Notes from the Elder Care Initiative

DECEMBER 2003


What's New

Medicaid Home Care for Tribal Health Services:  A Tool Kit for Developing
New Programs

Under contract from Indian Health Service (Elder Care Initiative) the UCLA
Center for Health Policy Research American Indian/Alaska Native Research
Program has developed and disseminated a series of state-specific guides to
funding for home and community-based long term care services for the
elderly. These toolkits identify the state programs which support home and
community-based long term care services, detail eligibility requirements for
elders, and outline the requirements for tribal programs as service
providers under the various programs.
Information includes:
        *       Why provide Medicaid personal care services
        *       What are personal care and other non-medical in-home
services
        *       Medicaid programs that provide in-home services
        *       How personal care and other in-home services are provided
        *       Tips for developing a plan for delivering Medicaid home care
services

This concise and readable guide will be a valuable technical assistance tool
for tribes developing long term care services.

The toolkit is available on-line at the Indian Health Service Elder Care
Initiative website:  <http://www.ihs.gov/medicalprograms/eldercare> or the
UCLA Center for Health Policy Research website:
<http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=79>.
Hard copies are available on request.



Pearls from the Literature

A number of studies have shown the benefit of anticoagulation in patients
with atrial fibrillation (including older patients).  Two new studies
emphasize this and add to our understanding.  Anticoagulation to an INR of
2.0 in those with nonvalvular atrial fibrillation and no contraindications
reduces frequency and severity of stroke and saves lives.

In a "real world" setting, Go et al followed over 11,000 persons, mean age
of 71, with nonvalvular atrial fibrillation and no contraindication to
anticoagulation, for up to 3 years.  Those on warfarin anticoagulation had a
reduction in risk of stroke and thromboembolism of 64% and a reduction in
all cause mortality of 31%.  Intracranial bleeding was "uncommon" but
increased in those on warfarin, while there was no increased risk of
extracranial hemorrhage.

In the second study, in the same cohort of patients, Hylek et al evaluated
the outcome of anticoagulation based on intensity of treatment.  There was a
clear benefit for those patients with nonvalvular atrial fibrillation whose
INR was above 2.0 compared to those with INR 1.5-1.9, with a reduction in
both frequency and severity of stroke.  There was no increased risk of
intracranial bleeding in those with INR under 3.9.

Go AS, Hylek EM, Chang Y, Phillips KA, Henault LE, Capra AM, Jensvold NG,
Selby JV, Singer DE.
<http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&lis
t_uids=14645310&dopt=Abstract>
Anticoagulation therapy for stroke prevention in atrial fibrillation: how
well do randomized trials translate into clinical practice?
JAMA.2003Nov26;290(20):2685-92.

Hylek EM, Go AS, Chang Y, Jensvold NG, Henault LE, Selby JV, Singer DE.
<http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&lis
t_uids=12968085&dopt=Abstract>
Effect of intensity of oral anticoagulation on stroke severity and mortality
in atrial fibrillation.
N Engl J Med. 2003 Sep 11;349(11):1019-26.



Conferences and Training Opportunities

Dates have been set for June 7-11 for the National Team Training in
Palliative and End of Life Care, Albuquerque, NM.    Let your Area CMO know
if your service unit or health center has a team to send.  For more
information contact:  Dr. Judith Kitzes (505-272-9134 or
[log in to unmask]) or Torie Heart (907-729-3642 or [log in to unmask]
<mailto:[log in to unmask]>).

June 17-19:  NMGEC Geriatric Summer Institute, Albuquerque, NM;  The Elder
In Crisis:  Managing Geriatric Emergencies.  Scholarships available for
Indian health professionals.  CHR track also.  For information contact:
Darlene Franklin at [log in to unmask] <mailto:[log in to unmask]>
or at 505-272-4934.


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IHS Elder Care Initiative
Bruce Finke, MD
45 Vernon Street, Northampton, MA  01060
(413)-584-0790      [log in to unmask]