probation for one year. -See the full 5 Investigates story. -Thanks to Marie Elena Gioiella for bringing this to our attention.
‘Blatant disregard’ for Safety at Brockton VA Nursing Home, US Finds Officials at the Brockton Veterans Affairs Medical Center nursing home, rated among the worst VA facilities in the country, knew this spring they were under scrutiny and that federal investigators were coming to visit, looking for signs of patient neglect. Still, when investigators arrived, they didn’t have to look far: They found a nurse and a nurse’s aide fast asleep during their shifts. One dozed in a darkened room, the other was wrapped in a blanket in the locked cafeteria. The sleeping staffers became a key focus of a scathing new internal report about patient care at the facility, sparked by a nurse’s complaint, according to a letter sent late last month to President Trump and Congress by the agency that protects government whistle-blowers. Investigators with the VA’s Office of Medical Inspector largely substantiated the whistle-blower’s complaints in September, concluding that a “a substantial and specific danger to public health and safety exists” in the 112-bed facility. “We have significant concern about the blatant disregard for veteran safety by the registered nurses and certified nurse assistants,” agency investigators wrote in a report. The problems at the Brockton nursing home are the latest to surface in a review of VA nursing home care by the Globe and USA Today. The Brockton VA nursing home is a one-star facility, the lowest rating in the agency’s own quality ranking system of its 133 nursing homes. Forty-five nursing homes received one star in the most recent ratings, including two other VA nursing homes in New England — Bedford, Mass., and Augusta, Maine. In June, the Globe and USA Today revealed the VA’s own secret ratings showed these facilities and more than 100 other VA nursing homes scored worse than private nursing home averages on a majority of key quality indicators last year. VA spokeswoman Pallas Wahl said officials took “immediate corrective action” in the wake of the internal investigation. The two sleeping nurses no longer work at the Brockton nursing home. The facility’s one-star rating, she added, is undeserved and is not an “accurate reflection of the quality of care delivered to our patients.” The investigators “did not find evidence of veteran harm or neglect,” Wahl said. According to the VA’s own data, Brockton residents were, on average, more likely than residents of other VA nursing homes to deteriorate, feel serious pain, and suffer from bed sores, according to agency data. They were nearly three times as likely to have bed sores than residents of private nursing homes. This is not the first time the Brockton VA has come under fire by the Office of Medical Inspector. In 2014, a doctor at the nursing home alleged that three veterans with significant mental health issues received “inappropriate medical and mental health care.” Two of them went years, he alleged, without appropriate treatment. Investigators largely substantiated the allegations, finding that two veterans with significant psychiatric issues did not receive adequate treatment for years. -See the full Boston Globe article.
Synergy Health Centers Closing Nursing Homes Amid Mounting Bills, Patient Injuries and Deaths Fending off creditors and repeated fines for patient deaths and injuries, a New Jersey nursing home company plans to close two of its 10 Massachusetts facilities as a court-ordered receiver works to sell its other properties. Synergy Health Centers’ facilities in Sunderland and Newton are set to close in February, according to state records. Synergy bought its first Massachusetts nursing home, in Sunderland, just six years ago. The company was quickly awarded subsequent licenses by the state despite mounting health and safety problems. Financial woes soon followed. The Globe reported in early September that Synergy had more than $31 million in unpaid mortgage loans and other debts, according US District Court records, and most of its facilities had been placed into the hands of a court-appointed receiver. Synergy facilities, which stretch from Central to Eastern Massachusetts, are licensed to care for about 1,200 residents. The company did not return a phone call seeking comment. Synergy has been penalized by regulators for a litany of problems including medication errors, inadequate staff training, poor treatment of pressure sores, and lax infection control. Arlene Germain, president of Massachusetts Advocates for Nursing Home Reform, a nonprofit patient advocacy group, said she has never seen a company “so egregious in their care and so draining in their finances.” “They are leaving with a wide path of destruction behind them, harming the workers and the residents,” Germain said. A Department of Public health spokeswoman said the agency, in addition to its standard inspections, has initiated random visits at Synergy facilities to monitor quality and patient care. Here’s a list of the Synergy Health Centers Closing
Sale pending to the Pointe Group
Sale pending to A & L Holdings
To be sold by receiver
Still under Synergy control
-See the full Boston Globe article.
UMass Commonwealth Medicine- Community Case Management Patients with MassHealth Standard or CommonHealth who require continuous skilled nursing for more than 2 hours a day may qualify for UMass Commonwealth Medicine’s Community Case Management program (CCM). CCM is responsible for approving continuous skilled nursing (formerly called block nursing) above the 2 hours a day threshold for all MassHealth patients, and serves the most complex, medically fragile individuals living at home. They can also authorize PCA services. For eligible patients not enrolled in an ACO they can coordinate all nursing, PCA and home health aid services and Durable Medical Equipment (DME). For those enrolled in an ACO they can approve and coordinate nursing services – responsibility for coordinating additional services such as those listed above will vary. The program accepts referrals from professionals, but patients can also self-refer as can friends and family members.
They also have a hospital liaison for patients who have passed the initial screening and have a discharge date within 42 days (6 weeks). Staff could come to the hospital, but with limited staffing they would need early notice. For more information see the website: https://commed.umassmed.edu/our-work/2018/01/28/community-case-management or email commcase@umassmed.edu. - Thanks to Sabrina Meyer for sharing information about this program.
New Leukemia & Lymphoma Society Patient Aid Program The Leukemia & Lymphoma Society (LLS) has opened a new financial assistance program- the LLS Patient Aid Program, which serves blood cancer patients in active treatment. Eligible patients will receive a one-time $100 stipend to help offset expenses. There are no income criteria to qualify for this program. To learn more about LLS Patient Aid, please visit: www.LLS.org/PatientAid. To apply, refer your patients and their caregivers or submit an application on their behalf:
Visit LLS.ORG or connect with LLS Information Specialists at (800) 955-4572 to learn more about LLS education and support services, including personalized clinical-trial navigation, disease booklets, and more. -Thanks to Lauren DeMarco for sharing this resource.
UnitedHealthcare Children’s Foundation – For Families with Commercial Insurance The UnitedHealthcare Children’s Foundation (UHCCF) strives to enhance either the clinical condition or quality of life of children who have health care needs not fully covered by their commercial health benefit plan. Eligibility
Benefits Qualifying families can receive up to $5,000 per grant ($10,000 lifetime) to help pay for medical services and equipment. Examples of qualifying services or equipment include medically required: physical, occupational and speech therapy, counseling services, co-pays, surgeries, prescriptions, wheelchairs, orthotics, diabetic supplies, hearing aids, medical beds, Applied Behavioral Analysis (ABA) services (up to age 7-8; note- in MA commercial insurance is required to cover ABA, but may not be required in other states) and more. Grants are available for medical expenses families have incurred 60 days prior to the date of application as well as for ongoing and future medical needs. To Apply To apply, or for more information, you can email customerservice@uhccf.org or call 1 855-MY-UHCCF / 1 (855-698-4223), or see the website https://www.uhccf.org/. The program will work directly with family. No social work referral required. -Thanks to Mary Barber and Mary Bennett for meeting with UHCCF representative Michael Cotnoir along with CRC staff to help us fully understand the program and staff information needs.
The MGH Clay Center for Young Healthy Minds- Encourages Resilience in Youth with Mental Health Disorders Based at Massachusetts General Hospital and led by a team of Harvard Medical School faculty members, The Clay Center for Young Healthy Minds is a web-based resource that educates parents and other caregivers about the psychological development and emotional well-being of children, adolescents, and young adults who struggle with behavioral, emotional, and/or learning challenges. The Clay Center provides engaging and educational mental health content delivered in a wide variety of multimedia formats, including blogs, audio podcasts, online videos, and interactive social media. The Clay Center content encourages resilience in individuals and families while increasing the awareness and decreasing the stigma of mental health disorders. Please note: The Clay Center for Young Healthy Minds is an educational vehicle only.They do not provide clinical services or referrals for treatment. -Thanks to Lynn Mazur for sharing this resource.
Medicare Announces Two-Year Gap in Competitive Bidding Supplier program for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) CMS has announced that, starting January 1, 2019, it will institute a two year "temporary gap" in its Competitive Bidding Supplier program for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). This means that for all of 2019 and 2020, Medicare beneficiaries in fee-for-service Medicare may purchase Medicare-covered DME from any Medicare-enrolled supplier. During the two years, beneficiaries will not be limited to a competitive bidding supplier list. A CMS fact sheet and press release discuss the temporary gap period. The temporary gap will allow time for CMS to hold new rounds of competitive bidding in accordance with changed payment methodologies that were finalized in a rulemaking in November. During the temporary gap, CMS will be paying suppliers using a temporary transition pricing methodology. Impact on beneficiaries may be mixed. CMS anticipates that for most beneficiaries there will be no change in supplier access. Some may benefit from access to a wider range of suppliers. However, CMS also anticipates that some suppliers may decide to exit the market for some DME, which could cause disruption for affected beneficiaries. The agency also warned about potential aggressive or misleading marketing, including false claims that individuals need to change suppliers. The change does not affect beneficiaries in Medicare Advantage plans. They must continue to get their Medicare-covered DME through in-network suppliers. Advocates: Justice in Aging is calling on advocates to tell them about what your clients experience in the temporary gap period. Let them know about access issues or marketing abuses and improved access or other benefits. -Adapted from CMS Suspends Competitive Bidding for DME for Two Years, Justice in Aging, November 26, 2018.
Advocates Say CMS Open Enrollment Materials Favor Medicare Advantage Over Original Medicare Earlier this month, the Medicare Rights Center and the Center for Medicare Advocacy sent a letter to the Centers for Medicare & Medicaid Services (CMS) expressing concerns with some of the agency’s Fall Open Enrollment education and outreach materials. These materials seem to promote Medicare Advantage (MA) over Original Medicare. Also known as the Annual Coordinated Election Period (ACEP), Fall Open Enrollment occurs each year from October 15 through December 7. During this period, people with Medicare can make unrestricted changes to their coverage options for the following year, including joining a new Medicare Advantage (MA) or Part D plan and switching between Original Medicare and MA. People can make as many changes as they need, and the last change they make on or before December 7 will take effect on January 1. Based on our experience assisting people with Medicare and their families, we know how challenging it can be for people to evaluate their coverage and make optimal decisions each year. This makes it critical that CMS provide beneficiaries with accurate, complete information about their options in advance of and throughout this decision-making process. Unfortunately, several of the agency’s 2018 enrollment resources fall short of this standard. Specifically, CMS recently announced a suite of online tools aimed at assisting consumer decision-making, including a Compare Coverage Options quiz. While we appreciate CMS’s efforts to develop more consumer-friendly materials, we are concerned that this tool may be doing more harm than good—by making overly-broad suggestions to enroll in MA when more nuance is required, and by failing to present individuals with the full array of Medicare coverage choices. We are also similarly concerned that CMS’ current Fall Open Enrollment email campaign and other messaging to beneficiaries is improperly biased towards MA. Many of these communications make no attempt to inform beneficiaries about their coverage options under Original Medicare, potentially preventing them from making a fully-informed decision. Although we are well into the 2018 Fall Open Enrollment period, CMS can still act to achieve greater parity in its materials in the remaining weeks when many people make their enrollment decisions. Accordingly, we are asking that CMS act quickly to revise both its online web tools and beneficiary outreach messages so they more equally and accurately reflect the availability of Original Medicare coverage options. Related Medicare Rights Center Materials -See the full Medicare Rights Center blog post.
Medicare Reminder- Your Rights When a Provider Refuses to Submit a Medicare Claim What are your rights when provider refuses to submit a claim to Medicare?
If you have Original Medicare: Below are some reasons why a provider may refuse to file a Medicare claim, along with information about what to do in each situation:
Your provider may ask that you pay in full for services.
Your provider has opted out of Medicare.
Your provider refuses to bill Medicare and does not specify why.
If you have a Medicare Advantage Plan or Part D prescription drug plan: If you are experiencing billing issues with providers or pharmacies in your Medicare Advantage Plan or Part D plan’s network, you can ask your pharmacy or provider to contact your plan directly. If you continue to experience issues or if your pharmacy or provider is unresponsive, you can file a grievance with your Medicare Advantage or Part D plan. Contact your plan to find out how to file a grievance.
Expanded Medicare Advantage Benefits Will Be Hard to Find This Year
As reported last month (MGH Community News, October 2018), Medicare Advantage plans may offer expanded supplemental benefits for 2019.
However, plans offering these services will likely have only some of the options and will have different eligibility criteria and other limitations. Advantage members will need a recommendation or referral from a health care provider in the plan's network. Then they may need to have a certain chronic health problem, a recent hospitalization or meet other eligibility requirements. Also, the same services likely won't be available in every county the plan serves. Change is Starting Slowly The services will be offered by some Medicare Advantage plans in about 20 states next year, expected to grow over time.There has to be a health-related reason to qualify, and costs will vary among plans. In some plans, there’s no added cost. But limits do apply. For example, a plan may cover one day per week at an adult day care center. Medicare Advantage open enrollment for 2019 ends Dec. 7. But it’s not easy to use Medicare’s online plan finder to search for plans with expanded benefits, so beneficiaries and their families will have to rely on promotional materials that insurers mail during open enrollment. Insurers under Anthem’s corporate umbrella are offering different packages in 12 of 21 states they operate in. They can include alternative medicine, like acupuncture, or adult day care center visits or a personal helper at home. Other major insurers like UnitedHealthcare and Humana are participating. Still, Medicare’s opening is no substitute for full long-term care coverage, which many people need for at least part of their lives and remains prohibitively expensive. According to Medicare, 12 insurers will be offering expanded supplemental benefits next year through 160 plans in 20 states. In four other states and Puerto Rico, such benefits may be available to seniors with certain health conditions. “The guidance came out fairly late in the annual planning process, and that’s one reason why some of these benefits may start out small,” said Steve Warner, head of Medicare Advantage program development for UnitedHealthcare. Medicare estimates that some 780,000 beneficiaries will have access to the new benefits next year. In-home helpers and support for caregivers are the most popular. Consumer advocates recommend that seniors carefully weigh whether Medicare Advantage is best for them. If they don’t like it, they can go back to traditional Medicare, but those with a pre-existing condition may not be able to buy a “Medigap” policy to help cover out-of-pocket costs. They can also switch to another Medicare Advantage plan. Medicare doesn’t pay the insurers more for offering added benefits. Under a complex formula, they’re primarily financed out of the difference between bids submitted by insurers and Medicare’s maximum payment to plans. If the companies bid below Medicare’s rate, they can return some of that to beneficiaries in the form of added benefits. Costs for beneficiaries may vary. Some will face no added costs. Sources and For More Information
-See the full Washington Post article
Temporary Protected Status (TPS) Extensions Likely As reported last month (MGH Community News, October 2018) U.S. District Judge Edward Chen has granted a preliminary injunction preventing the federal government from ending Temporary Protected Status (TPS) for immigrants from Sudan, El Salvador, Haiti and Nicaragua. So what does this mean for those with TPS? The analysis below addresses Haitians in particular, but should also apply to TPS holders from Sudan, Nicaragua, Haiti, and El Salvador, but with different pertinent dates. TPS for Haitians will virtually certainly NOT end on July 22, 2019; the government in early March will automatically extend it to approximately January 1, 2020, and quite possibly will do so for another nine months beyond that date, to September, 2020; Haitians with TPS who didn't re-register for it in 2017 or 2018 out of fear, confusion, or another good reason can and should seek to reregister now; the gov't has agreed to give such applications "presumptive weight" as being filed late for good cause—meaning they should be granted and then entitled to the TPS extensions described above/below; Automatic 9 month extensions, starting in April 2019, unless there is a loss at a court of appeals. "DHS will issue another Federal Register Notice approximately 30 days before April 2, 2019, that will extend TPS for an additional nine months from April 2, 2019, for all affected beneficiaries under the TPS designations for Sudan, Nicaragua, Haiti, and El Salvador. DHS will continue to issue Federal Register Notices at nine-month intervals so long as the preliminary injunction remains in place and will continue its commitment to [an] orderly transition period, as described above." (Advocates say that there’s no way the Ninth Circuit will decide by early March, much less the Supreme Court. So the early March additional Federal Register Notice referenced above will issue.) TPS work and legal status will be automatic for those registered—no need to pay for employment authorization cards or further registration. Under the agreement, for as long as the district court’s order is in place, people with TPS who have re-registered previously – or who re-register late – will not need to register again or apply for a new EAD. They can rely on their existing (to-be-expired) EAD or TPS approval notice, as well as the Federal Register Notice, as valid authorization to work or as proof of legal status in the United States. They do not need to pay any further money to the US government, and should not need to pay for additional legal assistance either. Re-registration possible—and likely guaranteed—for people who did not re-register during the Trump Administration. Crucially, Haitians with TPS who didn't reregister in 2017 or 2018 due to fear or other good reason can successfully do so now! If they now reregister for TPS late for good cause, the USG will give their applications "presumptive weight" as being valid! This means that any Haitian TPS recipient who failed to reregister in 2017 or 2018 should be successful in doing so now -- late -- if they explain that they didn't reregister on time due to fear, confusion, or other good reason. (This is extremely important for example for the estimated nearly 16,000 Haitians with TPS who let their TPS status lapse early this year by not trying to reregister!) No new terminations for these countries for now. The USG will not try to write new TPS termination notices for Haiti or the three other nations while the court’s order remains valid. At least 6 months additional protection even if there is a loss at a higher court. "In the event the preliminary injunction is reversed and that reversal becomes final, DHS will allow for an orderly transition period," which effectively amounts to about six months from the date of any such hypothetical future final, non-appealable order. This means that – if the district court’s order is overturned on appeal (at the court of appeals or the Supreme Court), the earliest that TPS holders from these countries could lose their legal status is about 6 months after the appeals court’s decision. More Information See the USCIS website: https://www.uscis.gov/humanitarian/temporary-protected-status -Adapted from Haiti TPS Extended to January 2020: Latest Developments on Haiti TPS, Haitian Deportation Network as posted to Health & Law Immigrant Solidarity Network listserv, on behalf of Alex Pirie, November 11, 2018.
Difficulty Accessing Assistive Technology? Disability Law Center Seeking Cases Barriers to wheelchair repairs and replacements have been a huge problem for many years. Long delays, wrong parts, and incorrect repairs are some of the biggest obstacles faced by people who use wheelchairs, which can impede their ability to live independently. Take Emma’s story for example: Disability Law Center (DLC) was recently contacted by Emma. She was having trouble getting discharged from the hospital because she had a broken wheelchair. DLC provided Emma advice on what she needed to do in order to get home. However, Emma was unsafe at home because of the long delay in getting her wheelchair repaired. DLC took the case to advocate for the repair (or replacement) of her chair. MassHealth approved a new chair for Emma and DLC was able to expedite the process. Emma is now living safely in her home and so happy to have her independence back. DLC is looking for cases, like Emma’s, where people with disabilities are seeking assistive technology to help them live independently in their community. Give them a call if you or someone you know is having an issue with assistive technology. 1-800-872-9992 Learn more about DLC’s work on their website. -From Barriers to wheelchair repairs, Disability Law Center, November 19, 2018.
State Funds Abstinence Only Sex Ed Programs The state will use federal money to teach teenagers to abstain from sex before marriage, sparking concerns among some sex-ed advocates who say abstinence-only programs are ineffective. Massachusetts is one of 35 states - including Alabama, Florida, Georgia, Louisiana and West Virginia - to accept a grant from the U.S. Department of Health and Human Services that must fund projects that teach participants to "refrain from non-marital sexual activity" and avoid risky behaviors such as underage drinking and drug use. The state Department of Public Health, which applied for the money, declined to make officials available to discuss how the $808,000 will be spent. In a statement, the agency said the money will complement existing programs including "education around healthy relationships, birth control (including emergency contraception), sexually transmitted infections, preventive cancer care such as cervical and breast cancer screenings, and overall reproductive health." The money will fund programs at several nonprofits including the Boys & Girls Club of Chelsea, Girls Inc. in Lowell, Revere CARES and the YWCA of Central Massachusetts. Groups such as the Planned Parenthood League of Massachusetts say studies have shown telling teens to “just say no” doesn't prevent them from having sex, and may even contribute to the spread of sexually transmitted diseases and unwanted pregnancies. "By distorting information about the effectiveness of contraceptives, blurring religion and science, treating gender stereotypes as facts and promoting medically inaccurate content, abstinence-only-until-marriage programs put young people, especially LGTBQ teens, at risk," said Jen Slonaker, the league's vice president of educational development. Advocates of sex ed programs that include contraception say they’re concerned about the effects of a shift toward abstinence-only messages on teen pregnancy. In 2015, there were an estimated 23 births per 1,000 girls aged 15 to 19, according to the U.S. Department of Health. That's compared to 41 births per 1,000 girls in 2007. In Massachusetts, the number of teenagers having babies has declined dramatically in recent years, which experts attribute largely to access to birth control and sex ed classes in schools. Statewide 2,140 babies were born to mothers ages 15 to 19 in 2015, according to the Executive Office of Health and Human Services.The state’s teen birth rate that year was 9.4 per 1,000 girls — lowest in the nation. Despite that, teen birth rates remain high in some communities north of Boston, including Lawrence, Lynn and Haverhill. Sex ed not required Conservative groups such as the Massachusetts Family Institute argue that abstinence-only programs are effective and teaching about contraception encourages early sexual activity. Republican Gov. Charlie Baker has increased funding for sex-ed programs that focus on contraception and signed a bill last year requiring state insurers to cover birth control without a copay. But the state doesn’t require sex-education classes, leaving school districts to decide whether to offer them and what kinds of standards to incorporate into local curriculums. -See the full Salem News article.
Firearms and Dementia: How Do You Convince A Loved One to Give Up Their Guns? Families of people with dementia will often take away the car keys to keep their family member safe. They might remove knobs from stove burners or lock up medicine. But what's less talked about is the risk of guns in the home for those with dementia. That's a growing problem, as the U.S. population gets older and the number of people with dementia soars. According to the Alzheimer's Association, that number is expected to double in the next 20 years to about 14 million — the vast majority over the age of 65. Researchers also estimate that nearly half of people over 65 either own a gun or live in a household with someone who does. Given those statistics, people who work with dementia patients are trying to raise awareness and make gun safety a top priority for families. The issue came into sharp relief recently for an Aurora, Colo., couple who have been married for 38 years. Ed was a fighter pilot who served in Korea and Vietnam. His wife Kathy, a retired nurse, asks that we use just their first names, out of privacy concerns. At age 87, Ed can still sing the songs from his favorite musical, "Oklahoma," by heart. He'll gladly launch into "Boomer Sooner," the fight song from his alma mater, the University of Oklahoma. But as one of the millions of Americans living with Alzheimer's disease, he also has significant memory loss and is prone to delusions. Late one night about a year ago, there came a turning point. For the first time, Ed didn't recognize his wife, and he grew agitated. "I realized that he was quite afraid," Kathy says, "and that he was afraid of me. He didn't recognize me as a loving, caring person." Ed was so afraid, that he walked into their bedroom, locked the door, and said something ominous."He [said], 'I have a gun,' " Kathy recalls. "And the truth was, there was a gun in that room." Kathy knew the gun was loaded. "I broke out in a sweat," she recalls. She spent an anxious night in the hallway outside that room, afraid things would escalate if she called the police. By morning, Ed had calmed down, and he unlocked the door. To Kathy's relief, she discovered that he hadn't found the gun. But the incident was so frightening that she immediately took the weapon to the basement, removed the ammunition, and locked it away. In hindsight, Kathy wishes she had been more vigilant and anticipated this turn of events. "I was angry with myself for putting my husband and myself in jeopardy," she says. But those who work with dementia patients say family members often don't want to think the worst. "Most caregivers tell us, 'I've been married to him for 50 years; he would never hurt anyone,' " says Joleen Sussman, a psychologist who specializes in dementia at the Veterans Affairs Medical Center in Denver. "And then it's talking to caregivers about, 'Yes, he would not, but his disease might hurt someone. So we have to talk about this.' " "Do you have guns? How many, and where are they?" Sussman wants this safety issue to be top of mind: "If I had anything to say to health care professionals across the country, it would be, please, along with driving, please ask about firearms, too," she says. Sussman advises those in health care to ask patients not just, "Do you have guns?" but also, "How many? And where are they?" "Once I ask about firearms," Sussman explains, "I'll say, 'So, do you keep those at your bed stand within arm's reach while you're sleeping at night?' Many veterans will say yes. 'Is it loaded?' Yes. 'Does your wife sleep with you?' Yes." If you couple that proximity with the confusion, paranoia, and anger that can accompany dementia, you get a potentially deadly mix. Sussman has found that using certain words can make the conversation about guns easier. For example, she says, the word "retire" can be "pretty palatable for both driving and firearms." For patients in the early stages of dementia, Sussman says she might tell them, " 'You're going to need to retire from driving and retire from the use of firearms.' Which changes it from, 'We need to take these away' or 'You need to stop.' So let's plan." Guns may represent independence For many gun owners, their firearms are so deeply entwined with their identity that asking them to give up their guns can be really difficult. "[Guns] represent something about independence and autonomy to them, that's their right to have," says Beth Kallmyer, vice president of care and support with the Alzheimer's Association. "They might say to you, 'I don't care. You're not taking my guns,' Kallmyer says. "But they might say to you, 'You're right. I want you to step in when I can't make that decision for myself anymore.' And then that helps the family later on." Kallmyer advises families not to wait, and to have these conversations early. Dr. Emmy Betz, who studies guns and dementia at the University of Colorado School of Medicine in Denver, suggests that families draw up a family firearms agreement — a kind of advance directive for guns. The conversation, Betz says, might include questions like "Who do you want to be the one to say, 'I think it's time'? Who do you want to give [your guns] to? Is it your family member? Is it Joe down at the gun club? So that you're still the one making the decision. Even if when the time comes, you're not aware of what's happening." -See the full NPR story.
New England Journal of Medicine Launches Case Studies in Social Medicine Series - Attending to Structural Forces in Clinical Practice Many clinicians and trainees see the social world as a messy, impenetrable black box: they may acknowledge its influence on their patients’ health, but they lack the understanding and tools for incorporating it usefully into their diagnostic reasoning and therapeutic interventions. But the social sciences of health and medicine provide such tools — theories and methods for understanding social processes and intervening to effect change. Leading organizations in medical education have recommended providing additional training in social medicine, which deploys these approaches to improve health. In this issue, the Journal launches Case Studies in Social Medicine, a series of Perspective articles, to highlight the importance of social concepts and social context in clinical medicine. The series will use discussions of real clinical cases to translate these tools into terms that can readily be used in medical education, clinical practice, and health system planning. In their first year in medical school, all students learn to take a social history. Yet by the clinical years of medical school, students learn that the social history is often collapsed into a record of three biobehavioral exposures — to alcohol, tobacco, and illicit drugs. Much of what they read in clinical journals appears to corroborate the assumption that in clinical medicine, the biologic and behavioral world of a patient’s body is more important than the social world outside it. This erasure flies in the face of increasing evidence documenting the role of social forces in determining health, disease, treatment, and recovery. The likelihood that certain conditions and the prognoses and treatment outcomes associated with them will develop are strongly predicted by social factors, including income, race, ethnicity, immigration status, and place of residence: they cluster in social networks and are exacerbated by social inequalities. The fundamental causes of health and disease, however, are not these seemingly static characteristics that mark inequalities, but rather the social, political, and economic forces that drive these inequalities in the first place — what we would call the structural determinants of the social determinants of health. If medicine is to reduce rather than augment health disparities, we will need solutions to both the social and the biologic bases of health and disease. As a field of research, social medicine seeks to understand the ways in which social factors influence health, disease, and medical practice. As a field of practice, it applies this understanding to inform health interventions at the individual, community, and society levels. Social medicine provides conceptual frameworks for approaching problems that otherwise seem intractable or outside the domain of clinical practice. Our hope is to show that social forces are just as amenable to analysis, investigation, and intervention as the cellular and molecular mechanisms of disease and to demonstrate that they are at least as important to analyze, investigate, and address. A structural analysis contextualizes health-related behaviors by charting how the design of complex social institutions (such as hospitals, insurance plans, prisons, regulatory agencies, and religious institutions) as well as powerful forces guiding everyday social life (such as racism, gender bias, social networks, neighborhood segregation, and language) determine what happens to individual bodies. Structural analysis also extends to tools clinicians can use to approach their patients’ social worlds beyond the narrow typology of cultural differences. Structural violence provides a key frame for understanding the disproportionate harm to certain groups of people inflicted by large-scale social forces, such as resource distribution or hierarchies of race, gender, or language. A related concept, “structural vulnerability,” describes the increased risk — for certain diseases, lack of access to care, or poor outcomes — caused by one’s location in the social world as defined by the intersection of these large-scale forces. To date, however, the clinical literature on structural violence and structural vulnerability has had limited impact on practice, for at least two reasons. First, much relevant social science work is perceived as negative critique that doesn’t provide clinicians with positive tools for understanding and intervening in the mechanisms by which structures harm patients. This series is designed to resolve this problem by teaching core concepts in social medicine and offering steps for addressing specific problems that arise in clinical practice. How do health systems participate in the creation of racial disparities in health, and what can be done to prevent and counteract that dynamic? Second, some clinicians and trainees may find structural analysis somewhat overwhelming on first encounter. Unlike resectable lesions or targetable drug receptors, structural social forces may seem too large and entrenched to be altered — a perception that reinforces the assumption that they lie outside the purview of clinical medicine. Each case in this series illustrates social analysis as an integral part of clinicians’ understanding of disease and efforts to improve their patients’ health. Many of the articles present unfamiliar skills, such as an approach to developing a “structural differential” for a particular problem — one piece of a proposed “structural competency” for medical education. More specifically, each case discusses clinical implications — steps by which a social medicine concept can be applied to everyday problems. Research indicates that clinicians may be more empathetic when they learn about the structural factors affecting their patients’ health. They may also be less overwhelmed when they learn about historical and contemporary examples of actions that can alter those factors.22 Socializing the Case Study Case studies have long been essential to medical education; the genre we know as the clinicopathological conference was introduced by the Journal thanks to clinical pathologist Richard C. Cabot. From the first publication of the Case Records of the Massachusetts General Hospital, Cabot advocated for cases as the best way to practice processing information as it unfolds in real clinical encounters. The case subsequently developed into a key way that clinicians learn and reinforce the process of converting subjective information (history) into objective signs (physical exam and studies) to pinpoint internal pathologic processes cleanly demarcated from alternative explanations. These cases typically began with the patient’s voice but ended with the patient’s body speaking truths about the nature of disease. Yet Cabot also devoted his career to addressing the social roots of disease. In 1905, he created one of the first positions in the world for a clinical social worker, paid out of his personal salary, and he campaigned vigorously for socialized medicine as an ardent supporter of universal health care. The goal of Case Studies in Social Medicine is to reunite these two intellectual traditions: the case study as a mode of teaching elements of diagnosis, therapeutics, and prognosis and the exploration of and response to the social forces affecting people’s health. -See the full NEJM article. |