Long Term Care Social Workers of Iowa 1040 Market Street, Carlisle, IA 50047 ltcswi@mchsi.com www.ltcswi.com 515-989-6068

FALL CONFERENCE

2019

Gateway Hotel and Conference Center ~ Ames, Iowa Friday, October 25, 2019

Dementia: Its Impact, Our Charge

Lyn Hilgenberg , BA, CDCP, CSA

Owner/Consultant

Daylily Inc.

Develop your Medicaid Competency Skills Cynthia Letsch, JD

Attorney

Letsch Law Firm

The Iowa Medical Cannabidiol Act: What Providers Need to Know

Owen Parker, MPH

Program Manager

Office of Medical Cannabidiol, DPH

AGENDA

Friday, October 25, 2019

8:00 - 8:25 a.m. Registration/Breakfast (Breads and Pastries, Fruit, Yogurt)

8:25 - 8:30 a.m. Announcements

8:30 - 9:30 a.m. Dementia: Overview

9:30 - 9:45 a.m. Break

9:45- 10:45 a.m. Dementia: Immersion Demonstration

10:45 - 11:00 a.m. Break

11:00- 12:00 p.m. Dementia: Caregiver Burnout & Fatigue

12:00 - 12:45 p.m. Lunch

12:45 - 2:15 p.m. Medicaid

2:15 - 2:30 p.m. Break

2:30 - 3:30 p.m. Medical Cannabidiol

3:30 p.m. Evaluations & Attendance Certificates

This program complies with the Iowa Board of Social Worker Examiners Rules For Continuing Education,

meeting 5.5 general continuing education contact hours.

Long Term Care Social Workers of Iowa 1040 Market Street, Carlisle, IA 50047 ltcswi@mchsi.com www.ltcswi.com 515-989-6068

LTCSWI FALL CONFERENCE 2019

The Gateway Hotel and Conference Center ~ Ames, Iowa October 25, 2019

WORKSHOP GOALS AND OBJECTIVES

Dementia: Its Impact, Our Charge • Explain the diagnosis of dementia, brain changes that affect care, and ways to successfully make a

connection with persons living with dementia

• Introduction to The Seven Domains of Well Being as a tool for understanding distressing behavior exhibited by persons living with dementia

• Summarize the opportunity for empathy with “Dementia Immersion” exercise

• Identify the signs of burnout and compassion fatigue and discuss prevention and coping strategies

Develop your Medicaid Competency Skills • Become familiar with income and asset eligibility rules for Medicaid

• Review when a Medicaid recipient’s spouse can keep assets and income

• Understand when assets can be legally transferred

• Learn about Iowa’s Estate Recovery Law

• Recognize specific fact patterns that necessitate the involvement of an elder law attorney

The Iowa Medical Cannabidiol Act: What Providers Need to Know

• Review the medical cannabidiol law as it pertains to providers, including: stakeholder definitions, roles, responsibilities and protections

• Review the compliance infrastructure of the medical cannabidiol program, as well as form and quantities of products allowed

• Review demographic and program data thus far

About Our Presenters... Lyn Hilgenberg’s career began working with families in crisis within the juvenile justice system and as a Child Advocate. This provided a unique skill set which she continues to use as she works with families and facilities to solve difficult issues with unique and individualized solutions. Lyn’s long career as an administrator in the medical and dental field has provided an understanding of medicine and a true appreciation for health and wellness issues. Through her company Daylily, Lyn is an advocate for positive culture change in geriatric care. She provides educational and consulting assistance for families and facilities regarding topics of healthy aging and dementia care.

Attorney Cynthia Letsch is an Iowa native who obtained her undergraduate degree at Southern Methodist University in Dallas, TX and her Doctor of Jurisprudence degree from Drake University Law School, in 1995, graduating from both universities with honors. Her legal career includes private practice, eight years as a university professor, and serving as corporate counsel for a long term care facility. Her current office opened in 2013, and the practice is limited to Elder Law, Estate Planning, and Probate/Trust Administration. She is a frequent speaker on topics of Medicaid for the Elderly; Medicaid Financial Risk Management for Care Facilities, and Fiduciary Responsibilities of Agents under Powers of Attorney, Guardians, Conservators, and Trustees; provided training to other attorneys, social workers, hospital discharge planners, LTC administrators, and financial planners.

Owen Parker is the Program Manager of the Office of Medical Cannabidiol at the Iowa Department of Public Health, where he has been developing the compliance infrastructure for Iowa’s program. This includes reporting-on and monitoring the state’s seed-to-sale tracking software, development of the product-testing program, development and maintenance of the Office of Medical Cannabidiol’s website and providing education and CMEs about Iowa’s program to healthcare providers across the state. Before joining IDPH, Owen was a project manager for a public health startup company in California, which led to working in operations, compliance and business development for a multi-state operator in the cannabis space for multiple years. He holds a master of public health in occupation & environmental health from the University of Iowa, and a B.S. in biology and minor in chemistry from the University of Northern Iowa.

Dementia and its ImpactLong Term Social Workers Conference

October 25, 2019

Lyn Hilgenberg, BA, CDCP, CSA

Daylily, Inc. ®

OBJECTIVES

• Learn about brain changes due to dementia

• Making a successful connection with PLD

• Introduction to the Domains of Well Being

• Summarize empathy opportunities with Dementia

Immersion exercise

• Identify signs of burnout and discuss prevention and

coping strategies to avoid compassion fatigue

Understanding DementiaSupporting a Meaningful Life

Lyn Hilgenberg, BA, CDCP, CSA

Daylily, Inc. ®

Not Normal Aging

Changes in mood & personality

Withdrawal from work or social activities

Decreased or poor judgment

Misplacing things & inability to retrace steps

New problems with words (speaking or writing)

Trouble understanding visual images & special relationships

Confusion about time & space

Difficulty completing familiar tasks

Challenges planning or solving problems

Memory loss that disrupts daily life

What is Dementia?

❑The general term for a decline in mental ability severe enough to interfere with daily life

❑Dementia is NOT a specific disease

❑At least two parts of the brain are failing▪ Memory

▪ Communication and language

▪ Ability to focus and pay attention

▪ Reasoning and judgment

▪ Visual perception

How the Brain Works

❑100 billion nerve cells, or neurons, creating a branching network

❑Generates enough electricity to power a low wattage blub

❑Signals traveling through the neuron forest form memories, thoughts, & feelings

❑Avg. Brain weighs 3lbs

❑Sensory neurons send signals @ 150 mph & motor neurons transmit @ 200/mph

FRONTAL LOBE

✓Located at the front of the brain

✓Coordinates voluntary movements

✓Contains most of the dopamine-

sensitive neurons

✓Associated with:

Reward

Attention

Planning

Motivation

WHAT TO EXPECT

✓Say whatever they are thinking

✓Don’t think through consequences

✓Can’t hold back on thoughts or actions

✓Loss of interacting with spontaneity

✓Easily distracted

✓Difficulty with problem solving

✓ Inability to plan complex movement sequences for multi-step tasks

✓Changes in social behavior & subject to mood changes

✓Think they can do better than they can

✓Difficulty holding attention

✓Unable to see from your point of view

✓Attempts can be dangerous or fatal

✓They will tell you one thing & do another

✓Families may want to over/under limit activities

POTENTIAL PROBLEMS

Frontal Lobe

TEMPORAL LOBE

✓Located at the side (Temples)

✓Contains the hippocampus

✓Associated with

Critical to memory formation

Language recognition

Auditory perception

✓Processes sensory & visual input

into memory function

WHAT TO EXPECT

✓Misses 1 out of 4 words – may miss “Don’t”

✓Uses old memories like new (time traveling)

✓ Interference with both short- & long-term memory

✓Follows visual cues due to selective attention

✓Seeks out the familiar

✓Concrete understanding of words

✓Trouble with identification and verbalizing about objects.

✓Trouble finding the right word

✓Forgets immediate past

✓May not ID self or others correctly

✓Confabulates

✓Can get stuck on an old emotional memory track

✓Becomes very vague & repeats

✓Speaks in “word salad”

✓COVERS

POTENTIAL PROBLEMS

Temporal Lobe

PARIETAL LOBE

✓Positioned before the slope

✓Involved in processing sensation &

perception

✓Associated with:

The sensory inputs from the skin

Language processing (emotional)

Spatial awareness

Navigation

Grasping & manipulation of objects

Dyslexia

Math & Spelling

WHAT TO EXPECT

✓Poor eye/hand coordination

✓Unable to multi-task

✓Difficulty reading

✓Difficulty writing

✓May not recognize objects

✓Lack of awareness of surrounding space

✓Struggle with complex movement

✓Uses objects incorrectly

✓Difficulty with dressing

✓Struggle complex movements

✓Some difficulty coordinating utensils

✓Trouble naming objects they may want/need help with

✓May struggle with “Right” “Left” instructions

✓Gets lost/ wayfinding

POTENTIAL PROBLEMS

Parietal Lobe

OCCIPITAL LOBE

✓Located just above Cerebellum

✓Smallest of the 4 lobes

✓Visual processing center

✓Associated with:

Peripheral vision

Perception of color

Perception of movement

Hallucination

WHAT TO EXPECT

✓Loss of peripheral vision

✓Binocular vision developing

✓Blurred or double vision

✓Loss of depth perception

✓Confused about what is seen

✓Won’t see you if you approach

✓Difficulty picking out their food

✓Will startle

✓Will think things are closer or farther

✓Fall risk!

✓Hallucinations (bugs, animals, family, etc.)

POTENTIAL PROBLEMS

Occipital Lobe

What stays strong? The Amygdala!

A New Definition…

“Dementia is a shift in the way a person experiences the world around him/her.”

Dr. Allen Power

TTi360- 2019

Principles of Communication:Making the Connection

Lyn Hilgenberg, BA, CDCP, CSA

Daylily, Inc. ®

What makes up communication?

• Your body language “speaks volumes” at 55%!

• How you say what you say, pitch and tone of voice is at 38%

• The words you use… only 7%

Eye Contact

• Seek information

• Show attention & interest

• Invite & control interaction

• Dominate, threaten, influence

• Provide feedback

• Reveal attitudes

Facial Expressions

• Second only to that of the eyes…

• The first part of person we look at

• Emotional states and attitudes toward others are clearly seen

• Expressions are frequently used in greetings

• Facial expressions & head movements are powerfully control both type & amount of communication

Smile!The most basic biologically uniform

expression

UC Berkley30-year longitudinal study…

Examined old yearbook photos

Measure success throughout their life by measuring student smiles

• How fulfilling & the length of a subject's marriage

• How well they would score on standardized tests of well-being

• How inspiring they would be

You look good & feel good

Others see you smile…

They mimic & smile

They look good & feel good

You smile…

Smile Impact

Smiling is Contagious!British researchers discovered that it helps you be healthier

• Can help reduce level of stress enhancing hormones

• Increase the level of mood enhancing hormones

• Reduce overall blood pressure

1 smile can generate the same level of brain stimulation as up to 2,000 bars of chocolates

Other Communication…

Head movements

Gestures

Body movements

Posture

Proximity

Sadness

• No single expression typifies sadness…

• Lack of expression

• Downward turn of the corners of the mouth

• Downward look

• “Sagging” features

Fear

• Wide open eyes

• Open mouth

• Trembling affecting the face and the body

• Loss of color and perspiration

Anger

• Characterized by a steady gaze

• Frowning or scowling

• Gritting teeth

• May go pale or go red

• Body posture is tense

Disgust

• Narrowing of the eyes

• Grimacing mouth

• Nose will wrinkle up

• Head turned aside

Communication & Dementia

• So MUCH MORE than talking!

• Gestures

• Facial Expressions

• Touch

• Non-verbal communication SO important as language skills are lost

Check the Environment

• Limit distractions & noise

• Radio or TV should be off

• Ask yourself: Buzzers going off, overhead speakers, doors slamming?”

• Are staff members talking to each other?

Essential Skill

“Recognition that the person with dementia’s need for comfort is more important than the direct care worker’s need to be right.”

Dementia Education Task Force 2010

Connecting for Care:Making Room for Empathy

Lyn Hilgenberg, BA, CDCP, CSA

Daylily, Inc. ®

How Humans Take in Data

• What you see

• What you hear

• What you feel/touch

• What you smell

• What you taste

Visual, Verbal, Touch

Do less talking and more showing

1. Show the person what you want them to do

2. Tell the person what you want them to do

3. Only then do you touch

Three Areas of Space

Public Space (>6’)

Personal Space (3’-6’)

Intimate Space

Writewhat should NOT be forgotten.

Isabel Allende – Chilean Author

Navigating Care Issues:Activity

Personal routines… think about yours…

Complete “My Way” exercise

What do you want to make SURE that your care partner knows and why?

Honor Every Resident!

Know Personal Routines

Respect & Protect Privacy

Promote Independence

Key Helping Techniques

Change the environment as needed

Short & clear verbal cues

Strong & easy to understand visual cues

Your approach…

Know your person receiving care!

The Seven Domains of Well-BeingA Tool for Understanding

Lyn Hilgenberg, BA, CDCP, CSA

Daylily, Inc. ®

PROBLEM-SOLVING STRATEGIES…

Physical Environment

Care Partner Knack

Social Environment

Medical Treatment/Needs

MEDICAL TREATMENT/NEEDS

Medication effects

Impaired vision or hearing

Acute illness

Chronic illness

Dehydration

Constipation

Depression

Fatigue

Physical discomfort

PHYSICAL ENVIRONMENT

Environment too large

Too much clutter

Poor sensory environment

No orientation information/cues

Unfamiliar environment

SOCIAL ENVIRONMENT

Excessive stimulation

Unstructured environment

Noise/Sound level

Social comfort level

CAREGIVING KNACK

✓Task request issues?

Too Complicated

Too many steps

Not modified to ability

Unfamiliar task

✓Communication issues?

Your approach

BEFORE you speak…

Working together

Do they understand?

Do you understand them?

ASK YOURSELF…Is this behavior a problem or is this a so what behavior?

ANGER… AGITATION

COPING STRATEGIES

✓Allow time for response to directions or requests

✓Give clearly stated directions/ step by step

✓Identify the stressful times of day

✓Have staff share successful or unsuccessful techniques

✓Be aware of how shift changes can provoke anxiety

BATH TIME

COPING STRATEGIES

✓Have everything ready!

✓Bathroom warm and inviting

✓Create a feeling of privacy

✓Adequate lighting

✓Shower cap to “protect their hair”

✓Give them a washcloth to hold or something

to “fiddle” with

✓Wrap a warm towel around shoulders

DEMENTIA DINING

COPING STRATEGIES

✓Dental checkup – partial, denture, broken or

infected teeth

✓Remember vision changes

✓Watch noise and distractions

✓Guide with gentle and respectful language

SLEEP DISTURBANCE

COPING STRATEGIES

✓All clues point to sleeping…

✓Treat pain history!

✓Temperature – cold or hot

✓Softly playing music for some

✓No caffeine intake or diuretics after 5:00 p.m.

✓Relax as a staff – you are there 24 hours

✓Watch out for noisy nighttime shift changes!

✓Gently remind that it is dark out and time for

sleeping

WANDERING

COPING STRATEGIES

✓Provide opportunities for exercise

✓Is it a stress reducing behavior

✓Allow safe exploration

✓Reinforce bathroom location

✓Clothes are comfortable and meet skill level

to get off & on

REPETITIVE ACTIONS

COPING STRATEGIES

✓Respond to emotion instead of the specific question

✓Calm voice when answering

✓Written signs (for those that read) that say the schedule

✓Discuss plans JUST PRIOR to the activity

✓Are they looking for response or just “self verbalizing?”

✓ Is the questioning the way they are finding to gain attention

✓Social “Chit Chat” remains…

TRADITIONAL APPROACHES

• View it as losses. They are victims…

• Disease-based approaches to care.

• See them as incapable so we

disempower them.

• Distress is seen mental illness.

Seven Domains of Well-Being

Joy

Meaning /Growth

Security /Autonomy

Connectedness

Identity

IdentityHaving Personhood; Individuality; Wholeness; Being Well-known; Having a History

ConnectednessState of being connected; alive; belonging; engaged; involved; not detached; connected to the past, present, and future; connected to personal possessions; connected to place; connected to nature.

SecurityFreedom from doubt, anxiety, or fear; safe, certain, assured; having privacy, dignity, and respect

AutonomyLiberty; choice; freedom; self-governance; self-determination; immunity from the arbitrary exercise of authority;

MeaningSignificance; heart; hope; import; value; purpose; reflection; sacred

GrowthDevelopment; enrichment; unfolding; expanding; evolving

JoyHappiness; pleasure; delight; contentment; enjoyment

Ikigai: (Okinawa Japan) A reason to get up in the morning.

What you LOVE

What world NEEDS

What you can be PAID FOR

What you are

GOOD at Ikigai

Passion

Profession

Mission

Vocation

Success Principles

• We CAN CHANGE the DIRECTION of care

• We must BEGIN with OURSELVES

• We CHOOSE how to react

• We must be willing to STOP & BACK OFF

• We can be the KEY to their sense of WELLBEING

They are doing the best they can

MAKING IT HAPPEN!

• Be willing to try something new

• Be willing to learn something different

• Be willing to see it through another’s eyes

• Be willing to fail and try again

Care Partner Self-Care:

Keeping the Tank Full!

Lyn Hilgenberg, BA, CDCP, CSA

Daylily, Inc. ®

This Photo by Unknown Author is licensed under CC BY-NC-ND

Reflection:Write down

a description of your work

Signs of Burnout

Physical & Emotional Exhaustion

Cynicism & Detachment

Feelings of Ineffectiveness & Lack of Accomplishment

Physical & Emotional Exhaustion

Chronic Fatigue: Lack of energy, feeling tired most days

Insomnia: Trouble falling asleep or staying asleep 1-2 nights a week

Forgetfulness/Impaired Concentration & Attention: Lack of focus and mild forgetfulness

Physical Symptoms: Chest pain, heart palpitations, shortness of breath, gastrointestinal pain, dizziness, headaches, etc.

Increased Illness: Immune system becomes weakened making you more vulnerable

Physical & Emotional Exhaustion (cont.)

Loss of Appetite: May not feel hungry, skip meals, begin to lose significant weight

Anxiety: Tension, worry & edginess

Depression: Sad, occasional hopelessness, feelings of guilt & worthlessness

Anger: Interpersonal tension & irritability which may turn into angry outbursts.

Cynicism & Detachment

Loss of Enjoyment: Not wanting to go to work or being eager to leave. Avoid projects and find ways to escape work all together

Pessimism: Negative self-talk, the glass is half empty not half full attitude

Isolation: Resistance to socializing, avoiding interactions

Detachment: Feeling disconnected from others

Ineffectiveness & Lack of Accomplishment

Apathy & Hopelessness: General sense that nothing is going right or matters

Increased Irritability: Stems from feeling ineffective, unimportant, useless, and belief that you are unable to do things as efficiently or effectively.

Lack of Productivity: Despite long hours, chronic stress prevents productivity like before resulting in incomplete projects and large “to-do-list”

If you are experiencing any of these symptoms…

Let this be your wake-up call!

Take time to honestly assess the amount of stress in your

life and find ways to reduce it.

Burnout doesn’t go away like the flu; it requires changes in

your life!

Turning Burnout Around

• Don’t ignore Basic Maintenance!

1. You have to sleep: as much as possible

2. You have to eat: don’t skip meals and eat healthy

3. You have to hydrate:drink a lot of water

• Get back to things you find relaxing

• Just say, “No.”

• Exercise: This is a great stress reducer

• Keep positive: Surround yourself with positive people

Turning Burnout Around

• Take an inventory: List the situations that cause you to feel stressed, anxious, worried, frustrated, or helpless.

• Control your devises: Don’t let gadgets consume your time & energy.

• Socialize: Meet others outside your “group“ to gain fresh perspectives and stimulating new ideas.

• Rediscover your passion!

People who wonder whether the glass is half empty or half full miss the point…

The glass is refillable!

THANK YOU

Lyn Hilgenberg, BA, CDCP, CSA

Lyn@DaylilyCares.com

Using Cues as a Care Partner by Teepa Snow, MS, OTR/L, FAOTA

Through my career as an occupational therapist, I have conducted research and provided direct care to a wide variety of people, including those living with dementia. This has allowed me to learn how people living with dementia navigate their world when challenged by the effects of a changing brain. I would like to share with you some of my observations and some cues provided to us that can improve our work as Care Partners Sensory systems - what a person sees, hears, feels, smells, and tastes - help human beings understand and interact with their world. All people live in continuous cycles of taking in sensory data, processing, and then using that information. When someone has dementia, there is interference within the sensory processes. People living with dementia want to get along in the world and are trying to figure out how to do that just like anyone else. When working with a person living with dementia you will encounter some challenging situations. What you might be experiencing is a breakdown in his/her sensory process. And while it might seem confusing and create frustration for you, this is likely a person's best attempt to understand and meet their own needs under the circumstances and with the abilities they are living with in that moment. People are driven and need to stay engaged with the world around them, although the abilities to do so safely and well are being eroded. Eventually, due to the effects of dementia, those we are caring for will need our help to do this. The first and most important step is to observe. If you take the time to observe, you will often be able to discover the abilities a person living with dementia is actually working with at any given moment. If we can understand more fully what someone can do, instead of focusing on what they no longer can do, then we can choose to support and care for them in a way that will make sense. This begins with observations, not assumptions about what is happening. Second, look for Sensory cues. All human beings are giving us clues and information about their ability through their action or behavior with others and the environment. Take an inventory by honestly observing and respecting how the person living with dementia is relating to the world through their five senses. When you observe the person doing or not doing something, it will provide you with valuable information about the person and his/her abilities. You will see both what that person is getting from their environment and their body as well as any unmet needs s/he is trying to address, but isn't able to on his/her own.

• Visual cues - Notice what a person is focused on. What can/do they see that might be different from what you are able to see? Visual cues are typically a human being's first method and favorite way to take in informational data. Over time dementia causes many changes in the brain's occipital lobe impacting a person's visual field, object recognition, figure-ground awareness, and depth perception. Due to these changes, a person

literally may not know you are sitting next to them. They can't see you, even though you might be able to see them. If you have observed and are aware of this, then you can help by moving yourself into a person's visual field, at a personally comfortable distance before attempting to communicate or provide support or care.

• Auditory and Verbal cues - If a person living with dementia is speaking to you but their words are not readily available, misused, or misinterpreted, what is the rhythm, the intensity, the pattern, the volume of what they are saying? Consider what they are saying or attempting to communicate with their actions, if not their words. Notice how they respond to you when you speak - or if they respond at all. A lack of response can also be a "cue" about ability in a particular moment. Do they hear you? Did they actually process what you said? Are they giving you a response that suggests they understood? What is happening in their body that might tell you? Set both of you up for success by looking for a cue from them for confirmation that what you thought transpired actually did.

• Movement and Touch cues - When you are observing a person, what is drawing interest, what is being avoided. What skill versus strength abilities are noted? Are there objects or tasks being attempted or avoided? Is there an action or reaction to movement, touch, or stillness that is worth exploring or paying attention to?

One important note is that typically people living with dementia exhibit curiosity, but frequently lack a sense of safety awareness. They may also see our behavior and efforts to keep them safe as threatening or unnecessary. Even though our failure to address safety concerns can result in problems and injuries, it is also likely that our impulsive attempts to enforce limits without thoughtful observation and use of skills can take a risky situation into a dangerous one in only a few seconds.

It's important to understand and be aware that over time there will be a change in all five experiences of sensation for a person living with dementia. This means change in visual abilities, auditory processing and comprehension ability. Please be careful not to confuse loss of comprehension with the hearing of sound, as these are two different things. In addition, one's ability to feel and manipulate an object, including touch sensation and find motor skills, will change over time. You will also notice a change in the ability to accurately identify smells and tastes as well as changes in a person's awareness of dangers associated with particular situations or items.

Every sensory experience is changing for the person living with dementia. This impacts behavior, the giving and receiving of communication, and therefore, relationships with others. If we truly understand this, and are willing to observe and stretch ourselves by looking at what's happening through the lens of curiosity, we can then further understand and choose to support and care for others in ways that make more sense. These changes in perspective will improve relationships and assist in setting realistic goals for care partner interactions. Most importantly, these changes give the person living with dementia - who is doing the best they can with what they have - a greater sense of value, individual choice, and sense of control throughout their life, as they are living it.

Domains of Well-Being

Identity: __________________________________________________

__________________________________________________________

__________________________________________________________

Connectedness: ____________________________________________

__________________________________________________________

Security: __________________________________________________

__________________________________________________________

__________________________________________________________

Autonomy: ________________________________________________

__________________________________________________________

__________________________________________________________

Meaning: _________________________________________________

__________________________________________________________

__________________________________________________________

Growth: ___________________________________________________

__________________________________________________________

__________________________________________________________

Joy: ______________________________________________________

__________________________________________________________

__________________________________________________________

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Dedicated to providing legal guidance and education

with compassion and understanding

Medicaid Benefits | Estate Planning | Probate

Elder Law | Trust Administration

112 NE Ewing Street, Suite D

Grimes, IA 50111

(515) 986-2810

www.LetschLawFirm.com

Cynthia P. Letsch, J.D.

Managing Attorney

MEDICAID FOR THE SOCIAL WORKER

ELIGIBILITY, ASSET TRANSFERS, AND PLANNING

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GOALS

• Become familiar with income and asset eligibility rules for Medicaid

• Review when a Medicaid recipient’s spouse can keep assets and income

• Understand when assets can be legally transferred

• Learn about Iowa’s Estate Recovery law

• Recognize specific fact patterns that necessitate the involvement of an elder

law attorney.

INFORMATION IS KEYHOW DO YOU GET ACCURATE INFORMATION?

• Family members notoriously do not provide complete and accurate financial

information, sometimes intentionally, sometimes out of ignorance.

• DEVELOPING RAPPORT

• GETTING THROUGH THE NOISE

• LETTING THE PARTICIPATNS TALK, EMPATHY, FAMILY DYNAMICS

• FIGURING OUT WHO THE PERSUASIVE PEOPLE ARE AND WHO HAS LEGAL

AUTHORITY TO MAKE DECISIONS

• DEALING WITH SUSPICION

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THE INTERVIEWINCOME

Specifically ask about each source of income

You will need GROSS income. The amount direct

deposited into a bank account is the NET income.

1) Social Security (yours and your spouse’s)

2) IPERS (Yours and your spouse’s)

3) VA benefits – find out what kind.

4) Pension

5) Annuities that cannot be cashed in.

5) Anyone who owes you money

(for example if they loaned money to a child or sold a

vehicle on contract.)

6) Required minimum contributions from IRA (most IRA’s

get liquidated, but not all, so you need to know)

HOW TO VERIFY THE INFORMATION

• Get written proof of income• SS award letters can be downloaded from the SSA web

site.

• Request letters from IPERS and Pension companies.

• Written

• DO NOT COUNT INCOME FROM INVESTMENTS*

• You will not know whether or not you will need RMD information until you have a plan

and know whether or not there will be any IRA account left.

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SPOUSAL ANTI-IMPOVERISHMENT ACTSSA SECTION 1924

• (h) DEFINITIONS.—In this section:

• (1) The term “institutionalized spouse” means an individual who—

• (A[212] is in a medical institution or nursing facility or who (at the option of the State)

is described in section 1902(a)(10)(A)(ii)(VI), and

• (B) is married to a spouse who is not in a medical institution or nursing facility; but

does not include any such individual who is not likely to meet the requirements of

subparagraph (A) for at least 30 consecutive days.

APPLICANT INCOME LIMITSAND THE MILLER TRUST

• 2019 asset limit is $2,313.00

• Spouse’s income is not used to pay for care.

• Medicaid Assistance Income Trust a.k.a. Qualified Income Trust a.k.a.

•Miller Trust

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MILLER TRUST

• ONLY USED TO DEAL WITH INCOME SITUATION

• Never used to shelter extra assets

• Understand the difference between income and assets.

• ALL INCOME goes into the trust bank account

• Trustee pays money out of the trust bank account

• Iowa Estate Recovery is the first beneficiary of the account, after death.

WHEN IS THE SPOUSE’S INCOME IMPORTANT?

When it is less than the Maximum Monthly Needs

Allowance.

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$3,160.502019

CLIENT PARTICIPATION2019

Recipients Gross Income $3,000 Spousal MMMNA $3,160.50

Personal Allowance $ 50 Spouse’s Gross Income $890

Med Supp. Premium $200 Spousal Shortage $2,270.50

Dental Premium $90

Part D Premium $70

Trust Administration $10

Spousal Diversion $2,270.50

Client Participation to the Facility $309.50

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EXCLUDED VS COUNTABLE ASSETS

WHY IT IS IMPORTANT TO MAXIMIZE COUNTABLE ASSETS

COUNTABLE VS. NON-COUNTABLE

NON-COUNTABLE

• Home

• Vehicle

• Personal property and

household goods

• Limited funeral products

COUNTABLE

• Cash at

home

• Checking /

savings

• CDs

• IRA

• Real estate

• Vehicle

• Business

interests

• Investments

• Cash value in

life

insurance/

annuities.

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CALCULATING THE COMMUNITY SPOUSE RESOURCES

Countable Resources

$ 5,345.40 Great Western Bank Savings

Joint

$ 8,379.61 Great Western Bank Checking

Joint

$ 18,622.08 People’s Bank CDs Joint

$ 254.20 Signature Federal Credit Union, Alexandria, VA

Sp.

$ 104.73 Signature Federal Credit Union, Alexandria, VA

Sp.

$ 31,897.93 Principal IRA Sp.

$ 70,278.39 Edward Jones IRA App.

$ 52,461.52 Edward Jones IRA Sp.

$ 15,000.00 NYL Cash Value App.

$ 202,343.86 Total

$ 101,171.93 CSRA

Formula

Total Resources on

Attribution Date /2=CSRA*

*Range $25,284 – $126,420

OVER AND UNDER

OVER RESOURCEDCountable Resources

$ 5,345.40 Great Western Bank Savings Joint

$ 8,379.61 Great Western Bank Checking

Joint

$ 18,622.08 People’s Bank CDs Joint

$ 254.20 Signature Federal Credit Union, Alexandria, VA

Sp.

$ 104.73 Signature Federal Credit Union, Alexandria, VA

Sp.

$ 131,897.93 Principal IRA Sp.

$ 70,278.39 Edward Jones IRA App.

$ 52,461.52 Edward Jones IRA Sp.

$ 15,000.00 NYL Cash Value App.

$ 302,343.86 Total

$ 151,171.93 Half

$ 126,420.00 CSRA

UNDER RESOURCED

Countable Resources

$ 5,345.40 Great Western Bank Savings

Joint

$ 8,379.61 Great Western Bank Checking

Joint

$ 18,622.08 People’s Bank CDs Joint

$ 254.20 Signature Federal Credit Union, Alexandria, VA

Sp.

$ 104.73 Signature Federal Credit Union, Alexandria, VA

Sp.

$ 15,000.00 NYL Cash Value App.

$ 47,706.02 Total

$ 23,853.01 Half

$ 25,284.00 CRSA

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ALLOWED TRANSFERS

Spouse

Disabled Child

Limited funeral products for parents, children, siblings.

2-year care rule for the houseChild only. Medical proof. House. No Pit Stop!

Special needs trust if under 65 years old.

CREATING A SPEND DOWN PLAN

• Timing of a spend down plan is

a huge factor.

• It is not a matter of how much

you spend, but how much you

have left.

• Once you tell a person he or

she has to spend money, they

tend to overspend or

underspend.

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SPEND DOWN PLAN

Pay high interest debt

Set aside money for

funerals

Pay nursing home

Upgrade vehicle

Safe, stable housing for

spouse

Purchase personal or household

goods

Create income for non-spouse

applicant (SPIA)

LEGAL ADVICE, ANYONE?

• An ELDER LAW ATTORNEY

• Assists people when their finances, health situation, and/or living situation

converge to start to cause problems.

• Educate, calculate resources, develop and execute a spend down plan, deal with

specific legal issues related to unusual assets and/or look back issues.

• Substitute decision-making

www.iowafindalawyer.com

Select “Find a lawyer on the left”

Select “Types of Law” on the left.

Select Medicaid and Medicare

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TRIGGERING FACTORMARRIED OR SINGLE

• Already under a Conservatorship

• Court approval required

• Unable to execute the spend-down plan him/herself

• May be able to execute a power of attorney document

• May need a guardianship/conservatorship

OTHER TRIGGERING FACTORS

Single owning real estate or with a look back issue to cure

• Over $30,000 in IRA resources to liquidate

• Real estate to liquidate

• Unusual resources to liquidate (life estate, time share, business interest, etc.)

• Life insurance to liquidate (transfer, sell, assign… time-table, issues with POAs)

• Negative client participation

• Co-owned assets with 3rd party.

• Joint countable assets over $100,000

• When excess assets should be turned into income for the community spouse

Married with

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SAMPLE PLAN

Income $2,700.00

Spousal allowance $2,304.50

Trustee Allowance $10.00

Health Care Premium $448.90

Personal allowance $50.00 Long term care premium, for example.

VA Personal allowance You will have to fill this in. $90 if the person is already getting VA aid and attendance.

CLIENT PARTICIPATION ($113.40) Note: client participation will change once Part A is no longer being deducted from the Social Security income.

APPLICANT INCOME Income source Gross Income

SS $2,700.00

Income Totals $2,700.00 If the total is Red, then a Miller Trust is Needed.

SPOUSE INCOME

SS 856.00

Minimum Spousal Set Off

856.00 $3,160.50 $2,304.50

There is no set off if this cell is still blue.

APPLICANT Ins Company Type of Policy Premium (Monthly)

Part B $135.50

Aetna Med Supp. $296.00

Aetan RX $17.40

Total $448.90

Spouse allowance Estimated $ available for Spend down

Total Assets at attribution

$202,343.86 $101,171.93 $195,000.00

$99,971.93

Net Income during the planning period $11,103.30

Total $106,131.37

Convert App. IRA to Income $18,000.00

Tax on App. IRA $8,000.00

Leakage on NYL policy $450.00

Tax on Spouse IRA $6,500.00

outstanding debts $435.90

prepay property taxes $1,868.00

Funeral Trust for applicant $11,000.00

Funeral trust for spouse $11,000.00

upgrade new vehicle for spouse $15,000.00

Montly household expenses $12,000.00 3 months

Pay the nursing home $15,000.00 2 months

legal fees $8,600.00

Total $107,853.90

INTENTIONALLY CREATING A CLIENT PARTICIPATION

• Benefits of this plan:

• 1) Saved the client $3,000 in income tax

• 2) Raised the spouse’s income to the

maximum allowed for the next 3 years.

• 3) Allowed the spouse to keep the maximum

resource allowance and pay for the things

needed (funerals, property taxes, etc.)

• 4) EVERY CASE IS DIFFERENT

Nursing home cost $24,000.00

Paid $15,000.00

short $9,000.00

CP $386.60

months to pay off 23.28

(36 month SPIA)

Income $3,200.00

Spousal allowance $2,304.50

Trustee Allowance $10.00

Health Care Premium $448.90

Personal allowance $50.00

VA Personal allowance You will have to fill this in. $90 if the person is already getting VA aid and attendance.

CLIENT PARTICIPATION $386.60 Note: client participation will change once Part A is no longer being deducted from the Social Security income.

APPLICANT INCOME Income source Gross Income

SS $2,700.00

Spia $500.00

Income Totals $3,200.00 If the total is Red, then a Miller Trust is Needed.

SPOUSE INCOME

SS 856.00

Minimum Spousal Set Off

856.00 $3,160.50 $2,304.50

There is no set off if this cell is still blue.

APPLICANT Ins Company Type of Policy Premium (Monthly)

Part B $135.50

Aetna Med Supp. $296.00

Aetan RX $17.40

Total $448.90

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WHEN TO BORROW TO INCREASE THE CSRA

UNDER MAX CSRA, NO DEBT AT MAX CSRA, WITH DEBT

Bank Accounts $10,000.00

Investments $150,000.00

Total Assets $160,000.00

Spousal Allowance $80,000.00

App. Allowance $2,000.00

Spend down $78,000.00

Paid for home/ no debt

Legal Fees $10,000.00

upgrade vehicle $20,000.00

Funeral Trusts $22,000.00

Shopping spree $5,000.00

Nursing home $8,000.00

Agonizing over how to spend $13,000.00 too small for SPIA

Attribution of Resources

Bank Accounts $10,000.00

Investments $150,000.00

Borrowed equity against home $92,840.00

Total Assets $252,840.00

Spousal Allowance $126,420.00

App. Allowance $2,000.00

Spend down $124,420.00

Repay Debt on home $92,840.00

Legal Fees $10,000.00

Nursing Home $8,000.00

Funeral Trusts $22,000.00

SINGLE PREMIUM INCOME ANNUITY

• Payable in equal monthly installments

• Irrevocable

• Non-transferable

• Payable within the annuitant’s life expectancy

• Iowa Estate Recovery is the first beneficiary to the extent that the state has

paid out money for the Medicaid applicant.

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IOWA ESTATE RECOVERY

• What resources can Iowa Estate Recovery claim and when?

• Only assets owned by the Medicaid recipient at the time of death

• Will not collect if there is a surviving spouse, until the surviving spouse passes

• Cannot claim life insurance left to a named beneficiary.

• Deduction can be taken for estate related expenses.

Myth: The state and/or nursing home

will take your house.

WHAT WE DID NOT COVER

• How and when to cure gifts or other lookback issues

• How and when to transfer real estate

• How to dispose of a life estate

• How to prove an asset has no value

• What personal items are actually countable

• How to deal with financial institutions that will not honor your power of attorney

• How to value farm animals or crops in the field

• How (and when it is s good idea) to save the death benefit of a life insurance policy

• What documentation is needed to prove personal loans

• How to value Medicare set aside accounts from personal injury cases

• How the VA benefits are tied to Medicaid benefits

• How to get a guardianship and/or conservatorship

• When court approval is needed to create and execute a spend down plan

• When and what kind of estate planning your spouse needs now.

Just off the top of my head:

And lots more

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DHS EMPLOYEE MANUALS

• Become familiar with the DHS Employee Manuals that guide the case workers in determining

eligibility and interpreting rules and policy.

• www.dhs.iowa.gov/policy-manuals/income-maintenance

• Title 8-C Non-Financial Eligibility (citizenship and residency)

• Title 8-D Resources (countable and non-countable assets)

• Title 8-E Income (includable and excludable income)

• Title 8-I Medical institutions (level of care, treatment of income and resources for married

persons, treatment of VA benefits)

• Title 8-L Aliens (citizenship)

• Title 8-N Home and Community Based Waivers ( application process, eligibility)

Dedicated to providing legal guidance and education

with compassion and understanding

Medicaid Benefits | Estate Planning | Probate

Elder Law | Trust Administration

112 NE Ewing Street, Suite D

Grimes, IA 50111

(515) 986-2810

www.LetschLawFirm.com

Cynthia P. Letsch, J.D.

Managing Attorney

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Office of Medical CannabidiolIOWA DEPARTMENT OF PUBLIC HEALTH

Protecting and Improving the Health of Iowans

Randy Mayer, MS, MPH Director, Office of Medical CannabidiolOwen Parker, MPH Program Manager, Office of Medical Cannabidiol

Iowa’s Medical Cannabidiol Program:What Providers Need to Know

Disclosures

I have no conflict of interest or financial interest with this presentation

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What We Will Cover• Introduction to Iowa Code Chapter 124E

o The Medical Cannabidiol Board

o Registration card application process

o Who is a patient? Who is a primary caregiver?

o Qualifying conditions

• Program data thus far

• Healthcare Practitioner responsibilities, protections and education

• Approved product forms and testing

• High-level, industry-wide considerations

Iowa Code 124E provides that:

• A person may knowingly or intentionally:

o possess, use, dispense, deliver, transport, or administer cannabidiol.

o If the recommendation, possession, use, dispensing, delivery, transporting, or administering is in accordance with the provisions of Iowa Code Chapter 124E and 641 Iowa Administrative Code 154.

• An elaboration of the previous bill, which allowed for cards, but not for licensing of in-state manufacturing or dispensing

o Licensing of two in-state manufacturers, and five dispensaries

o Can only be increased by legislature. Other states may have loose or no license cap.

• The Iowa Department of Public Health was charged by the legislature to write the administrative rules for the program o Many similarities to MN’s program in terms of statute and rules

HF 524 was enacted on 5/12/2017

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Medical Cannabidiol

Medical Cannabidiol is defined as:

• any pharmaceutical-grade cannabinoid found in the plant Cannabis sativa L. or Cannabis indica; or

• any other preparation thereof that has a tetrahydrocannabinol (THC) level of no more than 3%; and

◦ weight in milligrams per milliliter (mg/ml) for liquids and milligrams per gram (mg/g) for solids

◦ *This does not restrict the amount of THC in a product (expansion of inert material)

• is delivered in a form recommended by the Medical Cannabidiol Board, approved by the Board of Medicine, and put into administrative rule by the Iowa State Board of Health.

o They can recommend new forms if desired→ vaporization (effective date of 5/15/19)

*To be clear, we have products with high levels of THC

Medical Cannabidiol Board

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Medical Cannabidiol Board

The board is made of eight practitioners:• Neurology (vacant);

• pain management;

• Gastroenterology (vacant);

• Oncology (vacant);

• psychiatry;

• pediatrics;

• family medicine (vacant); and

• pharmacy.

• A representative from law enforcement (chair).

What are their primary duties?

• Accepting and reviewing petitions

• Making recommendations to the Board of Medicine regarding additions or deletions of qualifying conditions

• Making recommendations to the Board of Medicine regarding forms and quantities of medical cannabidiol

• Submit a report to the legislature each year, outlining areas for improvement

• *Considering whether to recommend a statutory revision to the definition of medical cannabidiol in Iowa Code Chapter124E that increases the THC level to more than 3%.

Practitioners shall be licensed in Iowa, nationally board-certified in their area of specialty,

and knowledgeable about the use of

medical cannabidiol.

Registration Card Application Process

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Patient Definition & Registration

Who is a patient?• Means a person who has one or more of the qualifying

debilitating medical conditions and:

o Is of any age;

o Is a permanent resident of Iowa;

o Has not been convicted of a disqualifying felony offense (related to possession, use, or distribution of a controlled substance).

o Minors are not given a registry number, they are associated to a caregiver

What do they need to apply?1. Healthcare Practitioner Form, signed by their

physician

2. Completed Patient Application (paper or online)

3. Scanned copy, or photo, of their driver’s license

4. Proof of reduced fee, if applicable

5. Payment ($100 or $25)

Caregiver Definition & Registration

Who is a Caregiver?

• Means a person who:

o Is a resident of this state or a bordering state (Illinois, Minnesota, Missouri, Nebraska, South Dakota, or Wisconsin);

o Is at least 18 years of age; and

o Is a patient’s parent or legal guardian, or another individual who has been designated by a patient’s health care practitioner as a necessary caretaker for managing the well-being of the patient with respect to the use of medical cannabidiol pursuant to the provisions of Chapter 124E.

What do they need to apply?1. Healthcare Practitioner Certification Form, signed by

the patient’s physician

2. Completed Caregiver Application (paper or online)

3. Scanned copy, or photo, of their driver’s license

4. Proof of reduced fee, if applicable

5. Payment of $25

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Medical Cannabidiol Registration Cards

Issued at any DOT driver’s license station in Iowa:

*DOT-integration allows law enforcement instant access to our patient registry through the DOT system

* Once issued, cards are effective for 365 days from the date of issuance. Patients must renew their card each year

Qualifying Debilitating Medical Conditions*

1. Cancer, if the underlying condition or treatment produces one or more of the following:• Severe or chronic pain.

• Nausea or severe vomiting.

• Cachexia or severe wasting.

2. Multiple Sclerosis with severe and persistent muscle spasms.

3. Seizures, including those characteristic of epilepsy.

4. HIV/AIDS as defined in Iowa Code Section 141A.1.

5. Crohn’s Disease

6. Amyotrophic Lateral Sclerosis

7. Any terminal illness, with a probable life expectancy of under one year, if the illness or its treatment produces one or more of the following:• Severe or chronic pain.

• Nausea or severe vomiting.

• Cachexia or severe wasting.

8. Parkinson’s Disease

9. Untreatable pain - any pain whose cause cannot be removed and, according to generally accepted medical practice, the full range of pain management modalities appropriate for the patient has been used without adequate result or with intolerable side effects.

10. Ulcerative Colitis –

11. Severe, intractable autism with aggressive or self-injurious behaviors –

* The Board recommended to add “chronic pain” to the list of conditions, it is on to the Board of Medicine for approval or denial

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Petitions for New Qualifying Conditions

Patient Percentages By Medical Condition

* ~ 70% of patients are certified for a pain-related condition

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Patient Demographics

* ~ 40% of patients qualify for reduced fee (low-income, elderly, disabled)

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

52.07

61.65

10.29

64.33

55.29

63.00

49.1552.26

70.07

35.58

56.8062.40 60.70

45.72

57.35 56.58

Average Patient Age

53

47

Gender Breakdown

Female Male

26 22 2846

6647 36

74 8469

200

383361

404 391

444421

310339 341

400

191 213 241 287 353 400 436 510594 663

863

1246

1607

2011

2402

2846

3267

3577

3916

4257

4657

0

100

200

300

400

500

600

700

800

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Patient Registrations

New Monthly Approvals Cumulative Approvals by Month

Registry Metric Number on 12/1/18 Number on 10/1/19 Percent Change

DOT-Issued Cards 681 4,486 +559%

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Health Care Practitioner Responsibilities

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* Iowa Code 124E provides that health care practitioners are under no obligation to provide the written certification of a medically debilitating condition for a patient.

14

28 27

20

15

2118

42

68

84

79

5659

40 41

3027

2522

157185

212 232 247268 286

328

396

480

559

615

674714

755785

812837

859

0

10

20

30

40

50

60

70

80

90

0

100

200

300

400

500

600

700

800

900

1000

New and Cumulative Certifying Practitioners by Month

New Monthly Certifying Practitioners Cumulative Certifying Practitioners

Registry Metric Number on 12/1/18 Number on 10/1/19 Percent Change

Certifying Physicians 387 854 +158%

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Is a special certificate or license needed to certify a patient’s condition?

“Health care practitioner” means individuals licensed under Chapter 148 to practice medicine and surgery or osteopathic medicine and surgery in Iowa. • No special certification or CME is necessary to certify a

patient’s qualifying condition

• *“Health care practitioner” shall not include a physician assistant licensed under Chapter 148C or an advanced registered nurse practitioner licensed pursuant to Chapter 152 or 152E.

*HF732 would have changed this, and allowed for ARNPs and PAs to certify patients

What educational resources does the department provide for physicians?

The department is charged with implementing and regulating the medical cannabidiol program. However, we do provide resources on our website for physicians looking to further understand medical cannabidiol and it’stherapeutic utility.

https://idph.iowa.gov/cbd/For-Physicians

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What protections does the law provide for providers who write the certification?

Common Questions from Physicians• If I participate in the program do I place myself or my staff at risk of

criminal prosecution? Will I jeopardize my Iowa medical license or my DEA registration? Will I increase my risk of being sued for malpractice?

124E.12 Use of Medical Cannabidiol – Affirmative Defenses.• “A physician and their agents and employees are not subject to any

civil or disciplinary penalties by law enforcement or the Board of Medicine for activities related to certification or use of medical CBD in the treatment of a patient as authorized under chapter 124E”

• Disciplinary action against health care providers only when a provider acts inconsistently with state law (writing certifications for persons whom they have never examined)

DEA Registration• Federal government will not revoke DEA registration for a

physician’s involvement in state medical cannabis programs if the physician complies with state law (2013 DOJ guidance)

• Related case – Conant v. Walters (2000) – federal government cannot revoke DEA registration if a physician recommends marijuana to a patient if recommendation based on sincere medical judgment

Malpractice Concerns • No reported cases of malpractice brought against physicians for

activities related to medical cannabis• Medscape – “we couldn’t find a single case related to medical

marijuana” (July 2018)• Legal experts – legal risk is minimal because physicians are merely

certifying that the patient has a qualifying condition; they are not prescribing

• Physicians who choose to participate should discuss their role in certifying patients with the legal counsel and malpractice carrier

Storing and administering medical cannabidiol in federal funded facilities?

• Cannabis is still schedule I at the federal level, this creates complications with compliance for facilities which receive federal grants or Medicare (3 ways of handling):

1. Will not allow it within the facility at all

2. For state-certified patients, will allow the patient to store in their room, but not in central supply

3. For state-certified patients, the facility will store and administer the medication for the patient

• Generally, if they were to know about them, risk and quality managers will not allow these products in their facilities

• Privately funded institutions may be more likely to allow this, as they are less accountable to federal money streams

• Situations that occur because of this:o Patients do not tell staff

o Caregiver or family member takes the patient off facility grounds to administer medication

* The State cannot provide protections for facilities (Medicare, etc.)

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Are there any repercussions from my employer if I am a medical cannabidiol patient?

• Patients and prospective patients should review their employee handbook for policies related to THC or marijuana use to be sure that the use of cannabidiol products at work or outside of work is not prohibited by the employer.

•Patients using medical cannabidiol products may test positive for marijuana or THC presence in the event of a urinalysis or other test for the presence of drugs.

•At this time, there are no protections that the state can specifically provide to patients if their employer has an internal policy against THC or medical cannabis.

Manufacturing and Dispensing of Medical Cannabidiol in Iowa

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• Manufacturing includes the cultivation, manufacturing of products, and distribution to dispensaries.

• Iowa Code 124E called for two in-state manufacturers to be licensed by December 1, 2017.

• Manufacturing applicants pay a fee of $7,500 application fee, and a $10,000 deposit per owner for the Iowa DPS to conduct background record checks.

• An annual fee of $100,000 is assessed to each of the two licensed manufacturers.

• A competitive bid resulted in the licensing of one manufacturer – MedPharm Iowa on December 1, 2017.

• A second competitive bid in Spring 2018 resulted in the licensing of Iowa Relief on July 1, 2018. They will have products available during late Summer, 2019.

Manufacturing

* The legislature intended for the program to be funded solely through fees

Dispensing

• Licensing of up to five in-state dispensaries

• Dispensary applicants paid $7,500 application fees, and also a $40,000 annual licensing fee

• All dispensaries opened December 1, 2018:1. Have a Heart Compassion Care - Council Bluffs 2. Have a Heart Compassion Care - Davenport 3. Iowa Cannabis Company, Inc. - Waterloo 4. MedPharm Iowa - Windsor Heights 5. MedPharm Iowa - Sioux City

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How does the State monitor

licensee compliance?

• The Department has built a seed-to-sale tracking software that tracks the end-to-end processes of cannabidiol manufacturing and dispensing• Built by an experienced vendor from the

pharmaceutical IT space

• Tracks movement of all plants, processing, employees, transport, testing data, patient purchasing data, inventory and much more

• SalesForce backbone provides the State with robust tracking and reporting capabilities

Forms* and Quantities

Medical Cannabidiol forms approved (154.14(2)):

1. Oral forms, including but not limited to:• Tablets

• Capsules

• Liquids

• Tinctures

• Sub-lingual forms.

2. Topical forms, including but not limited to:• Gels

• Ointments, cream, or lotions.

• Transdermal patches.

3. Nebulizable Inhaled forms.

4. Vaporizable forms (available summer 2019)

5. Suppositories, including but not limited to:• Rectal

• Vaginal

Proposed Administrative Rules

*No forms may be edible (i.e., contained in food) or smoked.

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Over-The-Counter CBD Products & the Iowa Hemp Act

What is the REAL situation??

• Iowa was not one of the 41 states to adopt an industrial hemp pilot program. Under Iowa, CBD and most hemp derivatives are Schedule Io This will not change until the USDA accepts

our state plan, realistically early 2020

• Will consumable hemp or CBD products be legal at that time?o “hemp-derived CBD can only be added to

products intended for human consumption to the extent consistent with applicable federal law.”

o The only CBD product that is FDA-approved for human consumption is Epidiolex… EVERY other consumable product would still not be legal

• An industry out ahead of the skies…o “State law cannot preempt the federal law,

and Iowans engaging in the manufacture, sale, or purchase of hemp-derived products should carefully consider the legality of their actions under Iowa and federal law. ”

How are hemp-derived CBD products different from those I can purchase at Iowa’s dispensaries?

• The only product which is FDA-approved for human consumption is Epidiolex. Everything else is outside the FDA umbrella.

• “Buyer Beware” - There is absolutely no guarantee of what is in those products, or not; regardless of what the label or a website may tell you.

• Consumers should be cautious and wary of adulterants (pesticides, metals, solvents used in extraction, microbiological impurities) if they procure these products.

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How much can a patient purchase or possess?

A 90-day supply is the maximum amount of each product that shall be dispensed by a dispensary at one time

(purchase cap).

• In creating this bill, the legislature did not define what constitutes a “90-day supply,” nor was a professional (physician or pharmacist) given the authority to define it

•A specific possession limit is also not defined

•Without these definitions to track to, enforcement of a purchase limit is impossible for IDPH and law enforcement

• This was the reason to create the “X g/90 days” this past session, which was vetoed

• How does Iowa compare in this regard?

o Currently, patients could purchase as much as they could afford

o Even at the 25g, we would be in the bottom quartile of allowable THC

Iowa Products

Tincture

Capsules

Lotion

* As mentioned, 3% is not a limit, and a 90-day supply without a definition is not a purchase cap

Iowa Relief Tincture

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Product Testing and Safety

Iowa’s State Hygienic Laboratory is conducting all product testing, which is done at the process (oil) and final packaged (product) lot stages.

Testing will be done for the following:• Metals, Pesticides, Microbiological Impurities,

Solvents, and Cannabinoid Content

Formulation & Product Popularity

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Conclusions:

August 2, 2019 Board Recommendations

1. Removal of the 3% cap, and movement to “x g per 90 days”

2. Removing the felony disqualifier

3. Addition of ARNPs and PAs

4. Pharmacy-trained staff in dispensaries

5. Physician access to patient registry

6. Protections for use of products in federally funded facilities

7. Require Department research

8. All the Department to issue cards, and remove the DOT component

9. Renaming the program to reflect the comprehensive nature of the program

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Conclusions:

Overall Issues with Schedule I Status

• Domestic Research – Why so limited?o Very few ways you can get funding for

effectiveness research on schedule I substances.

oMost of the effectiveness data comes from countries who are farther ahead of the US on these policies (Canada, Israel).

o Really the only groups who do research get funding from the National Institute of Drug Abuse (NIDA). Therefore, most domestic research is harm-related.

• Insurance – Why no reimbursement?o Federal schedule I status keeps insurers,

Medicare, and Medicaid boxed out.

• Banking – Why is it all in cash?o Federal schedule I status keeps large banks

from taking part in these money streams.

o Although there is FINCEN guidance, most cannabis banking is local.

… no currently accepted medical use and a high potential for abuse…

Effectiveness Data

1. National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. doi:10.17226/24625.

2. Minnesota Department of Health, A Review of Medical Cannabis Studies relating to Chemical Compositions and Dosages for Qualifying Medical Conditions, July 2016.

3. Sativex – 1:1 THC:CBD oromucosal spray – MS; Approved in 30 countries; undergoing FDA approval process in USA; GW Pharmaceuticals

4. Epidiolex – Oral solution of CBD – Seizure disorders – Approved by FDA in June 2018; GW Pharmaceuticals

5. Marinol (dronabinol)/ Nabilone - THC – FDA approved currently for nausea and loss of appetite from HIV or chemotherapy

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Resources

1. Iowa Code Chapter 124E -

https://www.legis.iowa.gov/docs/code/124E.pdf

2. 641 Iowa Administrative Code 154 -

https://www.legis.iowa.gov/docs/iac/chapter/02-27-

2019.641.154.pdf

3. Office of Medical Cannabidiol Website -

https://idph.iowa.gov/cbd

4. Health Canada: Information for Health Care Professionals:

Cannabis and the cannabinoids - http://www.hc-sc.gc.ca/dhp-

mps/alt_formats/pdf/marihuana/med/infoprof-eng.pdf

5. Minnesota Medical Cannabis Program: Patient Experiences from

the First Program Year -

https://www.leg.state.mn.us/docs/2017/other/170739/FirstYear

Report.pdf

6. Epidiolex Titration Information -

https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/21

0365lbl.pdf

7. Sativex Titration Information - http://sativex.co.uk/404/

8. Conant v. Walters - https://www.justice.gov/osg/brief/walters-v-

conant-petition

9. MedPharm Iowa Website - https://www.medpharmiowa.com/

10. BioMauris Website - http://biomauris.com/

Questions?

Thank You,

Randy Mayer, MS, MPH

Director, Office of Medical Cannabidiol

Chief, Bureau of HIV, STD and HepatitisPhone: 515-242-5150Email: randall.mayer@idph.iowa.gov

Owen Parker, MPHProgram Manager, Office of Medical Cannabidiol

Phone: 515-725-2076Email: owen.parker@idph.iowa.gov

Protecting and Improving the Health of Iowans

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