Training family caregivers is a delicate undertaking

Hawaii has among the highest percentage of seniors in the United States. There are roughly a quarter-million caregivers who look after our kupuna and other disabled members of our community. The value of their unpaid services is estimated to be $2 billion annually, according to House Bill 490, introduced last session, which sets out requirements for hospitals regarding caregivers.

At the same time, hospital admissions and avoidable readmissions consume 1 in 3 health care dollars each year in the U.S. Nationally the AARP has set a legislative agenda that requires hospitals to identify and offer to educate caregivers prior to hospital discharge. While the potential exists to reduce hospital costs and improve quality of life at home through this initiative, many concerns remain, especially on the part of the hospital sector.

Those arguing against the proposed legislation say that hospitals already are following Medicare guidelines for planning and discharge. If hospitals were not compliant, they would not get Medicare payments. In addition, all hospitals undergo accreditation checks by the Joint Commission on Accreditation of Healthcare Organizations, or JACHO, a national entity that also has covenants for discharge coordination and planning.

The proposed statutes that go beyond these standards are a burden, according to George Greene, president and CEO of the Healthcare Association of Hawaii. Hawaii is already among the top states for health care of retired people, Greene said, citing AARP.

“We believe that community-based services that educate caregivers should be better funded, and this is a preferred venue for valuable caregiver training,” Greene said. “The most appropriate place for this work is the Aged and Disability Resource Center. This is a better, local environment which will also be effective in reducing hospital readmissions.”

However, Bruce Bottorff, director of communications for AARP Hawaii, argues that no one is in a better position to train caregivers in the complex medical tasks required for a given patient with a specific condition than the treating physician or relevant nurse at the time of discharge.

Greene also warns that asking hospitals to train lay, unpaid caregivers up to a clinical standard without accountability increases liability for inpatient facilities and places them in an impossible situation. In response, Bottorff says there is now a revised proposal with the intention of creating a strong limitation of liability for hospitals. He says this is among the most protective proposals for hospitals across the county and does so in the strongest way possible.

Another point of contention, says Greene, is that the burden of responsibility to identify, contact and offer to coordinate and educate caregivers might slow the discharge process and curtail the availability of beds needed for new admissions. But Bottorff insists that while the hospitals must identify caregivers and make every reasonable effort to make contact and offer to coordinate and train them in complex medical tasks to be performed at home, the hospitals have great flexibility to establish their own protocols and processes.

There were more than 5,000 30-day readmissions to hospitals in 2013, which cost a total of close to $240 million. Better training for the tens of thousands of unpaid family caregivers in Hawaii would go a long way toward mitigating these costs. More important, it would improve quality of life for both the seniors and their caregivers.

As usual, the devil is in the details. Hospitals should and will continue to follow discharge planning requirements in place per Medicare and JACHO. Every effort should be made in the community, including the ADRC, to optimize the level of care provided by unpaid caregivers for the long run.

Identifying and documenting contact information for caregivers at the time of admission is both reasonable and helpful. However, any requirement for hospitals to contact caregivers and offer to coordinate and train them in complex medical tasks is valuable in principle but delicate to implement.

Hospitals must be afforded protection from liability for any training of unpaid caregivers to perform complex medical tasks. To be sure, as technology advances, so does the complexity. Certainly, health care professionals undergo careful screening before being admitted for training and must demonstrate competence before graduating and gaining licensure. Unpaid family caregivers may be a support of last resort, and hospitals cannot be held to a professional standard when training them. Also to the extent that hospitals may be required to dedicate substantial staff resources toward training caregivers, insurance coverage should be available. Adding payers to this initiative is no small task.

Furthermore, necessary new hospital admissions must not be affected by any increased responsibilities to coordinate with caregivers. There can be grave consequences when patients are held in the emergency department for too long or when hospitals need to send patients to other facilities because they’re out of room.

AARP is providing an important role as it advocates for those who do not have the health or the time to lobby the Legislature. Better training for family caregivers so that they can keep their loved ones at home after hospital discharge is both a valuable pursuit and a delicate undertaking.

Ira "Kawika" Zunin, M.D., M.P.H., M.B.A., is a practicing physi- cian. He is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.