Notes 2004

Michael Komeya, MD, Medical Director of the Senior Behavioral Health unit at Wahiawa General Hospital, started the unit in May 2000 with former director Dr. Dan Tanahashi and others. The geriatric/psychiatric unit is the first of its kind in the State of Hawaii to offer a focused team approach to elder mental care. The ten-bed unit occupies a section of the Wahiawa General Hospital’s renovated second floor. Short-term stays are on a voluntary admittance basis.

"Knowledge gained from advanced technology and research highlights that the elderly have specialized medical needs," Dr. Komeya explained. Due in part to the effects of aging on the organs, elderly patients’ symptoms, complications, and responses often differ from younger patients with similar medical and mental conditions. For example, "depression in the elderly," he continued, "often can be misdiagnosed or undiagnosed. Unlike younger patients, the elderly rarely express their sadness. Instead they could appear confused, apathetic, or forgetful." Studies have shown that in Hawaii the leading causes of dementia are Alzheimer’s and stroke.

"A geriatric psychiatrist," according to Dr. Komeya, "is a medical doctor with special training in the diagnosis and treatment of mental disorders that may occur in older adults." These disorders include dementia, depression, anxiety, and late-life mental disorders. "Many of the patients admitted to the Wahiawa unit have delirium, dementia, or depression," he described. "We have also seen behavioral changes caused by chemical imbalances, medications, or medication interactions. Many patients greatly benefit from treatment."

Dr. Komeya explained that to diagnose and treat disorders, the geriatric psychiatrist takes a comprehensive approach. This includes listening, using talk therapy, and working with primary care doctors and other health professionals to develop medication regimens and other therapies. At the Senior Behavioral Health unit, a team comprised of therapists, a social worker, a community liaison director, psychiatric nurses, and others trained in geriatric health, psychiatric issues, and elder care focus on treating seniors suffering from non-chronic psychological and emotional problems. Prior to admittance, an assessment process determines whether an individual can benefit from the services. The team’s overall goal is to restore, if feasible, the patient to normal activities of daily life. Team members continue to monitor patients after release on an outreach/aftercare basis.

Research and recent advancements in technology have done much to dispel former misconceptions on elderly behavior disorders, but a stigma still exists which makes some family doctors and general practitioners reluctant to recommend their patients see a psychiatrist. Thus, individuals miss the opportunity for specialized evaluation. Currently, patients at the unit come through referrals from family members, nursing homes, therapists, physicians, clergy, and others.

Dr. Komeya emphasized that stress and fatigue can take a toll on caregivers and lead to "burnout." He stated that unit members assist patients’ caregivers with locating resources to lighten responsibilities.

Anyone interested in learning more about the unit, or inquiring about referrals and evaluations, may call Senior Behavioral Health at 621-4310. Messages may be left for Dr. Komeya at that number or at his private practice office (941-8803) located in the Ala Moana building.

For several decades, personal emergency alert systems have been available to assist Hawaii consumers. In this issue, Cullen Hayashida, Ph.D. (Sociology) provides information on one of the latest.

"Without timely attention, a small problem could become a big problem for anyone," explained Dr. Cullen Hayashida, but for the frail, disabled, and elderly living alone, a minor fall; being locked out of the house; forgetting to take medications or to eat meals can become devastating."

Dr. Hayashida serves as a member of the Hawaii State Board of Medical Examiners. He is the president of Assisted Living Options Hawaii, and works as graduate affiliate faculty with UH Sociology, the School of Nursing, and the Center on Aging; and with Kapiolani Community College.

For the past 24 years, Dr. Hayashida has been involved with long-term care service development in the hospital, nursing home, case management, and home health care settings. His experience as an educator, long-term care researcher, planner, home health care director, nursing home administrator, and the developer of over 24 long-term care projects have all been directed towards finding more effective solutions for long-term care services.

As part of his effort to prolong the independence of elders and to provide affordable assistance, he has introduced two personal emergency alert systems to Hawaii: Lifeline at Kuakini Medical Center in 1985, and ResponseLink Hawaii in 2003. He remains associated with the latter, a national personal emergency and safety system with over 130 affiliates nationwide, which offers various operator response services at the push of a button.

ResponseLink features include: 24-hour medical emergency service, daily wellness service, daily medication reminders, and a "social companion non-emergency access line."

ResponseLink equipment includes (1) a base unit with a backup battery and built-in power/phone line failure detection system and (2) a waterproof, lightweight push-button neck or wrist pendant with 10-year battery.

Dr. Hayashida cautioned that the pendant should not be taken off, especially while in the shower. "The door can be left slightly ajar, to allow the wearer, in case of an emergency, to hear the operator."

"Despite all precautions against falls and mishaps, situations occur when individuals require assistance," Dr. Hayashida expressed. "Emergency alert systems are one way to safeguard health and safety while maintaining the independence of our senior citizens."

Anyone interested in receiving information on ResponseLink Hawaii can call Dr. Cullen T. Hayashida at (808) 721-1201 or email him at cth@hawaii.rr.com.

“We rarely say, ‘No.’ We try to be very flexible to give families and clients the most benefit,” described Rosanna Evers, LSW, Director of Social Services, Waianae Coast Comprehensive Health Center (WCCHC).

The medical facility provides a number of services, including adult day centers in four different locations on the island, with a fifth being planned for Pearl City. The centers, offering various levels of care, currently operate in the communities of Waianae (Maili Ola), Wahiawa (Pekelo Hale), Waialua (Northshore Hale), and Alewa, Honolulu (Hale Kako‘o).

Ms. Louise Pia, LPN, also with WCCHC, travels to the centers daily to monitor activities and individual care plans. The plans identify client limitations and provide guidelines for best care. Ms. Pia explained that she regularly reviews the plans and updates them when necessary. “We stress safety first, client enjoyment, and client interest. We don’t want the clients to just sit. We want them to enjoy their time with us.” The programs include a number of supervised activities, including outings, various therapies (music, reality orientaton, remotivation, etc.), skills training, exercises, breakfast, lunch, and a snack.

Each center has distinct features. At Waianae, the program is available seven days a week, including holidays, and accepts those who need more attention. The program at Wahiawa allows only a few clients, but offers a fenced, home-like setting “where individuals can wander at will.” The recently-opened Waialua Center is located in an area church, and Hale Kako‘o, associated with the Alzheimer’s Association, accommodates individuals suffering from Alzheimer’s Disease and related disorders. Costs range from $40.00 a day at Waianae to $50.00 a day at the other areas. Various sources of public and private funding are available to those who qualify.

Program hours differ slightly, but generally begin at 8:00 a.m. Extended hours (until 7:00 p.m.) will soon be available at some of the centers. For more information on hours, qualifications, or financial assistance, please call Rosanna Evers at 696-4944 or 227-2178.

In addition to her work at WCCHC, Ms. Evers operates Respite Nanea, offering short-term, 24-hour care in private respite homes. “I saw the need to give caregivers the option of time away,” she explained when describing the 1986 start of her business. Respite Nanea distinguishes itself from other programs by its flexibility, fast response, and availability of private homes located throughout the island. Referrals often come from hospitals and various agencies. Occasionally, caregiver emergencies require immediate alternate care. “We have often found a care home, respite home, or private-duty CNA within minutes.” For others with time to plan, Ms. Evers will provide a list of care providers for caregivers to interview and visit. Cost for respite stays is approximately $130 a day. Respite Nanea will also assist with long-term care and short-term care placement in licensed care homes. “Since Respite Nanea started in 1986, there has not been one day without a client.”

Anyone interested in Respite Nanea can call the Physician’s Exchange (524-2575) 24 hours a day.

For about six years, Rachel and Elaine Sato, former primary caregivers, have served as trained volunteer counselors at Sage Plus, a federally-funded state health insurance and assistance program, directed by the state’s Executive Office on Aging. Both respond to inquiries and give presentations on Medicare, Medicaid, and related topics. Rachel and Elaine have both retired from professional careers and now donate much of their time to community service. Both are active members of our group. Rachel has also been facilitator of the Wahiawa/Mililani Alzheimer’s Support Group for almost nine years.

Medicare is a health insurance program for: (1) individuals 65 or older; (2) people under age 65 with disabilities; (3) people with end-stage renal disease (kidney failure, requiring dialysis or a kidney transplant). Those who have paid 40 quarters of work-related Medicare taxes receive Part A of the insurance premium free. Benefits can still be obtained for those who have earned less than 40 quarters by paying a monthly amount.

Part A. According to Rachel, for hospital benefits, in 2004, you will pay:

In addition, Medicare Part A includes benefits for skilled nursing facility care, home health care, and hospice care.

Part B. Covers doctor’s visits, x-rays, and services not covered by Part A. The monthly premium is $66.60 for 2004, with an annual deductible of $100.

Medicaid, according to Elaine, “provides medical assistance to individuals with an asset limit of $2000 ($3000 for couples). The income limit is $892 a month; for couples $1197. The program is funded by the federal and state governments and administered by the MedQuest Division of the Department of Human Services.”

Regarding Skilled Nursing Facility care, Elaine explained “new rules now require that homes placed in irrevocable trusts be taken out of the trusts when an individual enters a nursing facility. Homes held in revocable living trusts are considered assets.” The home is exempt if the individual can declare their intentions to return once discharged from the facility. Otherwise, the state may seek to recover costs by placing liens on the property of a Medicaid recipient whose stay in a facility is likely to be permanent. Recovery of the property will not be made while the following individuals lawfully reside:

Discount Drug Card Program is an interim measure until 2006 when Medicare’s new prescription drug benefit starts. Hawaii residents must choose from the approximately 75 national cards available. According to Elaine, “individuals with no drug plans or who rely on lower incomes might find the cards beneficial.”

Because laws and policies frequently change, Rachel suggests that interested persons call: MedQuest (587-3521), SagePLUS (586-7299) or Medicare (1-800-633-4227).

Exploring the issues of caregiving can sometimes lead to an examination of cultural beliefs, of physiological responses, and of a role that can touch almost all aspects of one’s life.

Linda McLaughlin, Ph.D., M.S.W., has worked as a medical social worker in home care and hospice agencies on Oahu. Currently with the University of Hawaii’s Cancer Research Center, she has been directing a study designed to explore the experiences and emotional situations of family caregivers. She hopes that, ultimately, study findings will contribute to better services for all Hawaii caregivers.

According to Dr. McLaughlin, other caregiver groups will be contacted to delve into issues of stress, grief, and perceived major concerns.

Grieving. For many caregivers, grieving starts long before the loss of a loved one occurs. “Do you recognize it? Do you attend to it? What causes grief?” Dr. McLaughlin inquired as she described the anticipatory grief and sadness from “little losses” that often occur “along the way.”

One member responded that seeing a once strong, intelligent parent become frail and less capable brought much sadness, as did witnessing failing memories, physical decline, inability to eat regular food, or to enjoy grandchildren. Grief came from the caregiver’s realization that, despite best efforts, conditions for the ailing person rarely improved or returned to the “way it used to be.”

Stress. “Do you ever feel that there are too many plates spinning at once, or that you are juggling all the time?” Dr. McLaughlin asked. She explained that in response to stress, the adrenal glands pump adrenaline and cortisol into the system, much as when the body prepares for a flight or fright response. Prolonged stress keeps levels high, which results in difficulty sleeping, becoming snappish, lashing out — further aggravating feelings of guilt and depression.

“The relationship between stress and grief comes,” she explained, “when someone may be too stressed and too busy to acknowledge grief and sadness. We need to pay attention to the little losses along the way and do something about it.”

Dr. McLaughlin asked whether caregiving brought any enjoyment. A member expressed that she could enjoy her mother’s unfailing sense of humor. Another stated that she was grateful for the chance to care for her husband. Many members agreed that despite difficulties, treasured moments existed.

Culture. “Cultural beliefs, practices, and background could also influence how caregivers deal with stress and grief, according to Dr. McLaughlin. “In our society, we, generally, come from collectivist cultures or individualist cultures. Neither culture is better or worse, right or wrong.” She went on to say that those from a collectivist culture often put family needs ahead of their own needs, while an individualist’s needs occasionally seem to outweigh those of the family.

In some cultures, it is very normal to express grief along the way, to openly cry. In other cultures, it is “No, we keep that emotion hidden, set it aside because we need to focus on caring for our family member.” A member offered that the Japanese custom of the eldest son being responsible for family care can no longer be assumed because of present day situations. Another member mentioned that, for the caregiver, cultural traditions sometimes create stress when time does not allow doing all that is expected.

“How do you cope?” Dr. McLaughlin asked. One member said that prayer helped. Another member found relief by talking to other caregivers. “Seek help to cope with stress and grief,” Dr. McLaughlin emphasized. “Get help through a support group or professional counselors. Everyone can benefit from assistance.”

Anyone interested in learning more about the study can reach Dr. McLaughlin at the Cancer Research Center of Hawaii, 586-2978.

Our guest speaker, Mr. Roy Doi, is a partner with Kobayashi, Doi, and Lum, CPAs. The firm maintains offices in Wahiawa and Honolulu. In addition to being a member of several professional CPA organizations, he has been Chair of Mililani Mauka/Launani Valley Neighborhood Board #35, and President of Wahiawa Community and Business Association. He is a current member of the Board of Directors, Wahiawa Hospital Association and Wahiawa General Hospital.

“Don’t take notes, just listen,” suggested Doi, as he explained his discussion would introduce data on household employees, tests for claiming dependents, medical deductions and exemptions. “The tax code contains so many variables and scenarios,” he described, comparing the sometimes complex code to rotating your right leg clockwise, while shaping the number six with your right hand (a baffling exercise indeed).

Household Employees. “If you have a household employee/caregiver who is not attached to an agency or who does not have their own business license, and you tell them when to come to work, what to do, and how to do it, you become that person’s employer. You may then need to pay certain taxes, such as federal and state unemployment tax and the employer’s share of Social Security and Medicare taxes,” explained Doi. “In addition, you will need to withhold the employee’s share of Social Security and Medicare taxes, as well as their federal and state income taxes. You will also need to obtain an employer identification number (Form SS-4) and have the employee complete a W-4 (Income Tax Withholding Form)." Although not a “tax” per se, another expense is the worker’s compensation insurance, which employers must provide.

Doi has found that most families choose not to be employers, but instead prefer to hire independent contractors (who pay their own taxes) or caregivers affiliated with agencies.

Dependency. You can deduct medical costs for you, your spouse, your dependents, and medical dependents. In general, the person claimed must pass five basic tax dependency tests. (For medical dependent, Tests 1, 3, and 4 apply).

1. Member of Household or Relationship Test. Must either live in the home all year or be a qualified relative. The IRS allows you to claim your child (birth or adopted), stepchild, grandchild, great grandchild, brother, sister, step or half sibling, parent, stepparent, grandparent, aunt, uncle, nephew, or immediate in-laws. The individual does not have to live with you. There are special rules for foster children and cousins.

2. Gross Income Test. The person’s gross income must be less than the annual exemption of $3,100 (2004). This restriction doesn’t apply to children younger than 19 at the end of the tax year or full-time students under the age of 24.

3. Support Test. Taxpayer must have provided more than half the person’s total support. This includes food, clothing, shelter, education, medical expenses, and recreational costs.

4. Citizenship or Residency Test. The person must be either a U.S. citizen or resident of Canada or Mexico for at least some part of the tax year for which the person is claimed.

5. Joint Return Test. You cannot claim as dependent anyone who files a joint tax return with someone else.

Because of individual circumstances, Doi recommends individuals consult a tax professional.

Medical Expenses.

Home Improvements. Although a number of doctor prescribed home improvements qualify as medical expenses, existing rules often limit the amount that can be deducted. For example, only expenses that exceed 7.5% of Adjusted Gross Income (AGI) can be deducted. If you add an improvement that increases the property value of your home, you can only deduct the difference between the cost of the improvement and the property value increase. To avoid IRS challenges, consult a tax professional about home improvement medical deductions.

Nursing Services. The services need not be performed by a nurse, but must be connected with caring for the patient’s condition. If the attendant also performs personal and household services, that time, in general, is not considered a medical expense.

Prescribed medicines and drugs, stop-smoking programs, exercise and weight-reduction programs are also allowable medical care costs.

Doi explained that the information provided has been chosen to give caregivers an idea of the types of deductions and exemptions that may apply to their situations. He reiterated that any claims should be confirmed with their accountants. Anyone with questions for Roy Doi should call him at 622-4188.

by Wes Lum, CRI Project Coordinator

The Caregivers Resource Initiative (CRI) Project continues to support Hawaii’s family caregivers through its quarterly newsletters, caregiver website, and the Hawaii Family Caregiver Network. Most recently, the CRI Project has played a major leadership role in the development of the Hawaii Caregiver Coalition.

The Hawaii Caregiver Coalition currently has a statewide membership of over forty individuals representing key organizations of various categories such as the Area Agencies on Aging, adult day care, family caregivers, business, health care, disability-related, kinship care-related, advocacy, faith-based organizations, government, and universities. Marilyn Lee and Lani Nedbalek have participated in its strategic planning sessions and represent the Central Oahu Caregivers’ Support Group.

The Caregiver Coalition has spent considerable time coming to consensus on its vision, mission, and goals because of the importance in developing buy-in and commitment. In the near future, the group will focus on articulating short-term goals, objectives, and projects.

In addition to facilitating the development of the Hawaii Caregiver Coalition, the CRI Project played a significant role in responding to legislation that passed last year. The 2004 Legislature adopted House Concurrent Resolution No. 154, requesting the Executive Office on Aging (EOA) to provide data on Hawaii’s family caregivers and the older adults to whom they provide assistance. In response to the resolution, the CRI Project assisted EOA in focus group data collection sessions that would aid in providing recommendations on caregiver data needs and usages for Hawaii. The need for statewide caregiver data was heightened during the 2004 Legislature when advocates needed more definitive statistics to garner support for caregiver-related proposals, particularly legislation that offered financial relief and incentives to family caregivers.

In 2005, the CRI Project will also be busy focusing on supporting kincare caregivers. EOA has been awarded a $10,000 seed grant as part of the Brookdale Relatives as Parents Program State Initiative. In an effort to support grandparents who are raising grandchildren, EOA will be offering mini-grants to community groups to subsidize the cost of providing educational opportunities and/or incentives to generate attendance at grandparent support group meetings.

There is still lots of work to be done. The CRI Project will be working in partnership with our caregiving community to address important, complex issues such as financially supporting family caregivers, expanding respite services, and balancing caregiving and employment.

If you would like more information about the CRI Project, please contact Wes Lum at 586-7319 or wlwlum@mail.health.state.hi.us.