Reducing “Road Rage” in Nursing Home Residents

So, maybe in seeing this title, what came to mind for you was the idea of nursing home residents crowding hallways and griping at each other about who gets to pass first (I work in a nursing home for veterans – a nearly all-male facility, so this actually happens fairly frequently). So, no, wheelchair “traffic jams” isn’t what I had in mind…. Although that might be a good topic for another post. I’ll make the connection in a few paragraphs here, below.

What I had in mind was the subject of the “call button,” something all residents of nursing homes (and pretty much anyone who’s ever spent any time as a patient in a hospital) knows about:

Hospital call bell

For residents in nursing homes, overwhelmingly older adults, many of whom who are completely dependent on nursing staff for their mobility, food, water, and other ADLs, the call button represents pretty much a lifeline. If you have a need to use the bathroom (and you’re able to use the toilet), but you need help from a staff member to get up from your bed safely, you hit the call button.

And you wait. And sometimes, you wait some more.

Although I haven’t run the numbers myself at the Community Living Center I work at (e.g., the nursing home care unit of the Palo Alto VA system), I would guess a significant proportion of both falls and behavioral issues such as yelling, verbal abusiveness, and agitation, are related to the interval between the time a call bell is answered (e.g., via intercom – a nurse usually answers and a disembodied voice speaks in the patients room, “how can I help you”), and the time it takes for a nurse to arrive in a residents’ room. There seems to be some consensus that extended wait times for call bells to be answered can be a contributor to fall risk (see here).

This makes intuitive sense, of course – the longer you wait (and the more urgent your need is), the more agitated and anxious you will be if you’re a resident / nursing home patient in need, correct? This seems to suggest a straightforward, technological or human-resources approach to fix to the problem – just increase staffing, or more intelligently balance staffing in order to minimize as much as possible the amount of time it takes for nursing staff to reach a patient who has depressed their call button.

Of course, there’s another take on this. While the above approach of increasing staffing obviously helps with the task of offering quality nursing care – it ignores the psychological dimension, and a possible psychological solution to the problem of the call button wait time intervals (as an aside, for a wonderful discussion of the value of paying homage to the psychological dimension in addressing human problems, I highly recommend viewing this “TED Talk” with UK advertising executive Rory Sutherland…. Goes to show you that sometimes the best psychologists are often people in the marketing field).

So what’s this possible solution? This brings us back to “road rage.” Imagine yourself at a red light (not hard to imagine for many of you – you may have had to wade through a dozen of them prior to getting to the office this morning). How many of you feel agitated, impatient, somewhat anxious when you’re at a red light and you’re on your way to an appointment, or to work? Most of us. Of course, studies have reportedly shown that longer, unjustified wait times for red lights increases driver frustration and can lead to increases in accidents – so again, the simple, technological approach, is to use advanced signaling technology, more intelligent use of sensors, etc., to minimize unjustified wait times at intersections, and to therefore decrease driver frustration and accidents. Of course, there’s a problem – drivers will still have to wait.

Enter the Eko Stoplight (mentioned in the TED Talk, referenced above):

Eko Stop Light

This stoplight, a really brilliant invention in my view, has as a feature a visual progress bar which gives immediate feedback to drivers at intersections how long they have to wait prior to the signal changing to green. Apparently there is data from Korea and also other data from the manufacturer that strongly suggests that this innovation significantly decreases red light running and accidents at intersections. Put simply – without even changing the wait time interval at traffic intersections, people are more able to be patient and wait, because they know how long they have to wait. And as you know, a minute at an intersection when you’re late for an appointment can sometimes feel like a hour!

So what if such an innovation could be applied to wait times for residents in nursing homes? As far as I can tell – although there is active work on improving call-bell technology in inpatient units (e.g., experimenting with wireless technology and IP-based call systems), as yet I have not seen this idea applied to the nursing home environment. But maybe it should! It would take some work – as my wife pointed out the other night, the Eko Stoplight idea doesn’t precisely map onto the nursing home situation – while the interval between when a stoplight goes from red to green is known precisely (thereby allowing the Eko to precisely calibrate the progress bar), the amount of time it takes for a nurse to reach your room after a call bell is activated tends to vary based on staffing, workload, and other factors. Still, one way of getting around that is allowing individual nurses to calibrate their assigned residents’ progress bars (their ‘Eko timers’) on-the-fly. As long as a nurse arrived before the progress bar elapsed in the patients’ room, I think this psychological, calming effect would still potentially hold. There could be other ways of implementing this idea.

What do you think?

The Crumbing State of Long Term Care Funding in the United States

This may be a bit of a downer, so be warned. However, I plan on following this post with a more uplifting, upbeat analysis of the state of home care alternatives to LTC placement (stay tuned!) – so just keep that in mind.

In the news recently was a conference of some high-level policy experts from the SCAN (Senior Care Action Network) foundation – which is a think-talk spinoff of the SCAN Health Plan, which is a modest-sized health plan with a number of beneficiaries mostly in southern California and Arizona.

At the conference these experts basically groused about something we all kind of know at this point – in the United States our ability to save for our own retirement is of course poor, but it’s downright terrible when it comes to saving for the cost of long term care. Which is unfortunate, because if you live past the age of 65 there’s apparently around a 70% chance you’ll need to stay at least temporarily in a skilled nursing facility (SNF).

The problem is that nursing home costs have soared over the past decade or so, and are projected to double within the next 15 years if current trends continue. Currently the cost of a nursing home bed in the United States costs between 50,000 and 100,000 annually – which is a cost structure that puts even college tuition and fees to shame (another sector of the economy in crisis due to near-hyperinflation).

At the SCAN conference the policy they noted several distressing issues, which we’ll review here. From the Forbes article linked to above:

“The existing system for funding paid long-term supports and services is built on a wobbly three-legged stool: low private savings, an underfunded Medicaid program, and a hobbled private long-term care insurance market.

 For whatever reason, the long term care insurance market has basically crumbled in this country. This may have something to do with the current financial crisis – insurance companies need to grow their premiums via investments in order to make a profit and also pay off beneficiary claims. In the current financial environment, basically at the same time their investments have tanked (recent stock market rally aside) and interest rates on savings have been basically set at subzero by the Federal Reserve, their costs have gone through the roof. Typically, insurance companies are rather risk-averse when it comes to their investments – they aren’t hedge funds. So, they’ve been investing in bonds. And they’ve been getting hammered.

Regarding “low private savings” – I think that this is somewhat of an unfair point, when you think about it. How in the name if all that is Holy can an family not in the privileged 1% even hope to afford to save up the tens (if not hundreds) of thousands of dollars one might need to pay for the cost of a year or two in a SNF? And mind you, again, if costs double in 15 years, it strikes me that it’s impossible, practically speaking, to put away enough unless one is essentially functionally super-rich.

Finally, they note Medicaid. In California, we have something called Medi-Cal, which is our state’s version of Medicaid. It’s generally the way everyone else pays for their skilled nursing care (everyone aside from the super wealthy, that is, and aside from those that require 30 days or less of skilled nursing, who can tap their Medicare benefits for this).

This is how Medicaid / Medi-Cal it works, from what I understand. First, you have a person (typically an older adult) who needs SNF care. Then they see the cost of private care, which is astronomical – this older adult may have a home, a car, and a savings account, and maybe some retirement money and a pension – but they realize that this money would be very quickly wiped out of they tried to do private pay. So, this older adult may try to do home care for awhile, or see if they can hack it in an Assisted Living Facility (ALF) – a less expensive, but still very expensive option. They may have already tried these things. They visit a financial planner and an attorney to discuss how to qualify for Medi-Cal.

In order to qualify for Medi-Cal, you have to prove that you are indigent and that you deserve to have the government pay your SNF tab. So, in this situation the older adult has to find a way to do what’s called “spending down” – which refers essentially to the process of getting rid of all of your ‘excess resources’ so that you can  meet the legal definition of being indigent. Then, Medi-Cal will pay for your long term care. Note there are a lot of exemptions (e.g., you can keep one car for transportation, one home, et cetera) but if you get any of it wrong the mistake can be financially ruinous (people have been pursued for five and six-figure nursing home bills due to not properly following spend-down rules).

Getting on Medi-Cal / Medicaid can be a lifesaver, however, as SCAN participants noted, the Medicaid program is underfunded and we can assume that it will continue to be so (at least, I will).

In the way of a personal anecdote, a social worker that I work with has let me know of an informal test she did of how nursing homes in California tend to treat “Medi-Cal beds.” She calls up Nursing home X and says, “I have this patient who needs placement at your facility – Medi-Cal is his funding source. Do you have any room?” Nursing home X says no. She calls Nursing home X back a half hour later, disguises her voice, and says, “I have this patient and he can pay privately. Do you have room?” She gets an enthusiastic yes. From what I am aware,  Nursing home X may be breaking the law here (e.g., nursing homes are not allowed to deny a patient admission based on their funding source), but I have a feeling this is a rampant problem. Medi-Cal pays at best an anemic, discounted rate to SNFs, and private pay (and Medicare) are much more generous, so they want to avoid it where possible. In the end, this means that the low-quality nursing homes that tend to be on probation with surveyors, provide poor care, and get frequent complaints are likely the ones with a number of “Medi-Cal beds” whereas the higher quality nursing homes that can attract private pay patients simply have a couple of token Medi-Cal beds just for appearances sake.

I’ve worked in nursing homes in California. We have a two-tiered system of skilled nursing in our state, at best.  And it’s getting worse.

What the SCAN participants suggested was a variety of reforms which focused on funding mechanisms almost exclusively. They suggested that people shouldn’t be inflexibly forced to spend down in order to qualify for Medi-Cal (which in many, but not all cases involves essentially sheltering assets so they don’t have to go towards paying for the exorbitant costs of nursing care). Unfortunately, that may have the downside of confounding what the actual point of Medicaid / Medi-Cal, which is reserving the program for the indigent.

Also brought up amongst the SCAN conferees, apparently, was the idea of “universal long term care,” basically a mandatory long term care insurance plan for all Americans. While this idea probably has some currency in the current political ethos, this was one of the areas that conferees didn’t agree on – probably because it’s not clear that it would do anything to address the problem of upward-spiraling costs in long term care.

Otherwise I wasn’t impressed with their proposed fixes, at least how they were represented in the Forbes article – it was all quite status quo. Other than discussions of nips and tucks in how to address affordability (none of which I think will work, politically or logistically), there was no discussion of implementing wide ranging innovation or reform in the business of skilled nursing care, or ways of encouraging competition as a way to bring down costs.

Regarding the issue of political will to start trying to address the sorry state of long term care in this country, my wife recently sent me this link. You ever heard of the “Class Act”? Well, you won’t – because it’s dead. This was a half-hearted attempt on the part of the Obama administration (and opposed by the Republicans) to implement a national, voluntary long-term-care insurance plan as part of the Affordable Care Act (ACA, also known as Obamacare). To be fair – it was hard to support it. The premiums were projected to be far too large to be affordable, and the program was generally thought to be unsustainable otherwise, so it was scrapped as part of the “fiscal cliff deal” from a few months back (As an aside, as far as the ACA goes – it’s a pretty good deal for older adults overall; apparently the way some of the law is structured, it essentially provides a subsidy for older workers over younger ones. While that’s great – at this point the ACA does nothing to address the downward spiral in the long term care market).

My take is that for the long term care industry to survive and be relevant in the future for the majority of Americans (as opposed to being just a niche specialty care market for the 1% and an inhumane warehousing system for the indigent), the LTC industry and the regulatory and funding structures surrounding  it need to innovate and evolve.

Let’s be clear – innovation is happening in long term care – but from where I’m standing it seems to be happening most intensively in home care. So, in a future article (or articles), I’d like to discuss and feature some innovative businesses that are capitalizing on the fact that more and more older adults are staying in the home rather than going into skilled nursing care (which doesn’t mean that demand for SNF care is going down, unfortunately – it just means there’s more older adults out there), and showcase them as examples. I personally believe that even with the coming ‘demographic tsunami’ we can innovate a long term care infrastructure that can serve the needs of this country’s growing older adult population – but we’re going to need to innovate, and fast – and we’re going to have to start fostering an environment where that innovation can happen.

We Can Build It… We Have The Technology

One thing is certain – over the next 10-20 years, regardless of what other economic or political events sweep the USA, this country will have far more older adults, as a proportion of the overall population, than we do now. This is sometimes referred to in the media as the “graying of America” or the “demographic tsunami” which has already been sweeping Japan and Europe.

On the one hand (as the linked article above accurately reports), members of this newer generation of older adults tend to be in better shape than counterparts of previous generations – and it appears that this trend will continue in the forseeable future; consequently the older adult of the future will be less likely to depend on long-term care than the older adult of today or yesteryear.

However – here’s the rub: we will be utterly groaning, bursting at the seams with older adults as a nation within the next few decades. Within the next 15 years, the number of people over the age of 60 in the U.S. will nearly double. By 2050, the numbers will nearly triple. That means that regardless of how much healthier the “baby boom” generation may be than previous generations of older adults and how much less prone to physical debility (and that’s also debatable, apparently), there will be much greater numbers of older adults requiring long-term care (as in skilled nursing care and assisted living) and even more older adults will require some sort of assistance in their home with basic activities of daily living (ADLs). So, while the proportion of the total number of older adults requiring nursing homes and intensive personal care arrangements may go down in the next 10-20 years, the overall number of older adults demanding nursing care will be skyrocketing.

And nursing care is absurdly expensive and getting more so. In California, nursing home beds at minimum fetch $60,000 per year and costs can go far north of that into the six figures. Hyperinflation of healthcare costs, for whatever the reason, has not excepted nursing homes (we’ll cover the challenge of affording nursing home care in an upcoming post).

So, with the costs so high and the “demographic tsunami” so clearly poised to swamp our system, what can be done? It’s worth imagining what the nursing home of the future will be faced with, and what they’ll need to do to accommodate these changes. Nursing homes of the future will be faced with patients with far more complex needs than the past – and that includes behavioral needs. Patients who make it into nursing homes today will be “triaged” to home care tomorrow so that nursing home beds can be saved for the neediest of the needy.

Long term care nursing staff, already working for one of the most heavily-regulated sectors of the US economy, generally have little time to spend providing and caring for patients’ psychosocial needs; tasks generally relegated to Recreation Therapy (RT) staff, volunteers, and the few-and-far-between mental health consultants who serve community facilities. So what are nursing homes to do? Modern long-term care facilities now offer cable television, and increasing numbers of nursing homes are offering wireless Internet capabilities to allow their increasingly-savvy residents to communicate with the outside world, but these kinds of technological innovations are cold comfort.

Some nursing homes have active “therapy dog” programs where residents are regularly exposed to animals for their well-recognized therapeutic purposes. Some nursing homes (particularly ones that subscribe to the “Eden Alternative” philosophy) even have animals that live in-house with the residents. Unfortunately, there are a number of issues with animals that make them impractical for use in many nursing homes in any widespread manner. First, there are the ever-present concerns about zoonoses (animal-to-human infection) and bites – no matter how vigilant a handler may be or how carefully veterinarian visits are documented, human error and the unpredictability of animals are always at play. Also, dogs and other animals need to be fed, toileted, cleaned, and with visitation therapy dogs need handlers to manage them – which make them a labor-intensive affair for an environment that tends to be starved for labor.

Meet the Paro Robot.


What is the Paro? Specifically, it’s what the developer has called a “mental commit robot” – a robot designed to elicit feelings of relaxation and happiness in the user (as opposed to the more traditional use of robots; e.g., for accomplishing specific tasks). Initially, the developers attempted to create these therapeutic robots using cats and dogs as models. However, they found that despite the cat and dog ‘paros’ being sophisticated machines, people were much too familiar with dogs and cats – they had far too well-developed prototypes of these animals in their heads to be fooled by a robotic cat or dog simulacrum.  So the developers hit upon using the ever-so-cute baby harp seal as their model – and it worked, simply because average consumers in the industrialized world have never encountered harp seals in their lives (and so had no prototypes in their minds to compare to).

I first discovered the Paro Robot approximately two-and-half years ago after I had spent some time struggling with a difficult case of an older woman in my VA nursing home who had severe dementia. This woman was in her 80s, had severe chronic pain (from arthritis), some previous issues with depression and anxiety that predated her dementia, and now spent much of her day in her bed screaming inconsolably. As the staff psychologist at my VA nursing home, they looked to me to address this issue (psychiatric medications were also being tried). The only thing I noticed about her is that she quieted only when the therapy dog volunteers visited her – unfortunately these visits were few and far between. The Paro Robot seemed an ideal solution.

Although this woman died before I was able to make full use of the Paro Robot with her, I have since used it on multiple patients and have encouraged other staff to use it at our neighboring geropsychiatric facility in Menlo Park. Since then we have collected data that suggest the Paro Robot is indeed an effective intervention for use with agitated and distressed older adults. When offered to these (frequently demented) older adult VA nursing home patients, we found that they significantly calmed and brightened in their demeanor, and that use of the Paro Robot often resulted in psychotropic medications not being used with our patients – which is an outcome of enormous value in and of itself.