maze

The Maze of Medicare

Sometimes it amazes me (no pun intended) how I stumble on this information.  I shouldn’t have to stumble. This information should be readily available and it’s not. I hope that, through this blog, you will pause and ask questions when you encounter a situation so you can learn about your loved one’s Medicare benefits in a more expedient manner than I have.

My dad was on Medicare Part A last fall after he came back from rehab after his hip surgery. He was getting physical therapy and nursing services for wound care. When he went into the hospital this last time, I learned about a specialized Physical Therapy practice that had particular expertise in Parkinson’s so I made a note to myself that when he came home, I would sign him up for their services.  What I learned was that because they came into the facility, they fell under “Home Healthcare Services” according to Medicare, which falls under Part B.

You cannot access Part B services at the same time as Part A services.

So I had him discharged from Part A because I really wanted to try out Dynamic Home Therapy, the specialized therapy provider.  I was not disappointed.  They provided superb therapy, both physical and occupational therapy services and went even further to suggest that he look into a different wheelchair. I was exceedingly pleased I had made that decision. Once he was discharged from Dynamic Home Therapy, I figured I would eventually move him back onto Part A for skilled nursing services as he always seems to have a skin tear that requires nursing services.

Last week, I finally got the paperwork together and today, the nurse stopped by to tell me that she would be starting next week and would be providing him with wound care.

And this is the KEY THING SHE SAID: She casually mentioned that when she opens a new “incident report” it comes automatically with 20 sessions of Physical Therapy!

There is no dollar limit like there is with Part B but there is a 20 session limit PER INCIDENT. She can re-certify him every time there is a new incident and, in my dad’s case, simply having Parkinson’s would qualify him to stay on because there is no longer a need to show improvement. And, he pretty much always has some sort of skin tear so nursing would always be able to re-certify him for that. This means he will have ongoing physical therapy. There is an in-house therapy team right where he lives which is convenient. It’s not the specialized therapy that Dynamic Home Therapy provided me, but I look at it as a way for him to continue to get structured one-on-one exercise 3 times a week, compliments of Medicare Part A.

Your welcome for the information.

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It Really Does Take A Village

village

This is a marathon, not a sprint.

The average length of time that a caregiver takes care of a loved one is 7-8 years. Most caregivers go into this experience thinking it will be for 2 years.

This is more like a marathon, not a sprint. I began taking care of my dad remotely about 3 years before I finally moved him out East. Most caregivers, including me, set off down the path of caregiving without much thought.  Of course, I will take care of my dad. He was a wonderful father and gave so much to me and to his community.  He deserves nothing but the best. Without thinking about the long-term consequences of that decision, I moved him out East to be closer to me…and assumably to be closer to his two sons and his niece and nephew who are up in the Boston area.  Surely being closer to all of us would be a good thing. He would get to see them more often because they aren’t as far away.

I knew that I would be doing the lion’s share of overseeing his care because I am the only one local, but I also assumed that my siblings would pitch in and help with this monumental job of taking care of our father. One of my brothers set up a secret facebook group which allows me to privately post status updates on how dad is doing, to post videos of him, keeping all of them in the loop on how dad is doing. I regularly update it and it is a better way of communicating with so many interested parties than to be bombarded with phone calls wondering how he is doing.

HOWEVER

I believe this facebook group has enabled my two siblings to become complacent. They see how well dad is doing and are able to keep up to date on his progress remotely. It is further exacerbated by the fact that dad really cannot communicate on the phone anymore so they cannot call him to keep that connection alive.  They really need to visit him in person. And to really see how he is doing, they need to visit for a few days, not a few hours a couple of times a year. Every day can be different with the Dementia experience. On one day dad could be pretty verbal for a short time and then be unable to communicate the rest of the day.  If you pop in for a few hours, you may catch him on a good day. This is wonderful, but it doesn’t give you a true sense of the magnitude of the job of caregiving day in and day out.

SO WHERE DOES THIS LEAVE US?

If you are not the direct caregiver because you live out of town, that does NOT let you off the hook of providing care for your loved one. What it means is you have to help in other ways. You should be calling the direct caregiver regularly and asking them how you can help. You should be doing things like sending notes thanking them for taking care of dad and telling them how much you appreciate it. You can be sending short notes to your father letting him know that you are thinking of him (since he cannot speak on the phone).

You have no idea how much of a sacrifice this is for the direct caregiver and their family. Unable to work, the family sacrifices current income and is not able to contribute to their own future retirement. Vacations become difficult to manage because you are your loved one’s voice and their advocate.

A large percentage of caregivers do not survive the person they are caring for. This is a highly stressful experience, both physically and emotionally.

I have it much better than someone who is caring for their loved one in their home because my dad is in an assisted living facility. However, that facility is taking care of just his basic needs. To care for him as he deserves, there is much more to be done. I am there 6-7 days a week normally. I spend hours with him. Most of the time he cannot communicate, so I am his advocate. I make him feel connected and feel like he is communicating (even though he does not make any sense) by doing improv with him (Oh really?  Tell me more!).

I walk him and do stretching exercises with him. These are just the basics.  Then there are all of the doctor appointments that can sometimes kill a half a day. Because of his mobility issues, I sometimes have to enlist my husband to help get him to the appointments, so now two of us have killed half a day.

This is what caregiving involves:

  • Medicare advocacy
  • Doing his laundry
  • Managing the inventory of his medications
  • Taking him to doctor’s appointments
  • A daily commute (sometimes more than once a day)
  • Trips to the VA in Philly
  • Trips to the VA in Coatesville
  • Fixing his wheelchair
  • Managing his hearing aids and batteries
  • Management of incontinence supplies
  • Healthcare advocate (acting as the liaison between about six doctors, none of whom communicate with each other as that is how our healthcare system is set up)
  • Parkinson’s expert (staying up to date, participating in webinars on the disease)
  • Paying his bills
  • Shopping for him (new clothes as his trousers frequently rip from people grabbing his waistband to hoist him to a standing position)
  • Constantly thinking about new ways to stimulate him mentally
  • Researching and finding specialized therapy, and being at every single therapy appointment (because he cannot communicate for himself and he tends to participate better if I am there)
  • Researching and locating a geriatric massage therapist and being at each massage to facilitate
  • Monitoring how he feels since he cannot easily tell the staff when something is bothering him, but I can tell
  • Figuring out the logistics of transporting a body interstate and pre-paying for his future funeral…and there is probably more that I am not thinking about.

I UNDERSTAND THAT YOU HAVE BUSINESSES AND JOBS.  I GET IT.  BUT YOU ALSO HAVE A FATHER.

You are missing out not only on the opportunity of spending time with him, and the rewards that come from knowing that you helped to take care of your dad after all that he gave to you. And you are also fracturing your future relationship with your sibling, the one who has shouldered most of his care.

I want to be clear, one of my brothers has been generous and recently took me to see my favorite artist perform when she was in town and sent me a gift card for a massage about a year ago. My cousins have each visited a couple of times.  My step brother and sister-in-law have visited a couple of times for short visits. For that I am grateful.

What I need is more than that.

Let me be brutally honest.  I need a week off.  I need a few days off now and again.  Not once a year, but periodically. I need my siblings to step it up and participate in the care of our father. Last night, I attended a session on caregiving sponsored by the facility where my dad lives. The examples they gave talked about how one sibling did the majority of caregiving because they were local but the others alternated visiting every few weeks to a month to give that primary caregiver a break. A break. What a novel concept.

I appreciate the fact that they came to dad’s recent 90th birthday celebration, but again, they came for 2 1/2 hours and then left to go home. That is not helping in the caregiving.

This takes more than a village. It is more than a full-time job. I want my village to wake up to the reality of what is at stake. This crisis in our family can either make our sibling relationship enriched and stronger or it can tear it apart.

PROS…and…CONS of Assisted Living

IMG_0828.jpgI couldn’t resist putting this FANTASTIC photo of my dad and me and in this post.  When the going gets tough…and with a progressive neurological disease, it gets tougher each day, I try to remember the good days. This was one of those.

Today was one of those days that reminds me that there are great things about assisted living facilities and not-so-great things. It’s a good to always remember that it isn’t going to be the same experience as if you were taking care of your loved one. And that can be a GOOD thing because, as is the case with my dad, I couldn’t possibly handle his needs because he requires complete 100% care.  He can do nothing for himself at this stage. If you are thinking about whether to place your loved one in a facility or try to cobble together aids to help your loved one stay in his/her own home, let me give you some frontline expertise.

In an assisted living facility, there is a community.  People need to be around others.  They need to feel as if they are part of something bigger than themselves.  Even if they no longer communicate or independently move about the planet, just having others in the room, having activities going on and other types of stimulation will add years to your loved one’s life.

And beyond years, it will add life to those years.

If you find a place, as I have with Daylesford Crossing, where the staff truly love being with the residents, it rubs off.  Today I witnessed two staff people singing at the top of their lungs as they walked down the hallway.  They were having fun and when the residents see that joy, it transmits to them. I have seen it in action.  One day, the music was on and the woman who is in charge of keeping the rooms clean was literally dancing with her mop to a Motown tune. It was hysterical! When shopping for a facility, try to come at different times of the day and catch the staff who work the different shifts. It will give you a good feeling as to whether this is a place that people come to live…or to die.

Now…the cons of living in a facility.

I have to remind myself that this is not a nursing home.  I specifically did not want to put my dad in a nursing home until it was absolutely necessary. So I cannot expect nursing home care in an assisted living facility. This means that I have to be more vigilant, have more of a presence so that when there is a shift…a change in his behavior, his mobility, or his cognitive abilities, it will probably be me who will see it first. Even though others may notice something unless it is a really BIG change they are not likely to mention it. Why? Because they have (in my father’s case) 18 others they are caring for and there are multiple shifts caring for these people. You’d like to think that they are attentive, but they just cannot be as attentive as you can be.  So don’t assume that by placing your loved one in a facility that you are off the hook. You absolutely need to be present as much as you can so you can notice these types of changes.  Don’t assume they will tell you (they might…but it might be 2 weeks later than you would have noticed).

This week’s events showcased this perfectly. Beginning on Monday morning (3 days ago) I noticed a change in my dad’s abilities.  He was sleeping way more than usual during the day. He had a great deal of difficulty rising from his wheelchair to walk (something he did twice a day, for exercise), really couldn’t walk at all and cognitively he was more confused.  His vision even seemed worse.  I chalked it up to maybe a bad night sleep. So I said nothing. I came the next day in the afternoon to see if there was any improvement.  There was not. Same thing on Wednesday.  I finally started asking around. It turns out the exercise physiologist who works with him to assist him on his walks was having the same difficulty as I was.  Also, the several CNAs who work directly with him caring for him also noticed a change.  No one said a word to me. As I collected my data, I saw enough to concern me.  So I called his doc who suggested getting him assessed.

We did that today and the nurse does not think it is a neurological issue; she thinks it might be as simple as a UTI (something he is prone to get). I normally can tell when he has a UTI because his behavior gets combative (not his usual personality). I wasn’t seeing that.  Apparently, a UTI can show symptoms like I was seeing….so we are off to collect a sample and see what it shows.

The bottom line is I went through an emotional roller coaster these last few days thinking the end was nigh because I thought he may have had a TIA (a mini-stroke) or some other neurological mishap.  I still don’t know for sure, but I feel more confident that it might just be a UTI.

If I hadn’t raised the red flag up the pole, this would have gone on for another week or two before it got REALLY bad.  So, the message is:

STAY VIGILANT.

 

5 Techniques for Caring for a Dementia Patient

memory-loss

I have been caring for my dad for about 4 years, 3 of which were remotely and the last one locally. Like everyone dealing with caring for a parent or other loved one, there is no advance cramming you can do to prepare for this job – you wake up one day and suddenly you need to be an expert in all things elder-care. It is the ONLY job that doesn’t come with a manual and there are few resources to help you other than learning on the job.

I thought it might be helpful to share some of the techniques I have developed and learned over this time period. These work with my dad, and I hope that they might be useful to you.  Unfortunately, there are over 70 different types of dementias so your loved one’s situation may be different from my fathers, but all dementias have many crossovers, so it’s worth trying some of these techniques.  You have nothing to lose.

  1. Pay attention. Be observant. To everything. I missed so many red flags when he was deteriorating.  I was so concerned with pushing him into assisted living that I stupidly was relying on him (someone who I now know had the early stages of dementia) to tell me when he was ready.  If you aren’t there, every day, then make sure a neighbor is watching out for signs.  Some of the early signs that I DID KNOW about didn’t register to me as signs.  Here they are:
    • Losing the ability to “work” the remote control on the TV; or conversely, saying that his/her TV is broken. Again.
    • Difficulty doing tasks that were, before, second nature.  In my case, my dad could send emails, was on facebook and was pretty “with it” for a guy in his mid-80s. The day I spent one full hour with him on the phone trying to instruct him how to open a browser window, should have been more than a red flag; it should have been a rocket blast. But it wasn’t.  Because I didn’t know anything about dementia.  I thought it was simply, short-term memory impairment.  It is so much more.
    • Impaired judgment.  One day, my dad decided to reheat a slice of leftover pizza. So he put the tin-foil-wrapped slice right on top of the burner and turned the burner on. Can you spell F-I-R-E? Again, didn’t register as a red flag.
    • Word finding difficulties.  This comes with aging for all of us.  It doesn’t necessarily mean dementia, but it is a possible pre-curser.  So if you see signs of this, be even MORE tuned in for other signs.
    • Forgetting doctor appointments or to take medicine. My dad even forgot that he brought his walker to lunch.  After lunch, he went crazy looking for it in his room because he had literally no recollection of it every leaving his apartment.
  2. When you enter the room where your loved one is sitting, make sure you are directly in front of them and have made eye contact.  First offer your hand (even if you plan to hug them next). By offering your hand, you give them time to process who you are. Processing slows down with Dementia.  Their vision narrows and eventually becomes binocular so don’t come at him from the side as you may startle them.  The instinct to shake hands will never leave them and by extending your hand to them, they will take yours instinctively.  Then tell them who you are, even if you think they should know you. And make sure to tell them your relationship.  “Hi Uncle Paul, it’s Bev, your niece.”
  3. Always tell them what you are about to do or where you are going (if you move them). Their world is very scary right now.  They want advance notice of any changes. The fewer changes you can make, the more comfortable they are.  If you never take them from the facility where they are living, they won’t care, as long as their routine isn’t disrupted.  For them, routine means safety.
  4. If you are a healthcare provider and want to take their blood pressure or re-bandage a wound, make sure to tell them what you are going to do and why and then, most importantly, ASK THEIR PERMISSION TO DO SO.  They have so little control left; they want to retain control over their body.
  5. Try to focus your activities on things they can still do.  Music is a wonderful activity as it is retained in a part of the brain that is unaffected by Dementia.  Dance together.  Do karaoke. Play name that tune. Play catch with a beach ball or a football, even from a seated position.  Hand eye coordination seems to stay in place and it can be fun!
I will continue with more techniques in future blog posts, so check back.  And if you haven’t subscribed, please sign up so you’ll get the next blog post delivered to your email. And finally, if you have any techniques that have worked for you, PLEASE SHARE THEM WITH ME!  I am always learning on this job.

 

The Roller Coaster Ride of Emotions a Caregiver Feels

roller coaster

If you are a caregiver providing support and care for a parent or loved one, then this blog post will confirm what you are already feeling.  I want you to know that you are not alone. If you are a sibling or a relative who is across the country and only checking in from time to time on your parent or loved one, let me give you an inside look at differences in your experiences to those of the direct caregiver.

As you know, I am the primary caregiver for my dad, who has Parkinsons’ and Dementia. Every day that I visit him, and it is EVERY day, I am mourning him. From the time I moved him near me after he fell last summer and fractured his pelvis and, I believe, hit his head, he effectively passed away for me. The father whom I spend time with each day, is not the father  I knew. Although from time to time he pops back in to show himself, for the most part, we don’t have many meaningful exchanges.  His language is completely compromised and I spent most of my time being his advocate and making sure he is getting proper and appropriate care. And I make sure to show him daily that I love him and will protect him.

That said, I mourn for my dad every single day.  It is an ongoing, dragged out sense of loss.  Very different than one feels typically upon the passing of a loved one where the grief is overwhelming and complete.  For me, it is a daily experience.  When the time comes that he does pass away, for me, it will be a celebration.  It will be a sense of relief.  I know that no one, unless you have experienced what it is like to care for someone – on the front lines – you may not understand this.  But it is real.  Very real.

Dementia and the Art of Improv

Think_Fast_Improv_Skills_site

Improv?  Yes.  Now that I am extremely experienced in the world of Dementia, I have observed how important the skill of improv is to my interactions with my dad.  A bit of background first…my dad not only has Parkinson’s Dementia but also has Aphasia, which is simply that the language center of his brain has been impacted.  He can no longer communicate in a way that makes any sense.

For instance, this sentence may come out of his mouth “It was really  interesting today.  The thistle came out of a grain and was car.”  Or, “did you see the biddle up the nickel?” Most of the time, I have no idea what he is trying to say to me.  But he clearly thinks he is communicating something and would like a response to either keep the conversation going or to answer his question.

The technique I have used is very much improv at its core, which is based on the concept of “Yes, and?”  Most of the time I answer with “really! Tell me more!”  And that gets him to continue talking.  I feel as if I can get him to continue to talk to me that is a win.  He feels as if he is expressing himself and occasionally I can decipher what he actually means, through context, and we can have a meaningful exchange.  Some days are better than others.  In fact, one day recently, it was as if he had an awakening of sorts.  He was making connections he hadn’t in awhile, remembering facts from the previous day, which is next to impossible for him typically and was able to talk on the phone with relatives fairly easily, again not typical. It was short lived, however, as it usually is, and the next day I was back to using my improv skills.

I am so lucky that my father has a pleasant personality, still smiles and laughs at himself and the staff where he lives generally enjoy him.  That, unfortunately, isn’t typical with Dementia.  I am hopeful that his personality will carry him through this terrible disease and that he will be smiling and laughing until the end

It has been awhile. Lots has happened.

relievedI haven’t posted in awhile.  There is a reason.  After moving my dad back into Sunrise of Paoli around Thanksgiving, it was a great deal of work getting him back into a groove…to a sense of normalcy after spending two months in skilled nursing, in two different rehab facilities. Honestly, I wonder sometimes if he has any clue where “home” really is.

After about 3 months at Sunrise, with no further broken bones, I made the decision to move my dad to a facility down the road from Sunrise, called Daylesford Crossing. This is where I had wanted him to move initially, but because he was out in Iowa and couldn’t be evaluated in person….and because he was coming off of an pelvic fracture, he was a “two person assist,” meaning he needed two people to help him with just about everything. They rejected him.

The one positive thing to come out of his time at Sunrise was he had a chance to fully heal following his pelvic, then hip fracture. He is actually more ambulatory now than he was when he moved in back in August. I took a chance and re-applied to Daylesford Crossing….and he was accepted!

When I toured Daylesford Crossing (particularly now that I had the experience of knowing what assisted living in a memory care unit really was like), the difference was palpable.  The vibe was calmer, quieter.  The staff was infinitely better trained. They had a multitude of ongoing activities for the residents, both in the memory unit itself and within the building (which the residents from the memory unit participated along with everyone else). The atmosphere was vibrant, alive, filled with people having fun.  It smelled nice. I know that’s a silly thing to mention, but Sunrise always smelled a bit like urine. I attributed it to the fact that there were 26 residents, all wearing depends. You should know, however, that it doesn’t have to smell. If it smells, it’s because the staff isn’t doing their job.

The move went smoothly and my dad transitioned to his new home with very little issues. It is a great relief, for me, to have him living in a place where I can reliably expect the staff to take care of him.  I never had the confidence that that was the case at Sunrise.

The internal communication was abysmal. At Daylesford, they use the latest technology throughout the building, using iPhones for all staff, so people are easy to reach and messages get shared easily. You have no idea what a difference that makes to my confidence level.  At Sunrise, I would make a request to one person and they never shared that request with anyone else! There are three shifts of staff!  I ended up doing most of the work which they should have been doing…Making sure he had fresh batteries in his hearing aids, that he was wearing them daily, that he had a handkerchief in his pocket, that he got up to exercise daily…these sorts of things. I wasn’t asking for the moon, but it seemed to feel like I was.

I cannot over emphasize the importance of choosing a facility based on the following very important criteria:

  1. How is the internal communication?  Exactly how does it happen? Do they use pagers? iPhones?  Can you text someone? How often is email checked? What are their systems really like?
  2. Is the facility run well?  Do they review care plans regularly and adjust? My dad NEVER had his care plan reviewed despite his improving condition.
  3. If your loved one is in memory care, how much overlap do the residents have with folks who do not have dementia?  It is important that they feel they are a part of a larger community for entertainment, parties, etc. At Sunrise, it seemed as if the two units operated independently from one another. As a result, my dad was isolated even further.
  4. Look at the other residents who live in the memory unit.  Are they at a similar stage of dementia as your loved one?  DO NOT place your loved one in a community where they are the least impaired. They will quickly sink to the level of who is around them. Look for a community where they will have people who are at a similar stage of the disease.
  5. Look at the percentage of women vs. men.  In many of these communities the population leans towards female. Not an issue on the surface, but it becomes an issue when most of the activities revolve around doing one’s hair and nails and crafts.  My dad was never interested.  Make sure there are activities that your loved one might enjoy. Also – make sure that the activities are MODIFIED for those who have dementia. If you see the list of activities and they include crossword puzzles, bingo and more traditional games you might find in senior living centers, just know that these are not going to work with someone with dementia.  They have to be MODIFIED. This requires that the staff have REAL training in dementia.  At Daylesford, all staff are trained in the methods of Teepa Snow, a well-respected dementia expert.  Who does the staff training? What kind of training is it? Dig under the covers a bit.
  6. Look at the size of the bathroom.  Look at the shower.  Is there a lip on the shower that requires someone to step over?  Better to not have that. It can become an issues as they decline. The size of the bathroom is critical for someone who uses a walker or wheelchair.  My dad’s bathroom at Sunrise was so small that it was a real chore getting him in position to sit on the toilet because there was never enough room for the walker.
  7. Come several times to visit, at different times of the day. Are the staff interacting with the residents or talking amongst themselves. This was a real issue at Sunrise.  Most of the time, staff was sitting around a big table chatting with other staff, while the residents watched TV, which, as it turned out, was the main activity in the memory unit at Sunrise.  Even though they posted other activities, often those activities were never done. If you see a place with the TV on all the time, that is not a good sign. Do they have lots of music?  Music is something that can be enjoyed by everyone, even those in the latter stages of dementia.
  8. If you notice people are spending a lot of time in their rooms alone, this is not a good sign.  People with dementia cannot safely be left in their room alone for long periods.  They no longer understand what is safe and what is not.  Often they can be quite impulsive, in fact.
  9. Find out if there is a dedicated med-tech for the memory unit.  This is important as you want it to be easy to find this person if your loved one’s medicine is late in arriving.  Because one of my dad’s medicines needed to be given on time, I spent many hours wandering through the floors of Sunrise looking for the med-tech and because they did not have technology to reach the staff quickly, I was often given this response when I asked where the med-tech was: “Oh…she just went downstairs, I think.”  It was then up to me to find her to haul her back to give my dad his medicine, which I was paying them to do.

I hope this helps you as you evaluate facilities and that you can learn from my mistakes. I am so happy that I found a facility that is well-run, my dad seems happy and most of all, I believe he is finally being well cared for. If you have any questions for me about what to look for or if you are worried about what you are seeing, please feel free to post in the comment section.  I am happy to help guide you, if I can.

Ciao!