Saying they are concerned about safety in California’s dialysis clinics, a coalition of nurses, technicians, patients and union representatives is backing legislation that would require more staffing and oversight.
The bill, introduced by Sen. Ricardo Lara (D-Bell Gardens), would establish minimum staffing ratios, mandate a longer transition time between appointments and require annual inspections of the state’s 562 licensed dialysis clinics.
More than 63,000 Californians receive hemodialysis, which filters impurities from the blood of those with end-stage kidney disease. Demand for the procedure is growing statewide and nationwide as the population ages and more people suffer from chronic conditions that can lead to kidney failure, such as diabetes, hypertension and heart disease.
If the legislation passes, California would join several other states that have imposed minimum ratios for dialysis centers, including Utah, South Carolina and New Jersey.Use Our ContentThis story can be republished for free (details).
The California bill, SB 349, says that inadequate staffing is leading to hospitalizations, medical errors and “unnecessary and avoidable deaths.”
In one case, three patients contracted an infection at a dialysis clinic in Los Angeles County after workers failed to clean and disinfect the machines properly, according to a report in the American Journal of Infection Control.
Patients undergoing dialysis are at risk for low blood pressure, fluid buildup or infections.
Problems can be overlooked if nurses don’t have enough time to devote to their patients and to transition between patients, said Megallan Handford, a registered nurse at a dialysis clinic in Fontana who helped draft the bill. Handford said nurses and technicians often have too many patients at once, making it difficult to ensure they are getting safe care. In some cases, patients left dialysis before they were ready, only to die in their cars, he said.
“We deal with short staffing day in and day out. … Enough is enough,” Handford said during a briefing at the offices of Service Employees International Union-United Healthcare Workers West (SEIU-UHW), which is sponsoring the bill and hopes to unionize dialysis workers. “We’re gonna do what it takes to change this industry.”
Lara agreed, saying oversight of the state’s growing dialysis business is overdue. “We need to keep a closer eye on the dialysis industry,” Lara said in an email.
Dialysis clinics in the state argue that the industry is already well-regulated and the bill would add unnecessary requirements.
Clinics already have a difficult time hiring enough workers and would need even more to satisfy the proposed staff-to-patient ratios, said Kristi Foy, assistant director of the California Dialysis Council, the statewide association of clinics. Besides, she said, there is no evidence that mandated ratios improve quality or patient satisfaction.
Foy added that while there have been “isolated problems,” California is outperforming other states in quality and patient satisfaction. She said a larger percentage of California clinics have high ratings from the federal government, based on factors such as complications, mortality rates and hospitalizations.
“There is no documented need for this bill,” Foy said. “We are very, very concerned that it will result in unintended consequences that will be bad for patients.”
In a survey of dialysis clinics in the state, the council determined that more than 100 of them would be at risk of closing if the bill passed, in part because of the inability to find staff, Foy said. Clinics in rural areas and those who treat large numbers of Medi-Cal patients are particularly vulnerable, she said.
If ratios are put into place, clinics won’t have flexibility when people call in sick or for night shifts that typically require lighter staffing, said Dr. Bryan Wong, a Berkeley-based nephrologist. That could force clinics to offer fewer appointments or turn patients away, he said.
“It would drive up the cost of care because the patient would have to be hospitalized to get their treatment.”
Dr. Randall Maxey, another nephrologist and clinic owner, said the bill is well-intentioned, but he believes the industry is already the “most regulated in the world.”
“If you pass legislation to put more regulations in … there is going to be less dialysis available for people in certain neighborhoods,” he said.
The dialysis industry is largely controlled by two for-profit corporations: DaVita Kidney Care and Fresenius Medical Care, which own nearly three-quarters of the clinics in California. As the demand for dialysis has grown around the country, both companies have acquired smaller dialysis providers.
Meanwhile, studies have shown poorer patient outcomes at for-profit dialysis clinics than at nonprofit facilities. One 2010 study found that mortality rates were higher for patients treated at sites belonging to for-profit chains than for those at nonprofit companies. Another study published the same year, based on data from 2003, showed that patients treated at nonprofit clinics spent fewer days in the hospital.
Supporters of the proposed legislation argue that companies such as DaVita and Fresenius put profits above patient safety.
“This is an industry that is incredibly profitable,” said Joan Allen, government relations advocate at SEIU-UHW. “There is a financial choice that the dialysis industry needs to make, and that is whether they are going to invest in patient safety and patient care or whether they would make a financial choice to reduce access.”
Spokesmen for both DaVita and Fresenius said they were part of a coalition opposing the legislation but declined to comment further.
The bill would require clinics to have one nurse per eight patients and one technician per three patients. The measure would require that patient appointments be at least 45 minutes apart, which supporters say gives staff time to thoroughly clean the equipment and ensure departing patients are safe.
The legislation would also mandate the state Department of Public Health to inspect dialysis centers annually. Lara said clinics are only inspected now about once every six years.
At the SEIU-UHW office in Commerce last week, dialysis technician Carlos Castillo explained why he supports the bill. Watching too many patients at once can be dangerous, he said, especially if one has an emergency. “Dialysis isn’t just about putting needles in patients,” he said. “You never know what will happen.”
Vince Gonzales, 54, who has been on dialysis for 20 years, recalled seeing a patient collapse in his chair and die.
“[Clinic staff] are so busy doing the things they are doing,” he said. “I always have that concern of, ‘Can you take care of me adequately?”
KHN’s coverage in California is funded in part by Blue Shield of California Foundation.
President Trump’s forthcoming 2018 budget will likely propose policies that would significantly damage the well-being of tens of millions of low- and middle-income people.
Some Senate Republicans are seeking additional changes to the per capita cap that would dramatically expand those already highly damaging cuts.
Biking to work is a commuting option that can help you stay fit, reduce carbon emissions, and/or get ready for a race. Whatever your reasons, Bike to Work Day is a fun way to get started on the habit. Lots of riders out there will be new to the habit of cycling to work on Bike to Work Day. Before starting out, it helps to get prepared with information from local biking associations that provide tips about pit stops, volunteer opportunities, riding with kids, and more. It was a biking association, the League of American Bicyclists (LAB), which started the holiday in 1956. In recent times with the increase of traffic congestion, the public’s awareness of the need for alternate commuting methods, and the increased activism from advocacy groups such as LAB, the event’s popularity has surged.When you do hit the pavement, you’ll need to know the rules of the road so you can ride safely. In Washington, D.C., there is a lot of competition for space on our crowded roads. Knowing your rights and responsibilities will help get you to your destination on time and unscathed. Your local biking organization and some biking law organizations that advocate for better legal protection for bikers can provide some guidance. Interested riders can always cycle over to the Law Library, which holds a number of volumes on current and historical biking law both here in the United States and abroad. Any excuse to take a bike ride is a good one!
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The bill that President Trump signed into law to fund the government for the rest of fiscal year 2017 has insufficient funding to renew all of the Housing Choice Vouchers in use last year, leaving a gap of roughly 60,000 vouchers. While some state and local housing agencies can use emergency reserves to close part of the gap, tens of thousands fewer low-income families will likely receive help this year, worsening the shortage of affordable housing.
Early word about President Trump’s 2018 budget — which the White House plans to release on May 23 — suggests it will likely break his promise not to cut Social Security, Medicare, and Medicaid.
Luz felt relieved and grateful when she learned that her 16-year-old son qualified for full coverage under Medicaid. Now, she worries that the information she provided to the government health program could put her family at risk of deportation.
Luz’s son is one of nearly 190,000 children who have enrolled in Medi-Cal — California’s version of the federal Medicaid program for people with low incomes — since California opened it to undocumented children last year. Luz, her husband and her son came to Merced, Calif., from Mexico without papers about 10 years ago. Luz asked that the family’s last name not be used, for fear of being identified by federal immigration authorities.
In the current political climate, immigration and health advocates worry that children, like Luz’s son, will drop out of Medi-Cal and that new kids won’t enroll out of concern that personal information may be used to deport families.
Luz would need to renew her son’s coverage in October, but she remains undecided even though the program paid for his hospital visit when he injured a foot. “I’m still thinking about it,” she said.Use Our ContentThis story can be republished for free (details).
Last May, the state Department of Health Care Services (DHCS) implemented the new “Medi-Cal for All Children” law allowing California children under 19 to receive full Medi-Cal benefits, including dental care and mental health, regardless of their immigration status. Previously, undocumented children could receive only emergency care through Medi-Cal.
California followed Illinois, Massachusetts, New York, Washington and the District of Columbia in offering state-supported health coverage to children in the country illegally.
The federal government pays for a significant portion of California’s Medi-Cal program, as it does for all states. But expanded coverage for undocumented kids is funded by the state.
From last May through April 6, 189,434 undocumented children signed up for the program, according to the most recent state data. The health care services department estimates that another 61,000 children are eligible but not enrolled. Advocates say now is the time for a push to sign up these “harder-to-reach” children and to encourage those already in the program to stay.
Immigrant families have become more reluctant to share personal information with government programs because of the Trump administration’s planned changes in health care and immigration policies, according to a recent survey of 62 individuals working for pediatric practices, community clinics, local public health departments and hospitals serving immigrant communities throughout the state.
Immigrants are also increasingly skipping doctor’s appointments because of similar concerns, according to the survey, conducted in March by the advocacy group Children Now.
Kelly Hardy, Children Now’s managing director of health policy, said some families even have sought to withdraw their children from the Medi-Cal program because they fear that their immigration status might be shared with immigration officials.
“Holding on to the kids who have recently enrolled is going to become critically important,” Hardy said. She said she hopes families will see that the coverage is a boon to their health and will not be scared away.
In an email last week, the DHCS reiterated to California Healthline that an applicant’s immigration status is “only used for the purposes of determining Medi-Cal eligibility.”
But that doesn’t eliminate the worry for some parents.
“This fear is horrible. We don’t know who to trust,” Luz said.
Before the coverage-for-all law took effect last year, undocumented children could get coverage through the Healthy Kids insurance program in some California counties. However, many of those children have been transferred to Medi-Cal, and the Healthy Kids programs are closing down.
Carlos Jimenez, a health policy advocate at the Mixteco Community Organizing Project in Oxnard, Calif., said the nonprofit doubled its enrollment assistance efforts after the law was implemented.
Community health educators known as promotoras, spread word about the new law in farm fields, in front of supermarkets and outside churches. Last year, enrollment counselors saw up to 400 people a month who had questions about Medi-Cal, the majority looking to enroll their children, Jimenez said.
But after the November presidential election, enrollment counselors at Mixteco saw the number of people seeking help drop by nearly half, Jimenez said. Staffers had expected more inquiries about renewals by now, he said.
Most people ask whether enrolling an undocumented child would bring any problems with the U.S. Immigration and Customs Enforcement agency, Jimenez said. “We tell them their information is safe. But even then, they’re afraid.”
The Children Now survey showed that participants had questions about the future of Medi-Cal for undocumented children — in particular, whether it would continue if the Affordable Care Act were replaced.
In an interview with California Healthline in February, Sen. Ricardo Lara (D-Bell Gardens), who authored the Medi-Cal for All Children law, said there was no reason for people to be concerned about the program’s durability.
Democratic Gov. Jerry Brown continues to make this program a priority, Lara said, noting that California is spending $279.5 million to continue benefits for undocumented kids this year. That’s up from the $188 million it provided for the program last year.
Health advocates in California are hoping to extend the program to young adults. Earlier this month, the California Immigrant Policy Center and Health Access California, launched an online petition requesting that full Medi-Cal benefits be made available to people ages 19 to 26.
It’s widely believed that older age is darkened by persistent loneliness. But a considerable body of research confirms this isn’t the case.
In fact, loneliness is the exception rather than the rule in later life. And when it occurs, it can be alleviated: It’s a mutable psychological state.
Only 30 percent of older adults feel lonely fairly frequently, according to data from the National Social Life, Health and Aging Project, the most definitive study of seniors’ social circumstances and their health in the U.S.
The remaining 70 percent have enough fulfilling interactions with other people to meet their fundamental social and emotional needsNAVIGATING AGING
Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.
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For more KHN coverage of aging, click here.
“If anything, the intensity of loneliness decreases from young adulthood through middle age and doesn’t become intense again until the oldest old age,” said Louise Hawkley, an internationally recognized authority on the topic and senior research scientist at the National Opinion Research Center (NORC) at the University of Chicago.
Understanding the extent of loneliness is important, insofar as this condition has been linked to elevated stress, impaired immune system function, inflammation, high blood pressure, depression, cognitive dysfunction and an earlier-than-expected death in older adults.
A new study, co-authored by Hawkley, highlights another underappreciated feature of this affliction: Loneliness is often transient, not permanent.
That study examined more than 2,200 Americans ages 57 to 85 in 2005 and again in 2010. Of the group who reported being lonely in 2005 (just under one-third of the sample), 40 percent had recovered from that state five years later while 60 percent were still lonely.
What helped older adults who had been lonely recover? Two factors: spending time with other people and eliminating discord and disturbances in family relationships.
Hawkley explains the result by noting that loneliness is a signal that an essential need — a desire for belonging — isn’t being met. Like hunger or thirst, it motivates people to act, and it’s likely that seniors reached out to the people they were closest to more often.
Her study also looked at protective factors that kept seniors from becoming lonely. What made a difference? Lots of support from family members and fewer physical problems that interfere with an individual’s independence and ability to get out and about.
To alleviate loneliness, one must first recognize the perceptions underlying the emotion, Hawkley and other experts said.
The fundamental perception is one of inadequacy. People who are lonely tend to feel that others aren’t meeting their expectations and that something essential is missing. And there’s usually a significant gap between the relationships these people want and those they actually have.
This isn’t the same as social isolation — a lack of contact with other people — although the two can be linked. People can be “lonely in a marriage” that’s characterized by conflict or “lonely in a crowd” when they’re surrounded by other people with whom they can’t connect.
Interventions to address loneliness have received heightened attention since 2011, when the Campaign to End Loneliness launched in Britain.
Here are two essential ways to mitigate this distressing sentiment:
Alter perceptions. Loneliness perpetuates itself through a gloomy feedback cycle. We think people don’t like us, so we convey negativity in their presence, which causes them to withdraw from us, which reinforces our perception that we’re not valued.
Changing the perceptions that underlie this cycle is the most effective way to relieve loneliness, according to a comprehensive evaluation of loneliness interventions published in 2011.
Heidi Grant, associate director of the Motivation Science Center at Columbia University, described this dynamic in an article published in 2010. “If co-worker Bob seems more quiet and distant than usual lately, a lonely person is likely to assume that he’s done something to offend Bob, or that Bob is intentionally giving him the cold shoulder,” she wrote.
With help, people can learn to examine the assumptions underlying their thoughts and ask questions such as “Am I sure Bob doesn’t like me? Could there be other, more likely reasons for his quiet, reserved behavior at work?”
This kind of “cognitive restructuring” is an essential component of LISTEN, a promising intervention to treat loneliness developed by Laurie Theeke, an associate professor in the school of nursing at West Virginia University. In five two-hour sessions, small groups of lonely people probe their expectations of relationships, their needs, their thought patterns and their behaviors while telling their stories and listening to others.
Joining a group can be effective if there’s an educational component and people are actively engaged, experts said.
Invest in relationships. With loneliness, it’s not the quantity of relationships that counts most. It’s the quality.
If you’re married, your relationship with your spouse is critically important in sustaining a feeling of belonging and preventing loneliness, Hawkley said.
If you haven’t been getting along, it’s time to try to turn things around. Remember when you felt most connected to your spouse? How did that feel? Can you emphasize the positive and minimize the negative? If you’re badly stuck, seek professional help.
Investing in relationships with family members and friends is similarly important. This is the time to move beyond old grievances.
“If you want to recover from loneliness, try to deal with difficulties that are disrupting relationships,” Hawkley said.
Also, it’s a good idea to diversify your relationships so you’re not depending exclusively on a few people, according to Jenny de Jong Gierveld and Tineke Fokkema, loneliness researchers from the Netherlands.
Training in social skills can help lonely people deal with problems such as not knowing how to renew contact with an old friend or initiate conversation with a distant relative. And learning coping strategies can enlarge their arsenal of adaptive responses.
Both of these strategies are part of a six-week “friendship enrichment program” developed in the Netherlands. The goal is to help people become aware of their social needs, reflect on their expectations, analyze and improve the quality of existing relationships and develop new friendships.
One simple strategy can make a difference. “If you have good news, share it,” Hawkley said, “because that tends to bring people closer together.”
KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.