The Perfect Storm
 
CSI’s goal is to bring cutting edge information related to Health Care each month. CSI Caregiver Services Inc. is the largest Nurse Registry in Florida.
 
It might be considered a perfect storm. Grown children need to come together to make life decisions for their aging parents. All the issues that were present in childhood are now given the opportunity to rise up again and destroy families. In the rubble you will find elderly people desperate for care, guidance and assistance. There’s a huge re-emergence of sibling rivalry over parents because when we see that our parents’ time is limited, all the unmet needs we’ve had resurface: to be loved, approved of, forgiven or finally be judged as important or as smart as your sister or brother. Most families have fear of getting together for holiday celebrations, none the less sorting out life decisions for their parents.
 
Boomers with aging parents face a myriad of issues – not the least of them being sibling rivalry, writes Francine Russo in her new book, They’re Your Parents, Too!: How Siblings Can Survive Their Parents’ Aging Without Driving Each Other Crazy.
 
The two main situations are:
 
1. One sibling who does all the caregiving and is angry at the other because they don’t do their “fair share.”
 
2. Where one sibling is insisting on doing it all and the other says, “She won’t let me help.” This sibling wants to contribute but feels the other is taking full control and shutting them out.
 
Unfortunately we are not talking about doing the dishes or taking out the garbage. We need to decide, who will mom or dad live with, will they want to stay at home? Will dad be placed in a hospice program or not?
 
What options do families have? If the sibling tensions are too high, get a professional in as early as possible. You can hire a geriatric-care manager, somebody who can hold the family meeting and say,
“These are the objective issues. What can each of you contribute?”
 
If possible, sort out the elder parents heirlooms with your parent present. Never throw anything out: “There’s no way anyone of us can know what emotional significance a table or an old book has for somebody.”
 
Communication is the key component to leaving the sibling rivalry in the past where it belongs. The elder parents can no longer be the referee, nor should they. The keys to remember are: be honest, be open minded, listen thoroughly, speak up when it is important, and always remember your parents are the focus and they need you and never forget they brought you into this world and one day your children will be going through the same thing.


October 10-16 marks a weeklong celebration of National Case Management Week, recognizing the contributions and commitments case managers make and the significant work they perform across the health care continuum. The theme for this year is “Case Management Is The Critical Connection To Optimal Health Care”.

It’s a remarkable time to be in healthcare, especially as a case management professional. Changes in health care are happening at an unprecedented rate and include:
• Far-reaching health care reform efforts;
• Innovative new models of health care delivery and reimbursement;
• Public policy mandates to reduce spending while assuring quality outcomes; and
• Significant advancements in implementing patient-centered models of health care.
 
Case managers have often been the unrecognized voice in the health care industry, and the impact of case management has historically been underappreciated. However, with the passage of the Patient Protection and Accountable Care Act (PPACA), case management has taken a giant leap forward. This is because the concepts of care coordination and case management are key components woven throughout the PPACA. At last, case management is being acknowledged for what it is: the “glue” that carefully, creatively, thoughtfully, and successfully holds together the multiple parts and pieces of health care, regardless of the setting or where the patient is along the care continuum.
 
As a direct result of the PPACA¸ we can expect to see more opportunities and more demand for case management. The role of case management will become more highly visible and will be seen as pivotal in effective implementation of new models of care. For example, case managers can step up to leadership roles within Accountable Care Organizations (ACOs) to help design and implement care coordination programs and evaluate the outcomes. Case managers are ready, willing, and able to take on this challenge to help coordinate patient-centered care and ensure successful outcomes in health care quality and practice improvement efforts underway.
 
Health care reform efforts and a renewed focus on improving quality outcomes mean that there will be an increased utilization of case manager professionals throughout a variety of care settings. For example, case management is a central component of the patient-centered medical home (PCMH) model of care delivery. Case managers will be working with health care consumers along all points of the health/illness continuum—from wellness and prevention to complex acute medical care to chronic care self-management.
 
However, as the need for case managers across care settings grows, so too does the responsibility to maintain tight linkages between and among case managers along the various points of the care continuum. It is essential that case managers recognize when silos of care exist and work together to break down these barriers—because successful case management depends on shared efforts united by an ever-present focus on the patient as the center of the total health care experience.
 
Topping the list of public policy and accreditation mandates faced by hospitals is the directive to reduce hospital readmissions and improve patient safety. Case managers offer a significant contribution to meeting these quality goals by focusing on effective care transitions. Care transition programs aim to ensure that care is well-coordinated, well-communicated, continuous, safe, and timely as patients move across care settings, or across levels of care within a setting. Case managers know that improving communication, coordination, and collaboration throughout the care transition process results in better identification and elimination of gaps in care, improved medication adherence, better self-care management and self-care efficacy, and more effective utilization of patient support systems and resources.
 
No one can deny we work in an industry that is ever-changing and being driven by reform efforts aimed at reducing costs, improving access, and assuring quality. Case managers provide the common denominator and the key to success to dealing effectively with these forces of change because:
• Case managers use a patient-centered process of care coordination that includes meaningful, goal-directed communication and interaction with all key stakeholders—the patient, their family and support system, physicians, social workers, other members of the multidisciplinary care team—with the goals of promoting quality, cost-effective outcomes.
• Case managers work hard to promote effective communication across care settings to ensure smooth, coordinated delivery of care and services.
• Case managers believe in the power of advocacy, collaboration, shared-decision-making and education to promote effective patient engagement and adherence with evidence-based care and treatment plans.
 
For these reasons and more, case management truly IS the critical connection to optimal health care. There has never been a time where this has been truer. As we celebrate National Case Management week, let’s take a moment to really recognize and appreciate case managers for the vital role they play in optimizing health care as we journey ahead.


A couple of months ago I went to a play a local playhouse. It was during intermission that I noticed how many men were using walkers and how hunched their shoulders were. I could see that at one time these men were very tall, but inches have been lost along with strength and balance. Indulging in a conversation with a few of them, they seemed resolved that this is the way life is now for them. Henceforth, is why I think men need to know a little more about osteoporosis and bone loss.

Osteoporosis is where bones lose density and fractures are likely to occur. This is put into the woman’s category of conditions, as it is related to women’s hormones and menopause. It is a well known fact that post menopausal women are at high risk and bone density test should be done before a woman is fifty. This is not your grandmother’s disease anymore as over eight million women over fifty will be at risk.
 
But, men beware as you too should worry about bone loss. Roughly two million American men have osteoporosis. Twelve million could be at risk and could be in the early stages of osteopenia. It was a fact that men did not live as long as women, so osteoporosis was considered. Today with modern medicine and healthier lifestyles, men are living longer. Men are generally more physically active over their lives in thus they produce more bone mass and have stronger bones. As the men age though, the physical activity decreases along with the decrease in bone mass, putting men at risk.
 
The key factor to preserving bone mass is weight bearing exercise. Many men spent much of their youth playing sports, so finding an exercise routine doing something they like can be fun and exciting. Exercise will help with bone strength, muscle strength, which will help maintain balance and coordination. Brisk walking, playing tennis, skiing and jogging are examples of low impact exercises, where your foot hits the ground with controlled force. Weight lifting and resistance training at least twice a week is an excellent way to keep bone loss at a minimum. This can be as simple at standing up and down from a chair ten or twenty times, doing push ups on a counter or wall or using soup cans to strengthen your arms. The heavier the resistance the better results you will obtain. I have seen amazing results after designing an exercise program for men. Posture improves along with their daily activity of daily living and activity level increases.
 
According to the National Osteoporosis Foundation the following risk factors are associated with osteoporosis in men:
1. Prolonged exposure to certain medications, such as steroids used to treat asthma or arthritis, anticonvulsants, certain cancer treatments and aluminum-containing antacids
2. Undiagnosed low levels of sex hormone testosterone
3. Lifestyle habits which include smoking, excessive alcohol use, low calcium intake and inadequate physical exercise
4. Heredity
5. Race, white men appear to be at the greatest risk. But men from all ethnic groups develop osteoporosis.
 
As with women, if men notice a loss in height or a change in their posture, which could include back pain, it is important to inform your doctor. Osteoporosis can be treated with lifestyle changes, making sure you take enough calcium, changing unhealthy habits and include exercise in your daily routine. Check with doctor in treating any underlying medical conditions and to identify and evaluate any medications that may be contributing to bone loss. Your bones will thank you.
 
Take charge of your life, no matter what age you are. Good health and fitness is not a destination, but a journey to be continued the rest of your life. Make fitness fun and live life to the fullest, you deserve it. The Golden Years should truly be Golden.


The last century saw remarkable gains in life expectancy—an extraordinary 30 years in the United States and in other developed countries. Whereas improvements in the earlier portion of the century were largely nonmedical (nutrition, sanitation, housing, etc.), those of the second half were clearly due to medical innovation—drugs, devices and procedures. It is therefore not surprising that health care expenditures have grown 2.8% per year more rapidly than the rest of the economy for the past 30 years. At the beginning of the 20th century, only 41% of live births could expect to reach age 65; by the end of the century the percentage doubled. However, these advances are not without their costs. At age 65, 4 out of 5 men and 9 out of 10 women are not in the labor force, and 4 out of ten have a physical or mental disability. Almost half of all hospital beds are filled with patients 65 years of age and older. Therefore, any gains in longevity are likely to be associated with increasing rather than decreasing societal financial burdens.

Since the vast majority of eldercare is financed through federal entitlement programs, the federal government, concerned with the very real potential of a crippling acceleration of national debt, is increasingly faced with the ironic conundrum of greeting each new medical advance/success with suspicion if not outright fear. If internal cardioverter defibrillators are shown (as they have been in large prospective randomized trials) to increase the life expectancy of patients with congestive heart failure who have reduced ventricular systolic function, the potential costs are enormous. Approximately five million Americans suffer from heart failure; approximately half of these have reduced ventricular systolic function. These devices cost upwards of $50,000 each, not counting hospitalization and implantation and care and monitoring expenses. This would amount to a total cost in the billions of dollars. If cardiac resynchronization therapy (placement of sophisticated biventricular pacemakers) is demonstrated to benefit a large portion of this population (as it has), the incremental expense is substantial. If cardiac surgery, once inconceivable in those over 75, is increasingly demonstrated (as recently shown by our studies at the Florida Heart Research Institute) to provide comparable long-term improvements in patient perception of quality of life with operative survival that rivals that of younger patients, how do we weigh the costs with the benefits? Clearly care of these elderly patients is more costly—they are more prone to complications, they tend to have longer hospital stays and a greater need for postoperative support care. What then becomes the metric by which we determine that the benefits warrant the expense??
 
There is a methodology for comparing the expenses of various medical interventions—the Quality-Adjusted Life Years. This methodology applies a cost-utility approach to creating a simple arithmetic model to compare various health-care interventions. It is assumed that one year of life in perfect health has a value of 1.0, death has a value of 0.0, and one year in less than perfect health has a value somewhere in-between. Therefore, one can compare the years of life predicted to result from a treatment, multiplied by the relative quality of life of those years, to arrive at the QALY’s. Unfortunately, there is tremendous subjectivity in the evaluation of life quality, with different values of the same status when assessed by different populations. Moreover, health status is personal—the manner in which one individual views his health status may differ radically from that of the population mean, even if perfect objective testing where available. Even more perplexing, health status is not static, but rather dynamic with time. Let us examine the 80 year old with congestive heart failure from aortic valve stenosis. The progressive shortness of breath and disability will increase with time. On the other hand, the postoperative disability after successful valve replacement surgery, although it may be profound, will dissipate with time. Assessment is likely to be based on perception at the time it is being asked, not over the course of years being evaluated.
 
In short, care of the elderly stands at the forefront of our values as a society—faced with increasing financial pressures, how do we choose to provide care for that sector of society which requires the greatest expense yet is least able to return productivity to the system? The answers are far from clear, but the questions need to be framed in a manner which will enable us to begin to make the decisions. Although we can certainly not be the arbiter of these decisions, we at FHRI are committed to supplying the information necessary to make informed decisions.


In spite of a shaky national economy that has wreaked havoc on the housing and commercial construction industries and slowed construction in the healthcare sector, South Florida’s Arellano Construction Company remains productive and busy.

Agustin Arellano, founder and president of Arellano Construction, attributes this endurance to the fact that the company concentrates almost exclusively on healthcare construction, developing hospital campuses, medical centers, life science facilities and other medical buildings throughout South Florida. “Healthcare construction is our niche and has represented the largest capacity of our annual volume for over twenty years,” Arellano says. “We chose this as our specialty and have never regretted it. When the housing boom happened in Florida, we didn’t pursue it but stayed with our niche. Our team is highly qualified and well-trained; they are experts in healthcare construction and have extensive knowledge of AHCA regulations. We have passed several hundred AHCA final inspections with a first time passing rate of 97%. We are very proud that in 37 years in the business, we have never had any litigation.”

Arellano Construction is one of the premier healthcare construction firms in the southeast, with a longstanding reputation for excellence and an emphasis on safety. The company has a track record of bringing projects in on time and under budget. Over 90% of the company’s contracts come from repeat business with satisfied clients. Arellano, an engineer who founded the company in 1973 at the age of 26, says that one of his company’s strengths is the ability to develop exceptional relationships with clients.
 
“Some of these projects involve several phases and may take a few years to complete, so you develop a genuine relationship with the client,” says Arellano. “A key part of that is assembling the right team for each project. It sounds simple, but there has to be chemistry – the project manager has to be a good match for the client. Some project managers excel at one particular type of work or deal well with a particular type of client. When you put the right players in place, the project will be a success, no matter how complex.”
 
“We work hand in hand with our clients in order to assist them in making their projects economically feasible. One of the ways we do this is through our pre-construction services, where we work with the architects, engineers and key subcontractors from early in the design process to determine the most efficient and economical ways to get the desired results. Our goal is to reduce costs without sacrificing quality or safety and still meeting all AHCA requirements.”
 
Even after nearly four decades in the healthcare construction field, Arellano continues to find the work exciting. “The most satisfying aspect of my work is when I get an unsolicited call from a client to tell me how happy they are with the work we are performing at their facility.” One such client is Miami Children’s Hospital (MCH), where, in recent years, Arellano Construction has built, among many projects, an ambulatory care center; a parking structure; a high-tech hybrid catheterization lab, unique to MCH, in which both diagnostic procedures and surgery can be performed in one space; and renovation of an existing space to create a 14-bed, private room Neonatal ICU. In addition, Arellano completed a Central Energy Center which will allow MCH to fulfill its future growth plans. Robert Nowlan, Vice-president for Clinical and Support Services at MCH, says that the hospital values its partnership with Arellano Construction. “We competitively bid our building projects and Arellano gave us the lowest bid and the best plan,” he states. “We like the fact that they are a local, family-owned company that specializes in healthcare; it sets them apart and they are passionate about what they do. Arellano Construction has given MCH something to be proud of.”
The construction or renovation of a healthcare facility differs substantially from other construction, says Arellano. Building a hospital, he believes, is special; it has a purpose that will positively impact the lives of others. He describes a hospital as a “live” environment – not an empty space, but an operating facility occupied with people and highly sophisticated equipment. It encompasses so many complex factors, including infection control, safety regulations, noise levels and a strictly enforced construction code that it represents a greater challenge for project teams.
 
“Working on a hospital,” says Arellano, “is never boring. Each project is unique. It’s the greatest feeling when the project is complete. I could not have lasted this long in the construction industry if I wasn’t doing this type of work.”
In 2008, Arellano Construction entered into an association with OHL S.A., one of the world’s largest healthcare construction and development groups. Based in Madrid, OHL has nearly a century of experience building complex, high-tech facilities. OHL brings to the South Florida market a blend of international experience and financing to complement Arellano’s strong history of customer service, efficiency and safety.
 
Although the economy has led some healthcare facilities to postpone or downsize construction projects, those that are planning a project can rely on Arellano Construction to help them achieve their goals economically and efficiently through comprehensive, state-of-the-art services provided by a team of expert professionals.