Podcasts about ltss

Caring for Boomer Generation: Building Upon History To Plan The FutureAs the baby boomer generation ages, America's current long-term service and support system (LTSS) faces mounting pressure. With the volume of seniors requiring care increasing, it's becoming clear that our existing infrastructure has opportunities to build person-centered systems to meet the needs and desires of this growing population. In this episode, we dive into how we can learn from our past to understand the critical need for expanding Home and Community-Based Services (HCBS), allowing more seniors to age in place while ensuring institutional services remain available for those who need them most. Join us as we explore what this shift means for families, healthcare providers, and policymakers and how it could reshape the future of aging in America.Objectives: Discuss societal history impacting the evolution of caring for the aging population. Describe characteristics of populations impacting the care of the aging population.Explain future considerations in the care of the aging population. Guests: Ashley l Ebert, MSN, ARNP, FNP-CWith over a decade of experience as a nurse practitioner, Ashley has spent 8 years mastering acute care across diverse settings and just over 2 years specializing in geriatric care.  In both roles, she has led initiatives to enhance quality care, advocated for better access to healthcare, and focused on the unique needs of rural communities.  Her passion lies in people leadership and fostering the growth and development of clinicians to ensure long-term success in the field of healthcare.She is honored to have been selected as her company's Senior Living representative for a national Townhall, sitting alongside senior leaders, bringing collaboration and a focus on improved care transitions to the forefront.  Additionally, Ashley was selected as a co-chair for a company-wide NP group, which boasts a vibrant community of nearly 5000 members, where she helps create a space for connection, professional growth, and networking.Casey Fowler, DNP, ARNP, FNP-C, GS-C, FAANPCasey Fowler is a family nurse practitioner sub-specialized in geriatrics. He has been working with older adults in institutional and community-based settings for more than fifteen years. The last eight years, he has been leading other nursing professionals caring for this population, and he has been advancing his knowledge in leadership. Casey earned his Doctor of Nursing Practice from Gonzaga University in 2015, studying the use of nonpharmacologic interventions for behavioral and psychological symptoms of dementia using the middle-range nursing theory of Person-Centred Care as described by McCormack and McCance. Casey has gone on to apply these principles to his leadership style, in what he calls person-centered leadership. Casey has been a speaker at many local, regional, and national events on a variety of topics, and this year, he was inducted into the Fellows of the American Association of Nurse Practitioners for his work building the first postgraduate fellowship for nurse practitioners to gain specialty training in geriatrics and complex adults as well as his work developing other leaders in his field. Casey's current focus is on leveraging our nation's resources to best care for our aging population in a way that meets the needs of both rural and urban populations.References: Administration for Community Living. (2-24, February 27). Retrieved from Administration for Community Living: https://acl.gov/news-and-events/announcements/acls-dcw-strategies-center-launches-multi-pronged-effort-strengthenAlzheimer's Association. (2011). Generation Alzheimer's: The Defining Disease of the Baby Boomers. Retrieved from Alzheimer's Association

Join us for this enlightening episode of VRTAC-QM Manager Minute, where we explore the transformative power of Value-Based Purchasing (VBP), also known as Performance-Based Payment (PBP). In the studio, we have Chip Kenney, Co-Project Director of the VRTAC-QM, and Lisa Mills, a consultant and subject matter expert in VBP, sharing their expertise. VBP is more than just a financial model—it's a strategic shift designed to drive better outcomes for individuals with disabilities. By aligning provider incentives with measurable performance outcomes, State Vocational Rehabilitation Agencies (SVRAs) can enhance the quality of services, improve consumer results, and optimize costs. Tune in to hear Chip and Lisa discuss how SVRAs can harness the power of this approach to revolutionize service delivery and create a meaningful impact. Whether you're considering adopting VBP or seeking to refine your approach, this episode is packed with insights you won't want to miss! Value-Based Payment Methodologies to Advance Competitive Integrated Employment: A Mix of Inspiring Examples from Across the Country   Listen Here   Full Transcript:   Chip: Virginia reached out and they wanted to include value based purchasing specifically in their Disability Innovation grant. I said, this is an opportunity we can't pass.   Lisa: Is there anything about our payment structure that incentivizes or rewards this kind of quality that we're saying we're not getting, thus reduce the amount we're investing in unsuccessful closures.   Chip: When we can get to that point where we can identify and measure and demonstrate and get quality outcomes that will move this whole system a gigantic step forward.   Intro Voice: Manager Minute brought to you by the VRTAC for Quality Management, Conversations powered by VR, one manager at a time, one minute at a time. Here is your host Carol Pankow.   Carol: Well, welcome to the manager minute. Joining me in the studio today are Chip Kenney, Co-Project Director of the VRTAC for Quality Management, and Lisa Mills, Consultant and Subject Matter Expert to the QM on Value-Based Purchasing. So here's a little context for our listeners. Value-Based Purchasing, also known as Performance-Based Payment, is a model that offers financial incentives to providers for meeting certain performance measures. And as state rehab agencies look to improve outcomes for individuals with disabilities, the quality of purchased VR services, and overall cost effectiveness. A Performance-Based approach might be an option, so I don't want to steal their thunder, and I'm going to let my guests discuss what they're doing today. So let's dig in. Lisa, lets' start with you. Can you tell us a little bit about yourself and how did you find your way kind of into this VR space?   Lisa: Sure. So I've been in the world of disabilities for my career, for the entire career. So, 33 years, I think where now I've lost count. But about 20 years ago, I got really interested in employment working with Self-advocates way back before there was such widespread support for ending Subminimum wage. You know, the support that we do see now, but that was at a time when that it wasn't even being discussed. But Self-advocates were very clear that they wanted to earn more money and have more opportunities. So I got interested in supported employment and why we weren't using it very much. And so I started working with Medicaid and long term support agencies on improving employment services and outcomes. Back then, there was something called the Medicaid Infrastructure Grants, which allowed states to create Medicaid buy ins for working individuals with disabilities. So I really dug in around what were we doing around employment services. And of course, that brought us to the relationship with VR. And about 16 years ago, I started working on customized employment and developing ways to pay for customized employment, and worked with a couple VR agencies at the time on payment structures for customize. And then most recently, I'm a mom of a transition age son who used VR supported employment services to get his first and second jobs, and he's been employed in competitive, integrated employment since 2020. He's about to turn 21 and that has changed his life. So I'm a firm believer.   Carol: Good for him. That's really cool to know. I always love it finding out the stories people have, because you never know, we all get here a different way. But I love your path. So Chipper over to you. And I'm going to say Chipper because I'm naughty. He Chip is my colleague. So for our listeners I do like to rib Chip a bit. So Chip, how did you find your way into the VR space?   Chip: So very similar to Lisa. My whole career has been in public rehabilitation for a bit then technical assistance centers, but fast forwarding to about 2009 was interested in customized employment and its applications, and the need for VR systems to have an employment system that really addressed what people with the most significant disabilities needed to be successful, and I was sort of glommed on to that space ever since. And then with the passage of WIOA, it just seemed a really necessary connection that VR agencies and systems have something new they can offer. People who would have considered going into sheltered employment now are coming out. What are you going to offer them that's new and different from when they went in and have been at it ever since, mainly focused on the implementation side of it, because there's a bunch of trainers in that space and they're all really good. But we learned early on that it takes an infrastructure to embed, implement and sustain customized employment over a period of time. And so that's been my focus the last several years. I mean, we're still learning a lot. And rate structure is part of that, which, I mean, I've known Lisa for years too, but rate structure is something every agency struggles with. And when the opportunity came to work with Lisa on this and move this forward, I thought, this is a big missing piece that we have to fill.   Carol: Absolutely, I'm underscoring that 100% because we know we get a lot of rate work with our QM work and the whole idea and customized employment with that sustainability. You can have the great idea. And we're going to do the thing and we're all excited. But then what happens. Year one and two and three and four as it goes on and it all fades away. And we don't want that to fade away. We need to have that good sustainability plan. So Chip, how did you get involved in bringing Lisa on board? What was kind of the impetus of that?   Chip: Virginia reached out. The state of Virginia reached out to us and they wanted to include value based purchasing. And they mentioned that specifically in their Disability Innovation grant, and somebody referred them to me. I mean, I knew a bit about it, but then as soon as I saw the Lisa connection and started reading her work on it, I said, this is an opportunity we can't pass, even though I don't have any experience. But Lisa brings all that and the knowledge and the background and said, it's really important to be a part of this.   Carol: Very cool. So, Lisa, I understand you have a very unique superpower. You can speak and interpret languages across multiple partner systems. How did you develop that?   Lisa: Well, I guess I'm a bit of a policy wonk. I did a lot of interviewing of people from different systems to try to understand what was going on with partnerships, what were the challenges. And this was probably 12, 13 years ago. I was doing some work with ODEP at the time, blending and braiding. And when I was doing a lot of my interviews interviewing the different partners, including VR, I figured out that a lot of what was going on at that time was sequencing. It was really not blending or braiding, and if we wanted to get to braiding and ultimately to blending, I felt like we really had to find what was going on then as something foundational, you know? And that's where I kind of coined the term sequencing and said, this is really what we're doing, but we can help people understand then what it means to switch from sequencing to braiding, what it means to switch from braiding to blending, and really start to get people interested in the advantages of moving away from sequencing. So it really was just wanting to dig into each system enough to figure out what solutions might improve collaboration and outcomes. Sometimes it can be easy to lay out all the issues, right? Everything that's not working, but to really dig into each system and figure out where could we align ourselves, where are we aligned, and we just don't realize it? That was more, I guess, the policy wonk side of me.   Carol: I love that because I think I've been on lots of work groups over the years, I mean, I just have when we've worked between, you know, departments of education and your state Department of like maybe developmental disabilities or whatever you are calling it back in the day. And then in the VR system when we all had different ways of describing everything and we could get stuck in the what's the problem? Here's all the problems. We got problems. We have a million problems. Here's all the hundred problems we have to get through before we can get to a solution. But if you go in and go, I love that. Like, how are we aligned right now and what are the things that we could build off of right now instead of always focusing on that whole myriad of things? But I think understanding each other, how we speak about things and we may say the same word, but it means something different to each of us. Once we can kind of clear up that dictionary and talk the same language, it makes it much easier to comprehend what's going on in each other's systems and how that can then work together. I love that you have that. So what is the essence of Value-Based Purchasing?   Lisa: So to me it's quality service combined with efficient service that results in quality outcomes. So I think about that. Efficiency without quality that would not lead to quality outcomes. We'd hurry up and do things, but we wouldn't really see the quality outcomes we wanted to see. And at the same time, if you have a quality service that goes on and on and on, you lose the cost effectiveness and you typically you lose the job seeker. They're going to give up or go find a job some other way. So to me, we have to recognize we need both quality and efficiency in the way services are delivered and that we have a set of quality outcomes we want to achieve. And we have to ask ourselves, to what extent are we getting those quality outcomes? And to me, if we can figure out a payment structure that balances rewarding quality and efficiency and is really clear about what is quality and service delivery, what is efficiency and service delivery, and then what are we looking for? As quality indicators and outcomes? We can design a payment structure that really will deliver on that. And I think as you start to think about that, you realize how the existing payment structures really aren't set up to do those things for various reasons. And that really, I think, helps people buy into the idea that there might be a better way to do this. And this idea of value based purchasing might actually have some legs.   Carol: So that payment structure piece, that's my interest. How did you really dig in and kind of figure it out? Because it sounds good and I understand all the things you're saying about quality outcomes, but how when it comes down, like putting the rubber to the road, do you get at the nuts and bolts of figuring out the payment structure?   Lisa: So everybody always wants that. Next they say, so tell me what it is. And I always say it is what you need to develop locally in your system. You need buy in from those who are purchasing and those who are providing, and you've got to bring them to the table in a constructive way. So in a really collaborative way, sometimes we talk about it as co-creation and you dig into what do we agree is quality service, how do we differentiate quality service from service that we would say is not high quality. And then what do we agree is efficient service? How do we differentiate efficient service from service we would say is inefficient but very important to VR agencies, at least those I've spoken to. Are these quality outcomes, the career path outcomes, the jobs with benefits, the jobs with more hours and better pay? You know, some of these things, you're just not necessarily seeing a lot. You're getting outcomes that you can count as a 26 closure, but they aren't the kind of quality outcomes that, and you see some revolving door effect of certain people who and I know that's a big issue in some states or you see a lot of dropouts in the process. So in every state it's important to sit together and figure out what should we be doing better, what does better quality look like, and then what is quality and efficient service look like? That's how you get the buy in to establish a payment structure that where people want to implement it and intend for it to work. I can certainly share examples of how that co-creation works going on elsewhere and what the ultimate outcome was, but that is what happened there. And I really like the idea that and really believe that you've got to do a local co-creation process to get to something everybody's bought into and something that has a high probability of working. I would never say, oh, Value-Based Purchasing is this. It's only this. Or you just take this model from this other state and you plunk it down here. That won't work.   Carol: Yeah, I can see why you sing to Chip's heart there. Because he's all about systems work, you know, and that whole and everybody's systems in your state are so different. How you're set up, what your relationships are like between your providers and yourself and other entities and all of that. So I do like that you're speaking to that and you can't just pick up and replicate because you've got all your nuances that are happening in your state, and you need to understand those before you can get to the agreeable solution. That makes a lot of sense.   Chip: And it's not only that, and we're finding this to be true now that providers are not a monolith, that there's not a state where you can go, okay, every provider looks like every other provider. There are a lot of uniquenesses, a lot of variables that have to be taken into account to bring at least the majority of them on board. And that's we're finding that to be true as every state system is different, every provider network or non-network is different.   Carol: Absolutely. And even when you think about the states, kind of just the like the geographic challenges they have and the things that are going on, we've saw such an increase, especially after Covid with people moving and some of the states go like our cost of living in certain areas has gone up exponentially, like 300% or something. And so you've got everybody like, decided because they could work from anywhere. We're all moving to this town and then other areas become depleted, maybe from people, and there's less resources available and harder to get providers to serve an area even though you have customers there. I just feel like we have a lot of geographic and economic challenges across states, even tiny states. It's been super interesting. We've found that work as we've been just doing plain old rate setting with states, so let alone what you guys are digging into. So what are some of the biggest challenges in implementing this value based purchasing?   Lisa: I would say the time it takes to do it right. I think sometimes state agencies and I'm not singling out VR, but they want quick solutions. You know, they think about it for a long time and then they say, okay, we want to do it. Let's get it done. Can we get this done in three months or can we, you know, and you have to say probably not in a way that would be successful. And so it is something not to take lightly and to really commit to invest in. I think there's a lot of additional benefits to doing this, including provider relationships and the learning that goes on. Providers now understand what it's like to step in the shoes of a funder. Funders understand what it's like to step in the shoes of a provider. I always think that helps with everybody getting on the same page and agreeing to a model they think will work, but it takes patience, it takes partnership. Some states are, they're very uncomfortable with bringing providers in. They tend to develop things and then release them to providers. So you've got to have a level of trust when you identify the providers you want to involve. I always encourage to identify who are your high performers. They are the providers you want this model to work for because you want more high performers and you want those that you have to expand their footprint, for example, to go into geographic areas that are underserved or to hire more staff. So always thinking about partnering with the high performing providers. But there's a bit of reluctance, you know, and risk in doing that and saying we're going to create something together. Lots of outside the box thinking. It's really hard to get away from payment models that you've been invested in for a long time. Milestone fee for service. Just to think beyond those can be very difficult, but I think once people start to and that's something I do, is kind of bring ideas and thoughts and stimulate thinking to get them to move away from those models and really say, what should we be paying for? What is important to value in the payment structure? I think it really gets to be very exciting, or at least I think so. You really need data to you cannot develop a model without good data. Sometimes the data is readily available. It's reports that VR agencies are already pulling out of their system. Other times the data's in the system, but they don't typically pull it. And so we have to work with them. And it helps to have a data analyst to assist with this process, to be able to pull pieces of data or data analysis and different ways that informs what we're doing. We want a data driven approach. And sometimes, of course, you probably know that data analysts are very, very busy or they're off doing something else. And it may be hard to get them committed to the work.   Carol: Have you seen improvements since? I'm just thinking since WIOA and kind of the requirements that RSA has put on state agencies about collecting a vast amount more of data. Have you seen improvement as you're working with states that they actually have data they may not have had years ago that you can get at. I mean, there might be a little bit of a problem with the staffing or getting your data analysts to pull it, but that availability of the data you need to really to dig into this, that it's actually there.   Lisa: Yeah, I do think the systems are pretty sophisticated, and it's a matter of helping them understand how to use more of the data they have, because we have the standard WIOA measures. We have the way that VR talked about its performance prior to WIOA but I think we're digging in to get it more data elements that help us understand. One of the most important things to understand is demographic information and how that affects maybe how difficult or how easy it is to serve someone. So, for example, adding criminal background to someone's demographic profile, or we know from history that, you know, that does create a challenge. So it's weeding out what are the things that differentiate people who VR would serve and try and understand better how that relates to cost. The other thing that's really important that I don't typically see is what's the average cost of a successful case? So I see this is the average cost of successful closures. So taking all successful closures and dividing it by the number and then average cost of unsuccessful closures, then average cost of a case. But for me what matters most is what are we paying for a successful case if we're including everything we're paying. So including all the that we're spending on unsuccessful closures in that and saying, basically this is what it costs to get a successful case, because we also have to pay for the unsuccessful closures and trying to focus on how do we reduce, how much we're paying for unsuccessful closures, and to really make sure more of the money that we're paying flows to successful closures. There's a little bit of complacency that goes on with every system where if we just compare ourselves to other states, we may say, look, we're doing better. We should be happy with our performance. We are better than 75% of the states. But if we stand back and compare that to people without disabilities and their participation in the workforce, I think that's when we say we're comparing it to school. Like if you got 60% on a test, would you pass it or would you fail it? So I think we have to challenge ourselves to say we may be doing better than so many other states, but we are not performing at a high level and we want to move up. We want to not just judge ourselves by other states. Now, 100% success is unrealistic. I don't think there's anybody who would disagree with that, but it's important for the providers and the funder to come together and say what kind of improvement above where we've been. Do we want to try to incentivize? Do we want to see and to develop the payment structure, to say we believe this structure will directly influence our ability to move those percentages up over time and thus reduce the amount we're investing in unsuccessful closures without reducing the number of people were serving, without cherry picking, but truly improving outcomes.   Carol: I love that that is a good way to challenge the thinking that's going on out there, because people sort of, I don't know, poo poo or they just this is over there in that bucket and they let it be. And we're kind of complacent with just, you know, we're doing better but is better. What's the next state like. You know, like better than what. And so what does that matter.   Chip: But I think I mean, the key to me is the concepts of quality, the quality of services and quality outcomes. And if you can define and you can measure and you can demonstrate quality of services and quality outcomes, it seems like you don't need to compare yourself with other states. You can say this is quality in our state. This is what we're doing. This is how we're doing it. These are the outcomes. So state by state national comparisons are way less important. So when we can get to that point where we can identify and measure and demonstrate and get quality outcomes that will move this whole system gigantic step forward.   Carol: 100% Chip. So what would be your best advice for states as they're listening. Right. You know, they're listening in and they're thinking, well, I want to do something, but I don't know what to do. Like what would be the next steps? What should they do?   Lisa: To me, it's, start the conversation. I find that the process of bringing state people together with providers, that they're all learning together about this different way of thinking, And it helps because it does take a little bit to get your mind around what Value-Based Purchasing is and how it's different from milestone payments or fee for service. And I've often seen like people have come up to me sometimes and said, you know, it was the third time I heard you talk that the bells finally went on, you know? And I said, that's fine. I think it's just the way it is. It's complicated in a way, because it's so different. So getting the conversation started and thinking about, you know, asking yourself questions like, is there quality in the outcomes that we want as an agency that we're not getting quality and service delivery? We don't feel we're getting quality and outcomes we're not getting. Then think about your payment structure and say, is there anything about our payment structure that incentivizes or rewards this kind of quality that we're saying we're not getting? Sometimes maybe there's something there. Sometimes you could say, no, there's absolutely nothing in the payment structure that does that. And then I always say, think about the providers that you think are doing the best work for you. Are they financially benefiting? Are they doing better financially. And in some cases I've seen no, there's no difference. I'm performing better, but financially that's not being recognized. And in other cases I've seen they're actually earning less because they're doing such a good job and they're very efficient. You know, they're producing quality with efficiency. They're actually doing more poorly financially than some of the providers who are performing at a lower level of quality. So I think when we start to think about those questions, people see that the need to try to figure out a different way to do things, then they're willing to, you know, let's talk about what this Value-Based Purchasing is what the principles are, how it's different, and begin to think about how we might bring our high performing providers into a conversation with us about this.   Chip: My advice for states is that you're in this for the long haul. To Lisa's point very early in this discussion that this isn't a quick solution. That's something that can just be laid in the state and just immediately adapted. It does take that level of discussion, that level of understanding, collecting data. It's complex. And sometimes I think to myself, why am I choosing to get involved in the complexity of Value-Based Purchasing overlaid the complexity sometimes of customized employment, but I think in the end result we will have a much better system, much more equitable service delivery system for everyone, including providers, including customers and job seekers. But just keeping the discussion going on things like this, things that CSAVR presentations Getting this into the national discussion, I think, is the first step.   Carol: Those are really good tips. Where outside of VR is Value-Based Purchasing being implemented?   Lisa: So definitely in the Medicaid world, most of your listeners are probably aware of that, but mostly in the Medicaid world, it's on the acute primary care side. So hospitals and doctors, primary care physicians and things. So I always caution people there's things we can learn from that and those examples. But it's not a wholesale import those approaches over to VR. I don't think that would work. But there are some principles or strategies that we can use, like there's a concept called shared savings. There's some other things that I think we can think about and use, but we still have to develop something that's specific to employment. In my work on this around employment on the Medicaid side has been with the long term services and support agencies, the DD agencies, the mental health agencies, managed care organizations who are doing LTSS and employment is a perfect place to start with them around their thinking, around Value-Based Purchasing. They're facing some pressure. I would say some to use Value-Based Purchasing because it's seen to be working on the acute primary side of Medicaid. So they're saying, why aren't we using it in LTSS? And they want better quality and better efficiency too. They want to see people supported to achieve their highest level of independence. They want their high performing providers to do well. So we worked on it with employment because it's so obvious that fee for service, which is the typical payment model, disincentivizes all the things that we associate with high quality supported employment, the better you are at getting people jobs, the better you are at coaching and fading because you're good at it. We reward providers under fee for service with less money. And those providers are performing more poorly, end up with more money. So it's not hard to get people to see why fee for service doesn't work for supported employment. So we've worked on models for job coaching that pay for hours worked rather than hours of coaching, so that providers are appropriately financially compensated if they do better at fading, which goes back to what kind of job did they get people, as well as how good they are at coaching. That model incentivizes them to get people more hours. So if you start with 12 hours a week, that doesn't mean you stay with it. If they're doing well, the employer wants to increase that. The person wants that they can get paid more in the model. Fee for service providers don't get any financial remuneration for increasing people's hours worked, even though we say that's a goal. So that's been a lot of where we see some of the value based models developing. We're paying for things up front services like exploration, which I'm really happy to see the results of states that have added exploration and exploration to their waivers, because we now have a way to tackle people who say no thanks in a planning meeting or I'm not interested, or their families say that we've been paying for developing payment models for that. That's an outcome payment. So they complete the service, then they get paid based on the quality of the information they submit and the efficiency. So there are ways to align what we're doing. Providers certainly appreciate that they would like to be paid the same way. Typically once they experience being paid in a Value-Based structure. So that's where it's happening. But think about just the general business world. There are so many examples of payment based on performance or quality, right. Sales Salespeople earn incentives for sales. So business has long been doing this in terms of creating those kinds of incentives and even nonprofits. Now, United Way and others are funding nonprofits based on outcomes and deliverables. They're no longer funding them to just provide service. So I think if you look, we're seeing it everywhere, really.   Carol: So you brought up a whole lot of points. If people are interested in more information, do you have resources we could send them to?   Lisa: Well, in 2021, I did a publication that looked at examples from around the country that I'd been in some way involved in. That's on the Lead Center website as well as there are a series of webinars we did at the time with representatives from various states. I have a lot of information about what's going on in the Medicaid side. Et etcetera. So I guess I would say that was my thinking in 2021, I continue to learn and evolve my thinking, and I think we're at a point now where we're trying to do in Virginia, is move beyond both fee for service and milestones, because neither are working very well, right? So you've got some state VR agency saying we're paying fee for service. It's not working. Should we move to milestone? But if you talk to states who are using milestone, they will also say it's not working very well. Some of them are thinking about going back to fee for service. And I'm thinking, I don't think we should do either. I think we should work together to figure out what's the next way we attempt this that addresses the shortcomings of both. And I think that pathway is Value-Based Purchasing.   Chip: and helping moving states to. Well, I'm a little concerned about the unknown. What we have may not be working now, but it's the known. I don't really know what's ahead, but I think where in Virginia at least, has done a really good job of creating that safe space. Like, let's explore this together and keep this comfort zone of what we currently have, but move forward into something that's more equitable and beneficial for them.   Carol: So, Chip, if people wanted to reach out, what would be the best thing? Should they contact you or what would be best?   Chip: Either one of us is if it's a state agency, probably me if it's others listening to this. Lisa.   Carol: Do you want to give them your email address?   Chip: It's r k e n n e y at SDSU (San Diego State University) dot EDU.   Carol: Awesome. And, Lisa, do you mind sharing your email address?   Lisa: No, but I'll warn you, it's long. So here we go, Lisa Mills l L i s a M i l l s, all one word, at M as in Michael, T as in Tom, D as in David, D as in David, dot On Microsoft, all one word, com. And that was my IT friends who gave me that ridiculously long email, which I hate.   Carol: Holy smokes, that is long. Well thank you both. I really appreciate it. And I will put a link in our podcast announcement out to your publication from 2021 as well. Then folks could at least see that. But thanks for your time. I really appreciate the conversation.   Lisa: Thank you.   Chip: Thanks. We really appreciate this opportunity.   Outro Voice: Conversations powered by VR, one manager at a time, one minute at a time, brought to you by the VR TAC for Quality Management. Catch all of our podcast episodes by subscribing on Apple Podcasts, Google Podcasts or wherever you listen to podcasts. Thanks for listening!

Tetyana Shippee first became fascinated with the power of structural forces to shape individual lives as a grad student from Ukraine studying the sociology of addiction in the United States. That academic interest soon expanded into gerontology and elder issues – including a two-year stint living in a continuing care retirement community as part of her studies. Shippee, now a professor at the University of Minnesota School of Public Health and the associate director for research at the Center for Healthy Aging and Innovation, joins the podcast to talk about her work to improve the systems that so often make life harder for elders seeking empowering care and supports. She also challenges leaders to tackle issues like racial and socioeconomic inequities head-on –and embrace the power of intergenerational connections. Learn more about the Center for Healthy Aging and Innovation: https://www.sph.umn.edu/research/centers/chai/ Explore AARP's LTSS scorecards: https://ltsschoices.aarp.org/scorecard-report/2023 Catch up with the Moving Forward Coalition: https://movingforwardcoalition.org/news-and-updates/

Bestselling non-fiction author ABBOTT KAHLER joins BOOKSTORM Podcast to discuss WHERE YOU END, her dazzling fiction debut! This novel thrills! We talk about mirror image twins and the unique physical and emotional bond they share ... even when one twin cannot remember their past. We talk about how the body remembers trauma. What does that mean for healing? What do we even know about the mind? How do we move forward when we haven't dealt with the past? Fascinating topics and a real-life backdrop! Join us!You can find more of your favorite bestselling authors at BOOKSTORM Podcast! We're also on Instagram, TikTok, Facebook, and YouTube!

Season 3: Episode 3 – Insiders look: A Day in the Life for a Trivium Long Term Support Services (LTSS) Client. Release Date – December 22nd, 2023. Summary – In this episode, we sit down with Tara Christensen, who has been a client of Trivium Life Services for nearly two decades. Tara kindly shares her unique perspective on life, recounting a typical day in her world and what she is hoping for in the future. Discover the profound impact Trivium has had on Tara's life, exploring the ways in which this supportive community has played a pivotal role in shaping her journey and empowering her to reach her goals. Join us for a heartwarming conversation that illuminates the transformative power of long-term support services and the boundless possibilities that lie ahead for individuals like Tara within the Trivium family. Guest Information – Corrie Tierney Market Director Missouri Valley at Trivium Life Services. Tara Christensen - a long term support services (LTSS) client at Trivium Life Services. Links and Resources www.triviumlifeservices.org Call to Action Want more information on the services offered by Trivium Life Services or how to support our mission? Visit our website at www.triviumlifeservices.org. Podcast and host information Hi! I'm Michelle Schaller, Senior Director of Behavioral Health, your host for this series of podcasts by Trivium Life Services. Each week, I'll be introducing you to real professionals who dedicate their lives to helping others, and individuals who have found hope amidst their struggles with mental health, substance abuse, domestic violence, and those with intellectual and physical disabilities. Our aim is to reduce the prejudices and misconceptions surrounding these challenges and create awareness and understanding in our communities. Disclaimer The contents of this podcast, including discussions, interviews, and shared resources, are for informational and educational purposes only. They are not intended to serve as a substitute for professional medical advice, diagnosis, or treatment. Acknowledgements Special thanks to Webberized Inc for their invaluable contribution to this episode. To learn more about their services visit them at www.webberized.com.

Beau shares how an initial stint as a temporary worker landed him a role with California's In-Home Supportive Sevices that became a springboard into his career as he ultimately become well versed in California's long term supports (LTSS) and services as well as home and community based services (HCBS). That foundation has helpd Beau become one of Anthem and California's leaders for the California Advancing and Innovating Medi-Cal (CalAIM).

On this episode of In Clear Terms with AARP California, our host Dr. Thyonne Gordon sits down with Kevin Prindiville, Executive Director with Justice in Aging, a National Advocacy Organization that fights senior poverty through law. He is a nationally recognized expert on Medicare and Medicaid policy, and has served as counsel in several class action lawsuits protecting low-income senior's access to public benefits. Not to mention, he is on the Board of Directors of the American Society on Aging and is quoted often in national and California media. Kevin joins Dr. Gordon to discuss long-term care services and supports, also known by its acronym as LTSS, and together they share essential resources for older adults and their families. So join us for another informative episode of In Clear Terms, brought to you by AARP California. Follow UsTwitter @AARPCAFacebook @aarpcaliforniaInstagram @aarpcaPresented by AARP Californiawww.AARP.org/CA

In this episode of “Inside Health Care,” we talk digital transformation with a prominent medical informaticist. Then, we hear a conversation on NCQA's long-term services and supports programs, a.k.a. LTSS, from a long-time accredited managed care supporter.Dr. John Glaser is Executive in Residence at Harvard Medical School Executive Education. Previously he was Chief Executive Officer of Siemens Health Services. He is former Chair of the Global Agenda Council on Digital Health in the World Economic Forum, and former Senior Advisor to the Office of the National Coordinator for Health Information Technology. He's also a member of NCQA's Board of Directors.Dr. Glaser will also be at NCQA's second annual Health Innovation Summit in October 2023. In addition to helping open the Summit, he'll sit on a C-suite panel alongside NCQA President Peggy O'Kane and other industry leaders, discussing, among other things, the transition to a digital health ecosystem.Centene is the largest Medicaid Managed Care Organization in the U.S., as well as the largest carrier on the Health Insurance Marketplace.Nicole McLean is an accreditation manager for Centene, and she spends much of her time working with NCQA on our LTSS programs. But which services are included in LTSS? What could they be? Well, as Nicole will tell you, in order to evaluate which services and supports people need, you first have to learn about...the patient.Later in our Fast Facts segment, we observe August as National Immunization Awareness Month. First, we present some tips from the CDC for providers' offices on how to talk about vaccinations to young patients and their families. We also mention NCQA's HEDIS "Childhood Immunization Status" measure.

In the United States, individuals needing long-term services and supports (LTSS) access care, utilize services, and pay for their services in various ways. The authors explore how the need for, utilization of and payment for long-term services and supports differ in the U.S. by population cohorts. Their primary focus is disparity by race and ethnicity, but they also consider variations by geography, family structure, age, sex, gender and other socioeconomic factors. Our guest on this podcast is Rebecca Sheppard, FSA, MAAA, from Risk and Regulatory Consulting.  R. Dale Hall, SOA Managing Director of the SOA Research Institute hosts the podcast.

Matt Hansen, NC Synod Candidate and member of St. Andrew, Andrews, joins Pastor Phil Tonnesen to discuss Isaiah 43:19 and how God is doing a new thing through his call to ministry. Music: Windswept by Kevin MacLeod Link: https://incompetech.filmmusic.io/song/4629-windswept License: https://filmmusic.io/standard-license This podcast was recorded at the 2022 North Carolina Synod Gathering at Lenoir-Rhyne University in Hickory, NC.

In the 11th episode of Season 2: Driving the Deal, Krist Werling, McDermott partner and co-head of the Private Equity Practice Group, and Brian Fortune, senior managing director at Farragut Square Group, are joined for a guest interview hosted by Farragut Square Group's own Jackie Williams and Hope Amsterdam. In this episode, Hope and Jackie interview Damon Terzaghi, senior director of LTSS policy at the National Association of States United for Aging and Disabilities, to provide an overview of the home- and community-based services (HCBS) space. Together, they discuss the following:  The increase in demand for HCBS before and after COVID-19 The increased Federal Medical Association Percentages reimbursement for HCBS The likelihood of increased funding to exist beyond the public health emergency Labor issues surrounding the HCBS space Priorities for states surrounding HCBS after the pandemic  

People are living longer and longer. While generally that's a good thing, it also means that more of us are going to need long-term care – and that can get expensive. What is long-term care? What options are there? And how can we plan for it?  In this episode, Cianna talks with leading LTC expert Matt McCann. McCann is recognized as one of the nation's leading long-term health care specialists, and is the publisher of LTC News.   Mentioned in this episode: Consumer focused news & resources: LTCnews.com  McCann Insurance Services: RadioLTC.com Information from U.S. Dept. of Health and Human Services: LongTermCare.gov American Association for Long-Term Care Insurance: AALTCI.org Medical bills are leading cause of bankruptcy U.S. Dept. of Health and Human Services report shows “70% of adults who survive to age 65 develop severe LTSS needs before they die and 48% receive some paid care over their lifetime”  About Larry Lujack

Rev. Dr. Mary Shore of LTSS joins us this week as we continue our study in Acts and also celebrate new members joining the church!

In this episode of Means of Grace, Dr. Melanie Dobson joins us again to share a series of visualization prayers for adults and children during another stressful back to school season for families. Over the course of the pandemic, we've shared several guided mediations and prayers to continue to support your spiritual and mental health and they've been some of our most listened-to episodes. You can revisit some of these episodes here and here and here. Our prayer is informed by this one from St. Thomas Aquinas: https://www.catholic.org/prayers/prayer.php?p=2802 Melanie is an ordained elder in the Western North Carolina Conference and an assistant professor of Methodist Studies at the Lutheran Theological Southern Seminary in Columbia, SC. She is the Director of the Spiritual Direction Certification Program at LTSS and a trained spiritual director in both group and individual settings. She is also a registered yoga teacher. She enjoys hiking, cycling, cooking, and being outdoors. She is a single mom to one son, Elijah.

"More than 40% of people over 65 years old misperceive that Medicare covers long-term care." -Marc A. Cohen, PhD Long-term care is care across a range of settings and can include medical and non-medical services that assist individuals who cannot care for themselves for extended periods. Also, long-term care is often provided at a person's home, largely by family and friends. Thus, it's a challenge to discern whether you even need long-term care insurance coverage. If you can afford this type of policy, it's even harder to know if the insurer and the policy will still be there with adequate coverage whenever you need it. In this episode of This Is Getting Old, Marc A. Cohen, PhD., will talk about the basics of how long-term care is paid for now - and discuss future trends for the long-term care insurance industry. Part One of “Do I Need Long-Term Care Insurance? And Future Trends” How Is Long-term Care Currently Financed? Long Term Services and Supports (LTSS) are services designed to help people with functional incapacities, limitations, or cognitive issues. These circumstances limit a person's ability to perform basic activities of daily living like bathing, dressing, toileting; all the things that one would need to be able to do in order to live independently. Unlike acute medical care, with services like hospital care, physician care tends to focus on curing people of specific ailments; long-term services and supports are designed to help people living with chronic illnesses maintain their function or reduce the decline in functioning over time. In today's market, long-term care is financed in three major ways: ✅ Out-of-pocket: Disabled older adults and their families pay out-of-pocket for care. ✅ Medicaid: A federal-state social safety net program. Older adults must qualify for Medicaid by meeting very low income and asset thresholds. ✅ and private long-term care insurance. Is Private Long-term Care Insurance Still And/Or Going To Continue A Valuable Product For Consumers? The long-term care financing problem in the United States is enormous. People over age 65 today, around twenty-five million of them will require long-term care services and supports projected to cost trillions of dollars; including family support provided care, which is not often evaluated. When we look at the dollars spent and put a dollar value to the care provided by families, it's more than seven times what our public program, Medicaid, pays. So given that the bulk of care is provided by families, we have these situations now, where the caring family network is stretched. We used to talk about the “Sandwich Generation” - where you had an older adult caring for an elderly parent and a school-aged child— Dr. Cohen now calls this the “Panini Generation”. In other words, paying for and providing long-term care can create a situation that crushes families. Given these circumstances, we need to have more financial resources flowing into this system. The problem is so big that no one sector can handle it on its own. That means that we can't fully publicly finance long-term care —and we've already proven that it can't be a privately owned, privately funded solution. Therefore, we need roles for the public and private sector in order to find a viable solution. Part Two of “Do I Need Long-Term Care Insurance? And Future Trends.” Can Long-term Care Insurance Still Play A Meaningful Role In Addressing The Challenges Of Long-term Care Financing? And What Public Policies Need To Change For Long-term Care Insurance To Remain A Viable Product? We've seen in the private market that private insurance companies can no longer handle that “catastrophic risk” that is called “long-tail risk” or “long-term risk”. Another one is that the private insurance industry is much better at handling folks who need care for one, two, three, four, maybe five years, but they get in trouble with rating agencies who think that they're taking on uncapped liabilities. With that, the private sector has stopped providing coverage. So the long and the short of it is that each financial option has a clearly defined role. The private insurance sector has to worry about developing insurance products that will work based on their terms. The public sector takes on the predominant part of the risk—the catastrophic. The idea is that by doing that, older adults can put together a package of comprehensive insurance that starts with the private sector and moves to the public sector. "It's no longer an accident that we live long lives —we expect to live long lives, but that brings functional impairment and cognitive impairment levels that we haven't seen. And because the long-term care financing problem necessitates bold action, it's going to require bold action." -Marc A. Cohen, Ph.D A Catastrophic Public LTSS Insurance Program Can Significantly Help The Market Thrive And Meet America's LTSS Financing Challenge. The notion of “catastrophic public long-term services and support” is an idea that proposes financial help would be variable, depending on your economic circumstance. For example: ✅ If you're lower middle class, the public program would pay after you need care for one year. ✅ If you are a little bit wealthier, you would pay for the first two years with your savings or insurance, and then the public program would kick in. ✅ And if you're wealthy, then potentially you have to worry about the first four years of care, and then the public program provides coverage. What's nice is there are a couple of good things about this scenario: ✅ First of all, when you have a well-defined public role, it will help people understand, "Oh, I've got some personal accountability or responsibility for worrying about whether it's one year, two years, or three." ✅ Number two is about how the middle-income folks accessed Medicaid because they spent down their income and assets. Well, if you have an insurance solution for those folks, that means you have fewer claims on the social safety net. This further means that states will have some pretty significant savings to their Medicaid programs. So it'll be relatively attractive to states and the people accessing Medicaid—people for whom there are no insurance alternatives and no savings alternatives. ✅ The third thing that it does is that it will stream new money into the system. All of us know what happened during the pandemic, especially in the beginning when the pandemic ravaged elders in nursing homes in particular. Part of the issue is that we have underfunded the entire long-term care system. So there has not been enough money to support levels of wages that we need to attract and keep people working, develop career ladders, pay for high-quality care and safety. A public insurance program with private insurance filling in the gaps and savings will stream more money into the system and will have everyone benefit from a better system. Congress.gov will have information on The WISH Act proposed by Rep. Tom Suozzi (D-NY-3) shortly! About Marc A. Cohen PhD Marc A. Cohen, Ph.D. is a Professor of Gerontology at UMass Boston and the Co-Director of the LeadingAge LTSS Center @UMass Boston. He is also a Research Director at the Center for Consumer Engagement in Health Innovation at Community Catalyst. Before joining UMass in 2016, Dr. Cohen founded and led LifePlans, Inc., a long-term services and support (LTSS) research and risk management company. Over his 30 year career, Dr. Cohen had conducted extensive research on LTSS financing and delivery issues, testified before Congress, served on an appointed Massachusetts' LTSS financing task force, and chaired a study panel on designing state-based LTSS social insurance programs. He has been quoted extensively by major news outlets and is viewed as a thought-leader on issues affecting eldercare financing. He received his Ph.D. from the Heller School at Brandeis University and his Master's Degree from the Kennedy School of Government at Harvard University. Connect With Dr. Marc A. Cohen through the following social media platforms: Twitter: @UMassBoston @LeadingAge @CCEHI @CommCatHealth Facebook: @UMassBoston @communitycatalyst @LeadingAge Instagram: @UMassBoston @LeadingAge For more valuable resources, check out the episode of Elder Care: Past and Future with Joanne Lynn, MD, MA, MS, and Carrie Graham, PhD, MGS.  Watch the full episode here: https://youtu.be/4S8ongyzMco About Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN: I earned my Bachelor of Science in Nursing ('96) and Master of Science in Nursing ('00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I genuinely enjoy working with the complex medical needs of older adults. I worked full-time for five years as an FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home, and office visits), then transitioned into academic nursing in 2005, joining the faculty at UNCW SON lecturer. I obtained my Ph.D. in Nursing and a post-master's Certificate in Nursing Education from the Medical University of South Carolina College of Nursing ('11). I then joined the faculty at Duke University School of Nursing as an Assistant Professor. My family moved to northern Virginia in 2015 and led to me joining the George Washington University (GW) School of Nursing faculty in 2018 as a (tenured) Associate Professor. I am also the Director of the GW Center for Aging, Health, and Humanities. Please find out more about her work at https://melissabphd.com/.

Rethinking Nursing Homes and Care of Older Adults "Communities should create solutions that aren't just involving geriatricians of the world or the geriatric nurses and social workers. It's going to take everybody pulling together."  -Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN ____________________________________________________________________ "Grow old along with me. The best is yet to be. The last of life for which the first was made." In 1864, as Robert Browning wrote those words, growing old was not regarded the same as it is today. Before nursing homes and assisted living facilities, older adults aged at home alongside their families. Today, most people still age in their communities; but for the aging population that becomes frail, they may need the support from these long-term care institutions. However, the current nursing homes and care parameters for older adults often stigmatize aging and overlooked what people want when they get older. To counter this, we need a shift in mindset, one that sees older adults as persons with diverse needs, dreams, and aspirations about their future rather than just patients in need of care. In this episode of This Is Getting Old, join Dr. Stuart Butler and me in rethinking nursing homes and care for older adults. Part One of 'Rethinking Nursing Homes and Care of Older Adults'. The Convergence Report on Rethinking Care for Older Adults    History and Background   The Convergence Report on Rethinking Care for Older Adults is released at the end of November 2020. It was supported by the John A. Hartford Foundation, which funds a lot of work in the long-term care area on aging.  The convergence conversation aimed to bring together about 50 people from very different backgrounds and different points of view to see if there are common ground areas. They were asked to brainstorm about the issues impacting today’s nursing homes, what's going on there, and what could be done differently. They were also asked to explore other ways that people can age outside of nursing homes.  A crucial part of the conversation revolved around the workforce and the caregiving field, the workforce's nature and how to think about it differently in the future, and the financing of aging in American care and nursing homes.   The Findings Of The Convergence Report On Rethinking Care For Older Adults   The resulting main areas revolved around living outside nursing homes, the payment system, and the caregiving workforce.  Today's nursing home system is increasingly out of date and the product of the payment system. The majority  of older adults need not stay in nursing homes. There are ways of enabling them to live more successfully in their own homes and their communities. People and institutions can help older adults stay in their own homes, avoid isolation, and be safer. Today, the caregiving workforce is predominantly low-paid, very heavily immigrant—It's a low-skilled, low-paid workforce.  "Only 5% of people over 65 ever end up in a nursing home, but they account for 50% of the state's budget." -Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN  Reimaging Nursing Homes and Other Care Institutions Alternative Business Models & Payment Systems The current payment system for long-term care forces many older adults to go into a care setting, which may not be the right one for them. It may not be ideal and indeed may not make them happy and may cut them off from their family.  If a family  asks, 'What's the next best thing for mom?' The first response right now will be, 'We need to talk about your finances to figure that answer out.'  Exploring The Financing And Workforce Elements   Medicare + Medicare   There's a lot of interest in revamping the rules and the regulations associated with, particularly Medicare and Medicaid, as to what they would cover. Medicare and Medicaid alternative services should be more open to covering home- and community-based services. However, exploring these options has the potential to  save government spending on Medicaid and Medicare in the long term.    Role Of Private Health Insurance   One possible solution for people who do have some savings but are afraid of them being exhausted and then ending up on Medicaid, is providing a so-called “catastrophic backup” to long-term care insurance. The idea is to have legislation that would set this up to stabilize the long-term care insurance industry to make it more viable in the future. When this happens, then far fewer people would fall into this trap of being unable to pay.    Role Of Long-term Care Insurance   The long-term care insurance industry has declined very sharply in the last several years, in part because younger people don't think of having long-term care insurance. The other thing is people are living longer, and they live longer with sometimes costly illnesses that impact their ability to be independent. So long-term care insurers face these enormous potential costs; so this approach is not working. Part Two of 'Rethinking Nursing Homes and Care of Older Adults'. Expanding the range of older adult-friendly housing and communities 95% of older adults do stay and age in their own homes. Below are some ideas to help people age at home.   Design and Collaboration   Architects involved in the convergence conversation think about how to design housing that is safer and more open. These perspectives include looking at group housing, in various forms, and thinking about how multifamily units can be designed so that an older person can have that privacy, and so on.  But more than these essential design features, we also look at how to build social capital  that helps an older adult live in their own home and community, but not be isolated and cut-off from the rest of society.   Role of Technology   There are also a lot of improvements in technology. For instance, monitoring older adults, a doctor, or a nurse in the area can know if that person is getting unsafe in some way like a potential fall, etc. Technology connects health care providers and older adults so that their needs can be addressed.  “We’re on the cusp of thinking differently about nursing homes in the future.” -Stuart M. Butler, Senior Fellow, Economics Studies Thinking About The Caregiving Workforce Differently Workforce Issues: Other Resources to Learn More   LeadingAge Report: Making Care Work Pay   LeadingAge released a new report, Making Care Work Pay. The report highlights health care professionals as an essential part of the United States' healthcare infrastructure and accounts for a significant portion of its workforce. Every day, nearly 3.5 million direct care staff operate in residential care centers and private homes to offer care for some of society's most needy members—the elderly, the disadvantaged, and the mentally impaired. Given the value of health care staff to our country's health and economy, health care professionals continue to be undervalued and underpaid. Poor wages and stressful working conditions exacerbate persistent workforce problems. As a consequence, efficiency and care delivery aren't as good as they should or could be.    Milken Institute Center for the Future of Aging Report   (Recommendations to Build a Dementia-Capable Workforce and System amid    COVID-19) The recommendation aims to endorse the GWEP program's recent sanction, which authorizes almost $39 million in funding to expand geriatric expertise across the healthcare system over five years. Such action is anchored because, despite the reality that the number of individuals living with Alzheimer's disease is predicted to increase by 2050, a lack of geriatricians, nurses, and social workers with advanced expertise in geriatrics and complex dementia treatment is on the horizon.·          Mathematica Report COVID-19 Intensifies Nursing Home Workforce Issues (Full report available as a downloadable PDF) Mathematica Report studies show that workforce shortages and turnover also strained nursing homes during the pandemic's climax. Many nurses and licensed nursing assistants have recently quit the industry due to low wages, inadequate working conditions, and the high risk of COVID-19 contamination at a period when their skills and experience are in high demand. Thinking About The Healthcare Workforce In Different Ways   Improving Training   Improve training for healthcare providers. At the moment, there's minimal federal training and federal requirements on states that need to be expanded enormously to raise the skill level. Want to know how your state is doing in terms of long-term care support and services (LTSS)? Find out from the AARP Foundation Long-Term Services and Supports State Scorecard 2020 Edition  About Stuart M. Butler, Senior Fellow: Stuart Butler is a Senior Fellow at Brookings. Before Brookings, he spent 35 years at The Heritage Foundation as the Director for the Center of Policy Innovation and, earlier, as VP of Domestic and Economic Policy. He has recently played a prominent role in the debate over health care reform and addressing social determinants of health. Butler is a member of the Health Affairs editorial board, an advisory board member of the National Academy of Medicine's Culture of Health Program, and the Board President for Mary's Center, a group of community health clinics.   About The Brookings Institution: The Brookings Institution is a nonprofit public policy organization based in Washington, DC, whose mission is to conduct in-depth research that leads to new ideas for solving problems facing society at the local and national level and globally. About Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN]: I earned my Bachelor of Science in Nursing ('96) and Master of Science in Nursing ('00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I genuinely enjoy working with the complex medical needs of older adults. I worked full-time for five years as FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home, and office visits), then transitioned into academic nursing in 2005, joining the faculty at UNCW SON as a lecturer. I obtained my Ph.D. in Nursing and a post-master's Certificate in Nursing Education from the Medical University of South Carolina College of Nursing ('11). I then joined the faculty at Duke University School of Nursing as an Assistant Professor. My family moved to northern Virginia in 2015 and joined the George Washington University (GW) School of Nursing faculty in 2018 as a (tenured) Associate Professor. I am also the Director of the GW Center for Aging, Health, and Humanities. Please find out more about her work at https://melissabphd.com/.

When Andrea Curley was 18 and had just graduated from high school, she lost her mother. That's when she enrolled in Family Care, Wisconsin's long-term services and supports managed care program, and her journey toward learning how to be independent began. In fact, just recently she made the decision to disenroll from Family Care because she's met her goals! In this episode you'll learn how Andrea did it, with a little help from some friends. Thank You to Old National Bank This podcast episode has been brought to you by Old National Bank - a Leading Disability Employer. Support the show (https://arcwi.org/donate/)

If you live in Wisconsin, the term Family Care has a pretty unique meaning. The Family Care program was known nationally as an innovative program when it was created in 1999. More than 20 years later, Wisconsin's version of managed care for people with disabilities and older adults is not without its critics, but it is hard to argue that the program has made a huge difference in thousands of lives, particularly those who spent years on waiting lists. In this episode we have an exclusive sit-down with Inclusa CEO Mark Hilliker who addresses Family Care criticisms,  talks about the evolution of managed care and reflects on Wisconsin's pioneer status. Learn why he says, "If you can dream it, you can do it."Thank You to Old National Bank This podcast episode has been brought to you by Old National Bank - a Leading Disability Employer. Support the show (https://arcwi.org/donate/)

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In this episode of “Inside Health Care,” Dr. Christopher Grimsrud, of Kaiser Permanente Northern California; Dr. Pallavi Kamjula, of Arnot Ogden Medical Center; and Nick D’Ambra, of WellCare Health Plans, Inc., discuss their NCQA Innovation Award-winning projects with Matt Brock, NCQA Director of Communications. The awardees talk about the motivations, goals and future plans of […]

What do you get when you put a group of people with disabilities, people who are fat, LGBTQIA+, elders and many other sorts on one street corner? No, not a bad joke! You get…a PROTEST to #CloseTheCamps because #NoBodyIsDisposable. Photo by Leslie Mah Hear highlights from speeches, interviews and other live recordings from this powerful show of solidarity at the August 28 ICE protest.  The protest was designed to bring together fat & disability communities as a united front.  It was part of the Month of Momentum:  30 Days of Action to Close the Camps (ICE SF) Photo By Regan Barshear More information about the protest Check out the photos gathered so far.   Add yours to the collection. Hundreds of people supported through an online campaign.  Check the #NoBodyIsDisposable hashtag on social media for hundreds of photos. Read and share scholar activist Caleb Luna's remarks from the action. There was a companion action on the same day organized by Fat Rose folks in Indiana! They had 100 folks come out! Check out the photos. Here's the short list of actions people can take from home. One group to connect with locally is the Coalition to Close the Concentration Camps Bay Area, whose campaign is targeting the tech companies who support ICE. The organizers encourage you to stay in touch with Fat Rose, Disability Justice Culture Club, Hand in Hand and Senior and Disability Action. Organizational Sponsors: Access-Centered Movement (accesscenteredmovement.com) AXIS Dance Company Big Moves Bay Area (bigmoves.org) Community Resources for Independent Living (CRIL) (crilhayward.org) Disability Justice Culture Club Disability Visibility Project (disabilityvisibilityproject.com) Diversability Inc. (mydiversability.com) Disability Rights Education and Defense Fund (DREDF) (dredf.org) Fat Lib Ink (fatlibink.com) Fat Rose (fatrose.org) FAT!SO? (fatso.com) FLARE (The Fat Legal Advocacy, Research, and Education Project) Hand in Hand: The Domestic Employers Network (domesticemployers.org) Health Justice Commons (healthjusticecommons.org) The Icarus Project (theicarusproject.net) Idriss Stelley Foundation (ISF) (bit.ly/IdrissStelley) Justice 4 Kayla Moore (justiceforkaylamoore.wordpress.com) Krip Hop Nation (kriphopnation.com) Making Waves fat swim (makingwavesswim.com) National Association to Advance Fat Acceptance (naafa.org) NOLOSE (nolose.org) PleasureNess Literary Academy/Reclaiming Ugly (pleasurenesslitacademy.com) POOR Magazine/PrensaPobre (poormagazine.org) Pushing Limits Radio (KPFA) (pushinglimitsradio.org) Reclamation Press (reclapress.com) Senior and Disability Action (sdaction.org) Sins Invalid (sinsinvalid.org) Urban Jazz Dance Company (realurbanjazzdance.com) Women's March Disability Caucus ————- Town Hall On Long Term Care Expanding Long Term Services and Supports for All Thursday, September 19 9:45 am – 12 noon Korat Auditorium Downtown Library 100 Larkin St, San Francisco Join us for a town hall about the solving the State's need for affordable long-term supports and services so that we may all live and age with dignity.   Get your free ticket here. By 2030 9 million Californians will be over the age of 65. That's 3 million more than there are today! This unprecedented growth in the senior population is driving a skyrocketing demand for long term services and supports (LTSS), yet we see increasing evidence that paying for these services is bankrupting middle class seniors and their families throughout the state. The event will include a panel discussion with state legislators, Senator Scott Wiener, Assembly member David Chiu and Assembly member Phil Ting on the challenges that seniors and people with disabilities face when seeking affordable long term care and the caregivers who provide these essential services. Food, childcare, Spanish interpretation and other accommodations will be provided. Be sure to fill out the RSVP. This event is hosted by the San Francisco Care Council, including UDW/AFSCME Local 3930, SEIU Local 2015, Caring Across Generations, the California Domestic Workers Coalition, SF Family Caregiver Alliance, Senior and Disability Action, California Foundation for Independent Living Centers, and Hand in Hand: Domestic Employers Network. ———— Agenda de Cuidado: Apoyo a Largo Plazo En Expansión Para Todos Únase a nosotros para un ayuntamiento sobre la solución de la necesidad del estado CA de servicios y apoyos asequibles a largo plazo (LTSS) para que todos podamos vivir y envejecer con dignidad. En 2030, 9 millón Californianos serán mayores de 65 años. Eso es 3 millón más de lo que hay hoy. Este crecimiento sin precedentes en la población de adultos mayores está impulsando una demanda vertiginosa de servicios y apoyos a largo plazo (LTSS). Sin embargo, vemos más y más evidencia de que pagar por estos servicios está llevando a la bancarrota a las personas mayores y a sus familias de clase media en todo el estado. Únase a nosotros para una discusión con legisladores del estado de CA sobre los desafíos que enfrentan las personas mayores y las personas con discapacidades que buscan cuidado a largo plazo asequible y los asistentes personales que brindan estos servicios esenciales. Se proporcionará comida, cuidado de niños, interpretación en español y otros alojamientos. Asegúrese de completar el forma para RSVP. Este evento es organizado por el Consejo de Cuidado de San Francisco, que incluye UDW / AFSCME Local 3930, SEIU Local 2015, Cuidado a Través de Generaciones, la Coalición de Trabajadoras del Hogar, Alianza de Cuidadores Familiares de SF, Acción de Mayor Edad & Discapacidad, La Fundación para Centros de Vivir Independiente de California, y Mano a Mano: El Red de Empleadores Domésticos. The post Close the Camps – Protest Coverage appeared first on KPFA.

These podcasts, excerpted from an August 2019 webinar, discuss the importance of care coordinators, person-centered care planning, and assisting members with management tasks required for self-direction for plans seeking to support consumers in directing their own care.

These podcasts, excerpted from an August 2019 webinar, discuss the importance of care coordinators, person-centered care planning, and assisting members with management tasks required for self-direction for plans seeking to support consumers in directing their own care.

These podcasts, excerpted from an August 2019 webinar, discuss the importance of care coordinators, person-centered care planning, and assisting members with management tasks required for self-direction for plans seeking to support consumers in directing their own care.

These podcats excerpted from a July 2019 webinar discuss strategies for providing direct care services with cultural sensitivity, as well as training elements for direct care workers to achieve cultural competence. Speakers share strategies for effectively identifying and meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences. Finally, a direct care worker shares her firsthand experiences and recommendations on providing culturally competent direct care.

These podcats excerpted from a July 2019 webinar discuss strategies for providing direct care services with cultural sensitivity, as well as training elements for direct care workers to achieve cultural competence. Speakers share strategies for effectively identifying and meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences. Finally, a direct care worker shares her firsthand experiences and recommendations on providing culturally competent direct care.

These podcats excerpted from a July 2019 webinar discuss strategies for providing direct care services with cultural sensitivity, as well as training elements for direct care workers to achieve cultural competence. Speakers share strategies for effectively identifying and meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences. Finally, a direct care worker shares her firsthand experiences and recommendations on providing culturally competent direct care.

In this episode of Eldercare Illuminated, host Lenore Tracey speaks with attorney Eric Carlson about the problems that nursing home residents and their caregivers may face — and what to do about them. Nursing homes throughout the country are bound by federal laws that are designed to ensure a person-centered, homelike experience for their residents. As Eric points out, even “good” nursing homes may have practices and procedures that violate federal law. This podcast offers insights and practical assistance to help caregivers advocate effectively for their loved ones' rights as nursing home residents.About Our Guest:Eric Carlson is the Directing Attorney at Washington D.C.-based Justice in Aging. Formerly the National Senior Citizens Law Center, since 1972 Justice in Aging has worked for almost 50 years to address the health and economic security needs of older adults with limited resources.Eric has experience in many forms of long-term services and supports (LTSS), including home and community-based services, nursing facility care, and assisted living facilities. He led Justice in Aging’s extensive research (funded through The Commonwealth Fund) on Medicaid-funded assisted living and currently is leading a project to assist consumer advocacy on Medicaid managed LTSS in Florida and New Jersey. Eric also serves as President of the national Assisted Living Consumer Alliance and is author of the legal treatise Long-Term Care Advocacy (Matthew Bender and Co.).Download Justice in Aging's Guide: 25 Common Nursing Home Problems and How to Resolve Them (link - http://www.justiceinaging.org/guide-25-common-nursing-home-problems-and-how-to-resolve-them/)And Stories from the Field (link - http://www.justiceinaging.org.customers.tigertech.net/wp-content/uploads/2015/06/Stories-from-the-Field.pdf) , a guide for nursing home residents and their loved ones to recognize and address issues that LGBTQ+ individuals may encounter.

In this episode of Eldercare Illuminated, host Lenore Tracey speaks with attorney Eric Carlson about the problems that nursing home residents and their caregivers may face — and what to do about them. Nursing homes throughout the country are bound by federal laws that are designed to ensure a person-centered, homelike experience for their residents. As Eric points out, even “good” nursing homes may have practices and procedures that violate federal law. This podcast offers insights and practical assistance to help caregivers advocate effectively for their loved ones' rights as nursing home residents.About Our Guest:Eric Carlson is the Directing Attorney at Washington D.C.-based Justice in Aging. Formerly the National Senior Citizens Law Center, since 1972 Justice in Aging has worked for almost 50 years to address the health and economic security needs of older adults with limited resources.Eric has experience in many forms of long-term services and supports (LTSS), including home and community-based services, nursing facility care, and assisted living facilities. He led Justice in Aging’s extensive research (funded through The Commonwealth Fund) on Medicaid-funded assisted living and currently is leading a project to assist consumer advocacy on Medicaid managed LTSS in Florida and New Jersey. Eric also serves as President of the national Assisted Living Consumer Alliance and is author of the legal treatise Long-Term Care Advocacy (Matthew Bender and Co.).Download Justice in Aging's Guide: 25 Common Nursing Home Problems and How to Resolve Them (link - http://www.justiceinaging.org/guide-25-common-nursing-home-problems-and-how-to-resolve-them/)And Stories from the Field (link - http://www.justiceinaging.org.customers.tigertech.net/wp-content/uploads/2015/06/Stories-from-the-Field.pdf) , a guide for nursing home residents and their loved ones to recognize and address issues that LGBTQ+ individuals may encounter.

These podcasts, excerpted from an April 2018 webinar, focus on how to identify LTSS preferences, values, and needs of members from diverse cultural backgrounds. It addresses provision of services with cultural sensitivity and training the LTSS workforce in strategies to achieve cultural competence. Speakers share concrete strategies for effectively meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences.

These podcasts, excerpted from an April 2018 webinar, focus on how to identify LTSS preferences, values, and needs of members from diverse cultural backgrounds. It addresses provision of services with cultural sensitivity and training the LTSS workforce in strategies to achieve cultural competence. Speakers share concrete strategies for effectively meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences.

These podcasts, excerpted from an April 2018 webinar, focus on how to identify LTSS preferences, values, and needs of members from diverse cultural backgrounds. It addresses provision of services with cultural sensitivity and training the LTSS workforce in strategies to achieve cultural competence. Speakers share concrete strategies for effectively meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences.

These podcasts, excerpted from an April 2018 webinar, focus on how to identify LTSS preferences, values, and needs of members from diverse cultural backgrounds. It addresses provision of services with cultural sensitivity and training the LTSS workforce in strategies to achieve cultural competence. Speakers share concrete strategies for effectively meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences.

These podcasts, excerpted from an April 2018 webinar, focus on how to identify LTSS preferences, values, and needs of members from diverse cultural backgrounds. It addresses provision of services with cultural sensitivity and training the LTSS workforce in strategies to achieve cultural competence. Speakers share concrete strategies for effectively meeting beneficiaries’ LTSS needs, in both institutional and community-based settings, while respecting their diverse cultural preferences.

Older adults and individuals with disabilities share desires to live independently in the community and age with dignity and respect. However, our current system of long-term services and supports (LTSS) forces individuals to impoverish themselves, places enormous burdens on unpaid family caregivers, and is based towards nursing homes and institutional services. This episode of ADA Live! is the first of a two-part conversation with the National Council on Aging (NCOA). In this episode, Joe Caldwell, Director of Long-Term Services and Supports, will discuss: Important community living policy issues for older adults, including: LTSS financing, access to Medicaid home and community-based services, and healthy aging and falls prevention. Collaboration among national aging and disability organizations to advance community-living policy. Speakers: Joe Caldwell, Director Long-Term Services - National Council on Aging (NCOA) Leslie Fried, Senior Director - Center for Benefits Access - National Council on Aging (NCOA) More Information and Transcript available at: https://www.adalive.org/episode54

In this episode, we interview Adam Hughes, who is the Chief Information Officer for the Peel District School Board. He shares how the work being done in Learning Technology Support Services (LTSS) connects to Empowering Modern Learners. He also shares the new vision for LTSS and the journey they took to get there.

JSJ 267 Node 8 with Mikeal Rogers, Arunesh Chandra, and Anna Henningsen On today’s episode of JavaScript Jabber we have panelists Joe Eames, AJ O’Neil, Amiee Knight and Charles Max Wood and we are talking about Node 8. To help us we have special guests Mikeal Rodgers, Arunesh Chandra, and Anna Henningsen. It’s going to be a great show. Tune in. [1:56] Is Node 8 just an update or is there more? More than just an update Two main points: Improved Prana support Native API Native APIs are helpful for Native Add-ons. For both the consumer and the developer side. Prior to update these Node Native modules ran in C++ and bound to specific to Node 8 APIs. Causes these modules to be updated or reconciled every time these modules are rereleased. Creates burden for module maintainers. Creates friction in upgrading Node versions in production departments. If you have a deployment depending on a certain Native module, some of the modules may not get updated in time when updating your Node versions. Keeping people from updating Node. Creates compatibility issues with Node users not using Node 8 Experimental support for a Native layer in Node 8 to eliminate these issues as much as possible. Important milestone for the module ecosystem. You can write extensions for Node in C++ and it decouples V8 so you can use something else on the front. Modules takes dependency on V8 API specific to a particular version. So if V8 changes your module will be extracted from that. As a side benefit, you can have another VM to take advantage of that. Major version upgrades mean updating Native modules and usually some of those modules haven’t updated to the newest version of Node and be complicated. Deep dependency wise, about 30% depends on a Native module somewhere In the future, with the Native API, you’ll be able to update Node without breaking modules. [5:51] What kind of work went into this? Most of the work was in C++ First thing that was done was, they looked at the top dependent Native modules in the ecosystem. Looked for what kind of V8 exposure they had and cataloged it Looked at how these APIs and what their purposes were Looked for a way to extract them so that they are part of Node Core Created neutral APIs, now part of the Node core. All C APIs Also has a C++ wrapper to improves usability of the API. [7:17] What’s an example of what you can do with these APIs? Native modules allows for tighter integration and better module performance Specific APIs that you can use in V8 that isn’t available through JavaScript If you have a C++ variable code and you want to expose a variable into JavaScript, that is V8 API note a Node 8 API Having it bound directly to the VM was something they wanted for a long time Google controls V8 and they bind to V8 Created a better relationship with Google starting in IOJS Also worked with Microsoft with their Node Shocker work. Same with SpiderMonkey SpiderNode is in the works [9:23] Have you guys done any testing for performance? Some. There is a performance working group. There is a need to stay on top of V8 V8 team has focused on new language features Many features have been added over the years Many didn’t come in optimized The performance profile has changed with these features If you’re using new language features, you will see a performance boost In core, still tracking down code that was specific to the old optimizer and rewriting i to work the new optimizer Turbo C compiler hasn’t landed yet, but is to come. Will have a completely different performance profile In most real world applications it will be faster Waiting on the release to take a version of V8 to make it easier to upgrade features in the future [11:28] Are the new features picked up from V8 or implemented in Node? It’s all in V8 Better longterm support Promises are made better in Node as a platform Added new method called util.promisify() Implementation comes from V8 Allows for more optimization for promises in Node core Promise support for the one-deprecated domains module. [13:02] Is there anything more than NMP 5? First off, delete your NMP cache. It’s in your home directory usually with a .npm extension [14:09] What are the new features in V8? Unlimited heap sizes, previously had a 4gb limit. No fixed limit. [14:09] Will you see things like chakra come out tuned for servers? Profiles of a server for application process are getting smaller Getting cut into containers and VMs and micro services Vms that have cold boot time and run quickly in a strained environment is looking more like what we will see in the future Yes, especially if you’re using cloud functions V8 is optimized for phones, but Chakra is even more so Looking for opportunities for VMs can be solely optimized for a device target Node take advantage of that VM VM neutrality is an interesting concept VM Vendors trying to optimize it based on workloads of a server Opens opportunities for Node Node Chakra has been proved to iOS. You can cut off jitting off which was a requirement to be able to be in the Apple App Store Node is not just for servers anymore Node doesn’t take a long time configuring it When a developer runs code on an IoT or a mobile app they don’t control the VM that is bundled, they run it on top of Node and it just works. VM neutrality gives a new vector, so you can swam a whole different VM [18:44] When running different engines like iOS vs Android, does the profile change? What it comes down to is if it’s eventive programming The browser is an eventive environment, is very efficient waiting for things to happen before it does something The way that we program servers and nodes are the same as well the basics are the same generally environmental differences exist but the programming model is usually the same What does impact it is memory and processor and hardware and things like that That is where tuning the VM comes into play [20:29] What is the new Async Hooks API used for? Node has been lacking for automated inspection of Async Hook No way for Node to tell you when scheduling and beginning of an Async operation. Hook helps with that it’s a way for developers to write debugging features Node tells the application that it’s working with Asynchronous way. The embedded inspector has been embedded since Node 6 Now has a JavaScript API to use it You can use things like Chrome debugger inside the running node process Old debugging protocol has been removed VM.run is still there but in the process of being deprecated [22:34] How like is the experimental Node API will change? Marked as experimental because it’s the first time in the open Hopefully out of experimental soon Soon can port API to the existing LTS Looking for more people to participate with the new API and give feedback Fix any concerns before it goes to LTS Some other experimental things are in the works like ASync Hooks and how it interacts with promises Renaming some features Another new feature - serializer and deserializer that comes with V8 experimental but will most likely stay [25:31] what is your standard for going to LTS? Major releases every 6 months Next Oct Node 9 will come out and then Node 8 will be LTS Documentation, updates, additions etc will be ready then Plan to do it for 2.5 years Every even releases come out to LTS as the odd release comes out Helps keeps a current line while having something new in the release line Node 6 is the current LTS version [27:26] What are you taking out or deprecating in Node 8? Use the word deprecate sparingly If many people use features, it’s hard to get rid of Security issue with Buffer, constructor argument was ambiguous Had added APIs that were more explicit over time and pushed those Now it will be deprecated [28:43] 21% - 33% Performance increase with some Node updates Someone online updated their React app to Node 8 and found an 21% - 33% increase Benchmarking group tests to make sure things are getting faster V8 is always getting faster as well Code changes fast and so there is a chance performance slows down so they have people to check Benchmark test are all automated by a team [30:47] Is it safe to just switch to Node 8? For front-end, yes clear your NPM cache Back use cases will usually wait until LTS [31:28] Where any of the features hard to implement? The API work took about a year It was a collaboration which made it interesting IBM, Intel, Google were involved The collaboration took a while Also Async hooks took at least a year. Async hooks used to be called async wraps and has been in the work for almost 3 years many of the changes were the accumulation of small chances [33:07] It’s the little things Letting people get small changes in accumulate into a big difference the product gets much better that way [33:57] What versions of Node are you actively updating? Current releases of Node 8 for a half of year Node 6 is LTS Additional year of maintenance of previous LTSs. Schedule is at http://github.com/node8js/lts in a chart Support for Node 4 with only critical updates, Node 6 minor updates, and Node 8 Node 7 doesn’t get much support unless it’s vital security supports. If you’re running 0.10 or 0.12 stop. Those do not get security fixes anymore [35:42] Where do you see things going from here? Mostly still working out Async hooks Maybe add some web worker or worker support for Node JS ES module support Working to make promises better Working on the performance profile and internal systems [20:29] What is the adoption like of Node 8? Node team gets better at getting people to adopt quickly but about 5% - 6% will not upgrade community doubles each year at 8 million users right now Here is a graph on Twitter posted by NPM Limiting breaks and softly deprecating things makes it’s easier to upgrade [40:11] How can people contribute and get involved? NodeToDo.org shows how to make contribution Occasionally major conferences have information on how to contribute Test it out and help make it stronger [42:08] If people install Node 8 and have issues what can they do? If it’s an NPM problem check with them clear cache! install newest version with: npm install -g npm@latest Report problems to either NPM or Node If you’re not sure where the problem is, check github.com/nodejs/help Links Node8 Node’s Twitter Node’s Medium Node Evangelism Group Mikael on Twitter and GitHub Arunesh on Twitter Anna on Twitter Picks AJ Overclocked Remix Super Mario RPG Window to The Stars Amiee Blogpost RisingStack on Node 8 2 Frugal Dudes Charles Homeland House of Cards Joe Shimmer Lake Mikael Blake2b-wasm Aremesh Current Nightly News

JSJ 267 Node 8 with Mikeal Rogers, Arunesh Chandra, and Anna Henningsen On today’s episode of JavaScript Jabber we have panelists Joe Eames, AJ O’Neil, Amiee Knight and Charles Max Wood and we are talking about Node 8. To help us we have special guests Mikeal Rodgers, Arunesh Chandra, and Anna Henningsen. It’s going to be a great show. Tune in. [1:56] Is Node 8 just an update or is there more? More than just an update Two main points: Improved Prana support Native API Native APIs are helpful for Native Add-ons. For both the consumer and the developer side. Prior to update these Node Native modules ran in C++ and bound to specific to Node 8 APIs. Causes these modules to be updated or reconciled every time these modules are rereleased. Creates burden for module maintainers. Creates friction in upgrading Node versions in production departments. If you have a deployment depending on a certain Native module, some of the modules may not get updated in time when updating your Node versions. Keeping people from updating Node. Creates compatibility issues with Node users not using Node 8 Experimental support for a Native layer in Node 8 to eliminate these issues as much as possible. Important milestone for the module ecosystem. You can write extensions for Node in C++ and it decouples V8 so you can use something else on the front. Modules takes dependency on V8 API specific to a particular version. So if V8 changes your module will be extracted from that. As a side benefit, you can have another VM to take advantage of that. Major version upgrades mean updating Native modules and usually some of those modules haven’t updated to the newest version of Node and be complicated. Deep dependency wise, about 30% depends on a Native module somewhere In the future, with the Native API, you’ll be able to update Node without breaking modules. [5:51] What kind of work went into this? Most of the work was in C++ First thing that was done was, they looked at the top dependent Native modules in the ecosystem. Looked for what kind of V8 exposure they had and cataloged it Looked at how these APIs and what their purposes were Looked for a way to extract them so that they are part of Node Core Created neutral APIs, now part of the Node core. All C APIs Also has a C++ wrapper to improves usability of the API. [7:17] What’s an example of what you can do with these APIs? Native modules allows for tighter integration and better module performance Specific APIs that you can use in V8 that isn’t available through JavaScript If you have a C++ variable code and you want to expose a variable into JavaScript, that is V8 API note a Node 8 API Having it bound directly to the VM was something they wanted for a long time Google controls V8 and they bind to V8 Created a better relationship with Google starting in IOJS Also worked with Microsoft with their Node Shocker work. Same with SpiderMonkey SpiderNode is in the works [9:23] Have you guys done any testing for performance? Some. There is a performance working group. There is a need to stay on top of V8 V8 team has focused on new language features Many features have been added over the years Many didn’t come in optimized The performance profile has changed with these features If you’re using new language features, you will see a performance boost In core, still tracking down code that was specific to the old optimizer and rewriting i to work the new optimizer Turbo C compiler hasn’t landed yet, but is to come. Will have a completely different performance profile In most real world applications it will be faster Waiting on the release to take a version of V8 to make it easier to upgrade features in the future [11:28] Are the new features picked up from V8 or implemented in Node? It’s all in V8 Better longterm support Promises are made better in Node as a platform Added new method called util.promisify() Implementation comes from V8 Allows for more optimization for promises in Node core Promise support for the one-deprecated domains module. [13:02] Is there anything more than NMP 5? First off, delete your NMP cache. It’s in your home directory usually with a .npm extension [14:09] What are the new features in V8? Unlimited heap sizes, previously had a 4gb limit. No fixed limit. [14:09] Will you see things like chakra come out tuned for servers? Profiles of a server for application process are getting smaller Getting cut into containers and VMs and micro services Vms that have cold boot time and run quickly in a strained environment is looking more like what we will see in the future Yes, especially if you’re using cloud functions V8 is optimized for phones, but Chakra is even more so Looking for opportunities for VMs can be solely optimized for a device target Node take advantage of that VM VM neutrality is an interesting concept VM Vendors trying to optimize it based on workloads of a server Opens opportunities for Node Node Chakra has been proved to iOS. You can cut off jitting off which was a requirement to be able to be in the Apple App Store Node is not just for servers anymore Node doesn’t take a long time configuring it When a developer runs code on an IoT or a mobile app they don’t control the VM that is bundled, they run it on top of Node and it just works. VM neutrality gives a new vector, so you can swam a whole different VM [18:44] When running different engines like iOS vs Android, does the profile change? What it comes down to is if it’s eventive programming The browser is an eventive environment, is very efficient waiting for things to happen before it does something The way that we program servers and nodes are the same as well the basics are the same generally environmental differences exist but the programming model is usually the same What does impact it is memory and processor and hardware and things like that That is where tuning the VM comes into play [20:29] What is the new Async Hooks API used for? Node has been lacking for automated inspection of Async Hook No way for Node to tell you when scheduling and beginning of an Async operation. Hook helps with that it’s a way for developers to write debugging features Node tells the application that it’s working with Asynchronous way. The embedded inspector has been embedded since Node 6 Now has a JavaScript API to use it You can use things like Chrome debugger inside the running node process Old debugging protocol has been removed VM.run is still there but in the process of being deprecated [22:34] How like is the experimental Node API will change? Marked as experimental because it’s the first time in the open Hopefully out of experimental soon Soon can port API to the existing LTS Looking for more people to participate with the new API and give feedback Fix any concerns before it goes to LTS Some other experimental things are in the works like ASync Hooks and how it interacts with promises Renaming some features Another new feature - serializer and deserializer that comes with V8 experimental but will most likely stay [25:31] what is your standard for going to LTS? Major releases every 6 months Next Oct Node 9 will come out and then Node 8 will be LTS Documentation, updates, additions etc will be ready then Plan to do it for 2.5 years Every even releases come out to LTS as the odd release comes out Helps keeps a current line while having something new in the release line Node 6 is the current LTS version [27:26] What are you taking out or deprecating in Node 8? Use the word deprecate sparingly If many people use features, it’s hard to get rid of Security issue with Buffer, constructor argument was ambiguous Had added APIs that were more explicit over time and pushed those Now it will be deprecated [28:43] 21% - 33% Performance increase with some Node updates Someone online updated their React app to Node 8 and found an 21% - 33% increase Benchmarking group tests to make sure things are getting faster V8 is always getting faster as well Code changes fast and so there is a chance performance slows down so they have people to check Benchmark test are all automated by a team [30:47] Is it safe to just switch to Node 8? For front-end, yes clear your NPM cache Back use cases will usually wait until LTS [31:28] Where any of the features hard to implement? The API work took about a year It was a collaboration which made it interesting IBM, Intel, Google were involved The collaboration took a while Also Async hooks took at least a year. Async hooks used to be called async wraps and has been in the work for almost 3 years many of the changes were the accumulation of small chances [33:07] It’s the little things Letting people get small changes in accumulate into a big difference the product gets much better that way [33:57] What versions of Node are you actively updating? Current releases of Node 8 for a half of year Node 6 is LTS Additional year of maintenance of previous LTSs. Schedule is at http://github.com/node8js/lts in a chart Support for Node 4 with only critical updates, Node 6 minor updates, and Node 8 Node 7 doesn’t get much support unless it’s vital security supports. If you’re running 0.10 or 0.12 stop. Those do not get security fixes anymore [35:42] Where do you see things going from here? Mostly still working out Async hooks Maybe add some web worker or worker support for Node JS ES module support Working to make promises better Working on the performance profile and internal systems [20:29] What is the adoption like of Node 8? Node team gets better at getting people to adopt quickly but about 5% - 6% will not upgrade community doubles each year at 8 million users right now Here is a graph on Twitter posted by NPM Limiting breaks and softly deprecating things makes it’s easier to upgrade [40:11] How can people contribute and get involved? NodeToDo.org shows how to make contribution Occasionally major conferences have information on how to contribute Test it out and help make it stronger [42:08] If people install Node 8 and have issues what can they do? If it’s an NPM problem check with them clear cache! install newest version with: npm install -g npm@latest Report problems to either NPM or Node If you’re not sure where the problem is, check github.com/nodejs/help Links Node8 Node’s Twitter Node’s Medium Node Evangelism Group Mikael on Twitter and GitHub Arunesh on Twitter Anna on Twitter Picks AJ Overclocked Remix Super Mario RPG Window to The Stars Amiee Blogpost RisingStack on Node 8 2 Frugal Dudes Charles Homeland House of Cards Joe Shimmer Lake Mikael Blake2b-wasm Aremesh Current Nightly News

JSJ 267 Node 8 with Mikeal Rogers, Arunesh Chandra, and Anna Henningsen On today’s episode of JavaScript Jabber we have panelists Joe Eames, AJ O’Neil, Amiee Knight and Charles Max Wood and we are talking about Node 8. To help us we have special guests Mikeal Rodgers, Arunesh Chandra, and Anna Henningsen. It’s going to be a great show. Tune in. [1:56] Is Node 8 just an update or is there more? More than just an update Two main points: Improved Prana support Native API Native APIs are helpful for Native Add-ons. For both the consumer and the developer side. Prior to update these Node Native modules ran in C++ and bound to specific to Node 8 APIs. Causes these modules to be updated or reconciled every time these modules are rereleased. Creates burden for module maintainers. Creates friction in upgrading Node versions in production departments. If you have a deployment depending on a certain Native module, some of the modules may not get updated in time when updating your Node versions. Keeping people from updating Node. Creates compatibility issues with Node users not using Node 8 Experimental support for a Native layer in Node 8 to eliminate these issues as much as possible. Important milestone for the module ecosystem. You can write extensions for Node in C++ and it decouples V8 so you can use something else on the front. Modules takes dependency on V8 API specific to a particular version. So if V8 changes your module will be extracted from that. As a side benefit, you can have another VM to take advantage of that. Major version upgrades mean updating Native modules and usually some of those modules haven’t updated to the newest version of Node and be complicated. Deep dependency wise, about 30% depends on a Native module somewhere In the future, with the Native API, you’ll be able to update Node without breaking modules. [5:51] What kind of work went into this? Most of the work was in C++ First thing that was done was, they looked at the top dependent Native modules in the ecosystem. Looked for what kind of V8 exposure they had and cataloged it Looked at how these APIs and what their purposes were Looked for a way to extract them so that they are part of Node Core Created neutral APIs, now part of the Node core. All C APIs Also has a C++ wrapper to improves usability of the API. [7:17] What’s an example of what you can do with these APIs? Native modules allows for tighter integration and better module performance Specific APIs that you can use in V8 that isn’t available through JavaScript If you have a C++ variable code and you want to expose a variable into JavaScript, that is V8 API note a Node 8 API Having it bound directly to the VM was something they wanted for a long time Google controls V8 and they bind to V8 Created a better relationship with Google starting in IOJS Also worked with Microsoft with their Node Shocker work. Same with SpiderMonkey SpiderNode is in the works [9:23] Have you guys done any testing for performance? Some. There is a performance working group. There is a need to stay on top of V8 V8 team has focused on new language features Many features have been added over the years Many didn’t come in optimized The performance profile has changed with these features If you’re using new language features, you will see a performance boost In core, still tracking down code that was specific to the old optimizer and rewriting i to work the new optimizer Turbo C compiler hasn’t landed yet, but is to come. Will have a completely different performance profile In most real world applications it will be faster Waiting on the release to take a version of V8 to make it easier to upgrade features in the future [11:28] Are the new features picked up from V8 or implemented in Node? It’s all in V8 Better longterm support Promises are made better in Node as a platform Added new method called util.promisify() Implementation comes from V8 Allows for more optimization for promises in Node core Promise support for the one-deprecated domains module. [13:02] Is there anything more than NMP 5? First off, delete your NMP cache. It’s in your home directory usually with a .npm extension [14:09] What are the new features in V8? Unlimited heap sizes, previously had a 4gb limit. No fixed limit. [14:09] Will you see things like chakra come out tuned for servers? Profiles of a server for application process are getting smaller Getting cut into containers and VMs and micro services Vms that have cold boot time and run quickly in a strained environment is looking more like what we will see in the future Yes, especially if you’re using cloud functions V8 is optimized for phones, but Chakra is even more so Looking for opportunities for VMs can be solely optimized for a device target Node take advantage of that VM VM neutrality is an interesting concept VM Vendors trying to optimize it based on workloads of a server Opens opportunities for Node Node Chakra has been proved to iOS. You can cut off jitting off which was a requirement to be able to be in the Apple App Store Node is not just for servers anymore Node doesn’t take a long time configuring it When a developer runs code on an IoT or a mobile app they don’t control the VM that is bundled, they run it on top of Node and it just works. VM neutrality gives a new vector, so you can swam a whole different VM [18:44] When running different engines like iOS vs Android, does the profile change? What it comes down to is if it’s eventive programming The browser is an eventive environment, is very efficient waiting for things to happen before it does something The way that we program servers and nodes are the same as well the basics are the same generally environmental differences exist but the programming model is usually the same What does impact it is memory and processor and hardware and things like that That is where tuning the VM comes into play [20:29] What is the new Async Hooks API used for? Node has been lacking for automated inspection of Async Hook No way for Node to tell you when scheduling and beginning of an Async operation. Hook helps with that it’s a way for developers to write debugging features Node tells the application that it’s working with Asynchronous way. The embedded inspector has been embedded since Node 6 Now has a JavaScript API to use it You can use things like Chrome debugger inside the running node process Old debugging protocol has been removed VM.run is still there but in the process of being deprecated [22:34] How like is the experimental Node API will change? Marked as experimental because it’s the first time in the open Hopefully out of experimental soon Soon can port API to the existing LTS Looking for more people to participate with the new API and give feedback Fix any concerns before it goes to LTS Some other experimental things are in the works like ASync Hooks and how it interacts with promises Renaming some features Another new feature - serializer and deserializer that comes with V8 experimental but will most likely stay [25:31] what is your standard for going to LTS? Major releases every 6 months Next Oct Node 9 will come out and then Node 8 will be LTS Documentation, updates, additions etc will be ready then Plan to do it for 2.5 years Every even releases come out to LTS as the odd release comes out Helps keeps a current line while having something new in the release line Node 6 is the current LTS version [27:26] What are you taking out or deprecating in Node 8? Use the word deprecate sparingly If many people use features, it’s hard to get rid of Security issue with Buffer, constructor argument was ambiguous Had added APIs that were more explicit over time and pushed those Now it will be deprecated [28:43] 21% - 33% Performance increase with some Node updates Someone online updated their React app to Node 8 and found an 21% - 33% increase Benchmarking group tests to make sure things are getting faster V8 is always getting faster as well Code changes fast and so there is a chance performance slows down so they have people to check Benchmark test are all automated by a team [30:47] Is it safe to just switch to Node 8? For front-end, yes clear your NPM cache Back use cases will usually wait until LTS [31:28] Where any of the features hard to implement? The API work took about a year It was a collaboration which made it interesting IBM, Intel, Google were involved The collaboration took a while Also Async hooks took at least a year. Async hooks used to be called async wraps and has been in the work for almost 3 years many of the changes were the accumulation of small chances [33:07] It’s the little things Letting people get small changes in accumulate into a big difference the product gets much better that way [33:57] What versions of Node are you actively updating? Current releases of Node 8 for a half of year Node 6 is LTS Additional year of maintenance of previous LTSs. Schedule is at http://github.com/node8js/lts in a chart Support for Node 4 with only critical updates, Node 6 minor updates, and Node 8 Node 7 doesn’t get much support unless it’s vital security supports. If you’re running 0.10 or 0.12 stop. Those do not get security fixes anymore [35:42] Where do you see things going from here? Mostly still working out Async hooks Maybe add some web worker or worker support for Node JS ES module support Working to make promises better Working on the performance profile and internal systems [20:29] What is the adoption like of Node 8? Node team gets better at getting people to adopt quickly but about 5% - 6% will not upgrade community doubles each year at 8 million users right now Here is a graph on Twitter posted by NPM Limiting breaks and softly deprecating things makes it’s easier to upgrade [40:11] How can people contribute and get involved? NodeToDo.org shows how to make contribution Occasionally major conferences have information on how to contribute Test it out and help make it stronger [42:08] If people install Node 8 and have issues what can they do? If it’s an NPM problem check with them clear cache! install newest version with: npm install -g npm@latest Report problems to either NPM or Node If you’re not sure where the problem is, check github.com/nodejs/help Links Node8 Node’s Twitter Node’s Medium Node Evangelism Group Mikael on Twitter and GitHub Arunesh on Twitter Anna on Twitter Picks AJ Overclocked Remix Super Mario RPG Window to The Stars Amiee Blogpost RisingStack on Node 8 2 Frugal Dudes Charles Homeland House of Cards Joe Shimmer Lake Mikael Blake2b-wasm Aremesh Current Nightly News

This podcast, presented by Karen Luken, Project Director of the North Carolina Office on Disability and Health, explores the role that community supports afford participants to function and integrate in their homes and communities. This podcast will also explore the range of LTSS options that may be available. We will learn more about the importance of mobility and home modification assessments and the exploration of community services such as recreation and religious centers and health clubs. This podcast is excerpted from a webinar which is available, along with many more resources, at http://www.ResourcesForIntegrateCare.com

Listen NowThe most expensive Medicare beneficiaries are not those with multiple chronic conditions.  They are those with chronic conditions AND functional impairment (i.e., those needing help with routine life activities).  For example, the 15% of Medicare enrollees with both chronic conditions and functional limitations disproportinally account for one-third of Medicare spending.  Alternatively, Medicare enrollees with three or more chronic conditions but no functional impairment (48%) account for roughly the same percent of spending (51%).  The challenge therefore both in improving quality care for the chronically ill and reducing costs (via, for example, reduced hospitalizations) is in improving long term care supports and services (LTSS). During this 26-minute podcast Dr. Alkema defines "functional limitation" and "care coordination", explains the current lack of care coordination for Medicare patients with chronic conditions and functional limitations, describes three exemplary models of care coordination and what Medicare can or should do to improve care for these patients.Dr. Gretchen Alkema currently serves as Vice President of Policy and Communications for The SCAN Foundation.  Prior to joining SCAN Dr. Alkema was the 2008-09 John Heinz Health and Aging Policy Fellow serving in the office of Sen. Blanche Lincoln.  Dr. Alkema earned her PhD at the University of Southern California's Davis School of Gerontology and and completed her post-doctoral training at the VA Greater Los Angeles Health Services Research and Development Center of Excellence.  Her academic research focused on evaluating innovative models of chronic care management and translating effective models into practice.  She is a Licensed Clinical Social Worker and has practiced in government and non-profit settings including community mental health, care management, adult day health care, residential care and post-acute rehabilitation.For background information concerning this topic see this paper by Georgetown's Harriet Komisar and Judy Feder: http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf  See also too SCAN's "10 Conversations to Plan for Aging with Dignity and Independence" at: http://www.thescanfoundation.org/10-conversations-plan-aging-dignity-and-independence. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Geoengineering, as a response to climate change, raises serious ethical and socio-political issues. Drawing on the latest developments in philosophy and ethics of technology and science, I consider a post-humanist way of analysing such issues. Along with mitigation and adaptation, geoengineering, i.e. "the deliberate large-scale manipulation of the planetary environment to counteract anthropogenic climate change" has become increasingly visible as a third option in response to anthropogenic climate change. Yet, it has also been widely acknowledged that geoengineering - whether its research and development or implementation - will raise serious ethical, socio-political and legal issues. Instead of examining specific ethical issues in the ethics of geoengineering, I shall argue for a specific approach to ethics of geoengineering. Drawing from the latest developments in philosophy and ethics of technology and science and technology studies (STS), I outline a post-humanist virtue ethics, which, I believe, offers an alternative way to analyse ethical issues raised by geoengineering.My argument is based on the view that geoengineering should be understood as large technical systems (LTSs), i.e. large infrastructural and production systems. If such an understanding of geoengineering as LTS is correct, then it immediately raises two problems with the ethical analyses that focus on the decisions about (or, decision-making procedures for) and/or outcomes of geoengineering: firstly, the high degree of uncertainty with respect to the outcomes from LTSs, which is especially true in the case of geoengineering, has challenged the ethical analyses which based their judgments on the outcomes from LTSs. Secondly, as Susan Leigh Starr notes, "[b]ecause infrastructure is big, layered, and complex, and because it means different things locally, it is never changed from above. Changes take time and negotiation, and adjustment with other aspects of the systems are involved. Nobody is really in charge of infrastructure"; Starr's remark highlights the insignificance of individuals' decisions (and intentions) in the context of LTSs. Against this background, Brad Allenby proposes "macroethics" as a different level of ethics that takes systems as the unit of ethical reflection, and focus on the process in LTS's research and development and implementation. Allenby's call for a macroethics, I think, echoes on one hand with a recent shift towards a more distributed sense of morality, and on the other hand a shift towards ethics of design. Here, I argue that virtue ethics provide the best theoretical and normative underpinning of macroethics. Epitomised by the question "how should we live?" - instead of "what is the right decisions and-or actions?" or "what is the best consequence?", virtue ethics is particularly fitting as an ethics for processes. The obstacle for adopting virtue ethics in ethical analyses of geoengineering (or, any LTS), however, is that virtue ethics is largely humanist, and therefore it seems to be inapplicable to LTS such as geoengineering. Yet, I argue that an extension of agency to nonhuman entities in recent research in philosophy and ethics of technology (e.g. Luciano Floridi and Peter-Paul Verbeek) and STS (e.g. Bruno Latour) provides us a valuable opportunity to reconceptualise virtue ethics and develop a virtue-theoretical approach to geoengineering.

Topic: Finding light & hope in the midst of confict or crisis. Guest: Drew Goodson, pastor of Our Redeemer-Greenville. Host: Jonathan Boynton, seminarian at LTSS and soon to be vicar of Prairie Star Lutheran parish in Willow Lake, SD.

Topic: Finding light & hope in the midst of confict or crisis. Guest: David Hinshaw of Epiphany-Winston-Salem. Host: Jonathan Boynton, seminarian at LTSS and soon to be vicar of Prairie Star Lutheran parish in Willow Lake, SD.

Topic: Finding light & hope in the midst of confict or crisis. Guest: Rosemary Peek, pastor of Shepherd of the Hills, Sylva. Host: Jonathan Boynton, seminarian at LTSS and soon to be vicar of Prairie Star Lutheran parish in Willow Lake, SD.