Spiritual Rituals within the Long-Term Care Community

Author:   D. Eargle, Ph.D., M.Ed.   2018

Spiritual Rituals within the Long-Term Care Community

“wanting to finish my living…”

 Many Chaplains and Spiritual Care Practitioners offer their belief that long-term care facilities should be in the business of helping elder residents finish-their-living, while also creating a strong community presence.  They go further in arguing that spiritual care must be an integral part of the facility’s service programs, with spiritual assessment and care planning being as essential as nutrition, physical therapy, and nursing care plans. 

 Familiar religious rituals should be anticipated and regularly scheduled throughout the year.  All residents, regardless of their health status, should be encouraged to play meaningful roles in spiritual practice. 

While it is beyond the scope of this blog, I wish to share several methods effectively used by practitioners in their spiritual practice with long-term care residents.

Forgiveness, Guided Reminiscence, and Life Review

“seeking forgiveness…”

An important question posed to Pastoral Counselors and Spiritual Care Providers: “What is the biggest need motivating older adults to seek spiritual guidance?”  Resoundingly, the answer went something like this… healing old wounds of troubled relationships, resentments, anger, regrets, forgiving Self, forgiving Others. (Ramsey, 2008).

On an interesting side note: as a scientific field of research, forgiveness has had a brief history.  Since the 1980s, however, it has become a major topic in medicine, psychology, and theology.

According to Ramsey, a family therapist, all forgiveness work includes a life story.  Moving forward in life is perhaps best facilitated for struggling older adults when a spiritual guide helps the person search for exceptions, imagine new and more hopeful endings, and begin to assume more flexible, empowering roles rather than the passive suffering of victimhood (Ramsey, 2008).

Reminiscence & Life Review:

Depending upon the individual, guided reminiscence may take different forms and serve various adaptive functions, e.g., recalling the “good old days,” reinforcing one’s positive self-image & abilities, and entertaining others via story telling.  Some reminiscing, however, may serve the purpose of a life review, often in preparation for death.  Pressing topics typically include resolving issues of the past, seeking forgiveness, leaving a legacy, and completing one’s “unfinished business.”

Ramsey counsels Spiritual Care Providers to help elders use this life review as an impetus to evaluate, make peace with, and give thanks for what has been.  She goes further in encouraging elders to become spiritual mentors to young adults, a life stage that is also often filled with struggles, conflicts, fears, and lack of meaning (Ramsey, 2008).

Fr. Oberle, a Spiritual Care Director, offers a definition of forgiveness that I find especially meaningful:

“Forgiveness is the giving up of all hope of a better past” (Oberle, 2002, p. 7).

  By acknowledging that the past cannot be changed, forgiveness focuses on the future.  This process can be particularly important for elders nearing the end of life. 

Spiritual Legacies, Autobiographies, Ethical Wills,

Life Stories, Journals, and Story Telling

As noted throughout the thanatology research, most older adults have a willingness and a need to speak openly about death.  In fact, elders express a greater openness to such discussions than do younger generations.  Most practitioners are also in agreement that leaving a spiritual legacy is vital for elders nearing the close of life.  In addressing their own mortality, many questions surface:

  Will I be remembered?    How Will I be remembered?

Did my life matter?

In what ways can I contribute to something of lasting value?

Spiritual autobiographies and ethical wills are two examples of avenues for contributing something of spiritual substance to others.  According to Richards, the importance of life stories for all generations can be affirmed in the context of the story of a Higher Power, religious beliefs, and personally important values.  Others find that keeping a written or taped journal, formally or informally, plays a central role in their legacies and can also be experienced as a stress management tool (Richards, 2008).

Reflection Question

Many view our Internet Age as providing additional ways in which older adults can document and share their stories and legacies.  Do you feel our advanced Computer Technologies will impact the ways in which we provide spiritual care in the future?

In Closing…

The following quote has meaning for me, so I want to share with you….

Aging is a moral and spiritual frontier because its unknowns, blessings, terrors, and mysteries cannot be successfully crossed without humility and self-knowledge; without love and compassion; without acceptance of physical decline and mortality; and a sense of the sacred (Cole & Winkler, 1994, p. 5)

Resources

Aging & Spiritual Rituals

_____________________________________________________________________________________

Address, R. (2005).  Creating Sacred Scenarios:  Opportunities for New Rituals.  In Religion, Spirituality, and Aging.  Binghamton, NY:  The Haworth Press.

Black, K., & Elkins, H. (2005).  Wising Up:  Ritual Resources for Women of Faith in their Journey of Aging.  Cleveland: Pilgrim Press.

Cavanaugh, J., & Blanchard-Fields, F.  (2014).  Adult development and aging (7^th ed.).   Belmont, CA: Thompson Wadsworth.

Cole, T., & Winkler, M.  (1994).  The Oxford book of aging: Reflections on the journey of life.  New York: Oxford University Press.

Griffin, R.  (2005).  Caregiving and our inner elder: Insights from a spiritual master.  In H. R. Moody (ed.) Religion, Spirituality, and Aging.  Binghamton, NY: Haworth Press.

Hooyman, N., & Kiyak, H.  (2018).  Social gerontology: A multidisciplinary perspective (10^th ed.).  Boston: Allyn and Bacon.

Moody, H. R.  (2005).  Knowledge, practice, and hope.  In Religion, spirituality, and aging.  Binghamton, NY:  Haworth Press.

Moody, H.R. (2010).  Aging: Concepts & Controversaries (6^th ed).  Thousand Oaks, CA: Pine Forge Press/Sage Publications. 

Nelson-Becker, H., Nakashima, M., & Canda, E. (2012).  Spiritual Assessment in Aging: A Framework for Clinicians.  Journal of Gerontological Social Work, 48, 331-347.

Oberle, J.  (Fall 2002).  Forgiveness: A spiritual value that fosters physical, psychological and spiritual health.  In Newsletter of the Forum on Religion, Spirituality and Aging. 14(3), 7.

Ramsey, J.  (Summer 2008).  Forgiveness and healing in later life.  Generations, 32(2), 51-54.

Richards, M. (Summer 2008). Spiritual Challenges and Hope in Sharing Care.  Generations. 32(2), 68-69.

Blog Author:

Dr. Donnelle Eargle  

deargle@sjcme.edu 

With a background in geriatric rehabilitation psychology, Dr. Eargle teaches gerontology-related courses at Saint Joseph’s College.  Standish, Maine.

Individual Mandate Repeal: Impact on the Affordable Care Act

Individual Mandate Repeal: Impact on the Affordable Care Act

                   The Patient Protection and Affordable Care Act, commonly known as the Affordable Care Act (ACA), was passed into law in 2010.  Implementation of the law was spread out over four years, with every citizen required to carry a minimum level of health insurance by March 31^st, 2014.  Those failing to submit proof of health insurance coverage with tax returns faced an income tax surcharge.  The intent of this requirement, often referred to as the individual mandate, was to help lower overall spending on healthcare by the federal government.  

                   In 2017, a new tax reform bill was passed that included a repeal of the individual mandate required by the ACA.  Starting in 2019, citizens will no longer be required to provide proof of health insurance with their tax returns (Mukherjee, 2017).  The impact of the removal of the individual mandate is not yet known, but speculations and estimations indicate that premiums will increase and fewer citizens will carry health insurance, which could have consequences on cost and quality of care available.

                   One of the main goals of the ACA was to reduce the number of emergency room visits by focusing on preventative care. Researchers at John’s Hopkins published a paper in the Annals of Emergency Medicine on this topic.  Their study took place in Maryland over an 18-month period. During that period, access to health insurance increased by 20 percent, but visits to emergency departments only decreased by one percent.  It was estimated by the authors that patients who newly obtained health insurance continued to use the healthcare services to which they were accustomed, rather than seeking out a primary care physician and preventative care (Xu, 2017).

                   An article published by the Washington Examiner written by Robert King (2018) investigated the potential changes that could result from the repeal of the individual mandate.  In the article, King outlines several potential outcomes including the raising of health insurance premiums.  In the article, he states the Congressional Budget Office predicts that up to 4 million people will choose to forgo insurance in 2019 and up to 13 million people will loose coverage.  This could result in a 10 percent premium raise every year, starting in 2019.  One of driving factors for premium increase will be linked to the population most likely to forgo coverage – the young and healthy.  Without a penalty or fine, this population will lack an incentive to obtain health insurance.  The loss of their contribution negatively impacts the risk pool (King, 2018).  

Another potential problem is the closure of federal exchanges, which were created to

meet a need in states that did not expand their Medicaid programs.  Without the individual mandate, there might not be enough interest in the federal exchanges, especially in states with lower populations.  Many states already only have one federal exchange option, and those signing up are usually in a higher risk population than is possible to sustain the insurance offerings (King, 2018).

                   In addition to the removal of the individual mandate, the tax reform bill also allows for the return of short-term insurance plans, as well as plans that do not include ten key requirements for a health insurance plan to qualify under the ACA, such as maternity care (King, 2018).  These short term and lower-risk plans might attract individuals looking for coverage with a lower premium, drawing more customers away from the federal exchanges.

                   Fortune magazine also published an article regarding the future of the ACA in light of the tax reform bill (Mukherjee, 2017).  In that review, it is estimated that Americans will not be largely impacted by the removal of the individual mandate.  They propose that a majority of American citizens already have health insurance coverage through their employer, Medicare, Medicaid, or the military, so will not greatly be affected by the tax reform bill.  Options to purchase health insurance increased with the passage and implementation of the Affordable Care Act and these options are likely to stay in place, regardless of the removal of the individual mandate.  They did predict that premiums would go up, on average, by 10%, but for some individuals, increased federal subsidies will offset those increases.  It is estimated that by 2027, 13 million fewer Americans will have health insurance due to the removal of the individual mandate (Mukherjee, 2017).

In FindLaw (2018), the same potential outcomes are outlined.  However, the authors point out that many aspects of the ACA will stay the same, which comes with advantages and disadvantages.  There will continue to be options available to those who are not covered by their employer, Medicare, Medicaid, or the military, however as long as individuals cannot be denied insurance coverage due to pre-existing conditions, the removal of the individual mandate might encourage citizens to wait until they have a health emergency before signing up for coverage.

                   As mentioned above, the true outcome of the repeal of the individual mandate will not likely be known until 2020 or beyond.  However, based on the literature review, the following implications are most likely:

                   1.  Premium rate increases, by as much as ten percent each year.

                   2.  A loss of health insurance coverage by up to 13 million individuals.

                   3.  A reduction in federal exchange options due to loss of enrollment.

                   4.  Continued access to health insurance options, with new options becoming available                             in the form of short-term policies with reduced coverage.

                   5.  Overuse of emergent care will likely still continue as more individuals lose                                           health insurance coverage.

                    

References

FindLaw (2018).  Obamacare basics: What is the Affordable Care Act?  Retrieved from

https://healthcare.findlaw.com/patient-rights/obamacare-basics-understanding-the affordable-care-act.htm.

King, R. (2018, January 14).  The Obamacare individual mandate is repealed.  Here’s what’s

           next.  Washington Examiner.  Retrieved from https://www.washingtonexaminer.com/the

           obamacare-individual-mandate-is-repealed-heres-whats-next

Mukherjee, S. (2017, December 20).  Tax bill individual mandate.  Fortune.  Retrieved from

           http://fortune.com/2017/12/20/tax-bill-individual-mandate-obamacare/

Xu, T. (2017, July 24).  Research shows one aspect of the affordable care act has no significant

          impact on emergency department patient visits.  John Hopkins Medicine.  Retrieved from

          https://www.hopkinsmedicine.org/news/media/releases/research

Opioid Mortality Rates in States with Medical Cannabis Laws

Opioid Mortality Rates in States with Medical Cannabis Laws

                  

Opioids are frequently used in the United States to treat acute and chronic pain.  In the 1990’s, pharmaceutical companies assured the medical community that opioids were not commonly associated with addiction.  This led healthcare providers to prescribe opioids as a common treatment for pain related issues.  It soon became apparent that opioids were in fact addictive to many, and by the mid 2010’s, the rate of people addicted to opioids became a public health crisis.  The Health and Humans Services (HHS) department of the United States Federal Government declared opioid addiction a public health emergency in 2017 (U.S. Department of Health and Human Services, 2018).  In 2016, opioid overdoses were the cause of more than 42,000 deaths in the United States.  Opioid overdoses increased by 30% in 45 states from 2016 to 2017.  In the Midwestern states, that increase was more than 70% (NIH, 2018).  Both the HHS and the National Institute of Health are looking for alternative methods to treat acute and chronic pain.  One of the suggested alternatives is to consider safe and effective non-addictive drugs, such as medical marijuana, to help manage pain. 

                    

Marijuana is labeled a Schedule I drug by the United State’s Drug Enforcement Agency.  Schedule I drugs are considered not to have any medicinal purposes and are not legal to sell or carry across state lines (DEA, 2018).  In November of 1996, California passed Proposition 215, which allowed for the harvest and utilization of marijuana for medical purposes.  This opened the door for other states to do the same.  By 2013, 19 other states and the District of Columbia had passed similar legislation.  The Supreme Court and the federal government fought these laws until 2013 when the Justice Department announced it would no longer attempt to block any states from implementation of medical marijuana laws.  Currently, 30 states and the District of Columbia allow marijuana to be used for medical purposes (New York Times, 2013).  It is still illegal to carry cannabis across state lines or sell it for recreational uses in most states, however it is commonly used for various medical purposes.

                    

One of the first studies to look at medical cannabis laws and opioid overdose mortality rates was completed in 2014 (Bachhuber, 2014). Results of the study indicate that states with medical cannabis laws had a lower average number of deaths associated with opioid overdose. In his study, Bachhuber (2014) indicated that there was a correlation of lower opioid overdose mortality rates, but no established causation.  In addition, the increased access to cannabis for medical purposes could influence opioid misuse in either direction, which indicates a need for further study.  A few limitations were noted, as well; the study was limited to a specific time period, not all opioid overdose mortalities are properly identified on death certificates, and the study does not take into account characteristics of the individuals within the different states (Bacchuber, 2014).

                     

Bradford (2018) conducted a longitudinal analysis of daily doses of opioid prescriptions filled by patients who utilize Medicare Part D.  The primary outcome of the study focused on the total number of daily opioid doses prescribed.  Results from this study indicate that from 2010 to 2015, 23.08 million daily doses of opioids were dispensed per year under Medicare Part D.  States with medical marijuana laws had fewer doses filled than those without.  Specifically, states with active dispensaries had 3.7 million fewer doses filled on a daily basis.  In addition, hydrocodone prescriptions decreased by 2.3 million and morphine decreased by .3 million.  In this study, the author concluded that medical marijuana laws are associated with a significant reduction in opioid prescriptions in the Medicare Part D population, especially in states with active dispensaries (Bradford, 2018).

                    

Hockenberry (2018) conducted a cross-sectional study using quasi-experimental difference-in-difference design comparing opioid prescribing trends between states with and without medical marijuana laws from 2011 to 2016.  This study found that states with medical marijuana laws were associated with a 5.88% lower rate of opioid prescriptions.  States that allowed adult use of marijuana, without or without medical reasons, found a reduction of 6.38%.  The authors of this study concluded that medical marijuana laws have the potential of reducing opioid use, which could also reduce mortality rates. 

As opioid addiction has been declared a national public health emergency, it is important to consider viable options to reduce the use of opioids as a method to control and manage both acute and chronic pain.  The studies outlined in this literature review are not conclusive, but they do point to an overall decrease of opioid use in states with medical marijuana laws.  While these studies do not provide causation, the correlation is enough to consider the benefits of alternative pain reducing methods, including the use of medical marijuana.  

Suggestions for future studies would include an updated study similar to the one conducted by Bachhuber (2014).  Doctors have reduced access to opioid painkillers since that time, which has led some patients to seek similar drugs in the open market.  Some states, such as Colorado, have more strongly regulated access to medical marijuana since the 2014 study, as well (Ingold, 2018).  This tighter control has made it more difficult for patients to obtain cannabis as an alternative to opioids.  Finally, more states have legalized marijuana use, which would also provide greater opportunity for obtaining new data.

References

Bachhuber, M.A. (2014). Medical cannabis laws and opioid analgesic overdose mortality

in the United States.  JAMA Internal Medicine 174(10) 1668-1673. Doi:

0.1001/jamainternmed.2014.4005

Bradford, A.C. (2018).  Association between US state medical cannabis laws and opioid

prescribing in the Medicare Part D population.  JAMA Internal Medicine 178(5):

667672. Doi:10.1001/jamainternmed.2018.0266

DEA (2018).  Drug scheduling.  Retrieved from https://www.dea.gov/druginfo/ds.shtml

Hockenberry, W.H. (2018).  Association of medical and adult-use marijuana laws with

opioid prescribing for Medicaid enrollees.  JAMA Internal Medicine 178(5); 67

679.Doi:10.1001/jamainternmed.2018.1007

Ingold, J. (2018, February 22).  Do medical marijuana laws reduce opioid overdoses?  A

new study adds a layer of nuance.  Denver Post.  Retrieved from

https://www.denverpost.com/2018/02/22/medical-marijuana-laws-reduce-opioid

overdoses/

NIH (2018).  Opioid overdose crisis.  Retrieved from https://www.drugabuse.gov/drugs

abuse/opioids/opioid-overdose-crisis

U.S. Department of Health and Human Services (2018).  What is the U.S. opioid

epidemic? Retrieved from https://www.hhs.gov/opioids/about-the

epidemic/index.html

Hierarchical Condition Category (HCC) coding

Hierarchical Condition Category (HCC) coding is an adjustment tool that is used to calculate risk scores and to predict future health costs for populations. CMS talks about risk adjustments associating practices, or they use Tax Identification Numbers or TINs, to describe providers that my deliver care to populations that are now well and other TINs that provide care to those populations that are more well than others.

The critical element of this measurement is the ratio of actual-to-expected performance and then taking into account the National Average. This measurement can take two providers and measure the performance of the two based on clinical complexity. CMS takes an example of one practice treating a very sick population that has higher costs. When you look to compare a provider of a healthy population to this one who treats a sicker population, the one treating the sicker population looks like they may not be as efficient. However, if you compare the practice that is treating a sicker population to another same or similar practice, you may find that they are actually more efficient and have much lower costs than the other practice treating the same population type.

Some of the measures that are looked at in the risk adjustment are as follows:

30-day All-Cause Hospital Readmission Measure

Calculates the percentage of qualifying hospital admissions that result in unplanned readmissions within 30 days of discharge

Hospital admissions for Acute and Chronic ACSC Composite measures

Represents distinct conditions for hospital admissions are potentially avoidable with using the services of ambulatory care delivery options

Per Capita Costs for all attributed beneficiaries and per capita costs for beneficiaries with specific conditions

Calculates per capita costs through HCC and generates a risk score that identifies potential per capita costs attributed to the beneficiaries measured

MSPB measure

A measurement of Part A and Part B total expenditures before, during, and after a qualified hospital stay

Consumer Assessment of Healthcare Providers (CAHPS) for Physician Quality Reporting System (PQRS) measures

CMS uses other data for measurement such as age, education, overall health and mental health indicators

This process takes into account several methodologies, but the one that stands out is expected performance vs. actual performance.

Overall, HCC coding has a great many variables both in the provider scope and the population served. A good Healthcare Administrator that is working in the primary practice arena or Accountable Care Organizations will need to familiarize themselves with the HCC coding concepts and how they may impact your facility and the population that is served. Not monitoring this process can cost the practice or ACO a considerable amount of resources without adequate measures to recoup costs.

Submitted by Kevin Harrington, MATS, MSHA, RHIA, CHP

Assistant Program Director, Health Administration, Saint Joseph's College

Family Financial Responsibility for Senior Care

Several recent items got me thinking about how American society is planning for senior care needs as Boomers age and start accessing LTPAC services. 

 ·        A New York Times article titled “The New Retirement: Near the Kids”  (hhtps:nyti.ms/2HNJ1j5) details a discussion of retirees moving away from the “sunbelts” and in to senior communities near their children. The article discusses the importance of family contacts, isolation, and nutritional needs as we age. While news articles and anecdotal stories do provide some interesting examples, they are limited in their scope and might not reflect the trends in society as a whole. 

 ·        Another article reported from the life insurance company (Northwestern Mutual) reported that 21% of Americans have no retirement savings and 33% of Boomers have less than $25,000 in savings. Those savings amounts are considerable less than the cost of a year in any senior care settings.

 ·        Another article in the Wall Street Journal was a question in their “Market Watch” section from someone asking about children’s responsibility to support aging parents. The author reports that about two dozen states have laws that have “filial” responsibility or “piety” laws, which require that families have a duty to support parents of adult children. While these have rarely been used and date back to colonial times, they are enforced on an occasional basis.

 ·        The final article (The Investment News Adviser Center) reported that two-thirds of financial fraud against the elderly was perpetrated by those closest to the victim. (ie. family, friends or trusted individual).

 All of the articles are concerning individually, as they have broad public policy issues on how to provide, support, and finance senior care needs into the future. Taken together, the potential for seniors and their families to be able to find and afford quality senior care is very concerning. The demographics of American society are very well known and should be used by public policy makers to prepare society for the coming challenges of aging Americans. Doing nothing to change the service delivery and financing for seniors has grave potential for taxpayers and families of seniors.

Written by Steve Chies, Program Manager, Long-Term Care Administration, Saint Joseph’s College

Great Article!

One of our graduates has written a terrific article!  I have linked it here!

Why I Chose to Join the Nursing Home Profession