Health and Disability

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Rural hospitals are already more dependent on Medicaid and Medicare, which usually reimburse doctors at lower levels than private insurance. More than 40 percent of rural hospitals in the U.S. are regularly running deficits, according to the National Rural Health Association. Many of these facilities depend on subsidies from local or county governments, which often own the hospital outright.

Twenty-four states, including most of the South, have yet to expand the state-federal health program for the poor to adults earning up to 138 percent of the federal poverty level. People earning between 100 percent of the federal poverty line and 138 percent in those states generally don’t quality for public health care or for subsidies to purchase private health insurance through the exchanges created by the Affordable Care Act. The law’s designers never envisioned that gap would exist, but the Supreme Court made Medicaid expansion optional in a 2012 decision that largely upheld the rest of the law.

The Supreme Court decision also further imperiled rural and urban hospitals serving large numbers of the poor and uninsured because the law also cuts billions of dollars in payments those safety-net providers received to keep them afloat under the assumption that they wouldn’t need as much compensation because many of their patients would receive Medicaid coverage.

A revised version of a surgical procedure to treat severe chronic migraine headaches led to significant symptom relief more than 90 percent of the time in patients treated at Massachusetts General Hospital (MGH). Physicians from the MGH Division of Plastic and Reconstructive Surgery report that more than half of 35 patients treated with the non-endoscopic procedure - all of whom had headaches associated with compression of craniofacial nerves - reported complete symptom relief a year later. The team's paper has received advance online publication in the journal Plastic and Reconstructive Surgery.

"We confirmed that surgery through standard incisions used for cosmetic procedures can be very effective in treating some of the most severe cases of chronic migraine," says William G. (Jay) Austen, Jr., MD, chief of Plastic and Reconstructive Surgery at MGH, who led the study. "While the earlier version of this procedure used an endoscope, not every patient is a candidate for endoscopic surgery, and not every surgeon has access to or experience with the equipment. We hope that this may increase the availability of this treatment.

1. Meet Harsh Words With an Equal and Opposite Nonverbal Communication

My mother was saying over and over each day - get out, I don't want you here, I can take of myself. Of course I tried to explain to her she could no longer live by herself. All this did was make her angry and we had a bad day. Think about it. She just told me she could take care of herself. So why would it make her happy when I told her she couldn't? It didn't.

I tried every long winded explanation under the sun and none of them worked. In fact, they made things worse.

Finally after a couple of years of complete frustration, and after walking around in Alzheimer's World for a while, I got a brand new idea.


So I shut my mouth and didn't say a word when it started to happen. Instead I walked over, put my arm around my mother's shoulder, put my head on her head, and then said,

Resistiveness to care (RTC) in older adults with dementia commonly disrupts nursing care. Research has found that elderspeak (infantilizing communication) use by nursing home staff increases the probability of RTC in older adults with dementia. The current analysis used GSEQ software to analyze behavior sequences of specific behavioral events.

We found that older adults with dementia most frequently reacted to elderpeak communication by negative vocalizations (screaming or yelling, negative verbalizations, crying). Since negative vocalizations disrupt nursing care, reduction in elderpeak use by staff may reduce these behaviors thereby increasing quality of care to these residents.

The results clearly demonstrate that sequential analysis of behavioral events is a useful tool in examining complex communicative interactions and targeting specific problem behaviors.

Family carers of people with dementia may need more support with medication management, according to a recent study.

With so much care being delivered in hospital medical/surgical units, and with an estimated 35 to 40 percent of unexpected hospital deaths occurring on such units, IHI and The Robert Wood Johnson Foundation (RWJF) agreed to work together to create, test and implement changes that will dramatically improve care on medical/surgical units, and improve staff satisfaction as well.

• Safety and Reliability
• Care Team Vitality
• Patient-Centeredness
• Increased Value
This IHI white paper describes work in progress at 13 pilot hospitals, where staff are testing, refining and implementing change ideas within each category. Early results are promising, and the paper offers concrete suggestions for readers who wish to test and implement similar ideas in their own hospitals.

A 2013 report by the Autistic Self Advocacy Network (ASAN) found that youth with intellectual and developmental disabilities face a variety of barriers to accessing and managing their health care when they reach adulthood:

• They may no longer have access to the same source of health coverage that they had before they turned 18
• They may have difficulty finding adult-oriented health care providers who understand their health care and communication needs
• They may not get the supports they need in order to understand their health care options and make decisions for themselves.

ASAN has responded to this  healthcare dilemma by preparing a comprehensive toolkit to empower people with disabilities, their families, and other disability advocates to help youth with disabilities manage their own health care as they transition to adulthood.

Any who has had a loved one who sustains a hip fracture knows that these are life changing if not life-limiting events in the lives of older adults. A recently published article in JAMA Internal Medicine gives further credence to this, as well as giving us evidence to guide our prognostic estimates when caring for someone who sustains a hip fractures in a nursing home setting.

The study by Neuman and colleagues looked at survival and functional outcomes after hip fracture in 60,111 long-term nursing home residents who were hospitalized with an acute hip fracture between July 1, 2005, and June 30, 2009. The primary outcome was death from any cause within 180 days of hospital admission. They also looked at functional outcomes that were based on self-performance for 7 ADLs as recorded in the last available Minimal Data Set (MDS) assessment within 180 days after the index admission. 

What Were the Results? 

The median survival time after fracture was 377 days (the interquartile range was 70-1002 days).

Six months after hip fracture:

• 1 out of every 3 (36%) nursing home residents died
• 1 out of every 2 (46%) male nursing home residents died.
• Half (54%) of those who were not totally dependent in locomotion prior to the hip fracture had either died or developed new total dependence in locomotion

The evaluation found a positive impact of the peer support groups on participants' wellbeing, social support and practical coping strategies. Participants improved in their communication abilities and in managing their memory and their lives.

It also revealed benefits extending beyond group members to include staff, families, friends, other residents in the housing scheme and the housing provider.

A new study in Journal of General Internal Medicine reports that an hour-long educational coaching session and two or three follow-up phone calls after a hospital stay reduced re-admission odds by 39 percent amongMedicare patients. The study also found that the average cost of care was reduced by $3,700 per patient for those patients who received the education session versus those who did not.

This study is the first to report on a more comprehensive picture of healthcare use in the six months following the patient-centered coaching, called Care Transitions Intervention (CTI), and to estimate costs avoided using the data.

"When patients are discharged, they are often ill-equipped to self manage," said Stefan Gravenstein, MD, senior author of the study and Interim Chief of the Division of Geriatrics at University Hospitals (UH) Case Medical Center. "Typically, in the Medicare population, nearly one in five patients, or 20 percent, is re-admitted within the 30 days following discharge from the hospital. For all patients, 30-day re-admission is only about one in seven or eight patients instead of one in five.

"With this study, we found that sending someone to the patient's home who helped the patient (or their caregiver) gain confidence in recounting the patient's medical issues, medication, and when and how to reach out for help significantly reduced re-hospitalization and costs. And the teacher did not have to be a health care professional such as a doctor or a nurse, but just needed to be specially trained for this coaching activity," said Dr. Gravenstein who is also a Professor of Medicine at Case Western Reserve University School of Medicine and was at Brown University Medical School and School of Public Health during the time of the study.