Vision Work - coverage options with Medicare FFS +/- Medicaid

Published May 23rd, 2025 by Mike Wong

● Medicare FFS only covers: annual eye exam in diabetics, annual glaucoma testing in high risk (diabetics, fam hx of glaucoma, >50yrs and african american, >65yrs and hispanic), certain tests/treatments for age related macular degeneration, and one pair of glasses after approved cataract surgery with an intraocular lens (1, 2) ● Medi-Cal cover

Decision-making Capacity & Competence

Published May 23rd, 2025 by Mike Wong

● There are currently no formal practice guidelines from professional societies for the assessment of a patient's capacity to consent to treatment. ● Any physician can declare someone with capacity & competence. In certain legal settings, some attorneys, judges will require a physician trained in a specific clinical specialty (neurology, psychia

Role of Marajuana [TBD]

Published May 23rd, 2025 by Mike Wong

● Clinical trials underway based on benefits for agitation & sleep ● There are risks ● TBD: CBD vs THC

Dementia Prevention Tips That Don't Require Medications

Published May 23rd, 2025 by Mike Wong

A recent 2024 study published in a well known medical journal reviewed the available studies (systematic reviews and meta-analysis) for ways to decrease dementia & progression They recommended the following 13 actions across 14 risk factors: Ensure good quality education is available for all and encourage cognitively stimulating activities in mi

FAQ About Hospice

Published May 23rd, 2025 by Mike Wong

● Bias/Myth #1: It is common that hospice is associated in the general public as a service for just those with cancer at the very end of life. This is not true. It is a service for those with many other conditions including dementia, and meant for more than just the last few weeks of life. ● It is common that hospice is started TOO late in the cours

VA Benefit Eligibility Matrix

Published May 23rd, 2025 by Mike Wong

"Benefits depend on service connected disability ● https://benefits.va.gov/benefits/derivative_sc.asp" "10 point Veteran preference in federal hiring ● https://www.opm.gov/policy-data-oversight/veterans-services/vet-guide-for-hr-professionals/#2 " "No cost health care and prescription drugs for service connected disabilities (if income limits are me

Urine Incontinence/Urgency Treatment - Non-Pharmocologic

Published May 23rd, 2025 by Mike Wong

● The average patient only needs 40-50 ounces of all fluids in a day ● Reduce overall fluid consumption and specifically reduce evening intake ● Reduce salt intake, particularly for those with congestive heart failure. Major sources of salt come from processed/packaged foods, eating out, snacks, soups. ● Reduce evening consumption of diuretic drinks

Unsteady Gait/Falls/Difficulty getting up from chair Intervention Tips N Tricks

Published May 23rd, 2025 by Mike Wong

● Med review: identify meds (causing orthostatic symptoms, high dose statins causing proximal weakness) and OTC meds that may be causing drug interactions ● Consider ruling out UTI ● Home Health PT/OT assessment for home safety assessment, transfer training, and muscle strengthening ● Home Modificaitons: https://www.ncoa.org/article/18-steps-to-fall

Motorized recliner chairs - Medicare pay for? (GJ 12/1/24)

Published May 23rd, 2025 by Mike Wong

● Medicare pays 80% of the cost for motorized lifting device (not chair itself) in recliner chair if ALL of the following are met: patient has severe arthritis of hip or knee or a severe neuromuscular disease, patient is completely incapable of standing up from regular chair, patient can walk with/without assistive device once standing, and the seat

MediCal - Paid caregiving options and placement options outside the home, day programs

Published May 23rd, 2025 by Mike Wong

● MediCal doesn’t pay for assisted living or board in care (unless you are approved on the waiver program which has an average 4 year wait time) ● Medi-cal will however pay for these 6 things to help someone remain at home: ● IHSS (in-home care) ● Custodial care at a skilled nursing facility ● Assisted living waiver program with MediCal - 4 years av

Loss of appetite

Published May 23rd, 2025 by Mike Wong

● rule out depression, work-up weight loss, other causes. ● With disease progression the loss of smell and taste is common in dementia. Neurohormonal process. ● Salt and sweet and texture best preserved. ● Liberalize access to salty, sweet, and textured foods to increase intake. ● In AD/ADRD (LBD > AD), there is direct injury to olfactory neurons

GLP-1 Agonists and Dementia

Published May 23rd, 2025 by Mike Wong

● Half life of most GLP-1 agonists is 47 days, so daily dosing is likely too excessive. Thin line between therapeutic dose and adverse effects. Micro dosing (significantly lower than dose used for weight loss) probably effective, but no actual data on best dose (1) ● Neurocognitive benefits are observed after a few months of use (1) ● GLP-1 agonists

UTI Sample Collection

Published May 23rd, 2025 by Mike Wong

● Pick up urine cup from the lab (LabCorp or Quest) prior ● As possible, catch the urine sample mid-stream ● Urine sample can be stored at room temperature up to 2 hours and refrigerated up to 48 hours ● Remember to COLLECT the urine sample FIRST before taking the first dose of antibiotic. If you take the first antibiotic dose, the urine culture wil

Eligibility for Medi-Cal: Income cutoffs for eligibility

Published May 23rd, 2025 by Mike Wong

● Income cutoffs are determined by the Federal Poverty Level (FLP). The FLP is updated annually on April 1. ● "To qualify for Medi-Cal, income cannot exceed 138% FLP. ● https://www.dhcs.ca.gov/services/medi-cal/Pages/DoYouQualifyForMedi-Cal.aspx ● https://ca.db101.org/ca/programs/health_coverage/medi_cal/program2a.htm " ● "Medi-Cal holders must rene

Medicare Open Enrollment

Published May 23rd, 2025 by Mike Wong

● Medicare Open Enrollment is Oct 15 - Dec & ● Medicare Advantage Open Enrollment is Jan 1 - March 31 ● Medi-Cal Open Enrollment Version: YT 2/28/2025

Advance Care Planning, Advance Directive, POLST, Medical Decision Maker vs Financial Decision Maker, Living Will, Trust tips and Tricks

Published May 23rd, 2025 by Mike Wong

● Advance Care Planning is a discussion around a patient & their loved ones' treatment preferences, identifying a surrogate, and identifying goals of care. ● The advance directive legally documents the patient/loved one decisions around advanced care planning ● Advance directive document accomplishes 2 main things: 1) documents big picture decis

Which Medi-Cal Option is relevant to me?

Published May 23rd, 2025 by Mike Wong

● "If you are aged or disabled, and are not eligible for SSI, you may be able to get Medi-Cal through the Aged & Disabled Federal Poverty Level (A&D FPL) program. You must: ● Be either aged (65+), or disabled (meet Social Security’s definition of disability, even if your disability is blindness) ● Have less than $1,732 in countable monthly i

Caregiver Style around caregiving [TBD]

Published May 23rd, 2025 by Mike Wong

Caregiver Overview: Basics of what to know

Published May 23rd, 2025 by Mike Wong

https://www.aoascc.org/Customer-Content/www/CMS/files/info_library/Becoming_a_Caregiver.pdf Version: YT 1/2025

Wandering Alert devices tips and tricks

Published May 23rd, 2025 by Mike Wong

● Home monitoring - cameras for wandering ● Door alert/alarm ● Door confounding lock ● Stop sign banner ● Door Mural ● https://www.alzstore.com/searchresults.asp?Search=wandering&Submit= Version: YT 1/2025

Motivational Interviewing/OARS

Published May 23rd, 2025 by Mike Wong

● Motivational interviewing (MI) uses the OARS technique (Open-ended questions, Affirmations, Reflective listening, and Summaries) as its core communication skills. ● It allows practitioners to effectively engage clients, build rapport, and elicit their own motivation for change, rather than imposing solutions, by encouraging them to explore their t

Sleep

Published May 23rd, 2025 by Mike Wong

● RBD = REM sleep behavior disorder. ● Trial SSRI to help correct sleep cycle: ○ First line SSRI: lexapro or zoloft. ■ If you need something activating, and makes you more alert during the day, then use prozac in the morning. ■ If you need something that causes sleepiness at night, trial paxil at night time. ● Melatonin 2-3mg one hour before bedtime

Fall Alert Devices

Published May 23rd, 2025 by Mike Wong

● "Website that compares medical alert devices, including fall alert devices https://www.medicalalertscompared.com/bracelets?utm_source=google&utm_term=fall%20alert%20systems&externalcreative=671786745240&p=&utm_content=&utm_ad=155813388191&utm_medium=kwd-12350096125&externalcampaign=20501749865&matchtype=e&ts=&am

Communication Options for Complete or Near-Complete Hearing Loss, Speech to Text

Published May 23rd, 2025 by Mike Wong

● "TTY = Teletypewriter ● Conversation is typed on special equipment and users read text based messages." ● "CapTel = Captioned Telephone ● Similar to TTY. Special phone equipment that provides real time captions on voice calls. ● Free through a federally funded program compliant with the Americans with Disability Act. 3 options: a. Patient fills ou

Doses used in Cognitive Impairment Studies

Published May 23rd, 2025 by Mike Wong

● Medication: Dulaglutide (Trulicity) ○ Dose: 1.5 mg subcutaneous injection weekly for two years. Start 0.75mg once weekly for 4 weeks, then 1.5mg when minimal/no GI side effects ● Medication: Exanitide (Bydureon) ○ Dose: 2 mg subcutaneous injection weekly for one year. Comes only 2mg dose ● Medication: Liraglutide (Victoza) ○ Dose: 1.8 mg subcutane

Depression

Published May 23rd, 2025 by Mike Wong

● Depression is hard to screen for/catch in someone with advanced dementia ● It can present as apathy, sleep disturbance, behavioral issues ● When in doubt do a 3 month trial of a SSRI. There is very little downside. ● Ask the caregiver if a difference is noted at 1 - 3 months. It's not surprising to hear that the individual has had less "behavioral

Hearing Loss - coverage options with Medicare FFS +/- Medicaid PLUS hearing aid Tips N Tricks

Published May 23rd, 2025 by Mike Wong

● Correct hearing to improve cognitive function ● A key challenge is that hearing aides cost thousands of dollars with questions about quality/comfort. ● Costco has cost effective hearing aides ● $99 hearing aide that can be gotten WITHOUT a prescription: https://go.thegrommet.com/featured/atom/?utm_source=liveintent&utm_content=1387633&live

IHSS (In Home Supportive Services) Tips N Tricks

Published May 23rd, 2025 by Mike Wong

● "In Home Supportive Services" available to those on Medi-Cal that do not reside in a nursing home ● Family members and non-family members providing care can get paid for their caregiving ● https://ihssadvocate.com/how-to-get-ihss/ ● https://www.cdss.ca.gov/in-home-supportive-services ● Forms to complete: ● Health Care Certification Form - https://

Home Modifications: 18 steps to fall-proof home PLUS Medicaid benefits to cover

Published May 23rd, 2025 by Mike Wong

● https://www.ncoa.org/article/18-steps-to-fall-proofing-your-home/ ● Through Medicaid and home and community based waiver program, you can get the following home modifications covered: ○ "Wheelchair ramps ○ Grab bars and handrails ○ Lighting adaptations ○ Doorway widening ○ Shower modifications ○ Stair/wheelchair lifts ○ Accessible handles ○ Medica

Teach Back

Published May 23rd, 2025 by Mike Wong

● Technique used to check someone's understanding. This practice helps in assessing someone who understood the discussion, was paying attention, and/or has competence. This is an important step to support "adherence" and "buy-in" to treatment or care plans. ● Script: "To make sure I understood you well, what did you hear regarding XXX or what are th

VA - paid caregiving options and placement options outside the home, day programs

Published May 23rd, 2025 by Mike Wong

● VA doesn't pay for RCFEs (assisted living, personal care homes) ● VA pays for home care/caregivers through Aid and Attendance Benefits ● VA pays for custodial care at skilled nursing facility through Aid and Attendance Benefits ● VA pays for Day Programs through Aid and Attendance Benefits ● https://aging.ca.gov/Care_Options/Adult_Day_Services_Pro

Behavior Help Tips/Tricks:

Published May 23rd, 2025 by Mike Wong

● Use pictures to aid communication. Someone with dementia is more likely to remember with pictures than spoken ● Sing instead of speak to communicate. More likely to remember/engage positively ● Use a weighted blanket to help with sleep at night. The weight is comforting. Purchase on Amazon.com ● Address boredom Version: YT 1/2025

Eligibility for Medi-Cal: Income cutoffs for eligibility

Published May 23rd, 2025 by Mike Wong

● Income cutoffs are determined by Federal Poverty Level (FLP). The FLP is updated annually on April 1. ● "To qualify for Medi-Cal, income cannot exceed 138% FLP. ● https://www.dhcs.ca.gov/services/medi-cal/Pages/DoYouQualifyForMedi-Cal.aspx ● https://ca.db101.org/ca/programs/health_coverage/medi_cal/program2a.htm " ● "Medi-Cal holders must renew be

GLP-1 drug REFERENCE

Published May 23rd, 2025 by Mike Wong

● Benefits: Reductions in CV death & MI. Wt loss. Cognitive improvement? ● All once weekly subcutaneous injections ● Can use with insulin (lower the insulin dose) ● Can use with SGLT2 (like empagliflozin (Jardiance), canagliflozin (Invokana), and dapagliflozin (Farxiga)) ● Don't add onto DPP-4 agents (sitagliptin (Januvia), linagliptin (Tradjent

Brain Exercises in Dementia

Published May 23rd, 2025 by Mike Wong

● Activity programs tailored to the PLWD appear to improve quality of life, decrease neuropsychiatric symptoms, and decrease caregiver burden. (1) ● Brain exercises can help delay onset of dementia and/or improve symptoms in PLWD. The most important thing is to find one the PLWD enjoys and will continue to do. (2) ● Examples of brain exercises: cros

Caregiver - Self Care Ideas tips and tricks

Published May 23rd, 2025 by Mike Wong

Version: YT 11/20/2024

UTI Sample Collection

Published May 23rd, 2025 by Mike Wong

● Pick up urine cup from the lab (LabCorp) prior ● As possible, catch the urine sample mid-stream ● Urine sample can be stored at room temperature up to 2 hours and refrigerated up to 48 hours ● Remember to COLLECT the urine sample FIRST before taking the first dose of antibiotic. If you take the first antibiotic dose, the urine culture will be unre

SMART Goals

Published May 23rd, 2025 by Mike Wong

● SMART stands for "Specific", "Measurable", "Attainable or Actionable", "Relevant", and "Time Bound/Specified". It is a tool used to support goal-oriented plans. ● For patient/family-stated goals, SMART steps can be decided together with the family. Version: YT 1/2025 Setting SMART goals Creating and working towards goals is one of the most effecti

Elder Abuse - How to recognize

Published May 23rd, 2025 by Mike Wong

● No validated screening tool for elder abuse (financial, verbal, physical, sexual) ● Tips for staff to recognize any form of elder abuse (Yumi thoughts): Any interaction between PLD and caregiver observed that makes the staff uncomfortable OR caregiver behavior toward the staff that makes them uncomfortable; neglect - persistent physical appearance

Locating a GUIDE program by zip code. For individuals outside our county service area

Published May 23rd, 2025 by Mike Wong

● To find participating programs in your area, please visit: https://www.cms.gov/priorities/innovation/where-innovation-happening#model=guiding-an-improved-dementia-experience-guide-model. ● Scroll to the map, select Guiding an Improved Dementia Experience (GUIDE) Model from the Model list, and click Display Selected. Then click on the number closes

Medicare Beneficiary # / My Medicare Card / Medicare Eligibility Checking

Published May 23rd, 2025 by Mike Wong

● Your first and last name have to exactly match, otherwise we can't determine your Medicare eligibility ● Your social security # was replaced by a unique Medicare Beneficiary # (series of letters and #) to locate your Medicare coverage. This is for your identity safety. ● Request a new Medicare card for this # OR create an account/log on to Medicar

Pain Management in Dementia

Published May 23rd, 2025 by Mike Wong

● 1ST LINE - Non pharmacologic options: ○ Positioning/Re-positioning ○ Massage therapy ○ Heat pack for stiffness / Cold pack for inflammation ○ Physical Therapy ○ Music Therapy - playing music can temporarily distract and release natural endorphins that reduce pain. 1 ● 2ND LINE - Pharmacologic options (ALL HAVE SOME RISK): ○ "Tylenol - caution if h

Diabetes and Dementia

Published May 23rd, 2025 by Mike Wong

● There is an increased risk for hypoglycemia (LOW blood sugars) for those on certain diabetes medications AND this risk increases with dementia. ● As well, as your dementia progresses, we are less strict about your diabetes blood sugar control. The risks of tight diabetes control outweigh the benefits. ● Recommended changes are to stop medications

UTI Treatment

Published May 23rd, 2025 by Mike Wong

● Current workflow: Start keflex (cephalexin) and send urinalysis with reflex urine culture orders at same time. Counsel the family to OBTAIN urine sample BEFORE the first antibiotic use otherwise it wipes out the urine culture (i.e. we can't tell if the antibiotic will work) ● If there is an allergy to penicillin, counsel there may be cross-over re

Med Adherence Tips and Tricks

Published May 23rd, 2025 by Mike Wong

● Minimize # of medications (less is more) ● Minimize # of over-the-counter drugs (less is more) ● Change twice or three times daily drugs to extended release, once daily ● Make sure meds are all generic & minimize prior auths (as possible) ● Increase prescription refills from 30 days to 90 days ● Simplify insulin regimens (Diabetes patients) ●

Drugs that may delay dementia progression Lecanemab/Donanemab

Published May 23rd, 2025 by Mike Wong

● Individuals with mild cognitive impairment and Alzheimer type early stage dementia are eligible ● The 2 approved drugs are lecanemab and donanemab ● They are a monoclonal antibody that attaches to amyloid beta, a protein that builds up in the brains of people with Alzheimer's. This buildup is thought to be toxic to brain cells, causing them to die

Blood Pressure and Dementia

Published May 23rd, 2025 by Mike Wong

● There is an increased risk for LOW blood pressure, particularly when you stand up on blood pressure medications. This risk increases as you age, when you take multiple medications, and when you lose weight/muscle mass. It leads to feeling lightheaded, unsteady, and falling. ● As well, as age and dementia progresses, we are less strict about your b

How our services are paid

Published May 23rd, 2025 by Mike Wong

● We bill Medicare, not the patient for all our services. ● Most of the services are covered 100% by Medicare ● We bill Medicare for all our services. Most of our services are paid through Medicare 100% at no cost to you. ● Most of your support, messaging & check-ins will happen between a care navigator and the family caregiver and their service

DME Supplies

Published May 23rd, 2025 by Mike Wong

Medicare DOES pay for ● Blood sugar meters ● Blood sugar test strips ● Canes ● Commode chairs ● Continuous passive motion machines, devices & accessories ● Continuous Positive Airway Pressure (CPAP) machines ● Crutches ● Hospital beds ● Infusion pumps & supplies ● Nebulizers & nebulizer medications ● Oxygen equipment & accessories ●

FMLA - Can I take time off work for paid caregiving?

Published May 23rd, 2025 by Mike Wong

● CA has paid FMLA up to 8 weeks and up to 12 weeks unpaid, job-protected ● FMLA can be used for caregiving ● Q&A: https://legalaidatwork.org/wp-content/uploads/2023/08/PFL_Caregiver_Resource_9.pdf ● Apply for FMLA: www.edd.ca.gov/ ○ Have family caregiver's primary care team complete paperwork Version: YT 1/2025

Behavior Change: Delirium:

Published May 23rd, 2025 by Mike Wong

https://ucsf.app.box.com/v/DeliriumDementia Version: YT 1/2025

Medications to manage behavior changes

Published May 23rd, 2025 by Mike Wong

● All atypical anti-psychotic drugs have morbidity/mortality risk. ● Discuss risks w/ caregiver vs quality of life ● If you don't need something urgently, then do SSRI FIRST, regardless of whether there are OVERT symptoms of depression. Depression hard to screen/catch in someone with advanced dementia ● First line SSRI: lexapro or zoloft. ○ If you n

Long Term Care

Published May 23rd, 2025 by Mike Wong

Common Variables: ● Facility benefits: Duration? ie 3 years ● Covers which facility types: ie licensed facility (see on Medicare.gov) NH and RCFEs and memory unit in the nursing home. ● Covers what percentage of those facilities: ie NH (100%) and RCFEs (75%). Covers memory unit in the nursing home. ● Professional Home Care?: ie by a licensed profess

Nursing home (Assisted living, personal care homes) - checklist to evaluate

Published May 23rd, 2025 by Mike Wong

● How well do they know where the individual is at all times like for example whether they are using their walking devices so they don't fall or attending social activities? ie staffing ratio, staff culture, cameras/monitors ● How much do they encourage/support individuals to do group social activities? ie do they bring them out to a central dining

Medi-Cal Income Eligibility tip n trick

Published May 23rd, 2025 by Mike Wong

● "https://www.dhcs.ca.gov/Pages/Asset-Limit-Changes.aspx ● Starting January 1, 2024, assets will no longer be counted to determine Medi-Cal eligibility!" ● Eligibility for Medi-Cal is based on income and is renewed annually. Your INCOME cannot exceed ~$1,700 in countable monthly income as an individual (~$2,300 for a couple). ● "Examples of INCOME

See One, Do One, Teach One

Published May 23rd, 2025 by Mike Wong

A common teaching method around teaching something new. It is first showing how to do the task, then observing that person doing the task, then observing that person teaching the task to someone else. In all 3 scenarios, feedback is given especially in do one and teach one where the best hands-on learning happens. Version: YT 1/2025

Referral to neurologist when and brain MRI when:

Published May 23rd, 2025 by Mike Wong

● Young age onset (<65) ● Rapidly progressing symptoms over weeks to months ● Atypical clinical features or complex medical history ● Concerning neurological symptoms present (gait, language, rigidity) ● When a clarification of a diagnosis is requested by family ● Try to get a brain MRI prior to the referral. Version: YT 1/2025

Driving, Safety [TBD]

Published May 23rd, 2025 by Mike Wong

● Driving assessment ● Reporting to DMV

Dental Work - coverage options with Medicare FFS +/- Medicaid

Published May 23rd, 2025 by Mike Wong

● Medicare FFS typically does not cover dental services directly supporting the teeth, unless the patient requires hospitalization due to an underlying medical condition / clinical status or severity of the dental procedure (1) ● Medicare does cover dental services when they are inextricably linked to the clinical success of other medicare covered s

RCFE (Assisted living, personal care homes) - checklist to evaluate

Published May 23rd, 2025 by Mike Wong

Timely in communication, short staffed, quality, what supports can they provide. https://aging.ca.gov/Care_Options/Assisted_Living_Facilities/ Version: YT 1/2025

Toilet Lifts

Published May 23rd, 2025 by Mike Wong

● Availability: In store - Lowes, Walmart, Home Depot, etc.. vs Online - Amazon, various supplier websites, etc… ● "Wide range of prices and couple different types: ○ Toilet seat elevator/riser (no battery power, basically just raised handles and seat to help some sit down and get up, cheapest option, prices usually $50 or less) ○ Carex 3.5 Inch Rai