Elderly Health Care
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Colorado Nursing Homes Eye Traveling Nurses as ‘Quick Solution’
As Colorado faces the highest number of COVID-19 patients it’s seen in the past year with more than 94% of the ICU beds in the state currently occupied, Gov. Jared Polis has pointed to long-term care facilities as a possible lifeline for hospitals during this surge.
Last month the governor reactivated an executive order which authorizes the Colorado Department of Public Health & Environment to preserve hospital capacity by directing facilities to transfer patents that aren’t COVID-19 positive. It states that the department can direct the transfer of patients from hospitals to skilled nursing facilities and direct the facility to accept the patients.
While skilled nursing facilities have been opening up COVID wings since the pandemic began as a way to free up hospital bed space and spark collaboration among large health care systems, without adequate staffing that simply is not an option for many operators right now.
At a time when hospital referrals are still down for SNFs from pre-COVID rates and building better hospital partnerships is more important than ever in post-acute care, Vivage Senior Living Vice President of Ancillary Services Heather Terhark sees it as a missed opportunity for operators to step up in the care continuum.
Terhark admitted frustration over the bind that many operators are now in as they want to help out their hospital partners but are unable to. One way health care officials across the state have been pushing the state to make an immediate impact on staffing is by opening the state borders to bring in more nurses from outside Colorado for nursing homes to help unclog hospitals.
“We want to partner with our hospitals, we want to take these folks that are coming from the hospital but we are limited based on how much staff we have available, depending on the home,” Terhark said. “You feel like you’re letting the system down because you know they have this incredible need and you can’t meet that need the way you want to.”
“I don’t know what the solution is going to be,” he told Skilled Nursing News. “But I think the one that we spent the most time talking about was asking the state to pay for the cost of traveling nurses and to pay directly for those traveling nurses. That way our members can get staffed up immediately.”
With several open positions for registered nurses, licensed professional nursing, and certified nursing assistants, traveling nurses would help operators like Vivage open up more units to provide critical care.
Farmer has been working closely with state officials to figure out how to best decompress the hospitals during this latest surge, which includes tabulating how many hospital admissions need SNF-level of care.
“We’re pairing those up with our providers and where they have open beds and we’re having conversations with the state about what they can do to actually help bring in staff to be able to make those beds usable,” he explained. “There are plenty of vacant beds in skilled nursing centers around the state. The challenge is that we just don’t have the staff to fill those beds and provide the quality of care that we need to provide.”
Farmer thinks the state’s support to bring in some traveling nurses could help stem the tide with this latest surge.
“I wish I could tell you how much staff it takes to put in five residents or 10 residents, it depends so much on the individual building,” Farmer said. “It also depends on the nature of the resident that’s coming in.”
Farmer described traveling nurses as a “quick solution” if the state is able to contract with an entity that can provide quick access to traveling nurses.
“The willingness is there, we just need the staffing,” Farmer said. “If we can figure out the staffing, I think we can certainly help to decompress the hospitals of those residents that are appropriate for skilled nursing facility placement.”
Medical Directors Must Remain Innovative as Nursing Homes Treat Higher Acuity Patients
A medical director has to be more “engaged” than ever in its nursing home’s everyday operations at a time when facilities continue to see an influx of higher acuity patients, Dr. Justin Di Rezze, CEO of Theoria Medical, said.
Di Rezze said that while nursing homes were beginning to see more medically complex patients before the COVID-19 pandemic, hospitals continue to be overcrowded and overburdened with the patient population and are therefore discharging patients sooner.
“What’s going to happen is that skilled nursing facilities are going to be relied on to handle the highly acute patients that aren’t really sick enough to be in an ICU in the hospital, but they’re also not good enough to go home so they’re going to go to skilled nursing facilities, that’s really what’s already happening,” he said.
As a result, nursing homes need to be attentive to that acuity and develop protocols in place — led by the medical director — to care for “the sick of the sick.” Otherwise, rehospitalization rates “are going to shoot through the roof.” Di Rezze said.
Di Rezze spoke at Skilled Nursing News’ Clinical Executive Summit earlier this month, along with Joyce Turner, director of business innovation and strategic planning at Ciena Healthcare.
Responsiveness and a patient-first mentality are two key qualities Turner looks for when hiring a medical director. Making the right hire for an SNF can define the success of the entire health care organization, she said.
“There’s no one size fits all, so it’s critical you find a medical director that fits your unique needs for your organization,” Turner added.
On the topic of responsiveness, Turner said in addition to being visible and accessible, a medical director should also promote the use of technology, especially given the workforce strains the industry is facing.
Di Rezze echoed Turner’s thoughts on the importance of innovation and technology, adding that the health care industry has lagged 10-15 years behind modern-day trends and skilled nursing is even further behind.
And while it’s important to find a medical director who has the experience to treat complex patients, what can be even more crucial is finding a physician who has the ability to remain agile within the facility.
“The worst types of medical directors are the medical directors that are stuck in their ways and that are turned off to any type of innovation, any type of self-development or self-growth, and think that the way that they’re practicing medicine is the best way possible,” he said.
Entering the industry as a medical director himself, Di Rezze admitted he had his own misconceptions about post-acute care.
“A lot of the physicians that I know personally, they’re seeking opportunities like this, they just need to be presented with that opportunity,” he said.
Gone are the days when a facility kept a disengaged medical director who was affiliated with a particular hospital because they feared letting them go would mean they would lose referrals, Turner said.
“If you’re saving them money and they’re sharing in that savings with CMS, [the hospitals] don’t really care what doctor is doing that,” she said. “They just know that their patients are being taken care of. They’re not returning to the hospital, they’re keeping their costs down and they’re keeping their quality up, and that’s the bottom line.”
Photo by Muskan Anand from Pexels
Frustration Growing Over Unfair Federal Nursing Home Regulations
As nursing home operators across the country work to implement a staff vaccination mandate that many feel singles out the industry, those that work in nursing homes are expressing resentment over how the sector continues to be regulated and scrutinized.
Rather than penalizing and pushing staff out of these facilities even further, Andi Clark, chief nursing officer for Consulate Health Care, would like to see a more proactive and realistic approach to federal regulations moving forward.
“If you’ve had surveys lately, and we have, I think they are pretty ferocious,” she said during a one-on-one conversation at the Skilled Nursing News RETHINK conference this week. “I think they are very unfair. I think they forget how hard we’re still working.”
Clark referenced a recent infection control survey that was done at one of the Consulate’s facilities in which a nurse wore her mask beneath her nose and the facility received what she felt was an unfair and unhelpful citation.
“I think the way they look at regulating us during this time, we understand it needs to be strict, we all want our nurses washing their hands, but I think that it is still a hostile situation,” she said. “I don’t think they’ve appreciated what our team has done.”
At the beginning of the pandemic, Clark was pleased with the way that surveyors worked with industry professionals more.
“I actually thought for a while, and maybe some of you did too, that surveyors were actually being our partners for a little while,” she said. “They were being kind, they were watching how hard our team worked.”
She felt that was more of a productive relationship, but it didn’t last for long.
She also expressed frustration over the regulations that have been put in place over the course of the pandemic.
“I think some of it was put out too quickly,” she said. “There were conflicting regulations between the Centers for Disease Control (CDC), health care, county health care partners, everybody had a different slant.”
When the COVID-19 pandemic started, Clark saw annuals and complaints drop completely and instead were replaced by infection control surveys.
Infection control surveys became the new norm, she explained.
“It’s almost like they thought, we’ve ignored you for a little while so we’re going to get back at this and I think for our teams in the building that’s a little hard to take,” she said. “I think the other thing around regulation that we are seeing more and more is that there’s no such thing as substantial compliance.”
The tension and hostility that she felt prior to the pandemic has come back in a big way.
“After a little reprieve, I was actually hopeful,” Clark said.
She complimented the Joint Commission’s surveys as more proactive, kinder and better to her staff — which helps the organization learn from its mistakes.
Clark said she wants to see the administration be more realistic about the way it regulates nursing homes moving forward.
“We don’t have that same kind of relationship with our regulators,” she said.
Pandemic Unveils Growing Suicide Crisis for Communities of Color
This story is a collaboration between KHN and “Science Friday.” Listen to the conversation between KHN national correspondent Aneri Pattani and John Dankosky, Science Friday’s director of news and radio projects.
Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she’d viewed suicide as a problem most prevalent among middle-aged white men.
Until May 27, 2020.
That day, Maxie’s 19-year-old son, Jamal Clay — who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for the March of the Dimes — killed himself in their garage.
“Now I cannot blink without seeing my son hanging,” said Maxie, who is Black.
Clay’s death, along with the suicides of more than 100 other Black residents in Illinois last year, has led locals to call for new prevention efforts focused on Black communities. In 2020, during the pandemic’s first year, suicides among white residents decreased compared with previous years, while they increased among Black residents, according to state data.
But this is not a local problem. Nor is it limited to the pandemic.
If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.
Interviews with a dozen suicide researchers, data collected from states across the country, and a review of decades of research revealed that suicide is a growing crisis for communities of color — one that plagued them well before the pandemic and has only been exacerbated since.
Overall suicide rates in the U.S. decreased in 2019 and 2020. National and local studies attribute the trend to a drop among white Americans, who make up the majority of suicide deaths. Meanwhile, rates for Black, Hispanic, and Asian Americans — though lower than their white peers — continued to climb in many states. (Suicide rates have been consistently high for Native Americans.)
“Covid created more transparency regarding what we already knew was happening,” said Sonyia Richardson, a licensed clinical social worker who focuses on serving people of color and an assistant professor at the University of North Carolina-Charlotte, where she researches suicide. When you put the suicide rates of all communities in one bucket, “that bucket says it’s getting better and what we’re doing is working,” she said. “But that’s not the case for communities of color.”
Losing Generations
Although the suicide rate is highest among middle-aged white men, young people of color are emerging as particularly at risk.
Research shows Black kids younger than 13 die by suicide at nearly twice the rate of white kids and, over time, their suicide rates have grown even as rates have decreased for white children. Among teenagers and young adults, suicide deaths have increased more than 45% for Black Americans and about 40% for Asian Americans in the seven years ending in 2019. Other concerning trends in suicide attempts date to the ’90s.
“We’re losing generations,” said Sean Joe, a national expert on Black suicide and a professor at Washington University in St. Louis. “We have to pay attention now because if you’re out of the first decade of life and think life is not worth pursuing, that’s a signal to say something is going really wrong.”
These statistics also refute traditional ideas that suicide doesn’t happen in certain ethnic or minority populations because they’re “protected” and “resilient” or the “model minority,” said Kiara Alvarez, a researcher and psychologist at Massachusetts General Hospital who focuses on suicide among Hispanic and immigrant populations.
Although these groups may have had low suicide rates historically, that’s changing, she said.
Paul Chin lost his 17-year-old brother, Chris, to suicide in 2009. A poem Chris wrote in high school about his heritage has left Chin, eight years his senior, wondering if his brother struggled to feel accepted in the U.S., despite being born and raised in New York.
Growing up, Asian Americans weren’t represented in lessons at school or in pop culture, said Chin, now 37. Even in clinical research on suicide as well as other health topics, kids like Chris are underrepresented, with less than 1% of federal research funding focused on Asian Americans.
It wasn’t until the pandemic, and the concurrent rise in hate crimes against Asian Americans, that Chin saw national attention on the community’s mental health. He hopes the interest is not short-lived.
Suicide is the leading cause of death for Asian Americans ages 15 to 24, yet “that doesn’t get enough attention,” Chin said. “It’s important to continue to share these stories.”
Kathy Williams, who is Black, has been on a similar mission since her 15-year-old son, Torian Graves, died by suicide in 1996. People didn’t talk about suicide in the Black community then, she said. So she started raising the topic at her church in Durham, North Carolina, and in local schools. She wanted Black families to know the warning signs and society at large to recognize the seriousness of the problem.
The pandemic may have highlighted this, Williams said, but “it has always happened. Always.”
Pandemic Sheds Light on the Triggers
Pinpointing the root causes of rising suicide within communities of color has proven difficult. How much stems from mental illness? How much from socioeconomic changes like job losses or social isolation? Now, covid may offer some clues.
Recent decades have been marked by growing economic instability, a widening racial wealth gap and more public attention on police killings of unarmed Black and brown people, said Michael Lindsey, executive director of the New York University McSilver Institute for Poverty Policy and Research.
With social media, youths face racism on more fronts than their parents did, said Leslie Adams, an assistant professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health.
Each of these factors has been shown to affect suicide risk. For example, experiencing racism and sexism together is linked to a threefold increase in suicidal thoughts for Asian American women, said Brian Keum, an assistant professor at UCLA, based on preliminary research findings.
Covid intensified these hardships among communities of color, with disproportionate numbers of lost loved ones, lost jobs and lost housing. The murder of George Floyd prompted widespread racial unrest, and Asian Americans saw an increase in hate crimes.
At the same time, studies in Connecticut and Maryland found that suicide rates rose within these populations and dropped for their white counterparts.
“It’s not just a problem within the person, but societal issues that need to be addressed,” said Shari Jager-Hyman, an assistant professor of psychiatry at the University of Pennsylvania’s school of medicine.
Lessons From Texas
In Texas, covid hit Hispanics especially hard. As of July 2021, they accounted for 45% of all covid deaths and disproportionately lost jobs. Individuals living in the U.S. without authorization were generally not eligible for unemployment benefits or federal stimulus checks.
During this time, suicide deaths among Hispanic Texans climbed from 847 deaths in 2019 to 962 deaths in 2020, according to preliminary state data. Suicide deaths rose for Black Texans and residents classified as “other” races or ethnicities but decreased for white Texans.
The numbers didn’t surprise Marc Mendiola. The 20-year-old grew up in a majority-Hispanic community on the south side of San Antonio. Even before the pandemic, he often heard classmates say they were suicidal. Many faced dire finances at home, sometimes living without electricity, food, or water. Those who sought mental health treatment often found services prohibitively expensive or inaccessible because they weren’t offered in Spanish.
“These are conditions the community has always been in,” Mendiola said. “But with the pandemic, it’s even worse.”
Four years ago, Mendiola and his classmates at South San High School began advocating for mental health services. In late 2019, just months before covid struck, their vision became reality. Six community agencies partnered to offer free services to students and their families across three school districts.
Richard Davidson, chief operating officer of Family Service, one of the groups in the collaborative, said the number of students discussing economic stressors has been on the rise since April 2020. More than 90% of the students who received services in the first half of 2021 were Hispanic, and nearly 10% reported thoughts of suicide or self-harm, program data shows. None died by suicide.
Many students are so worried about what’s for dinner the next day that they’re not able to see a future beyond that, Davidson said. That’s when suicide can feel like a viable option.
“One of the things we do is help them see … that despite this situation now, you can create a vision for your future,” Davidson said.
A Good Future
Researchers say the promise of a good future is often overlooked in suicide prevention, perhaps because achieving it is so challenging. It requires economic and social growth and breaking systemic barriers.
Tevis Simon works to address all those fronts. As a child in West Baltimore, Simon, who is Black, faced poverty and trauma. As an adult, she attempted suicide three times. But now she shares her story with youths across the city to inspire them to overcome challenges. She also talks to politicians, law enforcement agencies and public policy officials about their responsibilities.
“We can’t not talk about race,” said Simon, 43. “We can’t not talk about systematic oppression. We cannot not talk about these conditions that affect our mental well-being and our feeling and desire to live.”
For Jamal Clay in Illinois, the systemic barriers started early. Before his suicide last year, he had tried to harm himself when he was 12 and the victim of bullies. At that time, he was hospitalized for a few days and told to follow up with outpatient therapy, said his mother, Maxie.
But it was difficult to find therapists who accepted Medicaid, she said. When Maxie finally found one, there was a 60-day wait. Other therapists canceled appointments, she said.
“So we worked on our own,” Maxie said, relying on church and community. Her son seemed to improve. “We thought we closed that chapter in our lives.”
But when the pandemic hit, everything got worse, she said. Clay came home from college and worked at an Amazon warehouse. On drives to and from work, he was frequently pulled over by police. He stopped wearing hats so officers would consider him less intimidating, Maxie said.
“He felt uncomfortable being out in the street,” she said.
Maxie is still trying to make sense of what happened the day Clay died. But she’s found meaning in starting a nonprofit called Soul Survivors of Chicago. Through the organization, she provides education, scholarships and shoes — including Jamal’s old ones — to those impacted by violence, suicide and trauma.
“My son won’t be able to have a first interview in [those] shoes. He won’t be able to have a nice jump shot or go to church or even meet his wife,” Maxie said.
But she hopes his shoes will carry someone else to a good future.
If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.
KHN senior correspondent JoNel Aleccia contributed to this report.
[Editor’s note: For the purposes of this story, “people of color” or “communities of color” refers to any racial or ethnic populations whose members do not identify as white, including those who are multiracial. Hispanics can be of any race or combination of races.]
More Discharges to Home, Have we Moved the Needle Too Far?
Sicker patients, after less time spent in a hospital, are being diverted from a skilled nursing facility in favor of home care and hospice, according to recent analysis by care coordination software provider CarePort.
Discharge trends have resulted in a struggling occupancy rebound for SNFs, Martin said, with referred patients reportedly between 60 and 75% since last March — pre-COVID referral percentages were clocked at 106% in January 2020, by comparison.
Data caught a small number of patients going to home care that, based on 2019 models, would have gone to an SNF and stayed there long-term depending on comorbidity. These are residents aged 80 and higher, often with dementia and neurological disorders.
This group is being readmitted to the hospital at a 7% higher rate than the typical home health patient, Tom Martin, director of post-acute analytics for Boston, Mass-based CarePort, said during a webinar on Wednesday.
Martin presented findings at the WellSky webinar, alongside Sherry Thomas, director of clinical services for LeaderStat. While CarePort’s data is pulled from a smaller dataset and is not representative of the nation, it gives us more of a real-time look into occupancy and referral trends, Martin noted.
“I think that is a little bit of a trade-off that patients and hospital discharge partners need to consider,” said Martin. “This spike in-home health readmissions might suggest we’ve moved the needle too far, and sent too many people home that require skilled nursing.”
Hospital inpatient volume, on the other hand, has been rebuilt after a 30% drop during the first wave of COVID-19 last spring. When the second wave of infections occurred in the winter, the dip inpatient volume wasn’t as “dramatic,” Martin explained. Given this insight, he doesn’t expect a third delta variant-related wave to as heavily impact hospital patient volume, and in turn referral volume for post-acute care.
“We’ve seen fewer people going to SNFs. Is that the profile of a patient, the clinical profile of a patient in the hospital that has changed somehow fundamentally, or is it the decision process of the patient and the discharge planner?” Martin said.
The analyst used December as an example, pointing to 38% of patients for a particular health care system that was discharged to a nursing home during that time period.
CarePort had predicted that statistic to be 60%: “These patients, pre-COVID would have been very good candidates to go to skilled nursing. We would have thought, based off the patient’s acuity, they would have gone to skilled nursing but they are not.”
Instead, patients with middling acuity are being sent to home care, while those with higher comorbidities are being discharged to SNFs. CarePort has seen a 9% increase in the average comorbidity of patients, what Martin calls a “catch-all” for patients with multiple severe acuity diagnoses.
CarePort data also found the average length of stay in an acute care setting before discharge dropped by half a day, Martin added, before being discharged. This is compared to 2019.
The three-day inpatient hospital stay requirement for Medicare coverage was temporarily waived in March of last year to reserve beds for COVID patients.
Typically a patient would need to stay at the hospital for at least three days before they’re allowed to be discharged and still receive coverage under Medicare. June bipartisan legislation introduced in the House of Representatives aims to make the waiver permanent.
Image by Sabine van Erp from Pixabay
Senior Rehabilitation Centers: Care Options After a Hospital Stay
Did you know that families have options when choosing where to complete rehab for elderly loved ones after they’re discharged from the hospital? From skilled nursing homes that offer 24-hour care to rehab services that can be carried out at home or at an assisted living community, learn about options that will help your loved one get better as quickly and safely as possible.
What is a rehabilitation center for seniors?
Senior rehabilitation centers are designed to help those recovering from an injury or serious medical event to reduce pain and improve function. Senior rehab facilities often include services such as:
- Physical therapy to help improve mobility, balance, flexibility, increase strength, and manage pain
- Occupational therapy to assist with activities of daily living (ADLs), use of adaptive equipment, or fine motor skills
- Speech therapy to help with conditions that affect communication, swallowing, or cognitive skills, such as attention or memory problems
Inpatient and outpatient rehabilitation services for the elderly
Senior rehabilitation centers may offer inpatient and outpatient services. Your loved one may need inpatient rehabilitation if they need around-the-clock care and continuous monitoring.
Inpatient rehab requires those recovering from a serious injury, debilitating disease, or major surgery to stay at a facility for a period of time. This type of rehab allows for intensive care that generally includes daily physical, occupational, or speech therapy.
Inpatient rehab facilities may offer meals provided by dietitians, exercise classes, social activities, and counseling services, while providing skilled medical care and assistance with daily activities, such as bathing and getting dressed.
Outpatient rehab also offers physical, occupational, and speech therapy. However, seniors live at home and go to a rehab center to complete their rehabilitation.
Short-term vs. long-term rehabilitation for elderly patients
Some senior rehab centers offer both short- and long-term inpatient rehab options. Your loved one’s health will dictate how much rehab they need.
For example, after a minor surgery, your parent may only require a short stay at a senior rehab center. However, chronic, serious conditions, such as heart problems or a stroke, may require several months of rehab services at a skilled nursing home that offers 24-hour care, seven days a week.
Your loved one’s doctor will consider the severity of their illness or injury to determine the type of rehab program they need. Together, you can decide if your parent is most likely to achieve rehab goals safely at a skilled nursing facility or a different rehab option.
Choosing a senior rehabilitation location after hospitalization
Senior rehabilitation can take place in a variety of settings.
Senior rehab therapy at skilled nursing facilities
Skilled nursing facilities (SNFs), also called rehab hospitals, offer short-term housing and rehabilitation services for people who require 24-hour nursing services and skilled medical care. These inpatient rehab facilities typically have a clinical feel, with hospital beds and shared rooms. Meals, dietary counseling, and social services are often provided.
Approved skilled nursing facilities may be covered by Medicare as long as your loved one enters the skilled nursing facility within 30 days of a hospital stay that lasted at least three days.
If your loved one is affected by COVID-19 or is not able to stay home during the coronavirus pandemic, they may be able to get Medicare coverage for a skilled nursing facility without a qualifying hospital stay.
In-home rehab for elderly after a hospital stay
Some senior rehabilitation services can be carried out in the home through home health agencies. Home health services are paid for by Medicare or insurance.
Home health services are provided by licensed medical professionals who come to the home to do a specific task that has been ordered by a physician. These tasks may include monitoring health, administering injections, providing wound care, or developing a strength training and physical therapy exercise program.
Home health rehab therapy can only be offered a few times a week. This means that seniors who receive these services must be motivated to follow their rehab program when the therapist is not there.
In-home therapies also lack the peer support and socialization that can be provided in skilled nursing facilities and assisted living communities. That support and socialization often gives seniors the extra motivation they need as they recover.
Elderly rehabilitation at assisted living communities
Many people are not aware that rehabilitation can also be completed in assisted living communities. Just like at home, home health professionals can provide specific therapies and nursing services that are paid for by Medicare, with the added benefit of 24-hour assistance from the assisted living community staff.
Many assisted living communities have a physical therapy and occupational therapy room in their building for residents to take advantage of high-tech equipment multiple times throughout the day.
For an older adult who expects to go home after rehab, ask about a short-term respite care stay at an assisted living community. A respite stay at an assisted living facility may also be a good option for your loved one who has completed rehab but is not yet confident enough to go home alone.
Respite care can allow a senior to have the peace of mind that someone is available 24 hours a day for assistance and for immediate response to emergencies.
Questions to ask about your hospital discharge plan
To help determine your loved one’s recovery options, ask their doctor these questions before leaving the hospital:
- What therapies will my parent require?
- What services will health insurance or Medicare pay for?
- Will my parent need help with dressing or bathing?
- Will my loved one need help with cooking and housework?
- Will my loved one be safe at home upon discharge or will someone need to be with them 24 hours a day?
- What is the average length of recovery time?
- What problems, symptoms, and side effects should we watch for?
- What should we do about any potential side effects or problems?
- What does each medicine do and why is it needed?
- What are the medication dosages and side effects?
- Who do we call if we have questions about medical equipment, such as oxygen or a walker?
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