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Long Term Care Advances THE DUKE LEADERSHIP IN AN AGING SOCIETY PROGRAM NETWORKS AND PARTNERSHIPS: BRIDGES TO THE FUTURE From the Editors
Leadership in an Aging Society Program Highlights Program Highlights from 1999
- 2000 include:
YEAR 2000 SENIOR LEADER PROFILES Louise Chut, (Pittsboro, NC) is
retired from an academic career as Associate Professor in Health
Administration at Kean University in New Jersey. She holds a M.A.T.
in Health Education from Trenton State College, a Ph.D. in Health
Education from Temple University, and a M.P.H. in Health Administration
from Rutgers University. Chut, who remains active in public health
professional organizations, is a Board member of the Carteret County
Division of the American Heart Association, a Trustee of Carteret
General Hospital, and author of a weekly column in the Carteret
News-Times on "Staying Healthy". MID-CAREER PROFESSIONAL PROFILES Wendy Sause is currently State Long-Term
Care Ombudsman with the North Carolina Division of Aging in Raleigh.
Responsibilities include oversight for 26 Regional Ombudsman and
over 1200 volunteers in the development of program policy, evaluation
and budget management. Previously, she was Regional Long-Term Care
Ombudsman for Triangle J Council of Governments,and Director/Administrator
of Clare Bridge of Cary. Sause holds an MSW from UNC-CH, and a BA
from UNC-Charlotte. She concentrated in Psychology, Gerontology
and Women's Studies. PRESENTING THE 2000 INTERNS UNZILA ALI, Senior,
Economics, Duke University
RASHELLE BROWN, Senior,
Psychology, Economics, Duke University
The Experience : Over the summer I had the wonderful
opportunity to participate and work on my internship at Crater District
Area Agency on Aging near my hometown in Petersburg, Va. This agency
is one of 25 in the state of Virginia whose primary function is
to provide leadership regarding supportive services and functions
as an advocate for people over 60 years of age. The agency offers
a wide variety of much needed programs and services for the elderly
including a Foster Grandparent program; health insurance, tax, and
pension counseling; legal services; a daily adult day care program;
housing repair and homemaker services; long term care ombudsman
advocacy; transportation and much more. Through these services and
the friendly atmosphere of being in a local area agency on aging,
I believe I gained insightful experiences of leadership and knowledge
within the field of aging and long term care. Mentor: Steve Fishler Site: The Forest at Duke Over the summer months I had the pleasure of working and learning at The Forest at Duke, in Durham, NC. The Forest at Duke is a full-service continuing care retirement community that contains 240 independent living residences, 60 health care units providing assisted living and skilled nursing, and a dynamic Community Center. Steve Fishler, the Executive Director of The Forest, served as my mentor, taking the time to work with me on fascinating tasks that occupied my time and mind, introducing me to individuals who could further my learning, and inviting me to accompany him to meetings. One of the major projects that I worked on was compiling a modified Eden Alternative proposal. The Eden Alternative is a concept that aims to integrate plants, animals, and children into the care of frail elderly to alleviate loneliness, boredom, and depression. Before my internship began, the Resident Health Committee expressed its desire to consider and critique a modified Eden Alternative proposal. Leslie Jarema, Director of Health Services, collected hundreds of pages of articles and opinions on the subject and developed a rough draft of a proposal. I helped to supplement and organize this research, contacting many experts and seeking out academic articles on the topic. Additionally, I assisted in developing a proposed schedule of care and cost for this project. Finally, I organized and refined this information into a 25-page proposal complete with tables and photographs. After my work on the Eden Alternative, I devoted time to The Forest's commitment to serving the wider community. The Forest at Duke's mission statement expresses its dedication to giving back to the broader community. The Community Relations Committee is a group composed of residents, Board members, and staff who are interested in advancing The Forest's efforts to donate time and resources to the broader community. To help this committee, I reviewed information from the state, county, city, and various aging advocacy groups with respect to the needs of populations experiencing hardships. From this information, Mr. Fishler and I generated a summary to begin to guide the decisions and actions of the Community Relations Committee. Next, I composed and distributed a survey of the residents and staff at The Forest regarding their current altruistic contributions, future interests, and opinions about various community service options. From this I generated a database of preferences, opinions, and quantifiable donations of time. Another principal duty during my months at The Forest was editing and translating various documents. I have always enjoyed proofreading and especially embraced the opportunity to assist in the revision of The Resident Handbook because it familiarized me with the amenities and structure of The Forest. My largest translation assignment was converting the Employee Handbook into a Spanish version. As unemployment drops and immigration from Hispanic nations increases, the number of Spanish-speaking staff members at The Forest at Duke is multiplying. This project consumed a great deal of time to ensure the accuracy of descriptions of rules, policies, and employee benefits. However, it was extremely gratifying to know that I helped Hispanic employees to understand their right to health insurance, sick days, and retirement packages. My last major assignment was to assist in the revision of the Benevolent Fund application process. The Forest promises that if its residents become unable to pay monthly services fees through no fault of their own, they will be eligible for assistance. The Benevolent Fund contains the finances to cover this support. I worked with the Director of Finance and my mentor, using the advice of other legal and financial experts, to draft a new application process. In the future it is likely that the Resident Benevolent Fund Committee and the Board will review a version of this process and come to a decision.
My exposure to the internal operations of The Forest was increased by casual conversation and observation of meetings with staff members. Nearly every day one of the directors of The Forest took the time to stop by my office with a lesson in the form of a story. Directing a community is a hard position as such an individual must consider the opinions of every affected party and bear much responsibility. This lesson became more real to me as I attended many Resident Association, Caucus Coordination Committee, and Long Term Planning meetings with Mr. Fishler. As a pre-medical student, I benefited from the invitation to attend Geriatric Grand Rounds at Duke University Medical Center and weekly Health Maintenance Committee meetings with The Forest's on-site geriatrician, Dr. Anthony Galanos. Here I became acutely aware of the complexity of treating elderly patients with multiple morbidities, the increasing importance of research and technology in medicine, and the heartache felt by many individuals as their failing health or mental status precludes independent lifestyles. Additionally, the internship allowed me to explore aging advocacy groups on a larger scale as I observed a meeting of the Medical Care Commission with my mentor, took part in a seminar at the Division of Aging, and learned about NCANPHA and AAHSA. Viewing these meetings made me sensitive to the immense expense of providing quality care, critical staff shortages, and unequal distribution of care. Further, it heightened my recognition that the growing elderly population needs advocates to ensure that their needs and rights are met. This internship was more than I dared imagine it would be. I did not type, file, and sort. Rather, I thought, contributed, observed, interacted, and learned. I would recommend this magnificent community as a place to work for any student and as a place to live for any retiree. CARON COX, Senior, School of Social Work, University of Pennsylvania Mentor: Judith Riggs Site: Alzheimer's Association, Washington Policy Office
During my time at the Alzheimer's Association, I worked on two major projects for the State Policy Clearinghouse. First, I researched Civil Monetary Penalties (CMPs) and compiled an analysis of how funds collected from CMPs were used in various states. Civil Monetary Penalties are funds that are collected from nursing homes when they are found to be out of compliance with state or federal regulations. Knowledge of how CMP funds were used in states was important to the Policy office as well as the local chapters of the Alzheimer's Association, so that together they could focus on how CMP money could be used to help enhance the lives of those with Alzheimer's disease and other forms of dementia. The second project that I worked on dealt with researching and compiling an analysis of dementia training programs and legislation in the states. This project was important to the Alzheimer's Association because the results showed that dementia training in the states is not standardized. Each state has its own standards for dementia training. Some states do not require certified Nursing Assistants or other direct service staff to have introductory or continuing dementia training, while other states have extensive dementia training standards for direct service staff and administrators. A project such as the dementia training project lets the Alzheimer's Association know that they have to continue to empower advocates to fight for uniform and better dementia training regulations both at the state and federal levels. While working on both of the projects mentioned above, I was able to go to many Congressional briefings and meetings in Washington to get a true understanding of what goes on in the policy making arena. This experience along with my individual projects at the Alzheimer's Association helped to complement my classroom and direct service experience and to give me a better understanding of how policy makers and direct service providers can come together to help provide the best care for those who need it. My internship at the Alzheimer's Association has impacted me greatly. At the beginning of the summer, I was uncertain of which career interests I wanted to follow once I graduated. I was interested in direct service, but also very interested in public policy. My summer at the Alzheimer's Association has shown me that my interest in public policy is stronger than my interest in direct service. I am especially interested in working with state issues as I did this summer. SUSAN DYSON, Senior, Healthcare Administration, UNC School of Public Health Mentor: Jan Busby-Whitehead and Mary Beck Site: (1) Geriatric Evaluation Clinic, Ambulatory Care Clinic (2) Planning & Program Development, UNC Health Care For my summer internship, I was fortunate enough to have the opportunity to work on aging related projects in two very different areas within UNC Health Care. Between the two areas, I was able to get a very well rounded appreciation of how geriatrics is aligned with all aspects of an academic medical center. I was able to work on improving administrative portions of an outpatient geriatric clinic, whilst at the same time, participating in the planning and development of future geriatric services at UNC. Under the preceptor ship of Drs. Jan Busby-Whitehead and Laura Hanson, I worked with the Geriatric Evaluation Clinic (GEC), which is a part of the School of Medicine's Program on Aging. The GEC provides a comprehensive approach to outpatient care for the elderly with multiple or complicated health issues. The clinic is staffed by a team of healthcare professionals including geriatricians, geriatric nurse practitioners, social workers, physical therapists, occupational therapists, geropsychiatrists, pharmacy students, and other allied health professionals. The patient undergoes a complete medical, physical and social evaluation, and together with the family, a care plan is constructed to assist in improving or maintaining the health of the senior as he/she ages. The clinic was interested in obtaining data from its patient encounter forms to assess physician productivity and clinic billings. Previous informal checks had highlighted some areas to address, but there had been no systematic data collection to detail these findings. I was responsible for collecting encounters from all patient visits in the clinic to determine: a) the amount of charges generated by each physician, b) the number and types of billing/charge errors that were occurring, c) reasons and underlying causes of the errors and d) recommendations for improved procedures or policies. After two months of tracking, it became evident that the previous reports had not captured all of the activity in the GEC. My analysis offered several suggestions, some of which the clinic was able to directly influence, others which will need the support and approval of the Department of Medicine. Some of the changes that I participated in included: a) redesigning the patient encounter form to make it clearer for providers and for charge entry staff, b) reconciling the encounter forms against batch records and correcting entries, and c) obtaining and relaying pertinent Medicare billing information to increase charges and reimbursement for the clinic. Other procedural changes are currently being addressed by the GEC staff and the Department of Medicine.
My other job was with the Planning Department under
the Senior Vice President for Planning and Program Development,
Mary Beck. A task force for geriatric services had been created,
and I was responsible for collecting data and information for the
group to use. Using internal and external data sources, I compiled
statistics on the current and future aging population in UNC's service
areas. This included demographics; hospital inpatient costs, discharges
and length of stay, service line usage; outpatient counts and costs;
home health, hospice and nursing home usage; payer mix; discharge
status, etc. Observations and interviews with healthcare organizations,
community agencies, and prominent aging activists and advocates
were also conducted. I also expanded on the Orange County Aging
Directory by including similar resources and information for the
counties surrounding UNC Hospitals. MICHAEL EHRLICH, Senior,
Public Policy Studies, Sanford Institute, Duke University
Although my internship focused on health related
issues, I worked on a variety of interesting projects. The hot topic
at the AARP this summer was prescription drugs coverage. My responsibilities
on this issue were three-fold. First, each morning I would search
the newspapers for news or editorials related to prescription drugs.
I carefully read these articles, complied them together, and emailed
the document to the AARP/VOTE state representatives. If these articles
raised questions by AARP/VOTE members, I would try and answer them,
or find someone who could. Second, as the different prescription
drug plans were introduced, I produced a side-by-side comparison
of the key parts of each plan, and developed a time line of all
the prescription drug happenings. Third, I cataloged all of the
polling data on prescription drugs so AARP/VOTE members could keep
award of changes in public opinion. These projects were updated
throughout the summer and were also sent to the AARP/VOTE distribution
list. Because it was the summer of an election year, it was quite
interesting to observe how the candidates' stances on the issues
developed throughout the summer. Mentor: Mary Reca Todd Site: NC Housing Finance Agency This summer I interned at the North Carolina Housing Finance Agency (NCHFA) and worked closely with Mary Reca Todd, the Agency's Supportive Housing Team Leader. My internship focused on models of supportive housing, with an eye toward the following question: What should the Agency do to respond to the "integration mandate" handed down a year ago by the U.S. Supreme Court in the case Olmstead v. L.C? In Olmstead, the Court declared that states may not warehouse persons with mental illness and mental disability simply as a matter of convenience. The Court held that the unjustified institutionalization of persons with mental illness and mental disability is a form of discrimination prohibited by the Americans with Disabilities Act (ADA). To avoid discriminating against persons with disabilities, the Court explained, states must move them into less restrictive settings - typically involving home- and community-based care (HCBC), - when appropriate. When I first considered Olmstead's implications, at the beginning of the summer, I had concluded that housing was the linchpin of any reform effort; after all, if there are no homes, no buildings in the community awaiting persons with special needs, then any mandate to integrate is moot. My work this summer hasn't altered that conclusion; indeed, when I attended a recent public meeting on Olmstead, convened by North Carolina's Department of Health and Human Services (NCDHHS), the attendees' top concern was housing. However, as I've learned about the financing of housing for special-needs populations, I've also learned that bricks and mortar represent only half the equation. A rent subsidy is equally important if housing is to serve low-income tenants. If you build it, they may come, but without rent assistance, chances are they can't afford to stay.
Olmstead also raises the possibility that the very way states finance long-term care may violate the rights of persons in institutional settings. State Medicaid programs, which account for about half of all long-term care spending in the U.S., have for years funded one-size-fits-all long-term care systems based on the medical model of the skilled nursing facility (SNF). This so-called institutional bias, which in many states allows SNF spending to account for more than 90% of all Medicaid LTC dollars, means that across the U.S. some people reside in SNFs not because the care is appropriate to their needs but because the states have provided them no option. This de facto segregation may violate the ADA as interpreted by the Olmstead Court. At least one lower state court has already applied Olmstead to plaintiffs with physical, rather than mental, disabilities. North Carolina's State/County Special Assistance (SA), an income supplement program for persons with disabilities, also suffers from institutional bias. Unlike the vast majority of states, North Carolina allows SA funds to be spent on only one kind of housing, adult care homes. These facilities house residents and offer some supervision and personal care services. However, because of their near-monopoly of SA funds they function as a repository for a wide range of low-income elderly and disabled individuals. Often ill equipped to care for such a wide-range of residents or prevent inappropriate case mixing, adult care homes are a problematic housing solution for special-needs populations. (Editor's note: There is now a small demonstration in North Carolina to allow SA funds to be used outside the adult care home setting.) The Olmstead decision rides the crest of a wave that has been building over the course of the past two decades. During this period, almost all the states, concerned about poor conditions and persistent lapses of care in SNFs, have undertaken at least small-sclae efforts to move people from institutional care to HCBC. North Carolina, for example, has for several years offered a Community Alternatives Program (CAP) and a Personal Care Services (PCS) program, which allow Medicaid recipients to live in their homes or in homelike settings and receive health and personal care services. Access to these programs, however, varies greatly and some areas of the state are plagued by long waiting lists and a shortage of health and personal care workers. Special-needs housing, I found, entails its own problems. Though housing finance agencies wield a number of tools designed to encourage private developers - both for-profit and non-profit - involvement in low-income housing, few tools address the plight of very low-income disabled persons - the very kinds of people likely to subsist on Medicaid and reside in an institution. The Low-income Housing Tax Credit program, for example, has been very successful in producing housing (535 units this year) that tends to help people within a certain income range (about 50% of area median income) but hasn't had much effect on people with very low incomes (about 30% of AMI). In some cases, federal subsidies, such as the federal HOME Investment Partnership program and state subsidies, such as North Carolina's Housing Trust Fund, have helped bridge the gap, but when a licensed level of care of service is involved, housing finance agencies, including North Carolina's, are reticent. The specter of "services" scares away one of the scarcest commodities in the affordable housing business, experienced developers. In addition, for-profit developers have little incentive to maintain their properties at below-market rents once their initial obligation has expired My research and conversations with NCHFA staff, developers, and advocates for the elderly and disabled kept pointing me to rental assistance. Lenders like the NCHFA have exploited almost every method of financing a new housing development. In the absence of more widespread Medicaid-funded HCBC, however, developers need ways to keep developments viable over the long-term. Rent subsidies are one way to do that. They can be tenant-based, like Section 8 vouchers and follow the individual, or they can be project-based and tied to a particular housing development. I plan to use my work this summer as a foundation upon which I can build a larger, more elaborate, research project that will investigate the differences between project-based and tenant-based rental assistance and how they relate to low-income special-needs populations. My hope is that the final product will assist the NCHFA as it decides how best to respond to Olmstead. ROBERT KAUFMAN, Senior, Public Policy, Sanford Institute, Duke University Mentors: Maryann Keenan and Kirsten Sloan Site: Federal Affairs, AARP This summer I interned with AARP and it was an extraordinary experience. Under the guidance of Kirsten Sloan, my mentor in AARP's Federal Affairs Department, I explored the fields of health policy, aging policy, and lobbying. Although I was exposed to a variety of issues, I concentrated on Medicare reform - an issue that was constantly in the national spotlight. This year many legislators proposed bills that would add a prescription drug benefit to the Medicare program, authorize "give-backs" to medical providers, create a new agency to administer the Medicare program, or accomplish a range of other objectives. Along with Ms. Sloan, I analyzed each of these bills and encouraged Senators and Representatives to incorporate the Association's goals into their legislation. During my three months of work in the Health, Education and Human Services Division (HEHS) at the GAO, I had the opportunity to work on a number of separate projects related to the issue of nursing home oversight. My primary responsibility was to assist in drafting a response to a request made to the GAO by Senator Charles Grassley, the Chairman of the Senate Special Committee on Aging. Senator Grassley sought to determine the accuracy of a claim made by the American Health Care Association, (AHCA) that both state surveyors and the Health Care Financing Administration (HCFA) are overzealous in citing nursing homes for violations. The nursing home lobbying group provided several examples of state and federal citations that it felt did not represent cases in which nursing home residents experienced actual harm. Senator Grassley asked the GAO to investigate this claim, and the Aging Committee forwarded the materials it had received from AHCA to our project team. The results of our investigation are reflected in the final report, which will be released to the public this fall.
Most lobbyists who opposed the "give-backs" argued that ordinary Americans would not benefit from these bills. AARP's approach was more complex. We analyzed each bill and considered why the Representative or Senator proposed it from a political perspective. We also considered the bills from the perspective of Medicare beneficiaries. If give-backs had to be made, which would help beneficiaries the most (or hurt them the least?) Often this analysis was tedious and time-consuming. Nevertheless, our arguments were more persuasive because we had considered both the policy and the politics behind the legislation. Besides my work on Medicare reform, I conducted several interviews with policy analysts, lobbyists, managers, supervisors, and lawyers at AARP to hear about aging policy, the political process, and their careers. My first interview came with Marty Corry, the director of Federal Affairs (AARP's lobbying division.) He told me about his first job with the Department of Health, Education, and Welfare - later renamed Health and Human Services. We also discussed how he obtained his current position and what a typical day is like. During my time in Washington, I also spoke with the director of the Health Lobbying Team, the director of Federal Lobbying, and the director of Political Affairs. All of these AARP officials told me about their jobs, their career paths, and their responsibilities. I asked each person the best way, in his or her opinion, to enter the field of healthy lobbying. Their responses were almost unanimous - practical experience, personal contacts, and good writing skills are extremely important. I gained all three this summer. ANN B. LONG, Senior, Gerontology, University of North Carolina at Charlotte Mentors: Cheri Anthony-Bergstone, Ruth Yoash-Gantz, Loren Wilkenfeld, & Frank Gantz Site: W.G. "Bill" Hefner Veterans Administration Medical Center, Salisbury, N.C. The internship that I enjoyed this summer consisted of two distinct experiences: (1) I observed the function of a portion of the Psychology department, a part of the Behavioral Science Services of the W.G. "Bill" Hefner VAMC in Salisbury, NC; and (2) I applied for and received permission to collect data for my thesis from a population of aging veterans who had been diagnosed with probable Alzheimer's Disease. Because of the separate natures of these experiences, I was able to observe VA policy from two distinct vantage points. The larger portion of my time was spent in the observation of how services are provided to veterans who have been diagnosed with dementia. The medical center at Salisbury houses a geropsychological center as well as a long-term care facility. Both of the units were appreciating a hiring boom due to VA fiscal changes; previously under the control of the Balanced Budget Amendment, VA staffing had been held at a minimum for a number of years. This year the VA was able to fill several key staff positions. Further, the psychology department was able to propose and have approved a post-doctoral internship for psychologists, thereby increasing their research potential. Prior to my arrival at the facility, I was unaware of how extensively the medical center employs interns and externs; however, I attended meetings with a number of medical students from Wake Forest, and met others who were completing the internship for a Pharm.D. The internship/externship program is well established on the campus with housing provided for those who wish this convenience. Another area in which I observed implementation of policy was in the Resident Assessment/MDS committees. The medical center has only been performing assessments using the Resident Assessment Instrument (RAI) approved by HCFA for six months, and is still in the policy review and implementation stages. Having previously had experience with this process in a long-term care facility, I was able to make suggestions about how to code some of the items on the assessment. It was interesting to see how an institution begins the process of compliance with OBRA regulations regarding assessments.
Prior to this experience, I had planned to pursue a Ph.D. in Gerontology, and to focus on Alzheimer's research; however, the internship introduced me to a different way of thinking of the future of healthcare for our aging society. This exposure has served to broaden my career objectives, and, as a result, I intend to pursue a DrPH in Health Policy and Administration. Not bad for a summer's work! DAVID NIGRO, Senior, Chemistry/Public Policy, Duke University Mentor: Gina Upchurch Site: Senior PHARMAssist, Durham, NC In pursuing my interests in healthcare for senior citizens, I became involved with the Duke Leadership in an Aging Society Internship Program. As an intern for the program, I was able to choose a work site for the summer of 2000. Senior PHARMAssist seemed to be a perfect fit for my interests. Senior PHARMAssist is a nonprofit organization located in Durham, NC, whose mission is to aid seniors with their pharmacy needs. One way they accomplish this is to help pay for prescription medicines for seniors. Clients that receive this assistance must be Durham County residents, have an income between 100% and 150% of the poverty level and not receive full Medicaid benefits. These clients can go to any Durham county pharmacy and pay an eight-dollar copay per prescription; Senior PHARMAssist covers the rest of the cost for formulary medications. In addition to this financial assistance, Senior PHARMAssist requires that clients have a one on one medication review with the pharmacist every six months to make sure the client is taking his/her medications safely and effectively. As an intern, I was able to participate in some strategic planning that Senior PHARMAssist was conducting this summer. The organization examined the current debate concerning a government sponsored medication assistance program as well as North Carolina's need for programs similar to Senior PHARMAssist. In this process, I helped develop and administer a questionnaire to over twenty-five hospitals, free clinics, and nonprofit organizations to determine what other counties are doing to widen pharmacy access. At the end of the strategic planning process I was able to deliver my thoughts on the future of Senior PHARMAssist in written form to the Board of Directors.
My summer with Senior PHARMAssist was a great experience as it combined my interests in policy and client interaction. I would like to thank Gina Upchurch, executive director of Senior PHARMAssist, and all the staff and volunteers for their help and support this past summer. R. HARBOUR PARTESOTTI, Senior, UNC School of Law Mentor: Wendy Sause Site: NC Division of Aging Like many other law students caught up in learning abstract legal theories and principles, during my first year of law school I often questioned why I was here. My internship at the North Carolina Division of Aging (DoA), however, renewed my purpose in law school and more importantly, life: to gain the tools needed to enhance the well-being of people as they age. While I anticipated that my internship would be exciting and insightful, my experience this summer exceeded all expectations. While Dr. Maddox gave the program participants an introduction to the "Territory of Aging" prior to our internships, my experience at the DoA truly fleshed out the concept of aging as a vast territory by providing me with unlimited opportunities to learn about all aspects of the aging network and aging policy in North Carolina. My main goal for the summer was to understand the laws that affect the elderly in our state and more importantly, the policies behind them. My work included research, legislative tracking and visits to a number of meetings and forums on diverse issues in the aging policy arena. Fortunately, working at the DoA allowed me to have many resources at my fingertips. While, at first I felt overwhelmed by the wealth of knowledge and opportunities made available to me, the guidance and support I received from my mentor and others at the DoA helped me grasp a solid understanding of the principles and issues in the field. During the summer, I primarily researched the differences between assisted living and nursing home facility regulations, and started a project that I hope to develop into a master's paper for my degree in Public Health. I also looked at the employment discrimination policies in facilities that care for the elderly and gathered pertinent materials for a new elder law attorney to use in her work. My summer internship went beyond exposure to issues that North Carolina needs to address to better care for its aging population. It introduced me to the major players in the state's aging network, people who care immensely about certain issues and are constantly forging new paths to accomplish their goals. I had the opportunity to meet and watch these leaders in action at various meetings and conferences across the state with groups such as the Senior Tarheel Legislature, North Carolina Coalition on Aging, North Carolina Legislative Study Commission on Aging, and North Carolina Institute of Medicine Long Term Care Task Force. Participation in the Summer Symposium on Aging in Asheville, Senior Plus Public Benefits Training, Division of Facility Services Surveyor Training and the Regional Ombudsman Certification program provided me with an interactive experience though which I greatly furthered my understanding of all that I had read and researched. I also had the opportunity to shadow Karen Gottovi, Director of DoA, during some of her visits to the General Assembly which proved to be a wonderful experience.
I was so very fortunate to work alongside the staff at the DoA. I was impressed by their dedication to improving the lives of elderly in our state and commitment to sharing their knowledge, and experiences with me. My mentor and the state's Long Term Care Ombudsman, Wendy Sause, provided excellent guidance and support. For her kindness in sharing so much of herself and her time, I am eternally grateful. Through working with Wendy and others at the DoA, I developed an appreciation for the successes and challenges related to working as an advocate and was able to meet and share ideas with other advocates across the state. The opportunity to interact with so many inspiring and interesting individuals was the highlight to my summer experience, and I aspire to continue and build on the good work that they do to benefit the lives of countless elders. ELIZABETH PRADA, Senior, Biology/Public Policy, Duke University Mentors: Laura Summer & Kristen Kilker Site: The National Academy on an Aging Society My sponsor for the summer, the National Academy on an Aging Society, is a non-partisan public policy institute that investigates the impact of demographic change on public and private institutions as well as families. The Academy functions primarily as a source of information for policy-makers, the media, and non-profit organizations on topics related to aging. As a research assistant, I worked primarily on two projects targeting underprivileged senior populations. My duties included extensive literature and internet research, memo writing, legislative tracking and attendance at various Congressional hearings and briefings. Under the direction of Laura Summer, MPH, I researched the effectiveness of outreach programs working to inform low-income seniors about Medicare Buy-in programs. Commonly known as QMB (Qualified Medicare Beneficiaries) and SLMB (Specified Low-Income Medicare Beneficiaries), Medicare Buy-ins are government entitlement programs that exist to provide financial assistance for out-of-pocket Medicare costs. Buy-ins provide a crucial safety net for millions of indigent seniors and disabled people who may not necessarily qualify for full Medicaid benefits to fill gaps in their Medicare coverage. Often, these individuals cannot afford necessities such as adequate food, utilities and prescription drugs because they must pay first for outpatient medical care. The Academy's Medicare Buy-in program research will be used to encourage innovative outreach programs.
I am extremely grateful to have had the opportunity to become involved in health policy research so early in my college career. My internship at the Academy was an important, practical learning experience. With the knowledge gained this summer, I now have a better understanding of the implications of aging, poverty and low literacy to the future of medicin. JANET ROSENBLAD, Senior, Joint Degree Student, Public Policy, Sanford Institute, and Law, Duke University Mentors: Walter Ochinko and Don Walthall Site: U.S. General Accounting Office As an intern with the U.S. General Accounting Office, my primary goal this summer was to better understand the distinctive roles that both the federal and state government play in developing and implementing long-term care policy. Recent work from the Health, Education and Human Services Division (HEHS) of the GAO on nursing home quality of care issues across the states served as a great starting point for me to analyze long-term care issues from both a state and federal perspective. My general assignment was on a team looking at the nursing home survey process within four states and evaluating whether the quality of care within nursing homes has improved since the GAO's initial work on this issue about two years ago. The project originated from a request made by Senator Charles Grassley, the Chairman of the Senate Special Committee on Aging, who was interested in learning about the progress in nursing home quality of care. My main contribution to this project was in creating an appendix to the report that consisted of a timeline delineating the status of numerous federal initiatives over the two years. This timeline helped demonstrate the extensive process involved in implementing federal initiatives into the complex and variable health care systems among the states. In addition to my work with the nursing home quality of care team, the majority of my time this summer was spent working on a study requested by Senator Bond, Chairman of the Small Business Committee. Senator Bond asked GAO to determine if there is a difference in the quality of care delivered by chain nursing homes compared to independently owned nursing homes. In analyzing this issue, I was responsible for working with the same four states on developing databases within each state that identified chain and non-chain nursing homes. After compiling this data, I used a federal database on quality of care problems identified during annual state inspections of nursing homes to highlight significant differences between the two groups. I also conducted more specific analysis comparing the performance of homes affiliated with the top ten national nursing home chains with all other chain homes. The great deal of effort required to create these databases demonstrated to me how difficult it can be to identify accurately chain nursing homes and how they are affiliated with other homes. Besides these particular projects within the GAO, I was also given the opportunity to attend congressional hearings on Capitol Hill, including one at which the GAO gave testimony. One hearing that was particularly interesting was regarding a nursing home staffing report recently released by the Health Care Financing Administration (HCFA). This area has become critical to evaluating quality of care issues in nursing homes and will likely continue to increase in importance as the situation appears to be worsening.
JEFFREY RURKA, Senior, Health Behavior/Health Education, UNC School of Public Health Mentor: Eleanor McConnell Site: Duke School of Nursing/Durham VA For my internship placement, I worked with Dr. Eleanor McConnell in the Geriatric Research, Education, and Clinical Care (GRECC) center at the VA Hospital in Durham, N.C. We primarily investigated several different ways to improve the independence and functional status of patients with dementia using new care techniques that are collectively called "abilities focused care". In the past, it was believed that the progression of Alzheimer's Disease and other dementing illnesses resulted in a continual decline in the functional abilities of the patient and increased dependence on caregivers. Research now shows that patients with early to mid stage dementia actually possess "preserved abilities" (i.e. self care abilities such as feeding, toileting, and bathing) that become hidden behind primitive reflexes. Examples of these reflexes may include clamping down one's mouth during mealtime feeding or forcefully grasping a caregiver's arm while dressing or bathing the patient. These uncontrolled behaviors can be extremely frustrating and are frequently misunderstood by the caregiver as being aggressive in nature. New research has demonstrated that many of these reflexes are unknowingly prompted. It is suggested that new caregiving techniques which use simple, direct commands that encourage patients to utilize existing skills for their own self care will reduce these episodes and increase the functional independence and dignity of the patient. The first protocol that I worked on sought to test the efficacy of a bedside storage tray that would keep a demented patient's sensory appliances (eyeglasses, hearing aids, and dentures) in one easily identifiable place. Such items are frequently lost due to staff changes throughout the day and differences in opinion regarding the "best" place to store such appliances when they are taken off. Misplaced items severely limit the patient's ability to attain even modest levels of functional independence due to a concept called "excess disability", or the disability above and beyond that which is caused by their dementia. The goal of this project was twofold. First, we wanted to see if the presence of the storage tray would prompt patients to use their appliances more often. Second, we wanted to examine the effectiveness of the tray in prompting nurses to check for missing appliances once the tray was incorporated into an everyday care routine. A research nurse and myself conducted behavioral observations on 12 patients in the nursing home care unit (NHCU) of the VA Hospital as well as separate follow-up interviews and focus groups with both the patients and the nursing staff to learn about their opinions of the tray and any suggestions they had for modifications. While we found only modest improvements in the use of sensory appliances among the patients, the nursing staff was extremely pleased with the tray's performance, stating that it saved a great deal of time in locating appliances during morning care practices. As researchers, we learned a great deal about improving our observation practices and inter-rater reliability for a larger upcoming multi-site study. Most importantly, the patients thoroughly enjoyed the "consulting" role that they played in describing improvements to the tray. I think many feel quite helpless and useless as their cognitive abilities decline and this project enabled them to have a participatory role in a project that would ultimately help other patients. My other responsibilities were to assist in the writing of a VA sponsored clinical initiatives grant that seeks to improve patient care and outcomes within the NHCU through staff and environmental changes. I had never before been involved in the writing of a grant application and this process was made all the more challenging because our research objectives and goals had to match clearly defined mandates according to new VA policies. The VA has recently undertaken an extensive re-evaluation of its goals and priorities in the past year which are expected to improve patient care and satisfaction across all aspects of the system. Any project sponsored by the VA must directly address and impact these mandates. My responsibility was to write a section on how our grant matched the new initiatives of the VA system. This exercise proved to be a terrific tool in teaching me how to frame research objectives in a way that met the needs of many different parties, including researchers and policymakers.
I also assisted in helping to conceptually define
how we were going to measure patient satisfaction among demented
elderly. Because this is a population that cannot readily speak
on its own behalf, I conducted extensive literature searches on
how best to measure satisfaction among this population. This work
not only further expanded my knowledge about dementia, but it again
spoke to the fact that many patients can retain a level of cognition
far beyond what we have previously believed.
GLAXO WELLCOME LTC CAREER DEVELOPMENT
AWARDS GARY G. BENNETT, Jr. Clinical
Psychology RECOMMENDATIONS RELEASED
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