Hospice Denied

End of life care is as tender, emotional, and difficult as it comes. There are so many different factors that lead people to hospice, but the common thread is the search for comfort for both dying patients and the families accompanying them on the journey. Hospice workers take on patients knowing that hope is essentially gone and all that is left is to ease pain and provide support until the end.

Yet hospice is not always the end. In fact, about 20% of hospice patients are discharged alive each year. Of these, about a third chose to leave the program, which means that nearly 13% of patients relying on hospice services are expelled from the program. It sounds like this means terminal patients are recovering, but sadly around 40% of these people die within six months of being released. If you’re not doing the math, that’s 5% of people who qualified for hospice dying without services. Fifty-five thousand people, every year.

Hospice is supposed to be a comfort – pain management, grief counselling, an easing of suffering and the fear of death. It seems worse than cruel to offer help to these desperate people and then yank it away, leaving them to find their own way again. And it is happening more and more often. Between 2002 and 2012 the number of people discharged from hospice rose by fifty percent. I’m sure the reason will come as no surprise: budget cuts. Many patients have their care covered through Medicare or Medicaid. In the year 2000, Medicare spent $2.9 billion on hospice; in 2009 the bill rose to $12 billion. And now the budget is shrinking. CMS has had to get tougher about approving payments. Payments that can be held up for months (or more) while being reviewed put small hospice centers under a financial strain. Rather than risk bankruptcy from delayed or denied claims, they are getting stricter about who receives care.

Hospice is intended for patients who have less than six months to live. If their prognosis improves while under hospice care, it is legal (or in CMS’s case, required) to discharge them. Whether it is ethical is another question, actually one of some debate. The difference between true recovery and a temporary plateau is hard to determine, especially over just a few weeks. Even though people can be readmitted if their condition worsens, the trust is gone. Hospice care cannot be a yo-yo, jerking people up and down, leaving them uncertain what each week will bring. This is not comfort and support, but torture at the worst time in families’ lives. Yet, where will the money come from to pay for services? Doing the ethical thing can put for-profit hospice centers out of business, and then all of their patients suffer. Where is the line?

It is a terrible thing to have to judge how fast a person should die.

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Do You Plan to Reach 100?

Living to be 100 used to be practically unheard of, but more and more people are making the trek thanks to better medical care and healthier lifestyles. Dissecting the choices these centenarians made has led to some interesting pointers for how to live to 100.

Some things won’t surprise you. Healthy eating and regular exercise are at the top of the list. A Mediterranean diet is the best for a long, healthy life. Foods like olive oil, fish, and vegetables are ideal for keeping your heart healthy and reducing the risk of certain cancers, Parkinson’s disease, and Alzheimer’s. One small change that may make a big difference is to eat a handful of nuts every day. This can reduce your chance of death by twenty percent. Beans and berries, especially blueberries, are the best source of antioxidants (which help reduce the effects of aging on cells). Rather than taking vitamins, get your nutrition from healthy foods. Add balance training to your exercise routine to reduce your risk of a fall, which is a serious danger for those of advanced age. Also, exercise your mind with mentally challenging activities to improve your chances of avoiding dementia. Likewise, social engagement and some type of religious affiliation will keep your mind healthier.

Living longer means making healthy lifestyle choices, but it also means avoiding certain risks. Obviously, avoid cigarettes and excesses like overeating or too much couch time. But did you know overtime can keep you short of your 100th birthday? So can traffic (think air pollution and frustration). People who leave work on time and take regular vacations tend to live longer. Keeping stress and anger levels down plays an important role in long term health.

It turns out that well-rested, optimistic, happy people actually live longer. Yes, into every life a little stress must fall, but don’t let it become an ongoing state. If you want to live to 100 (and enjoy it), here are a few more tips gleaned from those who have already made the journey:

∞  Be female. Of the 105,000 centenarians in the US, 80% are female. Sorry, guys!

∞  Have money. At least enough to be comfortable, take care of your health, and go on vacation now and then.

∞  Sleep. At minimum, 7 hours a night is recommended.

∞  Do it. Getting intimate around twice a week increases your life expectancy. But play it safe, diseases will shorten it.

∞  Get up. Keep TV time under 2 hours a day, especially as you age. After retirement, television keeps many people on the couch longer than is healthy.

∞  Pat a dog. Pets reduce stress and pet owners tend to live longer than those who aren’t.

∞  Laugh. As it turns out, it really is good medicine.

Sadly, there is no perfect formula to having a healthy, happy 100th birthday. But, as Theodore Roosevelt said, “Old age is like everything else. To make a success of it, you’ve got to start young.”

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Largest Senior Living Companies (combined list)

Each year different publications publish different lists of the largest senior living providers (read: companies). Senior Living Executive, a magazine published by the industry lobbying group Assisted Living Federation of America, just released their updated list for 2014. You can get a copy of it here, but be warned that they stuff it in a bloated, write protected PDF, in a clunky web viewer. Another annual list is put out by Ziegler, an investment bank in the industry, and LeadingAge, a buying-club for not-for-profit senior living providers. Their 2013 LeadingAge Ziegler 100 list is here, but again stuffed in a hard-to-use PDF.

As many of our long-term readers know, we’re obsessed with data at Silver Living. The multiple lists (in a format that is pretty useless) frustrated us (and some others in the industry) so annually we ‘digitize’ and combine the lists, a process that is scripted and automated. In the spirit of open data, below is the combined full list. Here is the Google spreadsheet of all of the data, in case you need it in a better format that allows sorting and exporting.

Note 1: These lists are not de-duped (although there shouldn’t be any dupes) or verify  (which we do elsewhere) this raw data.

Note 2: Brookdale and Emeritus are merging but haven’t done so yet. The new Broomeritus will be massive.


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Did Grandma Know How to Keep Us Well?

When it comes to getting sick, and then getting better, wisdom has been passed down through the generations in the form of old wives’ tales. In today’s age of scientific evidence, many have been devalued as ways to control kids (for better or worse) rather than actual health advice. Scientists have looked at some of the more common tales and you might be surprised what they found.

Don’t go out in the cold, you’ll get sick!

We now know that illness comes from germs and bacteria, not simply cold weather. But there is some validity to the tale. One study had half the participants dangle their feet in buckets of ice water for twenty minutes. Surprisingly, about 30% of them caught a cold as opposed to 9% of those who kept warm. This is pretty compelling evidence that getting cold does indeed lead to a cold.

What really happens is that blood vessels constrict when the body gets cold, reducing blood flow to extremities. The purpose is to keep the core of the body warm enough to survive, but a side effect is that fewer infection-fighting white blood cells get to the nose to protect against illness. Add in the reduced humidity, where viruses travel better, plus people spending more time indoors together and you have the perfect recipe for spreading the common cold.

You lose most of your body heat through your head.

So, if you do go outside in the winter, bundle up, right? And definitely remember your hat. An old study had volunteers dress warmly, but leave their heads bare. It isn’t shocking that 80% of their body heat escaped through their heads – where else would it go? Later studies found that in a burst of activity, blood flow initially increases to the brain, so that about 50% of heat loss is through the head. But after a little while, the body compensates and heat loss is more evenly distributed. At rest, only about 7% of body heat escapes from the head. While I still suggest a hat in winter, it isn’t quite the emergency situation we once believed.

Starve a fever and feed a cold.

Once you get sick, there is a ton of advice out there on how to get better. This is one of the most well-known…and untrue. In medieval times it was thought that a fever meant there was too much blood in the system and it needed to be bled out. The idea of starving a fever may come from the old idea that one’s system is overloaded and needs to be slowed down. Similarly, coughing up phlegm was thought to mean the system was depressed and so it needed to be boosted – feed a cold. Modern study has found that good nutrition is the best solution to illness, not an under- or over-abundance of food. In both cases, lots of rest and enough liquid to keep hydrated is well prescribed.

Chicken soup helps you get well.

This one seems like an ad campaign for soup companies. While there is little doubt that warm, yummy comfort food feels good to a sick body, does it actually help you get better? Recent studies suggest that it does. Chicken soup has anti-inflammatory properties and contains a compound which is very similar to medicine often prescribed to clear out congestion. Definitely a remedy worth trying!

Moms, grandmas and great-grandmas have been passing down these health tips for generations. It’s nice to have a little science to back them up. I would not automatically assume that all the tales are true, but not every bit of wisdom has to come from a laboratory, either.

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Can Your House Grow Old With You?

As the newest generation of seniors boom into retirement, the question many are asking is this: Will I be able to age in my home? Studies show that two-thirds of people over 45 would prefer to age in place. And as age increases, so does the desire to stay at home, up to ninety percent of respondents saying they would stay home given the choice. Unfortunately, the desire to stay at home does not always meet the reality of aging. Sometimes a home’s design presents insurmountable challenges. Too many stairs, narrow doorways, or an inaccessible bathroom could all force owners to remodel or leave their homes.

Enter a new trend in housing: Universal Design. This design plan creates a space everyone can enjoy at every stage of life. For the young homebuyer, the house is attractive and comfortable with subtle variations on traditional home design. The modifications generally go unnoticed, except that the whole house is a little easier to live in overall. Features like an entryway without stairs, wider doors and halls, and easier to reach switches and outlets are convenient for those without disabilities, but necessary for others who need a wheelchair to function. Many people find they need to make small adjustments to their homes as they age. In Universal Design homes, those modifications are integrated into the house. This saves remodeling time, cost, and frustration during an already stressful, life changing situation.

More of the features builders of Universal Design homes opt for are:

  • Single story accessibility
  • Lever-style handles instead of knobs
  • Raised and front loading washer/dryer units
  • Kitchen design with easy to reach cabinets and counter space accessible to wheelchairs
  • Bathrooms with raised toilets and non-slip surfaces
  • Easy open windows
  • Extra floor space for maneuverability
  • Thresholds level with floor
  • Good lighting for those poor vision

In some instances these homes are designed in neighborhoods called livable communities which also have aging in place in mind. Nearby shopping and services make life a little more convenient if driving is a problem and public transportation is easily accessible. Sidewalks may be a little wider and well maintained so those with ambulatory issues have an easier time being outdoors. Support services are located nearby and may even come directly into the community. Also important are community centers where neighbors can gather for social events and fun without having to travel too far.

The key to Universal Home Design and Livable Communities is options. They are created so that people can adapt to the challenges of aging without having to find new housing. Some loss of independence can be managed if the setting is appropriate, and well-designed homes allow for that level of flexibility. Technology can be installed, rooms can be repurposed, kitchens and bathrooms are ready for a variety of needs, and the home is accessible to people with different levels of independence. Of course, sometimes choices are removed and it is simply necessary to move. But for many, planning to age at home is a compelling reason to seek out a house that keeps that option a possibility.

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We’re All Senior Olympians

Are you gearing up for the next round of The Games? Whether your sport is Racing, Swimming, Archery, or Shuffleboard, it is already time to get ready for qualifying rounds. Of course, I’m talking about the 2015 National Senior Games! Every two years senior athletes and their supporters gather to compete in events like Badminton, Bowling, Cycling, Racquetball, Pickleball, and more. Participants range from 50 to 100+ years old and must qualify through state level events. It is a serious competition, though the ultimate goal is fitness and fun for the senior population.

Some of the sports require more athleticism than others, but The Games are intended to encourage seniors at all levels to stay fit and healthy throughout their lives. To that end, there are a variety of events offering people of different abilities the chance to participate. Some Olympic-style events are held, like swimming and racing competitions, but there are also less demanding competitions like Horseshoes and Table Tennis. Since its conception in 1985, the event has grown to attract over 10,000 athletes and 20,000 spectators. From seniors who have spent their lives as athletes, to those looking for new ways to stay healthy in retirement, The Senior Games gives those over 50 motivation to stay active.

For others who are not as motivated by competition, there is a personal best category of award. Every year the committee looks for entrants who have overcome difficult obstacles and personal challenges to bring their best to the games. Anyone can achieve this goal and it is a great way to shine the spotlight on people whose perseverance may not lead to a competitive win, but a personal one.

Those looking to compete on a global scale can check out the Huntsman World Senior Games. Every year participants from around the world come to southern Utah to test their skills and have some fun. In addition to the traditional competitive games, seniors can show off their expertise in bridge, horseshoes, shooting, and square dancing. The goal of the event is to promote healthy living and friendship between nations. While there, screenings are available for health risks like diabetes, cancer, glaucoma, and high blood pressure. Socials are held to give competitors a chance to become friends and to foster positive international relationships.

Both events give seniors a fun reason to stay active and engaged at a time when many feel like life is slowing down. Depression and decreased activity are common problems for retirees and both conflict with the goal of a long, happy life. For many, the time spent training is more valuable than the event itself. While the goal is meaningful, it is only the last step in a journey that improves one’s health and happiness. For those needing more social time, a team sport offers a reason to gather and a common goal to work towards. Some retirees lose that shared purpose that can be so rewarding in the workplace. Others may find that kind of camaraderie for the first time. The National and World Senior Games are a great way to make friends, stay healthy, and have fun throughout the senior years.

And in case you’re wondering…Pickleball.

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Are You Too Old to Drive? (silverliving.com)

Are Some People Too Old to Drive?

The debate over senior citizens and their driving abilities rages on. It is a very sensitive topic for many seniors and a very difficult subject to broach if you know someone whose driving skill is deteriorating (at any age). Losing the ability to drive means losing independence. It means admitting that you are not functioning as well as you once were. It is a major blow to self-esteem and pride. On the other hand, elderly drivers get into more fatal accidents than any other age group. Drivers over 85 are in four times as many fatal crashes as teenagers (the next most dangerous group). Impaired drivers endanger lives, and not just their own.

Part of the problem is how to tell if someone is too impaired to drive. Aging is a process that affects everyone differently. Some seventy year olds are sharper than other people in their twenties. And some 40, 50, and 60 year olds are much too impaired to operate a car safely. Changes often happen slowly, making it difficult to draw the line between safe driver and dangerous on the road. And the problem isn’t just with age-related impairments. People of all ages get behind the wheel when they shouldn’t and it costs lives.

Some diagnosable ailments like glaucoma, cataracts, dementia, or even powerful medications limit driving ability and a doctor can make that call for you. But if a shiver of fear runs through you every time a loved one gets behind the wheel, there are some warning signs to look for when assessing their ability to drive safely.  Poor judgment is a major red flag – not yielding right of way, cutting vehicles off, drifting or straddling two lanes, turning too widely or hitting the curb a lot – all are signs that a person is not able to navigate safely. Reacting slowly is another dangerous warning sign. Driving is often very humdrum and simple – until it isn’t. Someone who can just handle everyday traffic and familiar roads becomes very dangerous when a quick reaction is needed to avoid an accident. Another sign that indicates a problem is when someone starts getting lost in familiar places.

Cars are getting smarter and some have features that aim to offset the errors impaired drivers make. Companies have been developing vehicles that are actually aware of their surroundings, give warnings, and even take over certain functions of driving. Cars can now park themselves, brake when they sense a collision, nudge sleepy drivers to pay attention, apply extra brake pressure in certain circumstances, and brighten your view of objects at night. Even the driverless car is a lot closer than you may think. All of this technology has the potential to save lives and prevent accidents due to human error. Anyone shopping for a new car should at least consider if some of these features might make them more likely to avoid an accident on the road.

However, cars that take over for the driver may not be right for everyone. The technology is still new and there are drawbacks to having a driver surprised by the car’s response to a situation. Alerts are only useful if they are processed and responded to correctly. For some, a vibrating seat or flashing light would be confusing and distracting rather than helpful. Likewise having the car suddenly slam on the brakes may trigger a panic reaction in which the driver responds inappropriately and causes another problem. And what happens when the system malfunctions? I can’t tell you how often my smartphone freezes or reboots itself. (Granted, I’ve dropped it a few times, but it doesn’t endanger lives when things go wrong.)

Ultimately, impaired drivers should not be behind the wheel of a car. Yet it happens way more often than it should. Cars that can compensate for human error and save lives are a wonderful idea, but before you run our and purchase a car to drive for you, do your research and make sure the features work for you. If you know someone who’s driving skill makes you cringe every time they grab the keys, have the difficult conversation. If that doesn’t work, talk to a doctor for a third party evaluation. Sometimes getting a warning from someone outside the family makes it easier to hear and accept. There is not always a hard and fast line when someone needs to stop driving, but too late is too late when someone gets hurt or killed.

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Silver Caregivers

The senior care industry is one of the fastest growing job markets in the U.S. right now. The baby boomer population is aging and the demand for caregivers is rapidly growing. In fact, the market is expanding so quickly, employers can’t keep up. Fortunately, a new group of caregivers is stepping up to meet the growing need: senior citizens.

Traditionally caregiving jobs have been filled by younger workers. The work is physically demanding, requiring lifting, cleaning, and sometimes offering support for unsteady clients. The whole point is to do tasks for someone who cannot perform them which usually means more challenging physical activities. Lately, though, the demand for caregivers has been so high that retirees looking to help others or supplement their income are stepping in. There are certainly a wide variety of caregiving services that need doing and many retirees are in great shape. Why not lend a hand?

It is projected that by 2018, 29% of the caregiving workforce will be over 55. That’s a 22% increase from 2008, just ten years earlier. There are even services that specifically help people find a caregiver who is a senior citizen. The idea is growing in popularity across the country.

For many seniors in need of assistance with daily living, it is easier to connect with someone of the same generation. Even the best care worker does not have the same base of experience in her youth as an elderly caregiver does. A person with dementia can find familiarity with a senior caregiver in ways that a young aide could not match. A senior would also be better able to offer friendship in addition to care and understand some of the frustration and pangs of aging.

Being a senior care provider can be challenging at any age. Workers in the field are prone to injury, need to maintain a positive attitude in demanding situations, and pay is generally low. The turnover rate is high. This makes home care companies more willing to hire aging employees, but it also makes the job tougher for seniors. Aging muscles tend to move slower and tire more easily. Elderly workers are more prone to injury. But the rewards are high, too. For senior citizens who are fit and able, it is a rewarding way to give a hand to members of their own generation.

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A Dive into NJ’s Assisted Living Inspections


[ And also why complaints jumped 8-fold at the end of 2013 ]

State inspections have always been a critical component of our analysis of senior care communities. We focus mostly independent living, assisted living, and memory care communities. Inspections are not comparable between states since each state inspects differently and on a different scale, but they are very useful for comparing within the same state.

States also differ in how much they share with the public and run the spectrum from no disclosure to full disclosure. The best states are gracious enough to publish the full inspections online (like Georgia, Texas, and Florida). Others, including New Jersey, only publish summaries online. Some states happily provide the inspections through Freedom of Information Requests (thank you Connecticut).

But some states spend the effort to complete inspections and simultaneously believe that the public shouldn’t be able to easily review them. California,  the most notorious for this,  will be the subject of an upcoming article on how we’re overcoming their roadblocks.

Box of NJ State Assisted Living Inspections

Since NJ only provides inspection summaries online we were forced to submit freedom of information requests, colloquially known as the Open Public Records Act in NJ. Several months and a few hundred dollars in fees later we received boxes and boxes of printed inspections. After laboriously scanning the thousands of pages we were able to perform a little computer magic and automatically analyze and score each inspection.

Here is what we learned.

Once you get your hands on the data, analyzing it is usually very telling. For example, the biggest surprise in the NJ data set is the huge jump in complaints at the end of 2013:

Chart of the number of complaints and inspections per quarter for NJ assisted living facilities between 2011-2013


The average complaints over the last two years was just over 10 per month. In November 2013 it jumped to 8.5x to 85 complaints.

Perhaps related, the number of inspections plummeted in 2013. The state completed 6.5 inspections on average until March 2013. From March 2013 until November 2013 New Jersey completed just 2 per month, a 70% decrease.

Here’s another way to look at the huge shift from proactive inspections to reactive complaints:

Violations mix between complaints and inspections for NJ inspections of assisted living facilities between 2011 and 2013

Inspection/Complaint Mix


We dug in a bit further to find out what is going on in the Garden State. Here are where the 195 different communities in New Jersey that are categorized as assisted living:

Locations of assisted living facilities in NJ and density by county per capita for citizens over 70 years old

Left map: All communities
Right map: Communities per 10,000 residents aged 70+


The larger communities, as measured by the number of beds, are in the densest counties, as might be expected. Community size, however, is not correlated with how well they fare on inspections and complaints.

NJ state inspection and complaint violations by county and average assisted living facility size by county

Average beds per facility per county
Average violations per facility per county


While there isn’t a link between community size and violations, facilities in certain counties do much worse than the average. Here it is evident that communities in Camden, Salem, and Passaic counties receive considerably more violations per facility than the best counties.

Average number of violations per assisted living facility per NJ county from 2011 to 2013

Average violations per facility per county

The violations data also allows us to identify what the state believes to be the most pervasive issues. Topping the list are violations related to medication management (called pharmaceutical services) and sanitation.

Most common inspection and complaint violations for NJ assisted living facilities

Most common violations (click to enlarge)

After analyzing the distribution and nuances of inspections and violations in the state we can turn to individual facilities. There are many ways to slice the data but it is important to create a fair baseline. Simply adding violations is unfair because 39% of the facilities have not had a single inspection in over three years. Every facility in the state has either had an inspection or a complaint investigation, which is limited in scope but allows us to judge the outcome. We use several proprietary formulas to rank the communities but the simplest one is simply comparing the average violations per inspection and complaint investigation. Using this we see that 75% of all communities received violations from the state, and that the average number of violations was 1.3.

Most startling is that the communities with the biggest infractions have over five times the state average.

Worst assisted living facilities in New Jersey as judged by the highest average violations per inspection and complaint

Highest average violations per community (click to enlarge)


We don’t yet know why New Jersey halted their inspection program at the same time that complaints skyrocketed, but we do now know a lot more about what communities are “good” and which need significant help.

Note: We analyze each state’s inspections and will regularly publish the results here.

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