Justice in Aging Protects Low-Income, Older People from Improper Medicare and Medicaid Billing
From 2016 to 2018, RRF awarded three grants, totaling $250,000, to Justice in Aging (JIA) to address improper billing practices that affect low-income, older people who are eligible for both Medicare and Medicaid (referred to as “dual eligibles”). JIA’s advocacy efforts focused on educating the aging and legal services networks on ways to protect beneficiaries from improper billing; working with health systems to change the underlying policies that contribute to balance billing; and using litigation when necessary to enforce billing protections.
There are nearly 12 million low-income, older people enrolled in both Medicare and Medicaid. Many healthcare providers are not easily able to identify which older adults are Qualified Medicare Beneficiaries (QMB), for whom the government must cover certain health care costs, including premiums, deductibles, and copays. As a result, these providers bill individuals for costs that should be covered by the QMB program. Similarly, many individuals are unaware of their status as QMBs and do not know that the double-billing is illegal.
JIA’s advocacy brought about many improvements to reduce the incidence of improper billing. The Centers for Medicare and Medicaid Services (CMS) now puts QMB status on beneficiaries’ Medicare cards. This makes it easier for providers to recognize who can and cannot be billed for a balance. CMS has improved the training of its 1-800-Medicare call agents to identify QMB status for either the beneficiary or the advocate. CMS agreed to send notifications and reimbursements to California dual eligibles who had been improperly billed. Many received reimbursements. In collaboration with JIA, CMS trained nearly 10,000 attorneys who assist dual eligibles with billing problems. Through these trainings, issues surfaced in several states, including California, Georgia, Illinois, and Texas. These states worked with CMS to remedy the problems.
JIA was able to identify large provider groups that were repeat offenders for improper billing. Pre-litigation negotiations resulted in corrective actions to ensure that these provider groups no longer bill dual eligibles improperly.
JIA produced and updated a toolkit to guide lawyers whose clients may experience improper billing. The kit includes templates for letters that can be used for mailings to providers, insurance companies, and CMS. JIA also produced several fact sheets and briefs that are available online for advocates who need additional information.
This project had a significant impact. Huge numbers of low-income beneficiaries have been protected from improper billing and received reimbursement. Thousands of legal service advocates across the nation have become better prepared to handle these issues more effectively. Changes implemented by CMS will continue to have national impact by helping to protect nearly 12 million Americans from being double-billed and informing them of their status and rights as QMBs.
Community Partners Address Hoarding Problems
In 2018, RRF awarded a second-year, $85,790 grant to The Chicago School of Professional Psychology (CSPP) in continued support for a community-based approach to address hoarding problems among low-income older persons. In 2016, CSPP received its first RRF grant ($77,647) to establish a partnership with three agencies: The Community Builders, Japanese American Service Committee, and Heiwa Terrace Retirement Community. CSPP established an interdisciplinary team, comprising clinical psychologists with gerontology expertise, trained psychology graduate interns, social workers, Home Support Services staff, and residence coordinators, who interact regularly with residents. Working together, the agencies used the established practice model, “Hoarding: Best Practice Guide,” to identify and work with residents at risk of hoarding, increase community awareness and knowledge about the problem, and help at-risk residents remain living independently by providing the needed mental health services to identify and assist in mitigation.
CSPP hosted 35, four-session presentations for residents at the three sites. More than 195 people attended, exceeding the goal of 150. The curriculum included two sessions on mental health issues and two specifically on hoarding. Assessments were conducted on 186 individuals; 63 were identified as being at risk for hoarding. Of those, 50 accepted services, including individualized care plans, home visits, and homemaker services.
In addition to direct services, CSPP also worked to educate the partner organizations and other human service agencies to recognize early warning signs of hoarding. A core group of staff members from the partner agencies were trained to conduct hoarding assessments. CSPP also designed and delivered a three-hour workshop for mental health professionals. A total of 59 mental health professionals completed the training, a 10% increase over the projected number. In a post-workshop evaluation, all 59 reported that they would be able to describe hoarding disorder, including its prevalence, warning signs, and potential consequences. Almost all reported that they would be able to provide supportive interventions to increase residents’ safety as a result of the training. In addition, 31 staff members from the partner agencies completed an evidence-based training course, entitled Mental Health First Aid.
CSPP provided intensive training for 11 staff members of the three partner organizations who directly work with older residents. Each site developed a specific plan on future training for their team. CSPP recorded the trainings to ensure that new staff can be brought up to speed.
To build public awareness about hoarding, CSPP recorded a 30-minute television show which aired on Chicago’s Cable Access Network. CSPP also brought three students on as “RRF Grant Fellows” to build professional development in the field. They served in program development and leadership roles.
The project faced a challenge in follow-up evaluations to determine the effectiveness of home visits for residents who were identified as at-risk for hoarding and related mental health issues. The staff recognized that residents who were struggling with memory loss and dementia could not remember what had occurred several months earlier. In the future, the team indicated it would depend on obtaining feedback from caregivers directly about their observations of the residents who had received additional services. It appears that the partnership and services will be sustained through ongoing training and the use of the educational materials that were created by CSPP.
Little Sisters of the Poor, St. Joseph’s Home for the Elderly Expands Music Therapy and Volunteer Program
In 2018, RRF awarded a $38,790 grant to Little Sisters of the Poor, St. Joseph’s Home for the Elderly (Palatine, IL) to support a full-time volunteer coordinator and a music therapy program. Both components seem to have had a positive impact on the residents.
The music therapist established a residents’ choir, weekly group sing-a-longs, and daily one-on-one musical visits with residents. He enhanced the musical offerings of the IN2L (It’s Not Too Late) computer program and promoted the use of hand-held musical instruments. He was in the process of planning a “Best of Broadway” musical with the residents at the close of the grant period.
Little Sisters provided several examples of positive changes in the residents and reductions in the use of psychotropic drugs during the grant period. Nonverbal residents began ringing bells to the rhythm of the music. Residents with dementia were accurately singing the lyrics of the songs and participating in the choir. The music therapist brought a portable keyboard to residents who were reluctant to leave their rooms. He also brought music to residents in hospice to soothe them and their families.
The volunteer coordinator has greatly enhanced the types of volunteer activities and increased the number of volunteers. During the grant period, more than 130 adults and 20 teenagers provided nearly 10,000 hours of service. Volunteers engaged with residents by providing transportation, assisting with meals, sharing therapy animals, and serving as additional observers to identify problems that residents may be having.
Many of the volunteers took initiative beyond their assigned tasks. A volunteer nurse recruited several colleagues to help assist with meals. A volunteer landscaper contacted nurseries and obtained landscaping materials worth thousands of dollars. He also solicited a blacktopping company for materials and labor. An experienced carpenter organized a group to reface and trim cabinets. Little Sisters is committed to continuing the expansion of both its volunteer and music therapy programs.
Northwestern University’s Study Finds Ability of Older People to Engage in Emotion Regulation
In 2017, RRF awarded a one-year, $99,596 grant to Northwestern University to study the impact of emotion regulation training on short-term cognitive function in adults, age 65 to 80. Emotion regulation refers to the capacity to modify aspects of the emotional response system to meet personal, interpersonal, and social goals and standards.
The project’s objectives were to: 1) assess whether emotion regulation had positive, short-term effects on executive functioning (i.e., working memory, cognitive flexibility) in older adults and which of the strategies yielded the greatest benefits; and 2) examine age, functional status, and affective well-being as moderators of these effects.
Northwestern recruited 129 healthy adults, age 65 to 80, living in the Chicago area; the average age of the participants was 71. All were screened for pre-existing conditions that could affect emotional/cognitive functioning. Successful recruitment efforts resulted in nearly double the projected sample size. Half of the participants were female; 80% were White; and 94% had attained at least two years of higher education.
Participants were given a three-hour, laboratory-based assessment in which they completed a series of emotion and cognition trials while their physiological signals (e.g., heart rate; breathing) were monitored continuously. Participants were asked to watch emotion-eliciting video clips while physiological indicators were recorded as baseline measures of emotional reactivity. Participants were then trained on three methods of performance-based emotion regulation: positive reappraisal; detachment; and acceptance. Half of the participants were asked to complete the executive functioning task without an emotion regulation instruction (i.e., reactivity condition) and the other half with an emotion regulation instruction (i.e., regulation condition). After completing the tasks, they responded to questions about their perceived emotion regulation, functional status, and well-being.
This portion of the study found that older people could successfully implement strategies to regulate their emotions. When implementing them, participants experienced sizable changes in their subjective emotional states as well as in their autonomic physiology (e.g., heart rate, breathing), thus, demonstrating remarkable plasticity of the emotional response system in later life. Participants provided feedback on each of the three strategies and their specific effects on the emotional response system. Detachment was found to be the best strategy to reduce negative emotion and decrease physiological activation (e.g., heart rate) and was not considered too taxing or undesirable to implement. Positive reappraisal was found to be the best strategy for changing negative into more positive emotional experiences. However, it had little effect on physiology and was seen as more challenging and less desirable to implement. Acceptance left emotional experiences (e.g., sadness and, notably, compassion) intact, while also reducing physiological activation. It was rated as the most desirable and easy to implement.
To determine correlation between positive affect and cognitive function over time, researchers examined existing data from a large-scale national longitudinal study, Midlife in the US (MIDUS). While the laboratory arm of this project captured performance-based measures of emotion regulation, the MIDUS data included perceived emotion via well-established questionnaire measures of positive affect and phone interviews to assess cognitive functioning. A sub-sample of the study (N=571) had cardiometabolic risk factors assessed. Participants were engaged in three waves of data collection over 18 years. By expanding beyond the laboratory-based study, the project was able to demonstrate the importance of positive affect in predicting less decline in memory functioning over a longer period of time and the mediating role of cardiometabolic risk.
This project yielded important insights, providing evidence that older people have the ability to engage in emotion regulation. The study indicated that proper regulation was correlated with improved cognitive function. It also found a correlation between positive affect and long-term memory functioning. Findings were disseminated through conference poster presentations at the Society for Affective Science and the Society for Psychophysiological Research. A manuscript is under consideration by Psychological Science. During the grant period, the Principal Investigator (PI) received additional grants from the National Institutes of Health, Brain & Behavior Research Foundation, and Northwestern University.
Residents of Friedman Place Receive Vision Rehabilitation and Adaptive Technology
In 2018, RRF awarded a one-year, $18,545 grant to Friedman Place (also known as Maplewood Housing for the Visually Impaired) to provide the services of a Certified Vision Rehabilitation Therapist (CVRT). A total of 29 older residents were assessed by the CVRT. All new residents, age 65 or older, received an initial assessment and care plan. All older residents who had been living at Friedman Place in 2018 were re-assessed and had their plans updated. Assessments and goals focused on two areas: orientation and mobility, and activities of daily living. The residents either partially or completely achieved 97% of their service plan goals, exceeding the 85% projection.
The CVRT formed tech support groups to introduce and encourage residents to use adaptive devices. This strategy proved very successful. Nearly 80% of the older residents demonstrated regular use of 44 devices. In addition to providing support and encouragement for using the devices, the group sessions provided social opportunities for residents who tended to isolate themselves.
The Amazon Echo proved to be the most popular device used by the older residents. Other devices that were well-received included big button phones and magnifiers. There was less receptivity to the talking glucose monitor. Residents preferred nursing assistance for a condition they considered to be highly important to their well-being. Due to the positive effect of the CVRT’s services, Friedman Place plans to sustain the position.
“Bathing Without a Battle” Training Goes Online
In 2015, the University of North Carolina at Chapel Hill (UNC-CH) was awarded a three-year, $200,930 grant to convert the original Bathing Without a Battle video-based training program into an online version. The project’s objectives included: revising the modules for internet-based training; offering free access and continuing education credits to encourage use of the training; and creating a Spanish version of the program’s key concepts.
In 2001, RRF provided initial funding to create Bathing Without a Battle. This award-winning program was developed after more than ten years of research into improving bathing for persons with dementia. A 2014 randomized study of Bathing Without a Battle concluded that it is an effective means of improving the bathing experience of residents with dementia in nursing homes. After the intervention, negative verbal behaviors declined by almost 18%, while antipsychotic use declined by 30%. Use of Bathing Without a Battle in long-term care facilities is now considered an important indicator of quality culture change.
The program combines person-centered techniques with simple, practical approaches to make showering, tub bathing, in-room bathing, and hair washing safe and comfortable for the persons giving and receiving care. Bathing without a Battle also teaches methods for changing policies to promote and support person-centered care. The program is intended for all caregivers of persons with dementia, as well as anyone committed to quality, person-centered care. The original training products included a video and CD-ROM, and were distributed to nearly 17,500 recipients, including all nursing homes in the U.S., and 1,250 home care and state agencies.
Because of high turnover rates among long-term care staff, and the increasing number of caregivers (formal and informal) who will be responsible for bathing older persons with dementia, the need to educate paraprofessionals and others in Bathing Without a Battle techniques continues to be important. However, the original program was on DVD, which has become practically obsolete. Significant technology changes have occurred since the program’s training materials were first developed. Many of the materials needed to be recreated so they could be adapted to current internet-friendly formats.
With RRF funding, the program was converted into a series of eight, online interactive video training modules. Each module includes video-based questions, as well as multiple-choice quizzes to test user engagement and retention of information. The online training was built in the HTML 5 style, a robust technology that allows for easier access via desktops and mobile devices. Reporting functions were created that capture the number of registrants to the training program, their credentials, and the setting where the registrant typically gives care. The functions also allow tracking of registrants’ scores on post-training quizzes and their evaluations of the program.
The training program is available at no cost on the Bathing Without a Battle website, http://bathingwithoutabattle.unc.edu/. By registering as a nurse of any type (RN, LPT, or other), users are able to earn up to 2.5 hours of continuing education credits. A certificate is given to certified nursing assistants to verify their participation. UNC-CH widely marketed the revised version through for profit and nonprofit associations of nursing home providers. All members of the National Association of Directors of Nursing Administration received it as well. During the grant period, nearly 6,000 people registered for the program. Nearly 2,500 registrants requested continuing education credits.
Post-training evaluation showed consistently high marks for the course. Nearly 84% of participants agreed or strongly agreed that they would recommend the course to others and felt the information will help them be better prepared to bathe residents with dementia.
UNC-CH created a Spanish version of the key concepts of the program. While shorter than the full training, the video provides important basic information in both culturally and linguistically appropriate language for Spanish-speaking trainees. The video can be found at https://wimeo.com/222579420. By adapting to new technology, Bathing Without a Battle will continue to provide essential information to improve the bathing experience for both caregivers and care recipients.
Everyday Memory and Metacognitive Intervention Shows Promising Results for Older People
In 2018, RRF awarded an 18-month, $55,424 grant to Georgia Institute of Technology to investigate the feasibility, acceptability, and efficacy of the Everyday Memory and Metacognitive Intervention (EMMI). Created by Co-Investigators Pearman and Hertzog, EMMI is designed to prepare older people for cognitive and social changes by establishing habits and procedures of self-management that might ease their transition from work to retirement. Because retirement may be associated with changes in cognitive functioning, the time of retirement transition is seen as ideal for cognitive interventions and new metacognitive habit development. The study’s objectives were to: assess the feasibility of recruiting and conducting this type of study with adults age 65 and older who are transitioning to retirement; determine if participants regarded the intervention as useful and effective; and assess its effectiveness by evaluating cognition, affect, and well-being in everyday life. The project’s results were intended to lead to the design of a larger randomized control trial.
The project involved an intervention group and a waitlist control group; the control group had the option of participating in the intervention after the completion of data collection. The EMMI intervention occurred in two phases. The first phase (one week) involved group training on EMMI techniques. Training included basic memory skills known to be effective in everyday life, including active noticing, self-testing, and spaced retrieval. The second phase (one month) involved individualized training and customizing the use of EMMI techniques. Intensive habit-restructuring procedures were administered to the participants. They were encouraged to engage in mindful reflecting on daily tasks and cultivate new habits of reviewing goals, plans, and actions during the course of the day. The research team monitored progress, analyzed causes of memory failures, reinforced memory success, and shaped habit formation changes. The final part of the study involved participant focus groups to evaluate EMMI’s acceptability and investigate potential improvements in the program’s administration.
A total of 53 participated in the study; 33 were assigned to the EMMI intervention group and 20 to the control group. The project’s findings were very promising. Participants found EMMI to be very useful. They reported continued use of the strategies at the one-month follow-up. They indicated positive regard for the utility and effectiveness of the intervention techniques for accomplishing their daily goals and tasks in a variety of situations.
Almost every one of the outcome measures showed improvement. There were either differential pre-post test gains in the treatment group and/or post-test treatment versus control differences on variables not assessed at pre-test. Intervention participants were superior to controls on two different aspects of everyday memory function: subjective memory, with greater perceived memory ability and control over memory at post-test, relative to pre-test; and improvement in overall life satisfaction and lower stress.
The research team plans to submit a paper to The Gerontological Society of America’s journal, Innovations in Aging. Preliminary findings were presented at the American Psychological Association’s annual meeting last summer. Recently, results were presented at an Emory University Geriatric Medicine Grand Rounds. The research team has received a grant from the National Institute on Aging to improve data collection methods and run an active control group. The research team is also planning to submit a proposal to the National Institutes of Health to expand the study and make the findings accessible to a larger audience through training manuals and videos.
Study of Dynamic Useful Field of View Training Finds No Improvement Over Standard Cognitive Training
In 2017, RRF awarded a two-year, $130,553 grant to the University of South Florida (USF) to test the feasibility, acceptability, and potential efficacy of an intervention that added a motor component to a sedentary cognitive training program called Useful Field of View (UFOV). The UFOV intervention has been found to improve executive function and performance of instrumental activities of daily living. With growing evidence of the relationship between motor function and cognitive performance, the investigators hypothesized that adding a movement-based version of UFOV training could provide greater value than traditional UFOV.
The research team developed a novel intervention called “Training Under Cognitive Kinematics” (TUCK). Participants in the control group would be trained in the standard intervention (UFOV); they would sit in front of a computer and follow instructions to identify a particular image on the monitor. Images would be presented several times, with difficulty increasing each time the subject succeeded at a given level. Subjects would identify items, locate them on the periphery of the screen, and then respond with distractors added. Participants in the TUCK group would be trained in the modified motor-added version. They would respond to stimuli in the form of colored lights that flash from boxes affixed to a set of brackets on a wall, spaced 10 to 12 feet apart. They would move to and from the wall to hit the lights. Like the UFOV group, TUCK subjects would experience increasing levels of difficulty in which extra lights would be used as distractors and the duration with which the lights flash would be shortened. All participants would be trained twice a week for three months for a total of 15 hours. Outcomes would be measured within one to three weeks of completing the test.
The project was carried out as intended. A total of 69 participants were engaged in the study. They were age 65 or older, had a history of falls or self-reported balance difficulties, and were new to cognitive training. Acceptability of TUCK was determined, using the average of participant ratings on the Cognitive Training Expectations questionnaire. Feasibility was measured by quantifying the proportion of participants who successfully completed the intervention protocol. Balance, gait speed, and gait analysis were performed with measures including the 360° Turn test, Timed Up and Go test, and the OptoGait system. Cognitive function was assessed with the Useful Field of View test, which measures speed of processing for visual attention tasks.
TUCK participants found the training to be acceptable. On average, they agreed that TUCK training was enjoyable, challenging, engaging, and satisfying. With an 85% completion rate, the protocol was determined to be feasible.
Although the intervention was found to be acceptable and feasible, the TUCK group did not demonstrate improvements in cognition or motor speed when compared to the control group. Thus, incorporating movement into cognitive training exercises was not found to be a superior approach to computerized cognitive training. The investigators are continuing to study various dynamic aspects of gait in relation to vision, hearing, mental status, cognition, and established measures of motor function. A more advanced level of gait analyses may help determine which particular aspects of gait are associated with cognitive function and lead to a better understanding of the underlying mechanisms that contribute to age-related cognitive and functional declines.
The Principal Investigator submitted a manuscript to a special issue of Frontiers in Neurology and planned to present the study’s findings at the Cognitive Aging Conference in Atlanta.
Mount Mary University Receives Endowment in Honor of Trustee Emerita Hennessy
In January 2019, RRF awarded an endowment grant to Mount Mary University (MMU) on behalf of Trustee Emerita Marilyn Hennessy. Located in Milwaukee, MMU is a Catholic university committed to seeking social justice through education. The School Sisters of Notre Dame founded MMU in 1913 to mitigate educational inequity for immigrant women and has broadened its focus to welcome other under-represented groups.
MMU has used the endowment to purchase equipment for a Virtual Reality Room. Immersive virtual reality provides a variety of experiences that would be resource-intensive to create for students in real life. The technology utilizes a headset and motion-capture controllers so that participants can see and interact with a virtual environment. Television screens positioned in the lab allow classmates to visualize what the student wearing the headset sees.
In the fall of 2019, MMU’s Occupational Therapy and Counseling faculty were trained on using the immersive virtual reality technology. Additional faculty from Interior Design, Nursing, Social Work, and Psychology departments updated their curricula to incorporate the virtual reality lab into their lessons. The virtual reality lab has been used across departments and has fostered collaboration between students from different fields. For example, Interior Design students use specialized programs to create a 3D model of a space for a person with a disability. Occupational Therapy students “walk” through and evaluate the safety, ergonomics, and aesthetics of the space, and then provide feedback to the Interior Design students who developed the space. After this evaluation, Interior Design students can alter the 3D Interior Design program and re-visualize the space in virtual reality. Art Therapy and Psychology students practice Virtual Reality Exposure Therapy, using virtual reality headsets and software to treat anxiety disorders.
MMU plans to expand the use of the Virtual Reality Room to prepare students to navigate complexities of a wide variety of situations, which helps build empathy for the populations they are preparing to serve. Virtual Reality technology is not only providing better training for students, but it is also helping to prepare them for their professional careers through collaboration with peers in other disciplines.
Note: RRF staff takes much of the information for Grant Highlights directly from grantees’ final reports. Staff often asks questions and holds discussions with grantees to get a more complete understanding of the results of grants and to understand challenges grantees faced.