Meeting Notes 2005

Hospice Hawaii at Home

Ken Zeri has been President of the Board of Directors of the Hospice and Palliative Nurses Association and served on the National Hospice and Palliative Care Organization’s Nursing Section Steering Committee. Locally, he has been Chair of the Hawaii Cancer Pain Initiative, on the Hawaii Nurses Association Congress on Practice and Standards, and a member of the Kokua Mau leadership team, representing the Hawaiian Islands Hospice Organization. He also co-authored the 2000 "Statement on the Scope and Standards of HospiHoce and Palliative Nursing Practice."

Ken Zeri, RN, MS, CRNH, President and Chief Professional Officer of Hospice Hawaii, has spent the past 18 years in various hospice-related positions, ranging from giving bedside care to his current leadership role. He spoke to members about his organization, about the hospice philosophy, and about the efforts of all in the hospice community to promote improvements in care.

During the early years of his career, he describes, "I learned from patients that dying is not only a physical journey, it is also an emotional journey, a psychosocial journey, and a spiritual journey. Hospice care," he explained, "is more than relieving pain and attending to physical needs, it is also about being a guide for patients through the emotional, psychosocial, and spiritual aspects of their journey." This philosophy now exists as one of the purposes of Hospice Hawaii and is reflected in the effort of those who work there to provide comprehensive, compassionate care to the terminally ill and their families.

Hospice Hawaii, a community based hospice, developed more than 25 years ago from the vision of hospice and end-of-life care pioneers who sought to ensure death with dignity for the people of Hawaii. The organization now serves more than 500 patients a year on Oahu and Molokai and includes an interdisciplinary team of more than 40 professionals and about 200 active volunteers.

"With all that hospice has to offer - the opportunity to minimize suffering, to ease pain, to receive personalized care at little or no cost, to alleviate fears and concerns, to receive comfort and support - too many come to us too late to receive full benefit," expressed Ken Zeri.

He and others in the hospice field have been working to broaden policies, to make regulations more flexible, to educate the population on hospice care, to train health care professionals and others about hospice methods and philosophy, so that in time more will benefit. "When we come into this world, we are surrounded by love, comfort, and care. We all deserve the same when we leave."

Anyone interested in learning more about Hospice Hawaii, hospice care, financing options, etc. should call Hospice Hawaii at 924-9290 or visit their website at www.hospicehawaii.org.

Exercise for Caregivers

Rachel Sato, one of the facilitators of the group, provided the caregivers with an evening of stretching and light exercises to maintain bone strength, increase flexibility, and aid balance. Although not an exercise trainer, Rachel has, for years, regularly participated in a number of different exercise programs - aerobics, line dancing, Tai Chi, and Yoga.

Before starting, Rachel explained that stretching should always be done before exercising and can be done every day. Weight training should not be done daily, to allow muscles to rest and avoid overstraining. "You should be relaxed, don’t tighten up, and don’t hold your breath." Counting out loud helps you to breathe. "Avoid quick, jerky, or bouncing movements. Stretch until you feel a slight tension or gentle pulling in your muscles. Avoid comparing yourself to others," she explained, "everyone is different."

She described that you should be able to say phrases of three to four words while doing the activity. If you can’t talk at all, then the activity is probably too difficult for you. If you can sing, the activity is too easy. She stressed that safety should always come first and that, ideally, a training area should be created and weights should always be put away to avoid accidents.

Everyone enjoyed the opportunity to exercise and relax together.

Special Needs Trust

How can you provide additional funds for the care of loved ones, without affecting their eligibility to receive government benefits?

Gary A. Powell, one of the group’s facilitators, recently established PacConLTD, Professional Consultants to Hawaii. After years of being affiliated with national companies, he decided to develop his own business. Gary has earned his LUTCF (Life Underwriters Training Council Fellow) and CLTC (Certified in Long Term Care). In addition, he is licensed and accredited in Life and Health Insurances, Advanced Estate Planning, and Advanced Retirement Planning.

"Did you know that inheritance could disqualify an individual from receiving government benefits such as Medicaid or Supplemental Security Income (SSI)?" Gary inquired. "Did you know that the government has established rules allowing assets to be held in trust for a recipient of SSI and Medicaid, as long as certain requirements are met?"

"A Special Needs Trust (SNT) is such an option, a carefully designed legal tool that allows assets to be held in trust for recipients of SSI and Medicaid," according to Gary. An SNT may be appropriate for an elderly spouse with Alzheimer’s Disease, or for parents being cared for by an only child, or for a mentally or physically disabled child, or one impaired by drug abuse.

With an SNT, assets can be left to meet the supplemental needs of the disabled person. The SNT must be designed to supplement, not supplant, government benefits. It is not a bank account or a savings account. The money cannot be directly given to the individual, but must be distributed though a third party trustee, to pay for goods and services benefiting the disabled person.

Gary explained that the trust could be set up by mom and dad, son or daughter, or self-established. Many people fund the trusts with life insurance products, annuities, mutual funds, wills, or IRAs.

He repeatedly cautioned that the SNT must be prepared by a lawyer or estate planner experienced with the complexities of setting up an SNT. An improperly worded document could result in individuals losing their government benefits and having insufficient funds to meet daily expenses.

"Does someone with any form of dementia qualify to be an SNT recipient?" a member asked. Gary responded that individuals with dementia would qualify, especially if the possibility exists that the care receiver could outlive the caregiver.

"Does the condition need to exist prior to preparing a SNT?" "No, many people prepare the trust ’in case.’ If the need does not arise then other agreed upon arrangements can be made by the trustee."

Gary reemphasized the importance of seeking expert advice from an experienced attorney or estate planner. Anyone with questions regarding the presentation may call Gary at 722-1903.

Case Management Inc.

Ms. Donna Schmidt, LSW, QCSW, a Qualified Clinical Social Worker and Certified Geriatric Care Manager, serves as President and CEO of her business, Case Management Inc. (CMI), one of the few agencies to provide community foster care during the early expansion years of the program.

While a social worker at Kahuku Hospital, Donna Schmidt discovered the reluctance of island companies to provide homecare services and products to the distant north shore community. "I heard quite often, ’we don’t go out there.’ I had to tell people we couldn’t help them," she explained as she described the plight of caregivers and care receivers in need of services. In response, she started her own business, developing area adult foster care homes for the elderly and disabled, a relatively new concept at the time.

Ms. Schmidt located community Certified Nurses Aides (CNAs) with Intermediate Care Facility (ICF) and Skilled Nursing Facility (SNF) patient experience who were willing to contract their home for foster care. Houses had to be renovated, and CNAs received additional certification training. Comprehensive patient assessments preceded placement. "It was an exciting time," Donna Schmidt described of her first five homes.

Community foster homes differ from the more familiar community care homes. Unlike a care home that accepts five individuals, the foster care home accommodates up to two higher level-of-care residents (ICF or SNF). Because of federal and state subsidies, one of the two clients residing in the foster care home must be Medicaid qualified. The other may be on a private-pay basis. Care homes are licensed by the Department of Health; foster care homes are administered through a Department of Human Services waiver program.

Modeled after the program developed at Queen’s Hospital, expansion of the service included not only CMI, but also Hale Makua on Maui, and the Maluhia Wait List Project. Agencies such as CMI trained caregivers, certified homes, monitored patients, and did much of the paperwork.

Due to the growth of the program, changes have been implemented to create more stringent, uniform compliance standards and practices for the industry. A company from Tennessee has been hired to oversee the program and certify, audit, and monitor caregivers.

The requirement still exists that foster homes must work with a licensed case management agency. Thus, Ms. Schmidt continues to frequently monitor and assess homes, especially those caring for clients she "places." In addition to providing a number of services, she continues to recruit, train, intervene, and support foster home caregivers.

Ms. Schmidt has earned status as a Certified Geriatric Care Manager. This specialty provides additional benefit for clients who seek individualized care plans that maximize independence and well being.

Anyone interested in learning about foster care homes, case management fees, or developing care plans, should call Donna Schmidt at 676-1192.

SagePLUS / Medicare / Medicaid Update

For about seven years, Rachel and Elaine Sato, former primary caregivers, have served as trained volunteer counselors at SagePLUS, a federally-funded state health insurance and assistance program, directed by the state’s Executive Office on Aging. Both often respond to individual inquiries on Medicare, Medicaid, and related senior health insurance topics; both also provide the information through community forums.

Rachel and Elaine, both retired from professional careers, now donate much of their time to community service. Rachel recently ended her 10-year volunteer role as facilitator of the Wahiawa/Mililani Alzheimer’s Support Group. She recently agreed to serve as one of our three group facilitators.

The Medicare Modernization Act of 2003 changes Medicare in a number of ways, including adding prescription drug and preventive benefits. It also provides help to people with low incomes. The Satos highlighted a few key features of Medicare’s new prescription drug program, scheduled to start in January 2006.

Medicare Part D. All Medicare eligible persons (65 and older, people with certain disabilities, and people with End-Stage Renal Disease) will be able to enroll in the drug plan. The drug benefit plan will not be part of the traditional Medicare program, but rather will be offered through private insurance plans. Medicare beneficiaries need to choose and enroll in a plan. Plans might vary, but will likely have the following costs:

• $37 monthly premium
• $250 deductible (each year)
• 25% of drug costs from $250 to $2,250 (beneficiary pays $500, Medicare pays $1,500)
• 100% of drug costs from $2,250 to $5,100 (beneficiary pays $2,850)

After $3,600 in beneficiary out of pocket costs ($250+$500+$2,850), beneficiary pays 5% coinsurance. However, only Part D covered drugs that are included on a plan’s formulary or those with an approved exception count toward the deductible and out-of-pocket limits.

According to Elaine, "Each region will have a number of plans to choose from." Rachel continued that an extended initial enrollment period will be offered from November 15, 2005 to May 2006. "Once you choose a plan you cannot change until the next open enrollment period." Medicare handbooks, received in October, should contain regional plan information.

Rachel cautioned that "if you don’t currently have a drug plan and, for some reason, choose not to sign up for Part D, you could be assessed a 1% per month penalty when you apply later." For example, if you sign up 18 months after the initial enrollment period ends, you will be assessed an additional 18% a month.

According to Rachel, "Individuals with a drug plan should be notified by their providers if their plans are better than, as good as, or not as good as the Medicare drug plan. If your plan is better than or as good as, you don’t have to apply for the Part D plan. No penalty will be assessed if your drug coverage, deemed ’creditable’ is later dropped and you apply for the Medicare Plan. It’s very important," Rachel stressed, "to be alert for mailings from your drug plan companies."

Noncoverage. Certain drugs such as barbiturates, benzodiazepines (used for acute anxiety, seizure disorders, and muscle spasms in those with cerebral palsy), drugs for weight gain, and over-the-counter medications will likely be excluded from coverage.

Medicaid. Medicaid drug coverage will be eliminated for individuals who are dually-eligible for both Medicare and Medicaid. Low income subsidies will be made available for qualified individuals and couples, based on income and resource limits.

Anyone interested in obtaining more details on Part D, other benefit programs, Medicare, Medicaid, or low-income subsidies, can call the following: SagePLUS: 586-7299 (Oahu), 1-888-875-9229 (Neighbor Islands). Medicare Hotline: 1-800-633-4227. Social Security: 1-800-772-1213. Medicaid/MedQuest: 587-3521 (apply), 587-3540 (ongoing).

“Of Course, I’ll Take Care of Mom, But I Really Don’t Want To...”

Gary Powell, one of our three facilitators, has been a frequent presenter at our meetings, speaking on various topics that come from his life’s work and personal experiences. His caregiving has extended to family and friends. Born and raised on Oahu’s North Shore, Gary’s background includes traveled pianist, playwright, florist, and owner of a landscape company and plant nursery. He now owns PacConLTD (Professional Consultants to Hawaii) and is licensed and accredited in Life and Health Insurances, Advanced Estate Planning, and Advanced Retirement Planning.

Gary shared with us the format he developed to assist families with long-term care issues, including caring for family members who can no longer live alone. He cautioned, however, that assistance should always be sought from a licensed social worker, doctor, or other professionals.

Caring for elderly members at home should, ideally, be a shared effort by the entire family. But to yield the best care, families must have a common understanding of the problems, goals, and solutions. Gary suggests three family sessions, which could include the following:

1. Perceptions. Determine whether all family members perceive the situation in the same way. This is usually the first step in developing a care plan. A doctor’s diagnosis or a therapist’s evaluation should be obtained not only to clarify the patient’s condition, but also to avoid disputes among family members - "Dad is fine, he just tripped." "No, he is not fine. Dad falls frequently and shouldn’t be left alone." Once perceptions are clarified, goals and solutions can be discussed. "Dad can’t live alone. Can we all agree on that? What will we do to ensure his best care?" Family members need to understand best care for the condition. To proceed in union, everyone should read the same books and understand the diagnosis.

2. Competing goals. Ensure that all family members are working toward the same goal. Is the goal to care for Mom or Dad at home? Is the goal to find alternative living arrangements? If the decision for home care is reached, then how will that be accomplished?

3. Competing demands. Recognize that every family member has different circumstances and different demands that impact the amount of help they can provide. Someone could provide funds, but cannot give as much time. A family member with young children may not give as much time as the unmarried or childless sibling. "Fair doesn’t mean equal time," explained Gary. "Also, more people doesn’t always mean more hands to help." Schedules should be revisited as individual situations change.

4. Identify resources. Most of us do not have an unlimited supply of money. We need to candidly discuss resources to best fund Mom and Dad’s care. Will we use our parents’ resources, pooled resources? Will we need to consider day programs or respite programs? Do we need to hire someone to help? Become aware of local resources.

5. Attitudes, beliefs, and values. Recognize that family members will have different values and beliefs that will affect their attitudes. For example, one member may be a doctor while another may believe in alternative healing methods. Agree to disagree, find ways to compromise that will result in the best care for the elder. Don’t get frustrated if you can’t get people to "see it your way." Seek a compromise that will result in providing the best care.

6. Roles. What are you going to do? What do you expect me to do? Look at strengths and weaknesses, availability and demands. All requirements should be laid out to avoid, if possible, having most of the work fall on one person. Gary explained that occasionally a family member refuses to be involved or there is only one caregiver. In these instances, understanding available resources becomes even more important.

7. Unresolved conflicts. Be sensitive to conflicts that could affect best strategies. "I never liked my brother, now I have to take orders from him?" "Mom gave you money 20 years ago, but she didn’t give any to me." Long held resentment and unresolved issues should be recognized and acknowledged. It may be necessary to seek help from third parties to settle some of these conflicts.

Anyone with questions for Gary can call him at 722-1903 or email pacconltd@yahoo.com.

Who Are the Caregivers of the Central Oahu Caregivers’ Support Group?

During the nine years that the Central Oahu Caregivers’ Support Group has existed, many men and women have sat together to express their concerns, to learn from each other, and to gain support from shared experiences. Although individual stories differ, similarities exist among caregivers in their search for services and resources, in their emotional ups and downs, and in their expression of common concerns.

For most, the caregiving role began unexpectedly and without preparation. Mom, Dad, or other family members could no longer live alone and suddenly children, husbands, or wives became caregivers. A few took on the role with amazing enthusiasm, but most struggled to reschedule their lives, to adjust to new responsibilities, to deal with the concerns of caring for a frail loved one. “When the doctor told me ‘You can take your father home from the hospital,’ I was very concerned," one caregiver described. "My father had a stroke and could no longer walk without assistance. He couldn’t be left alone. I wondered whether I could handle it, about my options, about my career, about my finances, about my own family, about finding help.”

In 1997, at the first meeting of the Central Oahu Caregivers’ Support Group, several women from Wahiawa and Mililani attended the session held at the Wahiawa General Hospital classroom. There were a few acquaintances, but most knew no one. "I saw the article about a support group," said one person. Others had also seen the Ka Nupepa article, asking anyone interested in a support group to contact (now group president) Marilyn Lee.

All introduced themselves, one after the other, giving their names and situations - taking care of mother with dementia, father with stroke, mother with dementia and osteoporosis, father-in-law with cancer and dementia, father with stroke, three wives caring for husbands with Parkinson’s Disease. Some had family members in nursing facilities. A few were long-distance caregivers, traveling frequently, calling daily. Most still had their loved ones at home.

In the beginning, only women came. Later, men telephoned to inquire about the group and a few attended. Many of the men that have contacted the group are unmarried, some are already retired, others are still working. Husbands also attend meetings, contributing their ideas, asking questions, sharing experiences. These men have long overcome any discomfort with providing personal care and have learned to schedule nurses’ aides, tend to house work, and prepare meals.

Now, support group members comprise a mixture of genders and age groups. Several are in their 80s, with their own health concerns. They worry about the care of their spouse if something happens to them. A few have cared for more than one family member, some have no siblings, some are unmarried with siblings living on the mainland, some have no one they can call upon in times of emergency.

After a time, a caregiving routine establishes a degree of calm, information provides a better understanding of available options, and learned techniques lighten the workload. But fatigue is ever present. For those caring for family members with dementia, establishing a routine can prove most difficult. "My wife wanders away and we have to look for her." "My father becomes very aggressive." "Sometimes my mother doesn’t recognize me." These caregivers have inspired us with their ability to treat their relatives with love, respect, and dignity. "I know my wife can’t help it," a husband explains. "It’s not her fault, it’s the disease." Another caregiver’s wonderful sense of humor did much to assist her during difficult times. "Laughter really helps!" she frequently mentioned. But the task of coping with inappropriate and sometimes bizarre behavior is difficult.

For all caregivers, there are moments of frustration, and irritation. Occasionally there are feelings of guilt, anger, and burnout. Sleepless nights, rushing to complete tasks, worry about finances and other family members can easily become overwhelming. "I worry about my husband and children," mentioned one caregiver. "We can’t go on vacations or outings together; someone must always stay back to be with my father." Caregivers often put themselves last, forsaking trips to the dentist, the doctor, or to replace worn clothes. "There’s no time and money is so tight," a caregiver explained.

Former caregivers continue to attend meetings, to help those still providing care and support those who have recently lost loved ones. They frequently advise that short tempers and fatigue signal the need for help and respite and that a time may come, for some, when they can no longer do it all. "It’s not easy to admit you need help," expressed a former caregiver. "But part of caregiving is being able to recognize and accept that your loved one needs more care than you can adequately provide. Sadly, former caregivers have learned that grieving is also a part of the caregiving experience.

"Knowing others understand helps a lot," one caregiver mentioned. "We laugh together, learn from each other, and support one another. We grieve when a loved one passes away. Being together has allowed many of us to grow, to reevaluate our responses, examine our attitudes, and learn different ways to cope with our caregiving situation."

All caregivers are welcome to attend our meetings. Sessions are held every second Thursday from 7:00 pm to 9:00 pm at the Wahiawa General Hospital Nursing Rehab Center, second floor dining room.

State Long-Term Care Ombudsman Program

Mr. John G. McDermott, the state’s Long-Term Care (LTC) Ombudsman, has packed a lot of achievements and experiences into his years thus far. He has served as LTC Ombudsman since 1998. His previous positions include Director of Social Services at two local nursing centers; practicum instructor and guest lecturer for several Hawaii universities and community colleges; and co-author of the "Surrogate Decision Making Law," related to advance directives for health care. He has served as assistant chaplain on San Quentin’s "Death Row," worked with Samoan and Filipino gangs in Kalihi and Waipahu, and with youth at risk at the Queen Liliuokalani Children’s Center. He has a B.A. in American Studies and Master’s degrees in Social Work and Divinity. Mr. McDermott has been involved in numerous professional and community organizations including serving a stint as president of the Long-Term Care Social Workers Association for Hawaii.

"The Office of the Long Term-Care Ombudsman [LTCO] is one of several programs administered by the state’s Executive Office on Aging [EOA]," he explained while arranging piles of brochures and pamphlets on the table. The pamphlets describe EOA programs, which include SagePLUS, SageWatch, the Caregivers’ Resource Initiatives Project, and other programs that address elder abuse response, home and community services, caregiving support, and elder law.

The LTCO program, established by federal and state statutes, advocates for and protects the rights of residents of nursing homes, adult residential care homes, assisted living faciities, and other long term care facilities. Staff members arrive unannounced to visit residents and assess living situations. The program also provides referral assistance and informational opportunities to increase community awareness of elder rights. "Residents living in long-term care facilities have the right to privacy and the right to voice complaints," states McDermott.

He explained that his office receives calls from families, friends, and other concerned individuals about quality of care; the possibility of physical abuse and neglect; dietary needs; financial issues; transfer and discharge issues; privacy; and a lot of other matters.

The LTCO program staff is in the process of recruiting and training volunteers. Their goal of 700 volunteers to conduct "timely and regular" visits with over 8,000 long-term care residents in the state has yet to be attained. "We hope the word will spread and that more volunteers will come forward," McDermott expressed. Members nodded in agreement with the need for unannounced visits to check on the well-being of residents.

John McDermott explained that the small number of staff at LTCO makes it impossible to visit all the residents without the help of their unpaid advocates. Each certified volunteer is required to complete a written application, criminal background check, TB test, 20 hours of classroom training and eight hours of on-site orientation with the state LTCO. Volunteers are asked to commit to one year with the program. "We assign the volunteer to a facility close to their home, without a staff or resident family member to avoid conflict of interest."

A caregiver asked about the process after an infraction or unsatisfactory condition is uncovered. "It’s up to the resident or resident’s representative how we proceed. If necessary, the situation could be referred to the Department of Health, the Attorney General’s Office, Adult Protective Services, or even the Office of the Inspector General for further investigation and disposition," he explained. "In the interest of the resident, we need to help the facilities do their best. Then it will result in a win-win situation for everyone."

Anyone interested in information on the volunteer program, inquiring about resident rights, or expressing concerns on behalf of a long term care resident should call 586-0100. All complaints and inquiries will be kept confidential.

Legal and Financial Issues

Developed and produced through a joint effort of the American Red Cross and StayWell, the Family Caregiving Program prepares leader trainers throughout the nation to conduct instructional sessions on nine different caregiving topics. Gary, Rachel, and Lani attended the course given by the Red Cross at its Diamond Head office.

The Legal and Financial Issues module includes information on Advance Directives, Living Wills, Durable Healthcare Power of Attorney, Durable Power of Attorney, the Family and Medical Leave Act of 1990, Creating a Budget, Medicare, Medicaid, Long-Term Care Insurance, and Facts About Funerals. As owner of PacConLtd (Professional Consultants to Hawaii), an insurance, retirement, and estate planning firm, Gary Powell frequently dispenses this type of information to others. But for this session, he followed the format outlined in the Red Cross handouts, with occasional anecdotes from his own experience.

Gary explained that when caring for loved ones, we may be faced with handling legal issues and making important decisions, especially if the loved one is dependent or not mentally competent. "You need to gather important documents such as wills, insurance papers, business records, tax records, healthcare histories, and other business or financial records. Do you know whether everything is in order? Can you find everything?

Advance Directives allow people to make their healthcare choices ahead of time, while they can still make sound decisions. This ensures that decisions are recorded, which will relieve family members from guessing about end-of-life preferences. In Hawaii, a short form is available that contains, in Part 1, a section for the individual to express healthcare choices on whether to prolong or not to prolong life, provide fluids and food by tube into stomach or vein, and receive relief from pain. Part 2 provides a one page Healthcare Power of Attorney - Agent’s Authority and Obligation, authorizing an agent to make health care decisions in accordance with the individual’s best interests and wishes. Two witnesses or a Notary Public are required. One of the members stressed the importance of ensuring that the physician understands and agrees with the individual’s wishes. Gary also mentioned that if any possibility exists of wishes being contested, an attorney should be employed to ensure a binding document. Although considered a short form, additional instructions can be tailor-made and attached. Several people expressed that they would want two physician opinions of "no hope of recovery." A few mentioned that they would like life support for a specified short period to ensure no recovery. Others wanted fluids and pain relief.

Durable Power of Attorney is the legal document that gives a person (principal) the right to authorize another person (attorney-in-fact) to act on the principal’s behalf. This will allow the attorney-in-fact to handle personal and financial matters even if the principal becomes incapacitated or mentally incompetent.

Family and Medical Leave Act (FMLA) of 1990. The FMLA requires employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for certain family and medical reasons, including caring for family members. Under this law, eligible employees must have been employed for at least 12 months, worked at least 1,250 hours during the 12 months immediately before the requested leave, and be at a work site where 50 or more employees are employed within a 75-mile radius of the work site. Additional FMLA requirements have been imposed by state laws or regulations. Gary recommended that individuals discuss FMLA eligibility requirements with their Personnel Office to clarify medical coverage, return rights, and restoration of benefits.

Creating a Budget. Your loved one may need help with his finances. Make a list of all monthly sources of income and expenses on a chart. This will help both of you.

Medicare. Gary Powell introduced the insurance as a program for people 65 years or older, disabled people younger than 65, and people with end stage renal disease. Discussion moved to the upcoming new Medicare Part D prescription drugs program that will go in effect January 1, 2006. According to members and SagePLUS volunteers Ted Miyamoto, Rachel Sato, and Elaine Sato, misinformation still exists on the program. "Some people still think they have to be low-income to subscribe to Part D," explained Rachel. "Anyone who qualifies for Medicare can subscribe." Ted Miyamoto and Elaine Sato explained that Social Security has mailed out application forms for "Help with Medicare Prescription Drug Plan Costs." Eligibility to receive help is based on income and asset limits. "If you received the application, you should fill it out. You may receive some assistance." All three cautioned that individuals watch their mail for a statement describing whether their present drug plans are as good as, better, or worse than Part D. If your plan falls in the worse than category and you choose not to subscribe, you will be penalized for joining later. On October 13, 2005, comparisons of the various drug companies participating in the Part D program will be available, by state, at www.medicare.gov.

Gary Powell ended the session with a discussion on funeral plans, stressing that we all need to plan our funerals. "How could you start the conversation?" he asked. A member described that when a funeral scene appeared on TV, she asked her husband, "what kind of funeral would you like? How would you like that handled?"

Anyone interested in the programs and sessions offered by the Red Cross can call 734-2101.

Pills, Potions, and Tonics

We expect that taking medications will always make us feel better. But vitamins, herbs, minerals, food, drinks, existing allergies could all react with prescription medicines, causing adverse results. We can avoid most interactions by being informed and talking to our docctors and pharmacists.

Our speaker, Tom Lynch, RPh, has been a licensed pharmacist for over 33 years, more than 20 with Longs Drug Stores and currently with the Mililani Market Place branch. Over the years, he has come to learn a great deal about drug interactions and he willingly shares his knowledge with community groups and customers. He has received the prestigious "Hawaii Pharmacist of the Year Award," in part because of his extensive community service. He has been a lecturer at several of the island’s annual caregivers’ conferences and conducted forums through the "Senior Medication Review" and "Managing Your Medications" programs. As a volunteer at the Hawaii American Diabetes Association, Mr. Lynch has also chaired large-audience patient education programs. The members of our group are proud to announce his recent acceptance to be on our Advisory Council.

Detecting interactions. According to Mr. Lynch, whenever a doctor, dentist, or other medical specialist prescribes medication and it is paid for with medical insurance, the insurance company updates their computer files. Issuing pharmacies can access the information and inform customers if a new drug will interact with anything already being taken. Occasionally, a patient pays cash and the transaction goes unrecorded. "Bring the unrecorded medication to the attention of your regular pharmacy," suggests Mr. Lynch, "to ensure accurate record keeping." He warned that vitamins, over-the-counter remedies, herbs, and minerals can also cause interactions.

He explained that a common side effect comes from grapefruit and grapefruit juice. "Anyone taking certain blood pressure and heart drugs, cholesterol lowering drugs, Viagra, Neoral, or psychiatric and neurological drugs should avoid the fruit." Grapefruit juice contains a substance that blocks intestinal enzymes that normally regulate the amount of medicines entering the bloodstream. The substance could slow the rate at which certain medicines are broken down, causing them to stay in the system longer and accumulate to toxic levels. Pomelo (jabong) could also cause similar interactions. Ginkgo Biloba possibly increases the effect of blood-thinning medications and affects the body’s production and use of insulin. It may also interact with certain diuretics. St. John’s Wort could significantly reduce the effectiveness of many drugs, including Coumadin (a blood thinner), Digoxin, or migraine and depression drugs.

"Many of the osteoporosis pills will not work without a source of calcium," Mr. Lynch expressed. He recommended that calcium be taken and multiple vitamins be checked to ensure 100% of daily requirements of D and other supplements. Members inquired about absorption. "Chewables are the best, liquids can spill." "What about cutting pills in half?" "If your pill has a line down the middle, cut there. If not, it may be difficult. It would be advisable to check with the pharmacist." "What about generics, are they the same as brand?" Mr. Lynch explained that pharmacists fill equivalent generics. "Some of them are identical to their brand name counterparts." He explained that the existence of a generic indicates that the brand name patent has expired. But if a medical reason exists that a patient cannot take a generic, the doctor can prepare a prior authorization document to require the brand name only.

Drugs seniors should avoid. "The elderly sometimes react differently to medication," Mr. Lynch emphasized. "It has been shown that they could experience dramatically enhanced effects from certain drugs, such as Diazepam (Valium), Chlordiazepoxide (Librium), Propoxyphene (Darvon), Amitriptyline (Elavil), and Dipyridamole (Persantine)." In addition, beta blockers, calcium-channel blockers, certain barbiturates, and antidepressants and NSAIDS (non-steroidal anti-inflammatory drugs) such as naproxen, ibuprofen, indomethacin, etc., should be closely monitored for side effects.

"It is always best to inquire before adding over-the-counter remedies to your drug regimen. If you take medication and something doesn’t feel right, inquire right away. You could be having an allergic reaction or an interaction."

Tom Lynch encourages people to talk to their pharmacists. It is sometimes impossible for one doctor to coordinate medications given by others and to keep up with all the latest advisories available to pharmacists.

Anyone interested in more information about their medications, side effects, or Longs flu shot schedules can call Tom Lynch at 623-6636.

Advancing Public Policies to Support Family Caregivers at the 2006 Legislature

by Wes Lum, University of Hawaii Center on Aging

Locally, several long-term care advocacy organizations have collaborated to recommend comprehensive public policy to strengthen support for Hawaii’s family caregivers. Based on six national policy principles (see box), it is recommended that Hawaii’s program be implemented in phases:

Phase 1.  During the 2006 Regular Session, it is recommended that the Legislature:

• Appropriate funds to the Executive Office on Aging (EOA) to coordinate family caregiver support services and policies statewide;
• Increase EOA’s budget ceiling to develop long-term care access centers;
• Appropriate funds to the University of Hawaii to establish a Long-Term Care Resource Initiative at Kapiolani Community College; and
• Support the Department of Health’s development of Certified Nurses Aides Training and Certification.

Phase 2.  During the Legislative Interim of 2006, it is recommended that the Legislature establish working groups to examine:

• Respite-related issues and to submit a report and legislation for the 2007 Regular Session;
• The financial cost to the State to reimburse family caregivers who provide at-home daily care;
• The financial cost to the State to establish a caregiver tax credit;
• The Cash and Counseling model as a means of financially supporting family caregivers; and
• Hawaii’s work-family laws and policies in the context of eldercare.

Phase 3.  During the 2007 Regular Session, it is recommended that the Legislature:

• Give priority to respite-related issues;
• Fund a demonstration project that would provide financial incentives to caregivers to continue providing daily care; and
• Enact legislation to support families who are balancing work and caregiving.

The Caregiver’s Resource Initiative will be working with the Hawaii Caregiver Coalition and other long-term care advocates to advance the need for comprehensive public policy to support Hawaii’s family caregivers. If you would like to get involved, please feel free to contact Wes Lum at 586-7319 or email wes.lum@doh.hawaii.gov. Editor’s Note: We will be doing a legislative walk-through in 2006 to provide information to legislators. Details will be provided as the time approaches.