“The test of a civilization is the way that it cares for its helpless members.” Pearl S. Buck
Aurora Health Alliance held a community conversation titled “Nowhere to Go” about vulnerable Seniors stranded in emergency rooms on March 14, 2018. The topic of “granny dumping” (real terminology) was addressed. Granny dumping occurs when Elderly people, whose families have stopped caring for them or have disappeared, are dropped at an emergency room. As the world’s population speeds toward aging, it is a growing problem. Because many of the people in this written segment are not accessible to me, and often are not able to communicate effectively, I have to tell their stories through the recounts of the caregivers and program directors who attended this meeting.
“There was an Elderly woman wandering around an apartment complex. The manager said she was not dressed and was asking for food because she hadn’t eaten for days. The manager remembered seeing the Innovage van come to take her a few times, so he called Innovage to ask what he should do. It turns out that the lady’s daughter, who was her caregiver, had been taken to jail a few days earlier, leaving the elderly lady to herself. She was taken to the emergency room, but beyond giving her a meal, no one knew what to do with her.” Story told by Diane Kennedy, Medical Center of Aurora
Every hospital is dealing with this issue. In Denver. In Colorado. In the United States. And in many other countries. Japan included. With the aging population booming, lack of social preparation for this aging population, rising costs of in-home care, a more autonomous society, and the incredible situational tax placed on family-member care-givers, seniors being taken to an emergency room is becoming more common-place.
Senior citizens with no place to go are spending days, months, sometimes even years, inside of hospitals. Hospitals are absorbing the costs related to housing and treating these individuals. Bureaucratic red tape of diagnosis terminology and lack of payor information keeps them there. Ethical laws of “do not release to an unsafe situation” keeps them there. If the patient cannot be released to a safe situation, they are placed on what is called a “social” admit, meaning that they are admitted by society because there is no safe situation to release them to. And the hospital absorbs the cost. Sometimes a less-expensive hospital is found that is willing to take the resident.
Many people wonder, “What about the family?” The Seniors who are dropped at ERs or left to wander are often left by family members. Sometimes, they arrive at the emergency room with another elderly family member who has been caring for them but who also probably needs care. Sometimes the patient is admitted to hospital care. The family member who came with them often does not have the means or ability to leave, either. And so, the Senior care-giver sits in the emergency room and might eventually be admitted as well. One seminar attendee said that they knew of one such situation where the medical staff thought the attending family member was sleeping in a chair in the ER but had actually passed away while sitting there.
Sometimes younger family member(s) “dump” their elderly because they no longer can bear the extensive financial, emotional, or time burden. Sometimes, the Senior had been abusive to their children when they were younger, so the children do not want to expose themselves to continued abuse, or memories of the abuse. In some cases, the Senior does not have family. Maybe they never had children, or their children have passed before they did. In Denver sometimes, immigration status keeps family members away out of fear of being deported.
Long-Term Care Ombudsman Scott Bartlett of Pike’s Peak Area Council of Governments says that the longer a Senior “lives” in a hospital, the more quickly they decline. “A hospital is not a home. You cannot thrive in a hospital.”
After patient evaluation or retrieval of medical records (sometimes nearly impossible) it is usually discovered that the Senior has a co-existing diagnosis. An example is a patient who has both Alzheimer’s and a mental health issue such as bipolar disorder or schizophrenia. This complicates the issue because Alzheimer’s is paid for through physical health benefits. Bipolar or other mental health issues are an entirely different category of insurance billing and care. Usually the patient’s mental health disorder is creating the offending behavior which landed them in the emergency room. Generally, someone with mental health issues is helped through talk therapy, and in some cases medication. But a person with Alzheimer’s will not be helped by talk therapy. They can’t remember or reason through the talk therapy session, let alone implement the behavioral action tools the therapist would advise.
If the patient is lucky enough to have mental health benefits, the payors will play ping-pong with the diagnoses and say the other payor (physical health insurance rather than mental health insurance) is responsible for taking care of the patient’s treatment. All the while, emergency room staff, while wonderfully trained, are not set up to deal with psychological emergencies or Alzheimer’s. For example, at the University of Colorado Hospital, they have neither a psych unit nor a geriatric unit.
Doug Muir, Director of Behavioral Health Service Line, Porter Adventist Hospital says, “Every person is unique. The system is broken. We need to throw away the silos.” He is referring to the different payor entities that head up mental health verses physical health. He adds, “All of these definitions need to go because they have various funding tied to the definition.”
Another aspect of the psychological impact of Seniors who have both a medical brain diagnosis and a psychological diagnosis is the safety of other residents. Many of these Seniors who end up in the emergency rooms are there because they were difficult or dangerous residents at their assisted living facilities. Some of these Seniors were criminals in their younger days and have been combative and threatening. Ombudsman Shannon Gimbel of Denver Regional Council of Governments, states that there have even been residents who have been found making shanks, which is something that’s more closely associated with prison than Senior care.
One particular senior appeared normal to most, but because of his personality disorder, he was at-risk of acting dangerously. Staff at senior facilities are not trained to deal with these types of mental health disorders. And there are no facilities in Colorado that deal with someone who is both aging and mentally ill. With respect to this particular senior, over 500 various facilities were called in search of a place that would take him. Eventually, a place was found, but the agency knows that it will be only a short period of time before he will be moved again.
If this senior ends up hurting someone, he cannot be charged because he has Alzheimer’s. He cannot represent himself and will be deemed not guilty because of his inability to conduct himself. Sometimes when a facility wishes to move an unsafe resident of this nature, they will not tell the other residential facilities about the senior’s behavior. If the receiving facility doesn’t know about the dangerous background of a potential resident, they are more likely to accept them. Shannon Gimbel estimates that up to 40% of Seniors who need residency programs have some kind of serious mental disorder. The need for a different kind of facility is imminent. In these situations, there are also liability issues, as well as safety for staff and other residents to be considered.
Scott Bartlett says, “Hospitals are angry at long-term care facilities and long-term care facilities are angry with hospitals. They are hanging up the phone on each other. This is bad for the patient. We need the parties to sit with each other and figure out what the problem is. Regulatory? Payor?” “We have enough resources to combat this,” said another meeting participant, “but only if we act together. It takes a village.” The easy answer is to take them back to the facility where they were staying before their arrival at the ER. But this is not as easy as it seems.
Because “person-centered care” is the goal, a partnership between various entities is needed. Again, it’s the village that needs to be formed. However, Bartlett adds, “The long-term care facilities that wash their hands of these residents are not the ones who come to the table to work with the other entities.”
Bartlett says he knew of another senior who was HIV+ and hypersexual. The question came up again about charging the patient with a crime. There again, because of the patient’s medical and mental status, culpability would be difficult to impossible to prove. Senior care facilities are some of the most regulated entities in the US. One of the regulations require that proper discharge paperwork accompanies a resident when they are moved from a facility, otherwise the facility is charged. When a resident displays these behaviors, the facility is usually willing to take the charge. “You have to go with what is the greater good. What do we do with this guy?” says Bartlett. He adds, “Too often a person is defined by their paper rather than the person themselves. They are not accepted [at another facility] because the first thing they see on paper is an assault.”
Margaret Mohan, of Colorado Acute Care and Nursing Facilities, says that more regulations is not the answer. “Nursing homes are the most regulated entity after nuclear plants.” It is difficult to keep up with all the regulations, especially in the face of high employee turnover. Some of the regulations seem to contradict each other. Fines are charged, corrective action takes place, and the regulation is again broken. She added, “Hospitals tell on each other and Medicaid and Medicare threaten to cut funding if an entity is not in compliance.”
Bartlett says we need to look at these issues in new ways. Colorado is looking at Washington State. Washington has granny dumping in their statutes. At this discussion about granny dumping someone suggested that granny dumping be considered caregiver neglect so that the caregiver be charged. However, in some cases there are situations where the family or institutions literally cannot handle the Senior any longer and they have done their best. There are some foster care providers that take Seniors on a voluntary basis to care for them, knowing they might not be paid for their help. This sparked another idea, and someone suggested a law like exists in Colorado for newborn babies: that a Senior could be taken to a police or fire station and left with no questions. Could we have a similar law for the elderly? Doug Muir adds, “We need to transform our system. We are reactive. Think outside of the box. We need to become more interconnected.”
For more notes about the above meeting please click here. I’m sure that any of those who attended this meeting would be interested in ideas you might have to help work through this issue. Or you can send a comment to me via this web page and I will pass it along.
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