Death and The September Night…


The unmentionable odour of death

Offends the September night…

—W.H. Auden, “September 1, 1939”

Good morning, ProviderNation. Maybe it’s a seasonal thing—here in the decadent capital, the leaves are doing their lustrous wonders, the mercury sinks in the mouth of a dying day, and twilight comes earlier and earlier—or maybe it’s psychic convergence.

In any case, death is in the air.

It’s about time.

Shanda Fur Die Goyim

You’ll have seen our little effort to make sense of death, dying, and grief in the September issue. I remain proud of the work, but I have to admit that John Morley and the fine folks at JAMDA have wiped at least some of the smug off my face. No sooner had I let slip the September cover, feeling peacock proud of having dealt with a matter that so many providers had consigned to the shanda fur die goyim bin, when I see that Morley and Angela Sanford had stolen a march: Their essay in the August issue of JAMDA, “The God Card: Spirituality in the Nursing Home” is brilliant enough on its own, but it’s accompanied by an op-ed and an original study on palliative sedation in nursing homes.

And just as I’m recovering from my vertigo of watching Morley and company scoop me, the Institute of Medicine releases, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.” Meanwhile, AHCA super-lobbyist Clif Porter (and all-around decent chap) gives us an interview for the October issue of Provider in which he tells us that providers ought to look to hospice as a model for building goodwill with the public and with lawmakers.

So it appears that providers are more willing to talk openly about death and dying and grief than I had given them credit for.

‘Good Death’ Aspiration

Still, no one will claim that this refreshingly morbid September closes the conversation. And however much the Big Public may hymn the virtues of “a good death,” the attitude still seems aspirational.

“I wish there were a way we could get out into our communities,” says Robin Hillier, owner and operator of Lake Rehabilitation and Nursing Center in Conneaut, Ohio. “Having these discussions about what we want for ourselves at the end of life is something that we need to have throughout our lives. We all talk about estate planning, and tax planning, but not enough people do enough about end-of-life care.”

Robin Hillier

Robin Hillier

Hillier has acquired a grim expertise on grief and mourning. Not only does her center care for and treat the elderly, but it also has a pediatric unit.

“One of the biggest rewards for my staff is working with those people, because they have an opportunity to develop lifelong relationships,” she says. “But one of the problems is when one of those residents dies, it’s much harder. You’re sad when someone who’s older died, but you can celebrate a long life, well lived: It’s just much harder when someone young dies.”

That’s why The Talk starts early and continues often at Lake Pointe, Hillier tells me.

“We take that seriously, we talk about it clearly, and we want to provide you with the support you need to deal with it,” Hillier says at every new staff orientation (and beyond).

Family Values

Staff grief is only one mountain to climb, though. The biggest one is often families of the dying. (In fact, an earlier study in JAMDA found that nearly three-quarters of staff reported family members as a hindrance to offering quality end-of-life care.)

Debbie Meade

Debbie Meade

“We have to balance between a resident and families, often,” says Debbie Meade of Health Management, in Georgia. “The resident is tired. They’re tired of the fight. And there are times when they’re just ready to go. And they know it.”

For families, though, it’s often hard to “let go,” Meade says. The guilt, the sense of betrayal, the fear of loss all overwhelm families at what is literally the last minute. (But even the Supreme Court sometimes seems to struggle with teasing out the difference between letting someone die and actually killing them.)

“That’s where we miss the boat,” Meade says.

‘Your Mom Is Not Here Anymore’

Meade says that these are the moments where providers must find their voices.

“I had a resident—the flesh was literally rotting off her body. And the family had a feeding tube in her,” she recalls. “I sat down with the family and said, ‘I’m sorry, I can’t let you do this anymore. Do you understand that your mom is not here anymore?’”

The reasons so many providers balk at such blunt talk are easy to understand, Meade says. The fear of lawsuits, the fear of honesty—it’s all human, all too human. “They think they’ve given up on them, and they think they’re not doing what’s right,” she says.

But the consequences of human failure are absolutely inhumane, Meade says.

“We don’t sit down and have those honest conversations. And that’s when the resident suffers, when you watch the family not having enough love and courage to let them go to that better place,” she says. 

‘Granny Wants To Go’

Like so many in her line of work, Meade has dearly won experience. She had to help her beloved grandmother die. A vivacious, vibrant woman, “Granny” had been up and about until one more stroke drew a curtain down on her. Meade instantly moved her grandmother into Health Management’s skilled nursing center.

“I was trying to feed her, and she closed her mouth and shook her head, No. I said, ‘You don’t want to eat?’ She shook her head. No. I called my Dad and said, ‘Granny wants to go.’

“I know I did what she wanted,” Meade says. “She just looked me in the eyes and shook her head. And I knew what that meant.”

It took seven days for Granny to die. But she did so peacefully, and on her own terms. Meade says she misses her grandmother every day, but regrets nothing. She hopes that she and other providers can find ways to pass on what they’ve learned.

“It’s something that we need to talk about more,” she says. “It’s something we need to share.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.











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The Difficult (Yet Easy) Decision to Move Into Assisted Living

Guest blogger Ken Lund

Guest blogger Ken Lund

For those of us growing up in the ’50s and ’60s, our parents’ generation built a culture around the kitchen table. Mealtimes were a symbol of the health of the family. As our spiritual center of the universe, my mother had decades invested in planning, organizing, shopping, cooking, and finally savoring the magical “ta-da” moments when each meal came together. Mom sacrificed a lot for us, day after day, without a word. While she may have fantasized about having freedom to do other things, she never spoke or acted on them.

For the past 30 years, I’ve had the honor of leading teams dedicated to creating and optimizing magical places mature Americans call home. From solutions to keep people in their homes longer, to assisted living for those wanting the optimal blend of community and care, to centers for those needing professional skilled care to get well and go home as fast as possible.

Mom supported my career over the years with interest. Naturally, we had many conversations about her coming to live in one of our communities. No matter how many benefits I suggested, she lovingly pushed back with the same objection. She would be giving up a kitchen in which to cook a family meal. She’d be giving up an oven in which to bake cookies for grandchildren. She’d in essence be giving up the very culture that she had created, and her identity along with it. It was what made her whole.

The Aha Moment

As an executive in the senior care industry, my inability to convince her impacted me deeply and personally. I moved into one of our communities for months, hoping my fellow residents would lead me to the answers. Finally, after 10 years of trying different angles with Mom, the moment of epiphany came, as I was hearing my own children talk about their wants, goals, aspirations, and dreams. That was it: the dreams. The dreams we all have before life’s responsibilities set in. The dreams of traveling to far-away places, learning new things, and spending days indulging in favorite activities.

So I decided to approach the question differently. I asked Mom one day what she dreamed about when she was very young, before Dad and the rest of us consumed her life. We rolled back the clock 50 years. I asked about what she enjoyed doing with her friends, the places she visited, and things she wanted to accomplish. In essence, what was it that brought her joy—and that she had to put on hold for a while. I learned that she, like many in her generation, gave so much for and to their families that they lost themselves in the line of duty. I don’t think these were conscious decisions. But there is a distinct difference between the person who still believes in dreams and opportunities and the person who accepts the hand they are dealt as their burden.

Ready To Flip The Record

One memory led to another, and before we both knew it, Mom had talked for hours, and together we came to an important conclusion about time.

As we get older, time is no longer a commodity. It is to be prioritized and savored for every moment, not to grieve what is lost but to maximize what is left. Time must be thoughtfully allocated for becoming exactly the person we would like to be. That means rolling the clock back to embrace those young dreams that, moving forward, open a world of possibilities. I learned Mom still held those, and she was ready to flip the record over from the side of duty to the “dream side”—which had always been there, but had just not been played in a long time.

Not long after, Mom moved into a community, after deciding to put dreams first over cooking, shopping, laundry, cleaning, gardening, and many other activities that out of duty and habit had consumed her. She took the liberty to exercise her freedom to be who she imagined she could be. She trusted herself and her judgment. She prioritized possibilities, and today is living them: whether it be playing bridge with friends, enjoying theater, book club, traveling, volunteering, and so much more. She loves the light coming through her windows. She is surrounded by people of the same age who share common interests. She recently shared that she wished she would have made the turn decades ago.

Turning The Tables

And the kitchen? While she insisted on having an apartment with a kitchen, ironically, she has never used it to cook a single meal…or bake one cookie. When she craves an opportunity to cook, she joins the world-class chefs in the kitchen of her community, who welcome her company, in the planning of dining experiences for two to 200.

In the years I’ve been in the senior care industry, I’ve not had a single resident join one of our communities and later leave to gain a kitchen back (or the laundry, cleaning, or shopping, for that matter).

During my months living in assisted living, I learned from my fellow residents how they put egos aside to define a new culture of community—one created on maximizing the possible. I was amazed at how many of them give back their many gifts in schools, as big brothers/big sisters, as caretakers for the homeless, and more. Every day they are making life better for themselves and those they serve. In essence, the kitchen table is now a much bigger one—and still a symbol of the health of the family—made remarkable thanks to the embrace of a community.

Kenneth Lund leads Radiant PS, a congress of experts who help organizations design, execute, and optimize continuum-based models for the new era of health care.

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The Danegeld…

A furore normannorum libera nos, domine...

A furore normannorum libera nos, domine…

Good morning, ProviderNation.

Don’t I feel like an international man of mystery? Got a call from the Royal Danish Consulate yesterday. (You can’t believe how disappointed I was to learn it’s really a diplomatic outpost, not a donut shop.) Anyway, it seems that the fine folks of Denmark are eyeing the long term and post-acute care market here in the U.S.

Last month, Copenhagen hosted the Alzheimer’s Association International conference (it’s coming to D.C. next year), and it seems that the Danes are serious about exporting some of their person-centered design ideas (specifically, bathrooms and kitchens for nursing centers and assisted living buildings), according to one of my new best friends over there.

Contrary to what you may have read, the Danes aren’t all a melancholy bunch. But they are serious as Swedes about patient-centered care. Even as its population ages rapidly, the country is already demonstrating new models of care. Apparently, the House of Glücksburg thinks they can export their goods here.

In any case, things are early. But there are already signs that long term care is becoming a global business.

Speaking of paying the Danegeld, hats off to the fine folks at the Saint Paul Health Center near Denver. They passed the hat, through a crowd-funding Web page, to help send resident Nick (and his mom and aides) on a grand bus tour so he could dip his toes in the Pacific Ocean. You can read about the results here, but wow. Seriously, wow.

And while, we’re all feeling good, a hearty mazel tov to the fine folks at Mainstreet. The senior housing developer once again made the top 500 in Inc.’s list of fastest-growing entrepreneurial businesses. “Mainstreet’s No. 347 rank is based on a three-year revenue growth of 1,352 percent and 2013 revenue of $106.3 million,” the company says in a news release. “This is the fourth year Inc. magazine has recognized Mainstreet’s growth.” Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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Training Pays Off

Stan Szpytek

Stan Szpytek

Good morning, ProviderNation.

It is not uncommon to see negative news coverage when disaster strikes at or near a long term care community. The isolated challenges and opportunities for improvement during an adverse event seem to be the “low hanging fruit” for those looking to criticize the operation of health care facilities that suddenly face a crisis or disaster in the midst of their daily commitment of caring for our nation’s elderly and frail with compassion and dignity.Well, I say it’s time for some positive news.

While this local incident itself was somewhat minor in scope (an electrical fire in a SNF that required complete evacuation of a single facility), I believe the narrative provided by one AHCA state affiliate’s director of quality and regulatory services is worth sharing. The comments are directed to the emergency preparedness bureau chief at the state’s Department of Health Services (DHS) summarizing an event that underscores the true benefits of training and preparing LTC facilities to properly manage emergency situations:

Hello Teresa,

I just wanted to share a great success story with you. Yesterday in the early morning, one of our inner facility nursing homes had smoke filling the building. There are 30- to 50-year-old wiring and circuits there, and one arched in the conduit underground. The fire department deemed the building unsafe, and the facility had to be evacuated. There were 84 residents. This facility has many sister facilities here, and they reached out to them. DHS was notified. They set up their Emergency Operation Center (EOC) and donned their Incident Command System (ICS) vests!!!

Yes, this facility had attended the training (Disaster Planning and Nursing Home Incident Command System- NHICS) and were prepared.

Over 50 people arrived to help, and other facilities brought vans, and all residents were safely evacuated starting at 9:00 am and completed by 11:42 am. All families were notified, and the brand new administrator said he watched with great humility and admiration as everything hummed along. Because all the facilities receiving these residents have the same electronic record systems, transfers and transitions went well. Staff was dispersed to the other facilities to care for their residents and will continue to do so until they can return home. Every resident left with their meds and charts.

The facility may be cleared by the fire department today, and they are bringing in a huge generator to run the building until an electrical wiring issue can be addressed. They expect to be able to return residents by Monday at the latest.

I couldn’t be more proud to see something like this actually happen so successfully. I know this is only one facility, but when we evaluate how well this went, there is hope that we really will be “Disaster Ready” as we already are on our way. This facility has promised to tell their story at our state’s conference in October.

One nurse returning to get her car late yesterday evening told the DON, “This is why I love to working here!!!”

We are committed to continue to have more successes whenever the need arises.

Disaster Ready” is the name that this state affiliate created to “brand” its disaster planning and emergency management resource program. Through grant funding received from the Hospital Preparedness Program, this state, along with many others, is focusing on preparedness through the development and implementation of comprehensive training programs.

So, after reading this success story, you should ask yourself one simple question: “Is our facility Disaster Ready?”

Stan Szpytek is the president of Fire and Life Safety and is the life safety/disaster planning consultant for the Arizona Health Care Association and California Association of Health Facilities. Szpytek is a former deputy fire chief and fire marshal with more than 35 years of experience in life safety compliance and emergency preparedness. For more information, visit or email Szpytek at


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A Tale Of Two Summits

CEO of It's Never Too Late

CEO of It’s Never Too Late

Good afternoon, ProviderNation.

What a crazy world we live in, and a very crazy time to live in it! Bouncing between coasts over the last two weeks has been a fascinating, reflective journey. The 2,841 miles that separate northern California from Washington, D.C., can feel more like the distance between the earth and the sun, depending on your perspective. Here’s mine.

I had the pleasure of being invited to two separate events put together by two organizations over the past two weeks. Invited may be a bit generous; our company—It’s Never 2 Late—was a sponsor at both events.

Exhibit A was the What’s Next Boomer Business Summit: Brilliantly choreographed by Mary Furlong, it brings together, in the same venue, venture capitalists, leaders in the field of aging, and start-up companies—big ideas looking for big money.

Fascinating conversations, trends popping up left and right, smart people who have been around for awhile, such as Laurie Orlov of Aging In Place Technology Watch and Steve Moran of Senior Housing Forum, mingling with fresh new faces that have fresh new ideas, like Katy Fike from Aging 2.0.—bright-eyed entrepreneurs looking to change lives, including their own, while dissecting aging issues and offering technology solutions.

One week later, flashing across the country, I was invited to attend the 2014 Dementia Thought Leader’s Summit, sponsored by the Dementia Action Alliance. This event was also exceptionally choreographed, this time a joint effort between Karen Love and Jackie Pinkowitz.

It included a fascinating group of policymakers, senior living operators, dementia experts, and, most poignantly, people living with dementia. It was an eclectic group of passionate people trying to get their arms around a complex and challenging problem.

It was an interesting juxtaposition, looking at these two events from the inside out, and from the outside in. My first thoughts were about the striking differences between the two groups. On the one hand was the investment event that included dozens of entrepreneurs looking for capital to drive the development of the widgets they hope can profitably change the paradigm for older adults across the spectrum, while, on the other hand and one week later, policy folks and thought leaders were demanding Senate hearings, White House conferences, and additional funding to educate the public to the painful reality of the dementia tsunami coming our way.

Many were seeking solutions both for the individuals themselves and for their loved ones and/or professional caregivers providing support. Hearing Michael Ellenbogen, a 56-year-old successful banking executive diagnosed five years ago, give a hands-on testimonial as to what it feels like to have a judge, who won’t even physically see him, take away all of his rights to manage his own finances, was powerful.

Dementia Summit participants developed five goals to improve person-centered dementia care.

Dementia Summit participants developed five goals to improve person-centered dementia care.

From a personal standpoint, that’s not a remote person who is 95 years old living in a nursing home. That’s me—Michael and I are about the same age. It reminded me how I felt three decades ago when Magic Johnson dramatically proclaimed he had HIV. That experience resonated with me as a young adult and completely changed my perspective. Michael’s words resonated in the same vein with me that day. When people see the world of dementia as “their” problem, they will start to own the solution, and change will happen. I live and work every day trying to help people with dementia. Thank you, Michael, for making it personal for me, and I apologize for not seeing it on my own.

The Fourth of July kicked in, and with a nice couple of days off (and a couple of Heinekens along the way), I started reflecting a bit on the realities of the separate events, and also what a cool country we live in. It really is not so much that the people at the events are that different; they just have different perspectives as to how to solve problems.

And those perspectives are shaped by their own life experiences. If you’re an entrepreneur, you are consumed with finding a niche for your product. If you’re a gerontologist or a policymaker, you will look for solutions within the current framework we live in, oftentimes with governmental help.

It isn’t that entrepreneurs are greedy, heartless people, nor is it that the policy folks all are dismissive of business—it’s creatively looking at ways to deal with a crisis of epic proportions and both sides acknowledging the other side is vital and relevant.

Our company is a great example of that. It’s been our honor to develop a technology experience that completely changes the lives of people living with dementia; we benefit thousands of lives a day with our content and engagement experiences delivered across the U.S. The idea was not thought up through the government; we saw a niche and for 15 years have tried to fill it.

However, if not for a multitude of external grants and governmental and foundation funding during our formative years in the early 2000s, we would not have survived as a company and be thriving today.

And along the way, dementia experts such as Juliet Holt from Brookdale and Kathleen Curry from EMA have continued to push us to make our product better, which in turn benefits more and more people. There’s not one unilateral solution—we all can feed on each other.

By the end of the July 4th weekend, as I swatted mosquitoes and watched a cool fireworks display in Wisconsin, it hit me how unique this all is. Our country allows, even encourages, the intersection of policy and profit to help make people’s lives better and solve problems.

We don’t always agree on the ideal solution, but passion on both sides will get us to a different place as we try to deal with the painful realities of dementia. I can see why people want to live in this glorious country. I’m glad I do.

Today’s guest blog is written by Jack York, founder of It’s Never Too Late. He can be reached at

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The Annals of Oops (Bastille Day Edition)….


Allons enfants de la Patrie (d’Fournisseur), Le jour de gloire est arrivé.

In the annals of oops, there are career-enders, Hall-of-Fame makers, kitsch oops, the off-with-your-head oops and the oops that wake us, screaming, from our sleep. The fine folks at CMS, not to be outdone, have discovered a widespread hospital oops, affecting the Medicare benefits of people in at least three states.*

It appears that certain auditors goofed while performing their Recovery Audit Contractor (RAC) duties, and, well, hospitals started changing patients from “inpatient” to, um, not-inpatient. When the hospital staff tried to convince the auditors to give this another thought, they were given the old Major Major treatment. Result: automatic denial of skilled nursing benefits for patients in Utah, California, and Arizona, and maybe elsewhere.

Last week, CMS did their best to get everyone to remain calm. The agency issued a “Technical Director Letter” to the contractors, telling them, in polite bureaucratese, to straighten up and fly right. No later than Wednesday, contractors will have to post on their Web site that the old rules are, um, inoperative.

“Once the MACs post the information, [skilled nursing] providers that have received this edit in error may adjust their affected claims or contact their MAC in order to have their claims adjusted,” CMS Associate Regional Administrator Barbie Robinson says in a letter to the fine folks at AHCA/NCAL.

Now, it is notorious that the providers and auditors view each other much like the sans-culottes viewed Louis. And CMS is doing its level best to play Tom Paine in this little costume drama. But providers can perhaps be forgiven if they allow themselves a wintry, Madame DeFarge-esque smile: They saw this Bastille Day coming for a long time.

“I believe that CMS is struggling with the unintended consequences of RAC hospital audits, the new hospital two-midnight and rebilling regulations, and the hospital provider confusion that much of this has unintentionally caused,” one long term and post-acute care advocate has said. “And now this confusion on the part of both hospitals and MACs is indirectly hitting us.”

Meanwhile, more pleasant news from the Revolution. The fine folks at AHCA/NCAL have announced their new class for their own Legion d’honneur. Every year, the groups recognize the best and the brightest of their profession, “the men and women who give freely of themselves in caring for individuals in long term and post-acute care centers, ID/DD residences, as well as assisted living communities.”

This year’s honorees are:

  • Hero of the Year — Intellectual and Developmental Disabilities: Alicia Durham, Eureka, CA, who volunteers at Butler Valley Inc., Carole Sund Center.
  • Not for Profit Program of the Year: St. Benedicts Health Center and Benedict Court, Dickinson, ND.
  • Volunteer of the Year — Adult: Ruth-Ann Harrod, Wesley, ME, who volunteers at Maine Veterans’ Home.
  • Volunteer of the Year — Group: Amory High School Health Class, Amory, MS, which volunteers at Golden Living Center, Amory.
  • Volunteer of the Year — Young Adult:Bailey Austin Combs, Amburgey, KY, who volunteers at Knott County Health & Rehabilitation Center.

Vive le republique (and all that).

*Your humble correspondent isn’t above an oops of his own: In an earlier draft of this scintillating post, I neglected to add the extra “n” in “annals.”  I offer the mote in my own eye: with Muphry’s Law, c’est la vie.

Bill Myers est rédacteur principal d’Magazine Fournisseur. Email à . Suivre sur Twitter, @ProviderMyers.

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CMS on Backlog: ‘How Did Things Ever Get So Far?’


CMS says it will hire non-binding mediators to try to tackle its monstrous Medicare audit appeals backlog.

CMS says it will hire non-binding mediators to try to tackle its monstrous Medicare audit appeals backlog.

Good morning, ProviderNation. “How did things ever get so far?” the fine folks at CMS are wondering. The agency is launching an experiment it’s calling the Settlement Conference Facilitation Pilot, hoping against hope that it will help CMS deal with its monstrous audit appeals backlog.

You’ll recall that, in February, the Obama administration called a great big timeout because it was overwhelmed with administrative Medicare appeals from auditors. The People weren’t exactly thrilled with things.

Now, the administration will hire Medicare appeals officers they’re calling “facilitators.” Their mission, (should they choose to accept it) will be to mediate disputes between auditors and providers and, in CMS’ quaint words, “to discuss the potential of a mutually agreeable resolution for claims.” The facilitator won’t be able to rule on the merits of any claim. If he or she can get folks to set aside their feudin’ and a-fussin’, why, then, there will be the peace.

If not, of course, people are free to make their own offers to administrative law judges.

While we’re talking about the fine folks at CMS (and we’re epically mixing metaphors), the agency also says it’s giving a rethink to policies and payments for end-stage renal disease. Under the proposal, contractors and providers wouldn’t get a Medicare market basket update, but they’d get a slight wage-index bump. So you got that going for you, which is nice.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.



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