Highlights

• New CMS Hospital Ratings
• Talking with Your PCA
• REquipment - recycled DME
• Last Hours of Living- Practical Advice
• Supplement- HWM Budget

Sections

• Program Highlights
• Health Care Coverage
• Policy & Social Issues
• Of Clinical Interest
• Supplement- HWM Budget

Questions, comments about the newsletter? Contact Ellen Forman, x6-5807.

Under a Massachusetts law that went into effect April 7, 2015, businesses with six or more employees must allow new fathers eight weeks of unpaid leave (New Law Gives Massachusetts Fathers Paternity Leave, MGH Community News, January 2015). The law previously applied only to new mothers. The workers must be reinstated to their previous position, or a similar one, once they return from the leave.

Under the law, for the first time, small businesses will be required to grant paternal leave. Larger companies have been required for years to grant paternity leave under a federal statute, the Family and Medical Leave Act. Now, businesses in Massachusetts with six to 49 employees must allow fathers leave.

The biggest potential pitfall for businesses isn’t denying a leave request, but what comes afterward. Small businesses are likeliest to run afoul of the law by pressuring new fathers to take less than their allotted eight weeks, or by retaliating against them once they return from leave, such as by not giving them a raise or bonus.

The law makes more employees at large companies eligible for paternity leave, too. Under the FMLA, employees are only eligible for leave if they’ve worked for a business for at least a year. But under the Massachusetts law, employees who have been working full-time for three consecutive months can take leave.

An employee expecting twins? He can get double his time off. While the FMLA allots parents of twins and triplets the same amount of leave as single-birth parents, the state law allows an eight-week period of leave for each child. That means a father of triplets is entitled to nearly half a year of leave.

-See the full Boston Business Journal article.

State’s Utility Regulator Ends Bill Recalculations

After months of public outcry (as reported last month: Some Switching Electric Suppliers Hit with Large Retroactive Rate Hike, MGH Community News, March 2015), the state’s utility regulator has ordered an end to the practice of recalculating the past electric bills of customers when they switch to another electric supplier.

In an order posted online this month, the Department of Public Utilities scrapped a rule that required utilities to recalculate the bills of most households and small businesses if they left their utility’s “basic service” plan. Depending on when consumers switched their electric supplier, they could receive a surprise charge on their bill.

Although the rule had been in place for 15 years and many customers end up receiving credits instead of charges, this past winter’s high electric rates and aggressive marketing by competitive suppliers led many consumers to switch their electric provider. Hundreds filed formal complaints about the surprise charges, and some even ended up switching back to basic service.

Dana Gould, a Weston resident who switched to a competitive supplier recently, said she was stuck with $400 in payments to Eversource Energy after switching her house and a rental property to a competitive supplier. Even though she pulled out of her competitive supply contract, she said she was still stuck with the payment.

By default, residential and small business electricity costs are fixed for six months at a time in Massachusetts. Under the old regulations, however, past bills would be recalculated if customers switched in the middle of one of those six-month periods to reflect the actual, variable cost of electricity. The payments would go to power generation companies, and didn’t affect the utilities’ bottom lines.

Attorney General Maura Healey said she was happy with the regulator’s decision. She also supported the Department of Public Utilities’s decision to monitor when people switch to competitive suppliers to make sure ratepayers are treated fairly.

-See the full Boston Globe article.

CMS Announces New Star Ratings for Hospitals

The Centers for Medicare & Medicaid Services (CMS) has announced the release of the Hospital Compare star ratings system, designed to help beneficiaries choose where they receive their care. The star ratings are based on data from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) and take into account patient experiences in the following areas:

• The level of communication between doctors and nurses;
• The responsiveness of the hospital staff to patients’ needs;
• The cleanliness and noise level of the hospital; and
• The preparedness of patients when they enter post-hospital settings.

Of the new Hospital Compare ratings, Dr. Patrick Conway, Acting Principal Deputy Administrator for CMS and Deputy Administrator for Innovation and Quality said, “The patient experience Star Ratings will make it easier for consumers to use the information on the Hospital Compare website and spotlight excellence in health care quality. These star ratings also encourage hospitals and clinicians to strive to continuously improve the patient experience and quality of care delivered to all patients.”

Hospital Compare is part of a larger initiative by CMS to give beneficiaries useful information to help inform their health care choices. In addition to rating hospitals, CMS also provides star rating for nursing homes and Medicare Advantage and Part D plans.

See the CMS press release.

-From Medicare Star Ratings Coming to Nation's Hospitals, Medicare Watch, The Medicare Rights Center, April 23, 2015.

Governor Charlie Baker recently signed an executive order on reestablishing a council that brings advocates against sexual assault and domestic violence together with law enforcement and government officials.

The council’s aim is to improve prevention, enhance existing support services, and hold perpetrators accountable. The group will also help implement the state’s new domestic violence laws. The 30-member Governor’s Council on Sexual Assault and Domestic Violence was established by former governor Paul Cellucci’s administration, in which Baker served.

Last year, there were more than 2,000 cases of sexual assault reported in Massachusetts, a number that Baker said “does not reflect the countless incidents that go unreported. We fear there are many more.” This year, domestic violence has killed 10 people, the governor said.

Tammy Mello, the director of violence prevention in the office of health and human services will serve as the council’s executive director, overseeing the day-to-day operations of a group that will meet at least every two months.

Sarah Perry, who will serve on the council, said Monday the group will help keep a continued spotlight on sexual assault and domestic violence. “Keeping that focus there is really key to effecting societal change,” said Perry, executive director of The Second Step.

-See the full Boston Globe article.

First and foremost, your personal care assistant (PCA) is your paid employee through the MassHealth PCA Program.  As a side note, these considerations also apply equally to home health aides who provide in-home services through other programs. Even if the PCA is also a family member or a personal friend, it is important to maintain the employer/employee distinction when it comes to your personal care. You are the boss in this situation, because you best know your needs and how you want them met. So you need to be clear from the outset about your expectations. Clear reciprocal communication is key in any employer/employee relationship.

PCA management is especially complex because by its very nature the relationship between you and your PCA is very up close and personal. PCA work usually involves activities that are very personal, even intimate - things like toileting, bathing, and dressing. A long-term or live-in PCA may become a close companion and confidante, a stand-in for a family member or a dear friend. This can make it difficult to be direct about saying what you want done and give directions about how you want it done. So it is important to maintain a distinction between working PCA activities and personal time.

As the consumer-employer, you decide how to allocate your allotted PCA hours. You might decide on a particular day, for example, that you prefer your PCA spend some time accompanying you to a ballgame or doing your nails and skip your daily shower. Your PCA can provide any form of assistance you need with any activity that is mutually agreeable and is not illegal, destructive, or sexual.

So the very first rule in communicating with your PCA is mutual respect. Some examples are:

• Instead of, "Give me my cell phone." [Sounds demanding]  You can say, "Please hand me my cell phone"

• Instead of, "Could you/would you wash the dishes before you leave?"  [Never make a request as an indirect question.] "Please wash the dishes before you leave."

• Instead of, "I'd like you to fix my lunch now." [Not explicit.] "Please warm up the casserole leftovers for my lunch."

Secondly, it is unwise to assume that your PCA knows your mind about a task, even if he or she has done it before.  

• Instead of, "Put away my gloves." You can say, "Please put my gloves in the top dresser drawer."  [Polite and specific.]

Another PCA consumer-employer misstep of which I have too often been guilty of is bundling requests, just to get them off my mental to-do list (and onto someone else's plate). If you say, "Please sweep the floor, wash the dishes, start the laundry, and make my lunch", you will be lucky if the first two items are remembered and acted upon. It makes more sense either to state the most important task first and wait till that is finished before making the next request, or to make and present to the PCA a written note with the day's activities with the tasks in descending priority order. In either case, be sure to note deadlines: "The trash must be put out by pickup by 7:30 this morning." or "I must be bathed and dressed in time to leave at 1:30 for my 2:00 doctor appointment."

Another caution: If you have more than one PC, never gossip about or badmouth one to the other. This will almost certainly boomerang to bite you in the backside. Pointing out one PCA's shortcomings to another sets a negative dynamic. But pointing out one PCA's positive accomplishments to another can be motivating. At the same time, do not say (or imply) something like: "I wish you were more like Janet."

-Adapted from Tips for Talking with your PCA, By Ray Glazier, PhD, founder and Principal of disAbility Research Associates, LLC of Belmont, MA, in Disability Issues, Vol. 35, No. 2 (Spring 2015), SRH Disability Issues, April 13, 2015.

REquipment is a medical equipment recycling program that provides individuals and families in Greater Boston and Central Massachusetts with gently-used, refurbished durable medical equipment (DME). The REquipment reuse program launched in 2013 with the mission to provide adults, seniors, and families with easy access to quality gently-used DME and to save valuable equipment from ending up in landfills.

Through REquipment, people with disabilities and seniors can find refurbished power and manual wheelchairs, scooters, shower chairs and more to help them live safely in their communities. REquipment is provided at no charge and without the hassles of medical insurance. REquipment’s community-based reuse partners accept DME donations, refurbish and deliver items within Greater Boston and Central Massachusetts. REquipment provides a much needed, one-stop service for giving recycled, donated DME a useful second life with people who need it.

REquipment is currently supported by a collaboration of public and private funding from the Massachusetts Rehabilitation Commission's MassMATCH program, the Massachusetts Department of Developmental Disabilities (DDS), the Massachusetts Department of Public Health (the Massachusetts Hospital School) and grant funding from the Boston Foundation and the Boston Home.
For more information see the website:http://dmerequipment.org/

Or contact them for more information and assistance:
info@dmerequipment.org
617-204-3626
866-244-6156 Toll Free
A statewide guide to similar services, created by Mass Rehab Commission, is also available on their website: Guide to Medical Equipment Reuse Options in Massachusetts.

-Thanks to Kara Conway Raponi for sharing this resource.

The Irving K. Zola Center for Persons with Disabilities is located at 20 Hartford Street, Newton Highlands, MA 02461. The Zola Center operates a Free Food Distribution Program that is open to all residents of Newton and surrounding towns. There is no registration to receive food items. Items vary each week but can include fresh fruit, vegetables, prepared foods, fresh bread and rolls from local bakeries and pastry from Starbucks.

Beginning Saturday, January 17, 2015 this program will operate every other Saturday from 12:00-1:00 P.M. Doors to the building will open at 11:00 A.M. Please bring your own grocery bags to transport food.

The Zola Center also offers free "Meditation Class" and "Reiki Treatments" once each month. For more information call; 617-277-5131 or e-mail zolacenter@juno.com

-From Disability Issues, Vol. 35, No. 2 (Spring 2015), SRH Disability Issues, April 13, 2015.

Every day in Harvard Square, the nation’s best students, glowing with the aura of forward momentum, swirl past homeless kids huddled in doorways or slouched in the square’s central “pit.”

Sam Greenberg and Sarah Rosenkrantz, who graduated from Harvard last year, have been working to change that situation. They are leading an effort to create what is believed to be the nation’s first student-run nighttime shelter for homeless youth in the basement of First Parish in Cambridge, the wooden Unitarian Universalist church abutting the Old Burial Ground.

“Y2Y Harvard Square,” which is scheduled to open in November following a $1.1 million renovation of the church’s subterranean auditorium, will offer temporary shelter for young adults age 18 to 24 during the coldest six months of the year. The aim is to provide a sanctuary where young people can find their way to a stable housing situation and, eventually, a more promising future.

“A guest will feel safe in our space and have an opportunity to take a deep breath,” Greenberg said. After a stay of up to a month, he said, each young person will leave on “a concrete pathway out of homelessness.”

City officials and business leaders say the initiative is long overdue. Harvard Square’s vibrant, youth-oriented character has been a magnet for homeless young people for decades. “They can’t go to adult shelters because they get eaten alive there,” said City Councilor Marc McGovern, who is also a social worker. “These kids really don’t have a place, even in Cambridge, where they can go and feel safe.”

Youth On Fire, a 15-year-old program of AIDS Action Committee of Massachusetts that has offered a daytime drop-in center for homeless youth providing connections to medical care, counseling, and other services at Harvard-Epworth United Methodist Church, will operate out of the new shelter in the daytime, helping young guests find a path forward.

Interrupting homelessness “at this age, where there are more opportunities than there are later in life . . . could be a game-changer,” said Maria Dominguez Gray, the class of 1955 executive director of Harvard’s Phillips Brooks House Association, the umbrella organization for student-run service programs.

Ellen Semonoff, assistant city manager of human services for the city of Cambridge, said homeless young adults tend to be a hidden population.“They might spend a few nights on the street but often they are couch surfing, or they are, unfortunately, trading sexual relations for a bed for the night,” she said.

And homeless youths tend to need different kinds of help than their adult counterparts. Many wind up in the streets because they have aged out of foster care or because of violence at home. National figures suggest that as many as 40 percent are lesbian, gay, bisexual, or transgender.

-See the full Boston Globe article.

Tufts University announced this month it will “proactively and openly” recruit undocumented students and offer financial aid to eligible undergraduate students, a clear declaration that immigration advocates hailed as a significant victory.

Under the new policy, the private university will consider all students who are in the country illegally as regular domestic applicants, eligible for the same university aid as US citizens. Because undocumented students are ineligible for federal financial aid, the university will make up the difference out of its funds for undergraduates who cannot afford to pay their own way.

Under the policy, the university said it recently accepted and offered financial aid packages to at least five undocumented students for the fall semester. The university will also create a group to discuss ways to encourage more undocumented students to apply.

An estimated 65,000 undocumented students graduate US high schools each year, and their ability to attend college has been the subject of a divisive, long-running debate.

Critics of illegal immigration said the change was misguided and would wind up depriving some US students of admission and financial aid opportunities.

-See the full Boston Globe article.

The Medicare Doc-Fix

This month, the Senate passed, and President Obama signed, the Medicare Access and CHIP Reauthorization Act of 2015 that repeals the Sustainable Growth Rate (SGR) formula that determines Medicare physician payments and extends the Children’s Health Insurance Program (CHIP) for two years. Both political parties despise the current formula, which came out of a 1997 law aimed at deficit reduction. But they failed to come up with a long-term solution for more than a decade and instead used 17 short-term fixes. The “doc fix” bill replaces the SGR with alternative, value-driven payment strategies.

The bill also permanently funds the Qualified Individual (QI) program that helps low-income Medicare beneficiaries afford Part B premiums. While the Senate considered an amendment to the bill to permanently repeal the Medicare therapy caps, this measure was not successful. Instead, the therapy caps exceptions process will be extended for two years. When this exceptions process expires, Congress must again act to ensure that people with Medicare are able to retain access to needed therapy services.

Also extended for two years is federal funding for community-based organizations, including State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs) and others, to find and enroll vulnerable Medicare beneficiaries in low-income assistance programs. Like the therapy cap exceptions process, it will up to Congress to ensure this funding continues beyond the two-year extension included in the final bill.

-Adapted from Senate Passes Historic Medicare "Doc Fix" Bill, Medicare Watch, Medicare Rights Center, April 16, 2015 and Senate approves changes to how Medicare pays doctors, The Boston Globe, April 14, 215.

Workers at the state’s beleaguered child-welfare agency contend with decrepit working conditions and an overload of cases, eroding morale and leaving some workers with traumatic levels of stress, according a survey of more than 1,500 employees.

The employees said the biggest problem they face is heavy caseloads. About 1 in 3 handle more than 20 cases each.“DCF continues to fail completely at bringing down case-loads, the levels of which make it impossible to do the quality of social work that my coworkers and I would like to be able to do,” one worker wrote. “Most of the time I find myself struggling to keep up with the tasks required in responding to emergencies that might have been preventable if I had had more time to spend directly with parents and children.”

 “The atmosphere is fear-driven, and people here suffer from PTSD for fear that something bad could happen on our caseloads,” one of the workers wrote.

A lawyer with the state Department of Children and Families said the agency’s attorneys, who are responsible for cases involving abuse, neglect, and the removal of children from their homes, are each saddled with 100 cases on average, instead of the 60 recommended by the American Bar Association.

“We absolutely do not give the attention to each case that we should,” the lawyer reported. “We feel that we are violating ethical practices and delivering poor quality every day, because it is impossible to work up to standard with our excessive case loads.”

Morale in the workforce was “much worse” in December 2014 than in the previous year, according to those surveyed.

The confidential survey of 1,558 employees at the Department of Children and Families was conducted in December by the Office of the Child Advocate, an independent agency that monitors DCF.

The study was commissioned by the Legislature and released this month, after the responses were analyzed and compiled by the Moakley Center for Public Management at Suffolk University.

While some of the problems, such as heavy caseloads, have been documented in other official reports, this one was striking for including the unvarnished voices of social workers and managers who vividly described barriers to their mission of protecting more than 35,000 children in some of the most unstable families in Massachusetts.

In response to the report, Globe columnist Yvonne Abraham wrote “Even at the best of times, the agency has the impossible task of protecting kids who can never all be completely safe from harm. When something goes wrong, the thousands of children in DCF care are thrust onto the front pages, as are those who watch over their sad lives and, sometimes, their heartbreaking deaths. We suddenly care about the agency’s deficiencies with an intensity we seem unable to muster at other times. We bay for firings and reforms. Then we move on.  This survey reveals what happens after our attention flags. What happened after Oliver’s death is panic.” She calls for more sustained attention and action “We’ve been hearing this for years, even decades. And we keep letting those who could do something about it — governors, legislators — off the hook. As with so many of this state’s gargantuan problems (transportation, anyone?), the failings of one regime are left at the feet of the next. We get incremental change, but the big, dismal picture stays the same. Will the administration of Charlie Baker be any different?”

-See also the special supplement on the House Ways and Means budget.
-See the full Boston Globe article.
-See the Yvonne Abraham column.

Larke Huang, PhD, director of the Office of Behavioral Health Equity at the Substance Abuse and Mental Health Services Administration says that minority populations face prevalence of mental illness at about the same rate as whites do. However, racial and ethnic minorities — as well as lesbian, gay, bisexual and transgender people — face greater mental health risks and burden of the disorders because of disparities working against them.

One of the major risk factors for increased stress and mental health issues is poverty, Huang told The Nation's Health. "People of color are disproportionately represented in poverty, either below the poverty level, at the poverty level or just above it," Huang said. She also pointed out that people of color are more likely to hover near the poverty line, bouncing from under to over throughout their lives, noting that "With poverty, there's…post-traumatic stress disorder, depression, anxiety."

But along with poverty, access remains a major issue adding to mental health disparities among minority populations. Access, Huang said, can be defined in many ways. Access to mental health professionals might be limited by a person's insurance status, for example — more than half of U.S. residents without health insurance are people of color, Huang said.

Access goes beyond meeting with a specialist. Huang pointed to "enabling services" that need to align in order for a person to get mental health care. These can include transportation, child care, time off from work and other issues that people seeking mental health care might need in order to make and keep an appointment with a mental health professional, or even their primary care provider.

"We see life stress events that get in the way…of people completing treatment," Huang said. "People who are limited in resources often have a difficult time getting to or keeping appointments. (We also see) discrimination and racism creating stress responses and traumatic experiences, that can also lead to reduced capacity to cope, to adjust and to seek care when needed."

"Various studies have (also) shown that people of color report more dissatisfaction with the care," she said. "(We see) high rates of dropout because there is a feeling that they are not totally understood by their providers."

Huang also mentioned that peer mentors who have experienced mental health problems and who are in recovery are valuable sources of support and can help to address the workforce shortage.

-See the full Medscape summary article.

Many aspects of the economic picture have improved since the height of the recession in late 2008. Yet the number of children living in families categorized as poor or near-poor remains stubbornly high, recently released figures from the National Center for Children in Poverty (NCCP) at Columbia University show. 

Analyzing data from the US Census Bureau’s 2013 American Community Survey, the latest available, researchers found 44 percent of kids in the US live in low-income families, with half of these families categorized as poor. These figures are up 13 percent and 23 percent, respectively, from pre-recession rates in 2007. Low-income families of four with two children are defined as having an annual income below $47,248; poor families (also of four with two children) are defined as having an income below $23,624.

While more parents have gradually returned to full-time work, more are likely working in lower-wage jobs, helping to explain the high numbers, says Yang Jiang, senior research associate at the NCCP. The data shows that half of low-income children live with at least one parent who is employed full-time year-round, a slight increase from previous years.

A separate report prepared for last year’s US Conference of Mayors showed that since 2008, the fastest growth in jobs has been in the low-paying accommodation and food sector, which had average annual wages of just under $21,000 last year. 

Parents’ education levels are strongly linked with kids’ likelihood of living in low-income homes. An overwhelming majority — 86 percent — of kids with parents who didn’t finish high school are classified as low-income. Yet the same is true of nearly one-third of kids with at least one parent who has some college education. The strains of working, attending classes, and arranging child care might limit the amount of college some parents complete, Jiang says.

The data found persistent disparities by race and ethnicity. Nearly two-thirds of black, Hispanic, and American Indian children are categorized as low-income, while just under one-third of white and Asian children are. Percentages also varied substantially by region. While 48 percent of children in the South live in low-income families, 37 percent of kids in the Northeast do. (In Massachusetts, the figure is 30 percent.)

The NCCP and other advocates recommend a two-generation approach to reducing poverty that combines education and training for parents with high-quality care and education for kids. Many states have strong policies in one of these areas, but not the other, Jiang says.

“Policymakers have to think of children and parents together, because children do better when their parents do better,” she says.

-See the full Boston Globe article.

Under President Barack Obama's health care law, which aimed to end health insurance discrimination for mental health services, an estimated 62 million patients now have better coverage. But a new report from the National Alliance on Mental Illness (NAMI) shows the policies still have a long way to go before they can make a difference in the lives of people living with mental illness. 

From lack of access to psychiatrists to expensive costs for medications, the study reveals a variety of issues that NAMI says show insurance companies are falling short in coverage of mental health and substance abuse disorders, collectively referred to as "behavioral health" services. 

The Mental Health Parity Act, enacted in 2008, requires mental health benefits in some employer-sponsored plans be provided on the same terms of other medical care. When the Affordable Care Act became law in 2010, coverage was expanded to private health plans sold in state and federal marketplaces, where Americans can buy tax-subsidized plans based on their income. Mental health care is one of 10 required benefits, just like maternity care and vaccines, for all plans sold. 

But the definition of "parity" is murky at best. For instance, a plan might list that it covers in-patient psychiatric care but doesn't specify the kind of facility in which that care may take place. Nearly a third of NAMI survey respondents reported insurance companies denied authorization for mental health and substance abuse care because the insurance companies deemed the care not medically necessary. "In the absence of uniform criteria, insurers have adopted their own standards and have often not been forthcoming about informing beneficiaries about these standards," authors of the report wrote. 

In response to the report, Clare Krusing, the spokeswoman for America's Health Insurance plans, the trade association for the industry, said in a statement that health plans had a unique understanding of the challenges patients and their families face when it comes to managing behavioral health conditions. "The goal is to ensure patients have access to the right care at the right time and in the right setting,” she said. ​

Untreated mental illness can lead to unemployment or homelessness, and people may turn to substance abuse to self-medicate, which can make symptoms worse. Some turn to suicide, and many end up in prison instead of receiving care. "With mental illness, that’s the beginning of a slippery slope, and your life can come completely apart," says Sita Diehl NAMI’s director of state policy and advocacy. "It makes sense to pay at the front end and make it affordable." 

There also aren't enough mental health providers in the networks, the report finds. Participants in the survey said it was most difficult for them to find a therapist or a counselor, and only slightly less difficult to find a psychiatrist. According to the federal government’s Substance Abuse and Mental Health Services Administration, 55 percent of counties do not have a practicing psychiatrist, psychologist or social worker. Rural counties, in particular, are affected by the shortage. 

Even if the medical provider is included in a health care network, he or she may not be available. In January 2015, the Mental Health Association of Maryland published a study that revealed only 14 percent of psychiatrists listed in the qualified health plans in the Maryland marketplace were actually accepting new patients and available for an appointment within 45 days – the suggested wait time. 
Findings also showed that customers had a difficult time paying for medications, and that certain medications, like some antipsychotics, were not covered at all or only available with high out-of-pocket costs.  For marketplace plans, denials were nearly twice the rate for other medical care.

-See the full U.S. News & World Report article.

Imagine being so desperate to stay in rehab that you would deliberately relapse. That’s a choice some women are making at a Jamaica Plain treatment center.

When the city abruptly closed the bridge to Long Island last October, a bunch of city-run homeless and rehab programs shut down with it. So did some nonprofit facilities, but we’ve heard far less about their scramble to survive — or about the people whose lives depend on them.

Among them is Joelyn’s Family Home. After detox and stabilization, addicts go to recovery homes like Joelyn’s, which gradually reintroduce them to the community, helping them connect with therapists and find work. In Boston, recovery beds were in criminally short supply to begin with. The bridge closing evaporated two-thirds of the beds in women-only recovery homes in a single afternoon.

Since poor women coming out of treatment programs now have even fewer places to go, they’re staying in those intensive programs way longer than they should. At Women’s Hope in JP, run by Victory Programs, which also ran Joelyn’s, they’re staying for as long as 100 days, even though they’re supposed to move on after 28. And even then, some can’t find spots in recovery homes.

 “(Some women) will literally go back out and use just to get back into detox” said Nikki Sheldon, program manager at Women’s Hope. The rehab system has long been woefully inadequate to women’s needs, forcing them to take desperate measures. But it is more common since the Long Island closing took 75 women’s recovery beds offline.

Women’s Hope is squeezed at both ends: It receives 60 requests for treatment beds a day, but because so few women are moving on, only a few open up each week.

Jonathan Scott, who heads Victory Programs, is searching for a new site for the women’s recovery center in the crazy Boston market. After months without stepping in, the city has joined the battle, rounding up donations, and promising to help with renovations. There’s no question Mayor Marty Walsh cares deeply about what is going on here. But the city’s failure to maintain the bridge will cost Joelyn’s and others millions of dollars. Walsh didn’t let the bridge fall apart, but it’s his problem now. And it calls for extraordinary measures, like personal appeals to banks and property owners.

There are lives at stake here.

-See the full Yvonne Abraham column in The Boston Globe. 

There’s a lot of fuzzy math in American politics, but Representative Pete Sessions of Texas, the chairman of the House Rules Committee, recently set a new standard when he declared the cost of Obamacare “unconscionable.” If you do “simple multiplication,” he insisted, you find that the coverage expansion is costing $5 million per recipient. But his calculation was a bit off — namely, by a factor of more than a thousand. The actual cost per newly insured American is about $4,000.

Whatever your overall view of the Affordable Care Act, one indisputable fact is that it’s costing taxpayers much less than expected — about 20 percent less, according to the Congressional Budget Office. A senior member of Congress should know that, and he certainly has no business making speeches about an issue if he won’t bother to read budget office reports.

But that is, of course, how it’s been all along with Obamacare. Before the law went into effect, opponents predicted disaster on all levels. What has happened instead is that the law is working pretty well. So how have the prophets of disaster responded? By pretending that the bad things they said would happen have, in fact, happened.

Costs aren’t the only area where enemies of reform prefer to talk about imaginary disasters rather than real success stories. Remember, Obamacare was also supposed to be a huge job-killer. In 2011, the House even passed a bill called the Repealing the Job-Killing Health Care Law Act. Health reform, opponents declared, would cripple the economy and in particular cause businesses to force their employees into part-time work.

Well, Obamacare went into effect fully at the beginning of 2014 — and private-sector job growth actually accelerated, to a pace we haven’t seen since the Clinton years. Meanwhile, involuntary part-time employment — the number of workers who want full-time work but can’t get it — has dropped sharply. But the usual suspects talk as if their dire predictions came true. Obamacare, Jeb Bush declared a few weeks ago, is “the greatest job suppressor in the so-called recovery.”

Then there’s the never-ending hunt for ordinary, hard-working Americans who have suffered hardship thanks to health reform. Obamacare opponents really need a few sob stories, tales of sympathetic individuals who have been impoverished by some aspect of the law. Remarkably, however, they haven’t been able to find those stories. Early last year, Americans for Prosperity, a Koch brothers-backed group, ran a series of ads featuring alleged Obamacare victims — but not one of those tales of woe stood up to scrutiny. More recently, Representative Cathy McMorris Rodgers of Washington State took to Facebook to ask for Obamacare horror stories. What she got instead was a torrent of testimonials from people whose lives have been improved, and in some cases saved, by health reform.
In reality, the only people hurt by health reform are Americans with very high incomes, who have seen their taxes go up, and a relatively small number of people who have seen their premiums rise because they’re young and healthy (so insurers previously saw them as good risks) and affluent (so they don’t qualify for subsidies). Neither group supplies suitable victims for attack ads.

In short, when it comes to the facts, the attack on health reform has come up empty-handed. But the public doesn’t know that. The good news about costs hasn’t made it through at all: According to a recent poll by Vox.com, only 5 percent of Americans know that Obamacare is costing less than predicted, while 42 percent think the government is spending more than expected.

And the favorable experiences of the roughly 16 million Americans who have gained insurance so far have had little effect on public perceptions. Partly that’s because the Affordable Care Act, by design, has had almost no effect on those who already had good health insurance: Before the act, a large majority of Americans were already covered by their employers, by Medicare or by Medicaid, and they have seen no change in their status.

At a deeper level, however, what we’re looking at here is the impact of post-truth politics. We live in an era in which politicians and the supposed experts who serve them never feel obliged to acknowledge uncomfortable facts, in which no argument is ever dropped, no matter how overwhelming the evidence that it’s wrong.

And the result is that imaginary disasters can overshadow real successes. Obamacare isn’t perfect, but it has dramatically improved the lives of millions. Someone should tell the voters.

-See the full Paul Krugman Op-Ed in The New York Times.

Of all people who die, only a small minority (<10%) die suddenly and unexpectedly. Most people (>90%) die after a long period of illness, with gradual deterioration preceding an active dying phase at the end. Care provided during those last hours and days can have profound effects, not just on the patient but on all who participate, including both family and professional caregivers. At the very end of life, there is no second chance to get it right.

Many clinicians have little or no formal training in managing the dying process or death. Families usually have even less experience or knowledge about death and dying. From media dramatizations and vivid imaginations, most people have developed an exaggerated sense of what dying and death are like. Media portrayals of the outcomes of resuscitation have, for example, been shown to be overly optimistic compared with actual data. With appropriate management, it is possible to provide smooth passage and comfort for patients and their loved ones.

Preparing for the Last Hours of Life

A key role of all clinicians (physicians, nurses, social workers, and chaplains) is to help families understand that what they see may be very different from the patient's experience. If family members and caregivers feel confident, the experience can be a time of final gift-giving. For example, when parents feel confident about providing for the needs of their dying child, the sense that they are practicing good parenting skills is reinforced. If they are left unprepared and unsupported, they may spend excessive energy worrying about how to handle the next event. If events do not unfold as hoped or planned, family members may live with frustration, worry, fear, or guilt that they did something wrong or contributed to the patient's death.

-See the full Medscape article which include details about changes to expect in the dying process, managing symptoms and family expectations, and tips for steps to take after the death including notifying others.

Computer applications (apps) on electronic tablets such as iPads may offer a safe, effective, nonpharmacologic option for addressing agitation in dementia patients who have associated behavioral problems, new research shows.

Preliminary results from a small pilot/feasibility study of geriatric psychiatry inpatients showed that use of iPad apps was safe and well tolerated. In addition, episodes of agitation/restlessness were reduced in patients with mild, moderate, and severe cognitive impairment after using apps of varying difficulty.

"We found that the iPad was an incredibly versatile tool; and we found it was a way to do several different things using a single device," principal investigator Ipsit Vahia, MD, assistant professor of psychiatry at the University of California, San Diego (UCSD), and director of research at UCSD Senior Behavioral Health, told Medscape Medical News.

"The most striking finding was that even those with the most severe forms of cognitive engagement were able to interact with the device in a safe and effective manner," said Dr Vahia.

Although the greatest benefit in reduced agitation/restlessness was in the MCI group compared with the severely impaired group (P = .02), all three cognitively impaired groups showed benefit after iPad use.

Some of the interactive apps that proved especially popular included a pottery creation app that required hand-eye coordination, as well as one that showed water "ripples" or frogs jumping whenever a participant touched the screen as it displayed an image of a pond. "It was an engaging visual impact experience, which is not very easy to do on a normal basis. So the device really added a whole dimension of how we were able to engage these patients," said Dr Vahia.

Translation apps were also popular with bilingual patients. "For those where English was not their first language, we found that they weren't as stimulated or engaged at first. For example, a patient who spoke primarily Romanian was found to be quite apathetic and did not engage with staff. But when we showed Romanian videos from YouTube on the devices, this person seemed to come alive," said Dr Vahia. "We realized from that that what looked like apathy was possibly just boredom," he added.

The study is ongoing, and Dr Vahia reported that the investigators are now examining whether use of the iPads on a regular basis to engage with the environment reduces the incidence of agitation ― instead of just using the devices as a postproblem intervention.

The study was presented at the American Association for Geriatric Psychiatry (AAGP) 2015 Annual Meeting.

-See the full Medscape summary article.

Being overweight or obese might be a risk factor for developing depression. It is also possible that low cardiorespiratory fitness, rather than overweight or obesity, is the better predictor of depressive symptom onset. Adults in the Aerobics Center Longitudinal Study (Dallas, Texas) underwent fitness and fatness assessments between 1979 and 1998 and later completed a questionnaire about depressive symptoms in 1990, 1995, or 1999. Separate logistic regression models were used to test the associations between 3 fatness measures (body mass index, waist circumference, and percentage of body fat) and the onset of depressive symptoms. Analyses were repeated using fitness as the predictor variable. Additional analyses were performed to study the joint association of fatness and fitness with the onset of depressive symptoms. After controlling for fitness, no measure of fatness was associated with the onset of depressive symptoms. In joint analyses, low fitness was more strongly associated with the onset of elevated depressive symptoms than was fatness, regardless of the measure of fatness used. Overall, results from the present study suggest that low fitness is more strongly associated with the onset of elevated depressive symptoms than is fatness. To reduce the risk of developing depression, individuals should be encouraged to improve their fitness regardless of body fatness.