For Hourly Workers After the Storm, No Work, No Pay


Chantal Sainvilus, a home health aide in Brooklyn who makes $10 an hour, does not get paid if she does not show up. So it is no wonder that she joined the thousands of people taking extreme measures to get to work this week, even, in her case, hiking over the Williamsburg Bridge.


While salaried employees worked if they could, often from home after Hurricane Sandy, many of the poorest New Yorkers faced the prospect of losing days, even a crucial week, of pay on top of the economic ground they have lost since the recession.


Low-wage workers, more likely to be paid hourly and work at the whim of their employers, have fared worse in the recovery than those at the top of the income scale — in New York City the bottom 20 percent lost $463 in annual income from 2010 to 2011, in contrast to a gain of almost $2,000 for the top quintile. And there are an increasing number of part-time and hourly workers, the type that safety net programs like unemployment are not designed to serve. Since 2009, when the recovery began, 86 percent of the jobs added nationally have been hourly. Over all, about 60 percent of the nation’s jobs are hourly.


Even as the sluggish economy has accentuated this divide, Hurricane Sandy has acted as a further wedge, threatening to take a far greater toll on the have-littles who live from paycheck to paycheck.


“There’s a lot of people in our society that are living in a very precarious situation in terms of low wages or very insecure work,” said Arne L. Kalleberg, a sociologist at the University of North Carolina at Chapel Hill and author of “Good Jobs, Bad Jobs.” “That’s why it’s important to have a safety net that’s based on the idea of people working insecure jobs like this.”


On Friday, Gov. Andrew M. Cuomo announced that New York City and four suburban counties were eligible for disaster unemployment relief, which covers a broader spectrum of workers than regular unemployment benefits, including the self-employed like taxi drivers and street vendors as well as those who were unable to get to work.


New Jersey has also declared people in 10 counties eligible for disaster unemployment assistance. In Connecticut, residents of four counties and the Mashantucket Pequot Indian Reservation are eligible.


A New York Department of Labor spokesman emphasized that workers who lost wages should call to apply because the program is flexible and many eligibility issues would be determined on a case-by-case basis.


But the program might not help people whose commute simply lasted longer or cost more, like Ibezim Oki, a cabdriver who spent $50 on a cab to get from his Brooklyn home to Manhattan on Friday, rather than risk long bus delays, and “now I don’t know how long I’m going to have to wait for gas.”


The commute alone represented a hardship for workers whose jobs require a physical presence, while neighborhood coffee shops in the boroughs and suburbs overflowed with those who needed nothing more than a laptop and Wi-Fi to stay connected to work.


Ms. Sainvilus estimated that on Thursday, she had traveled eight hours to work for five, making her effective pay less than $4 an hour.


Others could not work because their place of business was closed. At a food distribution center in Chelsea, Mike Samuel, 55, a delivery man for a florist, was feeling the pain of five days of lost income. “We don’t work, we don’t get no tips, we don’t get no pay,” he said.


Muta Prather said the chemical company where he works in Newark was flooded, causing him to miss three days of work. He worked part of the day on Thursday helping to clean up, but worried about how he would pay for damage to his own roof.


“It hurts, you know,” said Mr. Prather, who is 49 and lives in West Orange, N.J. “I looked up at my roof, and it’s going to cost me like seven grand. I don’t make that kind of money.”


But at a playground in the Clinton Hill section of Brooklyn, Damien Carney stood with his baby daughter strapped to his chest and his toddler on a nearby swing, enjoying a surprise week off. For Mr. Carney, a salaried portfolio manager for a wine distributor that was closed because it had no power, the storm was amounting to something like a paid vacation with time for cooking and rearranging the living room. “They basically said, ‘Don’t worry about it,’ ” Mr. Carney said of his employers.


Federal labor laws include more protections for salaried workers than hourly workers when a disaster hits. Employers must continue to pay salaries if the worksite is closed for less than a week, even though they are allowed to require employees to use vacation or paid leave for the duration of the closure. Hourly workers, on the other hand, do not have to be paid if the worksite closes. If the workplace is open but salaried workers cannot get there, their pay may be reduced.


Of course, policies vary from workplace to workplace, and some hourly workers were luckier than others. Cassandra Williams, 54, waiting for the bus from Brooklyn to Manhattan with her 6-year-old granddaughter, said the family for whom she keeps house would pay her full wages despite her missing three days of work. Tinash Makots, a 24-year-old salesman at the Nike store in Midtown Manhattan, said he would be paid for the days missed as well.


One nanny in the bus line said she would be paid her regular wages, while another said she would not be compensated for hours missed.


A financial district worker who would identify himself only as William S. said he did not strictly need to go into Manhattan to do his job, but felt that he should make an appearance after one of his staff members showed up every day at 6 a.m. and another paid $40 a day to get to a distant office in Queens.


But Anthony Howell, a 42-year-old hair stylist in Chelsea, said he hadn’t worked all week because his salon, like his high-rise apartment, has no electricity.


“That’s the brutal part,” he said. “The hair industry is like that. You don’t do the work, you don’t get the money.”


Read More..

Second Illness Infects Meningitis Sufferers





Just when they might have thought they were in the clear, people recovering from meningitis in an outbreak caused by a contaminated steroid drug have been struck by a second illness.




The new problem, called an epidural abscess, is an infection near the spine at the site where the drug — contaminated by a fungus — was injected to treat back or neck pain. The abscesses are a localized infection, different from meningitis, which affects the membranes covering the brain and spinal cord. But in some cases, an untreated abscess can cause meningitis. The abscesses have formed even while patients were taking powerful antifungal medicines, putting them back in the hospital for more treatment, often with surgery.


The problem has just begun to emerge, so far mostly in Michigan, which has had more people sickened by the drug — 112 out of 404 nationwide — than any other state.


“We’re hearing about it in Michigan and other locations as well,” said Dr. Tom M. Chiller, the deputy chief of the mycotic diseases branch of the Centers for Disease Control and Prevention. “We don’t have a good handle on how many people are coming back.”


He added, “We are just learning about this and trying to assess how best to manage these patients. They’re very complicated.”


In the last few days, about a third of the 53 patients treated for meningitis at St. Joseph Mercy Hospital in Ann Arbor, Mich., have returned with abscesses, said Dr. Lakshmi K. Halasyamani, the chief medical officer.


“This is a significant shift in the presentation of this fungal infection, and quite concerning,” she said. “An epidural abscess is very serious. It’s not something we expected.”


She and other experts said they were especially puzzled that the infections could occur even though patients were taking drugs that, at least in tests, appeared to work against the fungus causing the infection, a type of black mold called Exserohilum.


The main symptom is severe pain near the injection site. But the abscesses are internal, with no visible signs on the skin, so it takes an M.R.I. scan to make the diagnosis. Some patients have more than one abscess. In some cases, the infection can be drained or cleaned out by a neurosurgeon.


But sometimes fungal strands and abnormal tissue are wrapped around nerves and cannot be surgically removed, said Dr. Carol A. Kauffman, an expert on fungal diseases at the University of Michigan. In such cases, all doctors can do is give a combination of antifungal drugs and hope for the best. They have very little experience with this type of infection.


Some patients have had epidural abscesses without meningitis; St. Joseph Mercy Hospital has had 34 such cases.


A spokesman for the health department in Tennessee, which has had 78 meningitis cases, said that a few cases of epidural abscess had also occurred there, and that the state was trying to assess the extent of the problem.


Dr. Chiller said doctors were also reporting that some patients exposed to the tainted drug had arachnoiditis, a nerve inflammation near the spine that can cause intense pain, bladder problems and numbness.


“Unfortunately, we know from the rare cases of fungal meningitis that occur, that you can have complicated courses for this disease, and it requires prolonged therapy and can have some devastating consequences,” he said.


The meningitis outbreak, first recognized in late September, is one of the worst public health disasters ever caused by a contaminated drug. So far, 29 people have died, often from strokes caused by the infection. The case count is continuing to rise. The drug was a steroid, methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass. Three contaminated lots of the drug, more than 17,000 vials, were shipped around the country, and about 14,000 people were injected with the drug, mostly for neck and back pain. But some received injections for arthritic joints and have developed joint infections.


Inspections of the compounding center have revealed extensive contamination. It has been shut down, as has another Massachusetts company, Ameridose, with some of the same owners. Both companies have had their products recalled.


Compounding pharmacies, which mix their own drugs, have had little regulation from either states or the federal government, and several others have been shut down recently after inspections found sanitation problems.


Read More..

Second Illness Infects Meningitis Sufferers





Just when they might have thought they were in the clear, people recovering from meningitis in an outbreak caused by a contaminated steroid drug have been struck by a second illness.




The new problem, called an epidural abscess, is an infection near the spine at the site where the drug — contaminated by a fungus — was injected to treat back or neck pain. The abscesses are a localized infection, different from meningitis, which affects the membranes covering the brain and spinal cord. But in some cases, an untreated abscess can cause meningitis. The abscesses have formed even while patients were taking powerful antifungal medicines, putting them back in the hospital for more treatment, often with surgery.


The problem has just begun to emerge, so far mostly in Michigan, which has had more people sickened by the drug — 112 out of 404 nationwide — than any other state.


“We’re hearing about it in Michigan and other locations as well,” said Dr. Tom M. Chiller, the deputy chief of the mycotic diseases branch of the Centers for Disease Control and Prevention. “We don’t have a good handle on how many people are coming back.”


He added, “We are just learning about this and trying to assess how best to manage these patients. They’re very complicated.”


In the last few days, about a third of the 53 patients treated for meningitis at St. Joseph Mercy Hospital in Ann Arbor, Mich., have returned with abscesses, said Dr. Lakshmi K. Halasyamani, the chief medical officer.


“This is a significant shift in the presentation of this fungal infection, and quite concerning,” she said. “An epidural abscess is very serious. It’s not something we expected.”


She and other experts said they were especially puzzled that the infections could occur even though patients were taking drugs that, at least in tests, appeared to work against the fungus causing the infection, a type of black mold called Exserohilum.


The main symptom is severe pain near the injection site. But the abscesses are internal, with no visible signs on the skin, so it takes an M.R.I. scan to make the diagnosis. Some patients have more than one abscess. In some cases, the infection can be drained or cleaned out by a neurosurgeon.


But sometimes fungal strands and abnormal tissue are wrapped around nerves and cannot be surgically removed, said Dr. Carol A. Kauffman, an expert on fungal diseases at the University of Michigan. In such cases, all doctors can do is give a combination of antifungal drugs and hope for the best. They have very little experience with this type of infection.


Some patients have had epidural abscesses without meningitis; St. Joseph Mercy Hospital has had 34 such cases.


A spokesman for the health department in Tennessee, which has had 78 meningitis cases, said that a few cases of epidural abscess had also occurred there, and that the state was trying to assess the extent of the problem.


Dr. Chiller said doctors were also reporting that some patients exposed to the tainted drug had arachnoiditis, a nerve inflammation near the spine that can cause intense pain, bladder problems and numbness.


“Unfortunately, we know from the rare cases of fungal meningitis that occur, that you can have complicated courses for this disease, and it requires prolonged therapy and can have some devastating consequences,” he said.


The meningitis outbreak, first recognized in late September, is one of the worst public health disasters ever caused by a contaminated drug. So far, 29 people have died, often from strokes caused by the infection. The case count is continuing to rise. The drug was a steroid, methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass. Three contaminated lots of the drug, more than 17,000 vials, were shipped around the country, and about 14,000 people were injected with the drug, mostly for neck and back pain. But some received injections for arthritic joints and have developed joint infections.


Inspections of the compounding center have revealed extensive contamination. It has been shut down, as has another Massachusetts company, Ameridose, with some of the same owners. Both companies have had their products recalled.


Compounding pharmacies, which mix their own drugs, have had little regulation from either states or the federal government, and several others have been shut down recently after inspections found sanitation problems.


Read More..

Cellphone Users Steaming at Hit-or-Miss Service





To wireless customers, cellphone networks might seem to be made out of thin air. But they are plenty vulnerable to catastrophic storms — and bringing service back can take an excruciatingly long time.




On Friday, four days after Hurricane Sandy, the major carriers — AT&T, Verizon Wireless, T-Mobile USA and Sprint — were still busily rebuilding their networks in the hardest-hit areas.


One-quarter of the cell towers in the storm zone were knocked out, according to the Federal Communications Commission. Many had no power, and their backup battery systems soon drained. The lines connecting those towers to the rest of the phone network were ripped out. Carriers deployed generators to provide power, but eventually those required more fuel — another limited resource.


In an emergency, a lack of cellphone reception can be dangerous, especially as more people have chosen to snip landlines out of their budgets. About 60 percent of American households have landlines, down from 78 percent four years ago, according to Chetan Sharma, an independent mobile analyst.


The carriers say they are trying their best to deal with an unusual disaster. But in the past, they have steadfastly objected to recommendations from regulators that they spend more money on robust emergency equipment, like longer-lasting backup batteries.


Neville Ray, chief technology officer of T-Mobile USA, said Hurricane Sandy was the biggest natural disaster he had ever dealt with and that service failures were inevitable.


“There’s an amount of preparation you can do, but depending on the size and scale and impact of the storm, it’s tough to anticipate every circumstance,” Mr. Ray said in an interview. “No degree of preparation can prevent some of those outages from happening.”


When networks fail, carriers deploy trucks, called C.O.W.’s, for cell on wheels, that act as temporary cell towers. But the companies say the challenge with deploying these trucks poststorm is connecting to power and to the wider phone network, which requires a microwave radio link to a working tower. Because of the density of the buildings in New York City, the trucks could serve only a small area, according to Mr. Ray.


The carriers have made other efforts to provide services while restoring their networks. AT&T wheeled out R.V.’s where customers could charge their phones. And it made an agreement to share networks with T-Mobile USA in the affected areas of New York and New Jersey. When customers of both companies place calls, they are carried by whichever network is available in the area.


But ultimately all of the carriers’ preparations and responses were not enough to get services running again in a hurry. Over the week the carriers reported gradual progress, and they declined to offer timelines indicating when customers could expect to have service again.


The unreliability of wireless networks may point to a bigger problem. Over the years, the phone companies have fought off regulators who want to treat them as utilities, arguing that if they are going to stay innovative, they cannot be burdened with the old rules that phone companies dealt with in the landline era. But as a consequence, there are almost no rules about what carriers have to do in an emergency, said Harold Feld, senior vice president for Public Knowledge, a nonprofit that focuses on information policy.


“With the new networks we’ve prized keeping costs down, we’ve prized flexibility and we’ve prized innovation,” said Mr. Feld, who wrote a blog post on Monday anticipating cell tower problems. “But we have not put stability as a value when we have been pushing to have these networks built out.”


Mr. Feld noted that after Hurricane Katrina in 2005, the F.C.C. recommended that carriers install backup batteries on their transmission towers that would last 24 hours, among other measures. But the carriers objected, presumably because they did not want to spend the money, he said. (Of course, 24 hours would not have been enough in many areas hit by the latest storm.)


In general, the carriers say it is in their own interest to fortify their networks for emergency situations, but Mr. Feld said this incentive was not enough.


“We ought to actually be doing this in the mind-set that there need to be actual rules, so that everybody knows how to behave when the crisis hits,” he said. “When I drive I have the best incentive in the world not to hit a telephone pole and not to slam into another car. But I still need speed limits, stop signs and stop lights.”


Debra Lewis, a spokeswoman for Verizon Wireless, said no amount of rules could have prepared carriers for the outcome of a storm like Hurricane Sandy.


“The fact is, regulation cannot anticipate the varied challenges that can arise in such situations, but we do learn from them and adapt accordingly to ensure we meet consumers’ needs,” Ms. Lewis said. She said the company prepared for natural disasters with generators and batteries that provided at least eight hours of power to cell sites.


Verizon Wireless said Friday evening that less than 3 percent of its network in the Northeast was still down. “In severely impacted areas, such as Lower Manhattan, while wireless service has yet to return to normal levels, coverage is good,” it said.


AT&T was the only major carrier that would not go into specifics about how much of its network was down. Anecdotally it seemed that in Manhattan at least, AT&T’s coverage was not as good as Verizon’s after the storm. One Twitter user directed this message at AT&T on Tuesday: “I live in lower manhattan. Vz has service u do not. You are ruining lives. I had to come midtown 2 call mom. Switching.”


Mark Siegel, a spokesman for AT&T, said the company would not comment because it was working on restoring its network.


Read More..

Petraeus’s Lower C.I.A. Profile Leaves Benghazi Void





WASHINGTON — In 14 months as C.I.A. director, David H. Petraeus has shunned the spotlight he once courted as America’s most famous general. His low-profile style has won the loyalty of the White House, easing old tensions with President Obama, and he has overcome some of the skepticism he faced from the agency’s work force, which is always wary of the military brass.







Brendan Smialowski/Getty Images

The low-profile style of David H. Petraeus, right, has won the loyalty of the White House, easing old tensions with President Obama.








Win Mcnamee/Getty Images

C.I.A. director, David H. Petraeus, right, appeared before the Senate Select Committee on Intelligence in Washington in January.






But since an attack killed four Americans seven weeks ago in Benghazi, Libya, his deliberately low profile, and the C.I.A.’s penchant for secrecy, have left a void that has been filled by a news media and Congressional furor over whether it could have been prevented. Rather than acknowledge the C.I.A.’s presence in Benghazi, Mr. Petraeus and other agency officials fought a losing battle to keep it secret, even as the events there became a point of contention in the presidential campaign.


Finally, on Thursday, with Mr. Petraeus away on a visit to the Middle East, pressure from critics prompted intelligence officials to give their own account of the chaotic night when two security officers died along with the American ambassador, J. Christopher Stevens, and another diplomat. The officials acknowledged for the first time that the security officers, both former members of the Navy SEALs, worked on contract for the C.I.A., which occupied one of the buildings that were attacked.


The Benghazi crisis is the biggest challenge so far in the first civilian job held by Mr. Petraeus, who retired from the Army and dropped the “General” when he went to the C.I.A. He gets mostly high marks from government colleagues and outside experts for his overall performance. But the transition has meant learning a markedly different culture, at an agency famously resistant to outsiders.


“I think he’s a brilliant man, but he’s also a four-star general,” said Senator Dianne Feinstein, the chairwoman of the Senate Intelligence Committee. “Four-stars are saluted, not questioned. He’s now running an agency where everything is questioned, whether you’re a four-star or a senator. It’s a culture change.”


Mr. Petraeus, who turns 60 next week, has had to learn that C.I.A. officers will not automatically defer to his judgments, as military subordinates often did. “The attitude at the agency is, ‘You may be the director, but I’m the Thailand analyst,’ ” said one C.I.A. veteran.


Long a media star as the most prominent military leader of his generation, Mr. Petraeus abruptly abandoned that style at the C.I.A. Operating amid widespread complaints about leaks of classified information, he has stopped giving interviews, speaks to Congress in closed sessions and travels the globe to consult with foreign spy services with little news media notice.


“He thinks he has to be very discreet and let others in the government do the talking,” said Michael E. O’Hanlon, a Brookings Institution scholar who is a friend of Mr. Petraeus’s and a member of the C.I.A.’s advisory board.


Mr. Petraeus’s no-news, no-nonsense style stands out especially starkly against that of his effusive predecessor, Leon E. Panetta, who is now the defense secretary.


Mr. Panetta, a gregarious politician by profession, was unusually open with Congress and sometimes with the public — to a fault, some might say, when he spoke candidly after leaving the C.I.A. about a Pakistani doctor’s role in helping hunt for Osama bin Laden, or about the agency’s drone operations.


Mr. Petraeus’s discretion and relentless work ethic have had a positive side for him: old tensions with Mr. Obama, which grew out of differing views on the wars in Iraq and Afghanistan, appear to be gone. Mr. Petraeus is at the White House several times a week, attending National Security Council sessions and meeting weekly with James R. Clapper Jr., the director of national intelligence, and Thomas E. Donilon, Mr. Obama’s national security adviser. Mr. Donilon said recently that the C.I.A. director “has done an exceptional job,” bringing “deep experience, intellectual rigor and enthusiasm” to his work.


Read More..

Estimate of Economic Losses Now Up to $50 Billion





Economic damages inflicted by Hurricane Sandy could reach $50 billion, according to new estimates that are more than double a previous forecast. Some economists warned on Thursday that the storm could shave a half percentage point off the nation’s economic growth in the current quarter.




Losses from the storm could total $30 billion to $50 billion, according to Eqecat, which tracks hurricanes and analyzes the damage they cause. On Monday, before the storm hit the East Coast, the firm estimated $10 billion to $20 billion in total economic damages.


The flooding of New York’s subways and roadway tunnels and the extensive loss of business as a result of utility failures across the region were behind the sharp increase in the estimate, the firm said.


“The geographic scope of the storm was unprecedented, and the impacts on individuals and on commerce are far larger,” said Tom Larsen, Eqecat’s senior vice president and product architect. “Lost power is going to contribute to higher insurance losses.”


Eqecat predicted that New York would bear 34 percent of the total economic losses, with New Jersey suffering 30 percent, Pennsylvania 20 percent and other states 16 percent. That includes all estimated losses, whether covered by insurance or not. The estimates and the share that will be covered by insurers are far from certain at this point, as government officials, property owners and insurance adjusters struggle to assess the destruction.


While the stock market, banks and other financial institutions regained some of their stride on Thursday, other sectors like retailing, transportation and leisure and hospitality face a much longer and more difficult recovery. With fuel in short supply in many areas and utilities warning that power may not be back for a week or more in some areas, businesses found themselves preparing for the equivalent of a long siege.


FedEx, for example, was trying to rent fuel tankers for its trucks in New York and New Jersey as commercial gas stations ran dry.


“We’re reaching out to everyone who has a gasoline tanker that we can move to these areas,” said Shea Leordeanu, a spokeswoman for the company. While FedEx had stocks of oil in advance of the storm for generators, it was not prepared for the gas shortages that caused long lines at stations on Wednesday and Thursday.


“There has not been an impact yet, but this is something we can see as an issue and we’re concerned,” she said.


As logistical problems mounted, and damage estimates surged, economists raised their estimates of the storm’s impact.


“I think the effect will be quite big,” said Julia Lynn Coronado, chief economist for North America at BNP Paribas. “In the fourth quarter, we’re probably looking at an impact of half a percentage point.”


She said some of those losses would be made up in the first quarter of 2013, as insurance reimbursements were distributed and homeowners and businesses rebuilt.


Hurricane Sandy will rank high among disasters in terms of economic impact but will not be at the top of the list, said Mark Zandi of Moody’s Analytics. He estimated that the losses would be less than half of those suffered because of the 9/11 terrorist attacks and from Hurricane Katrina.


Moody’s Analytics also put the impact in the $50 billion range, with about $12 billion in losses falling in the New York City metropolitan area.


About $20 billion of that total is from lost economic activity like meals not served in restaurants, canceled plane flights and bets not placed in casinos, Mr. Zandi estimated. The rest, about $30 billion, will be from property destruction, including damage to homes, cars and businesses, Mr. Zandi said.


Eqecat said it believed that various forms of insurance would cover $10 billion to $20 billion of the total cost. Other losses will be borne by individuals and businesses, or covered by federal government programs like the National Flood Insurance Program. Much of the federal spending will be used to repair damaged public infrastructure, rather than for private property.


Eqecat said that if insured costs remained at the lower end of its predicted range, at $10 billion, then about 60 percent of the losses would be covered by homeowners’ and, to a lesser extent, auto insurers. The remainder would be covered by commercial and industrial insurance.


The firm’s officials said that if total insured losses rose to the higher end of its predicted range, it would be because of costs like business-interruption losses — and in that case, commercial insurers pay more.


They said this possibility would depend to a great extent on how long power failures continued. They said there were no solid data yet on the number of transformers and power lines that had been knocked out. They added that in some cases, power might not be restored until well into December.


Moody’s issued a report on Thursday stating that the large nationwide insurers had “diversified exposures and strong capital bases to withstand” payouts related to the storm. It added, however, that the costs could disrupt the capital bases of smaller regional insurers.


State Farm, the largest writer of home and auto insurance in the region, reported having received nearly 25,000 homeowners’ claims and 4,000 auto claims as of Wednesday. Those numbers are probably a fraction of the eventual totals. Some of the losses will not be recouped. Lost Halloween sales will be especially painful for some retailers, according to a separate analysis by Moody’s.


“As shoppers in the affected regions focus on the storm, other discretionary spending will fall and not be recouped,” Moody’s said.



Read More..

The New Old Age Blog: How to Bypass the Revolving Door

Last week, I wrote about older people in nursing homes who are transferred to hospitals when their health takes a turn for the worse, even if they don’t want aggressive medical interventions. And you responded with dozens of stories about relatives who had had these experiences.

In fact, researchers who have studied the revolving door between nursing homes and hospitals think that as many as 45 percent of hospitalizations for nursing home patients (those covered by both Medicare and Medicaid) are avoidable or unnecessary.

So why do they occur? Often, nursing homes aides aren’t adequately trained to identify the early signs of deterioration in a resident’s condition and to act promptly to help prevent a medical crisis. Doctors typically aren’t present in facilities full time, and those on call often would rather be safe than sorry.

Frequently, nursing home patients’ wishes — what kind of treatment they’d like to have and under what conditions — aren’t known or included in their medical records. So aggressive care is given as a matter of course.

A new pilot program in seven states that is sponsored by the federal Centers for Medicare and Medicaid Services aims to address these issues. The effort involves so-called long-stay residents (those who live in homes for 100 days or longer) in 145 nursing homes. It gets up and running later this year.

I spoke with experts from three sites – Nevada, Indiana and New York City – at length. All are trying different models but share some common elements. Notably, each program will send extra providers (nurse practitioners, registered nurses or physician assistants) into nursing homes to teach front-line staff (certified nursing assistants and others) how to better recognize and respond to changes in an older resident’s health.

“Keep in mind that these long-stay residents are very frail, with multiple chronic medical conditions that can flare up at any time,” said Dr. Greg Sachs, chief of the division of general internal medicine and geriatrics at Indiana University’s School of Medicine. “By intervening upstream, hopefully we can interrupt a cascade of medical complications that can lead to a hospitalization.”

HealthInsight of Nevada, working with 25 nursing homes, will be implementing a “green, yellow and red light” system. For each of the colors, extensive protocols – what clinical signs to watch for, how to react – have been created and will be taught to nursing home staff members. (The protocols were developed by Dr. Joseph Ouslander of Florida Atlantic University and are being used by several programs.)

Green means “something has changed but the patient is stable and it’s O.K. to keep her here,” said Dr. Jerry Reeves, HealthInsight’s medical director. An example: An older person with congestive heart failure who develops swollen ankles, a sign that her circulatory system is under stress, will get a stronger diuretic and be monitored more closely.

Yellow means the patient is unstable but “it’s still within the ability of the facility to care for Mrs. Jones,” said Dr. Reeves. This could be a patient who’s stopped eating and is now vomiting but otherwise isn’t acutely ill. Again, a medical intervention and more frequent checks will be in order.

Red signals a major change like chest pain, blood pressure that’s hard to measure or a stroke that requires immediate attention from a doctor, nurse practitioner or physician assistant. In some cases, patients will need to be transferred to the hospital; in other cases, they may remain in place at the nursing home with extra assistance.

In Indiana, the pilot will help 20 nursing homes establish nonpharmaceutical interventions for older patients with dementia. Too often, these patients are medicated with antipsychotic drugs, which puts them at risk of falls, fractures and strokes, which then land them in the hospital, Dr. Sachs said.

Other priorities will be integrating symptom-relieving palliative care more fully into the nursing home setting and better managing transfers of nursing home residents to and from hospitals when these admissions are necessary. Making sure that information about patients is transferred between settings and that medical providers communicate with one another is an important part of that.

In and around New York City, the Greater New York Hospital Foundation will be working with 30 nursing homes to ensure that older patients and their families have in-depth discussions about “goals of care” and palliative care and incorporate the substance of these discussions in medical decision-making. That involves educating caregivers about the consequences of various interventions and treatments.

“Caregivers need realistic expectations about what a hospitalization means to a person living in a nursing home,” said Roxanne Tena-Nelson, executive vice president at the foundation’s long-term care unit.

Given the enormous cultural diversity of New York and the sensitivity of the topic, “we don’t pretend this is going to be simple,” said Tim Johnson, executive director of the foundation.

Also, the New York pilot will create an “electronic dashboard” for nursing homes that eases communication among doctors and nurses, enables front-line staff to more readily identify emerging medical problems, and standardizes information that passes back and forth between nursing homes and hospitals when a patient is transferred. Most nursing homes rely on paper-based medical records currently.

The bottom line is that frail older people “should not be going to the emergency room when their care could be better delivered in another setting,” Mr. Johnson said. “We really have to take this on and make things better for this vulnerable population.”

I’m sure many readers here would second the sentiment. I’ll check back to see how these pilot programs are doing, after they have some experience under their belt.

Read More..

The New Old Age Blog: How to Bypass the Revolving Door

Last week, I wrote about older people in nursing homes who are transferred to hospitals when their health takes a turn for the worse, even if they don’t want aggressive medical interventions. And you responded with dozens of stories about relatives who had had these experiences.

In fact, researchers who have studied the revolving door between nursing homes and hospitals think that as many as 45 percent of hospitalizations for nursing home patients (those covered by both Medicare and Medicaid) are avoidable or unnecessary.

So why do they occur? Often, nursing homes aides aren’t adequately trained to identify the early signs of deterioration in a resident’s condition and to act promptly to help prevent a medical crisis. Doctors typically aren’t present in facilities full time, and those on call often would rather be safe than sorry.

Frequently, nursing home patients’ wishes — what kind of treatment they’d like to have and under what conditions — aren’t known or included in their medical records. So aggressive care is given as a matter of course.

A new pilot program in seven states that is sponsored by the federal Centers for Medicare and Medicaid Services aims to address these issues. The effort involves so-called long-stay residents (those who live in homes for 100 days or longer) in 145 nursing homes. It gets up and running later this year.

I spoke with experts from three sites – Nevada, Indiana and New York City – at length. All are trying different models but share some common elements. Notably, each program will send extra providers (nurse practitioners, registered nurses or physician assistants) into nursing homes to teach front-line staff (certified nursing assistants and others) how to better recognize and respond to changes in an older resident’s health.

“Keep in mind that these long-stay residents are very frail, with multiple chronic medical conditions that can flare up at any time,” said Dr. Greg Sachs, chief of the division of general internal medicine and geriatrics at Indiana University’s School of Medicine. “By intervening upstream, hopefully we can interrupt a cascade of medical complications that can lead to a hospitalization.”

HealthInsight of Nevada, working with 25 nursing homes, will be implementing a “green, yellow and red light” system. For each of the colors, extensive protocols – what clinical signs to watch for, how to react – have been created and will be taught to nursing home staff members. (The protocols were developed by Dr. Joseph Ouslander of Florida Atlantic University and are being used by several programs.)

Green means “something has changed but the patient is stable and it’s O.K. to keep her here,” said Dr. Jerry Reeves, HealthInsight’s medical director. An example: An older person with congestive heart failure who develops swollen ankles, a sign that her circulatory system is under stress, will get a stronger diuretic and be monitored more closely.

Yellow means the patient is unstable but “it’s still within the ability of the facility to care for Mrs. Jones,” said Dr. Reeves. This could be a patient who’s stopped eating and is now vomiting but otherwise isn’t acutely ill. Again, a medical intervention and more frequent checks will be in order.

Red signals a major change like chest pain, blood pressure that’s hard to measure or a stroke that requires immediate attention from a doctor, nurse practitioner or physician assistant. In some cases, patients will need to be transferred to the hospital; in other cases, they may remain in place at the nursing home with extra assistance.

In Indiana, the pilot will help 20 nursing homes establish nonpharmaceutical interventions for older patients with dementia. Too often, these patients are medicated with antipsychotic drugs, which puts them at risk of falls, fractures and strokes, which then land them in the hospital, Dr. Sachs said.

Other priorities will be integrating symptom-relieving palliative care more fully into the nursing home setting and better managing transfers of nursing home residents to and from hospitals when these admissions are necessary. Making sure that information about patients is transferred between settings and that medical providers communicate with one another is an important part of that.

In and around New York City, the Greater New York Hospital Foundation will be working with 30 nursing homes to ensure that older patients and their families have in-depth discussions about “goals of care” and palliative care and incorporate the substance of these discussions in medical decision-making. That involves educating caregivers about the consequences of various interventions and treatments.

“Caregivers need realistic expectations about what a hospitalization means to a person living in a nursing home,” said Roxanne Tena-Nelson, executive vice president at the foundation’s long-term care unit.

Given the enormous cultural diversity of New York and the sensitivity of the topic, “we don’t pretend this is going to be simple,” said Tim Johnson, executive director of the foundation.

Also, the New York pilot will create an “electronic dashboard” for nursing homes that eases communication among doctors and nurses, enables front-line staff to more readily identify emerging medical problems, and standardizes information that passes back and forth between nursing homes and hospitals when a patient is transferred. Most nursing homes rely on paper-based medical records currently.

The bottom line is that frail older people “should not be going to the emergency room when their care could be better delivered in another setting,” Mr. Johnson said. “We really have to take this on and make things better for this vulnerable population.”

I’m sure many readers here would second the sentiment. I’ll check back to see how these pilot programs are doing, after they have some experience under their belt.

Read More..

Gadgetwise Blog: Q&A: Putting the iPad on the Big Screen

Is there a way to show iBooks pages on my iPad on an HDTV screen? If so, what would I need to do it?

You can display the pages of an iBook currently on the iPad’s screen on the television with the built-in “video-mirroring” technology in the iPad 2 and current Retina display models. In addition to books, you can mirror apps, games, movies or whatever else your iPad is showing at the moment.

Depending on your setup, you can mirror the iPad’s screen with an HDMI cable and an adapter (like Apple’s Digital AV Adapter) that connects the tablet to the TV. In addition to a model that fits the older 30-pin Dock Connector ports on older iPads, Apple’s digital adapter is also available in a version that fits the Lightning port connector on the new iPad Mini and fourth-generation iPad model.

If you prefer to do it without wires instead, you can stream the mirrored image over a wireless network and through an Apple TV (second-generation or later) connected to the television. This approach requires buying one of Apple’s $99 set-top boxes and having a home network that uses the 802.11a, 802.11g or 802.11n standard if you do not have these in place already.

If you opt to connect the iPad to the TV with the HDMI cable and adapter, use the television remote control to switch the TV to display the input from the iPad’s screen. Once you open an iBook on the iPad, the image should be mirrored on the TV.

If you choose the Apple TV and wireless method, switch the TV’s input display to the Apple TV. Open the iBook you want to show. Double-click the iPad’s home button to show the row of recently used apps and swipe from left to right until you see the AirPlay icon. Tap it to open the menu, where you can select the Apple TV as the display screen and tap the Video Mirroring button to On. Apple has illustrated instructions for video-mirroring the iPad screen with AirPlay here.

Read More..

Guinea-Bissau, After Coup, Is Drug-Trafficking Haven


Agence France-Presse — Getty Images


Soldiers in Bissau, the capital.







BISSAU, Guinea-Bissau — When the army ousted the president here just months before his term was to expire, a thirst for power by the officer corps did not fully explain the offensive. But a sizable increase in drug trafficking in this troubled country since the military took over has raised suspicions that the president’s sudden removal was what amounted to a cocaine coup.




The military brass here has long been associated with drug trafficking, but the coup this spring means soldiers now control the drug racket and the country itself, turning Guinea-Bissau in the eyes of some international counternarcotics experts into a nation where illegal drugs are sanctioned at the top.


“They are probably the worst narco-state that’s out there on the continent,” said a senior Drug Enforcement Administration official in Washington, who spoke on the condition of anonymity so as not to jeopardize his work in the region. “They are a major problem.”


Since the April 12 coup, more small twin-engine planes than ever are making the 1,600-mile Atlantic crossing from Latin America to the edge of Africa’s western bulge, landing in Guinea-Bissau’s fields, uninhabited islands and remote estuaries. There they unload their cargos of cocaine for transshipment north, experts say.


The fact that the army has put in place a figurehead government and that military officers continue to call the shots behind the scenes only intensifies the problem.


The political instability continued as soldiers attacked an army barracks on Oct. 21, apparently in an attempt to topple the government. A dissident army captain was arrested on an offshore island on Oct. 27 and accused of being the organizer of the countercoup attempt. Two critics of the government were also assaulted and then left outside the capital.


From April to July there were at least 20 landings in Guinea-Bissau of small planes that United Nations officials suspected were drug flights — traffic that could represent more than half the estimated annual cocaine volume for the region. The planes need to carry a 1.5-ton cargo to make the transatlantic trip viable, officials say. Europe, already the destination for about 50 tons of cocaine annually from West Africa, United Nations officials say, could be in for a far greater flood.


Was the military coup itself a diversion for drug trafficking? Some experts point to signs that as the armed forces were seizing the presidency, taking over radio stations and arresting members government officials, there was a flurry of drug activity on one of the islands of the Bijagós Archipelago, what amounted to a three-day offloading of suspicious sacks.


That surreptitious activity appears to have been simply a prelude for what was to come.


“There has clearly been an increase in Guinea-Bissau in the last several months,” said Pierre Lapaque, head of the regional United Nations Office on Drugs and Crime for West and Central Africa. “We are seeing more and more drugs regularly arriving in this country.”


Mr. Lapaque called the trafficking in Guinea-Bissau “a major worry” and an “open sore,” and, like others, suggested it was no coincidence that trafficking has spiked since the coup.


Joaquin Gonzalez-Ducay, the European Union ambassador in Bissau, said: “As a country it is controlled by those who formed the coup d’état. They can do what they want to do. Now they have free rein.”


The senior D.E.A. official said that “people at the highest levels of the military are involved in the facilitation” of trafficking and added: “In other African countries government officials are part of the problem. In Guinea-Bissau, it is the government itself that is the problem.”


United Nations officials agree. “The coup was perpetrated by people totally embedded in the drugs business,” said one official, who spoke on the condition of anonymity because of the delicacy of the political environment here.


The country’s former prosecutor general, Octávio Inocêncio Alves, said, “A lot of the traffickers have direct relationships with the military.”


The civilian government and the military leadership that sits watchfully in its headquarters in an old Portuguese fort at the other end of town rebuff the United Nations drug accusations.


Read More..