Coping With Medicare Changes

Some of you may have read my previous blog post and worried yourself sick over the future of PTs in the US.  Some of you are students, some are professionals on the path to achieving their US license and some are already PTs in diaspora scattered throughout the US.  Now, after reading my last blog entry, a little hope might have died on you or you may have lost a little faith in yourself and in your future as a therapist in this country.  This blog entry I am now writing, is intended to restore whatever was lost in you and make you dream big again.  

Once more, I am no expert in Medicare as well as in the many different practices of healthcare in general and physical therapy in particular.  Therefore, I would very much welcome all statements and comments from other US PTs in our community to help clarify the real goings-on in our practice.  

The thing I want all of you to engrave in all of your being is that there is a need for PTs in the US.  There is a need because the baby boomer population is getting older and they would need therapy eventually.  There is a need because PT programs here reach a staggering seven-year curriculum to get a DPT.  Education is very expensive in the US.  Unlike in the Philippines where it is considered the parents' responsibility to send their kids through university, here people work to get themselves an education.  A whole seven years to spend schooling is seven years of maintaining high grade point averages while working at least one job on the side.  Most people would have a hard time coping with such a schedule.  Thus, fewer Americans are taking up physical therapy as a career and as older American PTs go to eventual retirement, they would need replacements and even more PTs to keep up with the demand from baby boomers.  Most likely, they would hire Indian and Filipino PTs because of our good command of English and very close resemblance of our PT school programs to theirs.  

Now I did mention of Medicare going bankrupt and the Manual Medicare Review being a pain in the ass in my last entry.  It is largely out of frustration that I blurted that one out.  Though the fact remains that Medicare may run out of money if drastic reform is not undertaken to curtail unnecessary expense and fraud, I am hopeful that the reforms they will apply are reasonable and can be worked with.  The Manual Medicare Review (MMR) will eventually become more organized and efficient and will be streamlined with private insurance company procedures.  Now, private insurance companies may be stingy with the amount of treatment they would be paying for the patient (like allowing only 10 treatment days instead of the fifteen days you would request to work with a patient) and are also very demanding with paperwork, private insurance companies are efficient in their delivery of benefits.  It is like you contact them regarding a patient under their insurance policy, send them the necessary paperworks including your prognosis and expected outcomes for the patient, you would usually receive a reply from them within the next two days.  MMR, on the other hand, would take a month to process everything and send out a reply to you.  However, once the MMR system becomes more organized, delivery of services and reimbursements will be faster and more efficient.  

I would also like to clarify that the mess that MMR has gotten us into, so far has no effect on Medicare A patients.  Medicare A covers hospital care and that means PTs working in acute care rehab (hospital in-patient) and skilled nursing facilities (sub-acute care) are not affected.  MMR affects outpatient services under Medicare B which includes homehealth therapy, outpatient rehab and long-term care such as nursing facilities.  (Take note that a skilled nursing facility is different from a nursing facility. A nursing facility is basically a nursing home, a retirement home for the elderly  where the patients are usually long-term whereas a skilled nursing facility is more of sub-acute care.  Patients in SNFs are usually short-term; they are those that don't really require very close medical monitoring but are not yet healthy enough to go back home.  It is not unusual that a nursing facility may have several skilled bed units or a skilled nursing facility have some long term care residents).  The new Medicare changes will have the MMR process continued for this year, so hopefully those running the system start getting the hang of it and get things done faster.  To cap it all, life goes on easy for PTs working in SNFs and hospitals but PTs working in nursing homes, home health and outpatient facilities will have to make necessary adjustments. 

Another point I would like to stress out is that the demand for PTs continue to be really high in many parts of the US.  We probably never hear of them because almost all of our peers are concentrated on the Eastern and Western seaboards.  Almost everyone is in NY, NJ, California, Florida, Illinois, Maryland, Washington and Texas.  These become supersaturated with PTs that it seems you won't be able to find another place to work at if you move.  However, if you think about many other mid-Western states and other states without the very large metropolises, this is where PTs are needed most.  Think New Mexico, Arizona, Alabama, North Dakota, Oklahoma, South Dakota, Ohio, Oregon, Missouri, Iowa, North Carolina, Tennessee, South Carolina, Louisiana and Mississippi.  In these places where it is less flashy and more quiet, you can get the most out of your money.  I live in Northern Virginia, about thirty minutes from Washington DC, and I pay fourteen hundred for a two-bedroom apartment.  My friend in New Mexico pays five hundred for a three bedroom house with a fenced yard.  I get paid slightly higher than her but with the cost of living here, she gets a whoooole lot more for her money.  Try living in New York and your wallet would hurt more. True, you probably would have to drive at least two hours (or maybe five) to get to something exciting over there in New Mexico.  And true, Washington DC is but a half-hour drive for me.  But the fact remains: How many times do you really need to see the White House and get your picture taken before you're satisfied?  Even in a big city like New York, you won't even be able to enjoy exploring it if you are working hard five times a week.  At the end of the day, it is best to pick a place where you have a good work-life balance.  And another tip, if it is possible, don't pick a state where there are a lot of Filipinos.  You'd be free from all the drama and pataasan-ng-ihi events.  It is best to pick a state where Filipinos are afew and therefore are a much tightly-knit and closer community.  You'd thank me later. 

Finally, my friends, our best defense against evolving Medicare regulations is to hone our ability to perform a very necessary but seldom emphasized skill in the clinic: documentation.  In the Philippines, we take for granted writing notes because 1.) we directly communicate with a patient's family and his doctor regarding his progress and 2.) we copy/paste our notes for almost all our patients involved (e.g. PT Note dated today:  Pt was seen with the same management as so-and-so date.  Pt tolerated tx without untoward incidents.)  We write this PT note for all our patients sa Pinas.  This is way different how we do things here.  Our notes  are more detailed and functional progress (or regress) should be stated clearly and in a meaningful, complete but concise detail.  In order for you to be able to do that, first of all you should be keen in your observation and evaluation of your patients.  I mean, how can you write a good, accurate and scientific PT document, if you don't even know what to observe in a patient in the first place, or what questions to ask the patient in an interview or if what a patient is explaining to you may even be relevant in your note-writing?

Your clinical decision-making skill will be called upon if you want to keep a steady caseload.  It is very important to know how to screen patients who are appropriate to be picked up by physical therapy.  Take note that I used the term "appropriate" instead of "need".  Not all patients who need therapy are appropriate to be picked up by physical therapy.  It is you who make a clinical determination of that.  Remember that the appropriateness of giving skilled physical therapy services is among the factors that will ultimately determine denial or approval  of MMR.  Modesty aside, since October to early December 2012, from among the fifteen or twenty patients that I have sent out for MMR, I only had one denial.  That denial was based on technicality (wrong Medicare number or something) so that isn't my fault.  The reason for my success with the MMR process is simple: proper and complete documentation.  I am not saying my notes are perfect, but they are definitely suffice to the standards set by Medicare.

As I conclude this blog entry,  let me leave you with some advice.  1.) Don't worry about the future of PTs in the US; we have a good future here.  We are skilled professionals.  People will get old, people will have fractures, people will get sick.  There will always be a need for us.  Worry ka ng worry sa future mo hindi mo nga mapasa-pasa yang lintek na TOEFL na yan.  Focus on the present first and later on decide to cross the bridge when you get there.  2.)  Despite the rumors (or urban legend :-D ) that documentation is really hard, the truth is, it is only hard in the beginning.  Once you get the hang of it, it will just flow more easily from you. 3.)  Learn to drive.  Unless you want to live in NYC where you can get anywhere with trains, anywhere else you would need to be able to drive around.  So before you leave the Philippines, take some driving lessons (with an automatic transmission car); it will make your life way easier and acculturation way faster. 4.)  If your main goal of going to the US is just to earn money, you will never be happy here.  Better stay in the Philippines with your loved ones than come here and hate your job and situation.  To be satisfied with your lot in life as an expat PT, come here to LEARN first, and to EARN second.  Money is not the end-all and be-all of your life as a PT.  Happy New Year to all and I hope nabuhayan ng kahit konti ang mga pangarap ninyo.

P.S.  I would very much appreciate comments and additional information that you guys would like to add to paint a more complete picture of our experiences here.  Let us work hand in hand to ensure that more PTs will discover their true calling as extensions of God's healing hands. 

P.P.S  For the grammar Nazis, my apologies.  Tao lang po. 

How Medicare Reform Can Affect Your Future as a Physical Therapist

I originally wrote this piece on the 31st of December 2012 but unfortunately was unable to finish it until now.   It is the fourth of January, and the both Houses of the US Congress has finally set a deal a couple days ago preventing the much feared US fiscal cliff from happening. 

The US fiscal cliff is an economic apocalyptic event of drastic spending cuts and dramatic tax hikes to reduce the US budget deficit.  With spending cuts, jobs will be lost resulting in decreased consumer spending.  Decreased consumer spending means companies, for example Walmart or McDonalds, will not be hiring more people when they don't have a lot of costumers to cater to.  Otherwise, they might also start laying people off.  Imposing tax hikes means less money for every family to spend and presents the same effects regarding decreased consumer spending.  This will send the fragile US economy back into recession and will pull the world down with it.  Which leads me to my next point, what does it have to do with healthcare workers, in particular physical therapists?  Let me explain.

Medicare alone accounts for almost $600 billion in 2010 and is expected to rise to more than a trillion bucks in 2022, when most of the baby boomer generation would require more health services.  All physical therapists based in the US, in one way or the other, are dependent on Medicare reimbursements for their services may it be in out-patient clinics, home health services, skilled nursing facilities, nursing facilities or acute care rehab.  If this fiscal cliff happened, and the s--t hit the fan, cuts to Medicare will seriously affect delivery of care to patients and may result in loss of employment or underemployment for therapists.  For foreign trained PTs, like us from the Philippines, it may be harder to get working visas when there are no jobs available to start with. There is always talk of increased demand for therapists as the baby boomer generation enters their twilight years and would need more help to increase mobility, improve function and quality of life but the lingering question is who is gonna pay for their therapy when Medicare cuts are implemented here and there? Most won't be able to pay out of pocket.  Our skilled services are expensive so to speak as new PTs here spend an average of seven years to be a DPT. However, I personally think it is justified how much we are compensated for our services. 

 I work in a nursing home with a few skilled beds so I cannot really speak in behalf of other PT specialties but let me explain this one too.  As a PT, my job is not only to evaluate and make a program for every patient I have, short-term care or long-term care patient it doesn't matter.  It is also part of my job to constantly assess the patient and be in constant communication with other therapists (OT and speech) as well as nursing (which basically encompasses a broad base of unit nurses, restorative nurses, Medicare nurses, unit managers and nursing assistants/aides) with regards to the overall health of the patient.  Everyday that I work with the patient, therefore, I am evaluating him if he is making progress, if this program is working for him, if he is at baseline and most especially, if something is off with him.  I don't have to diagnose what is wrong with him as that is not part of my job but it is my job to let everyone involved in his care know that something isn't right and has to be put into observation or noted.  There are times when a patient is making good progress and then gradually declines for no obvious reasons.  Having reported it to nursing, nursing may reveal that his medications may have been changed and when they found out that the patient is not doing so well with the new meds may contact the physician.  To make the long story short, a therapist is involved in a large part of patient care and as we play a central figure in restoring patient function and overall quality of life, it is only right that we are paid decently for our clinical judgment and responsibilities. 

With a deal reached in Congress, the 27% pay cut to doctors (and by extension to us, therapists) will not happen, or perhaps more accurately,  at least not now.   However, Medicare reform will soon be an area of great interests to the politicians as they try to rein in the cost of healthcare.  According to Wikipedia, only less than 5% of all Medicare claims are evaluated, which means that 95% or more of claims get refunded without adequate verification of appropriateness of reimbursement.  Having said this, many firms, both bogus and legal, have turned Medicare into their cashcow, essentially draining the system of much needed funds faster than these seniors can go into full retirement.

In New York alone, Medicare must be losing hundreds of millions on fly-by-night physical therapy clinics that are essentially hot-packs-TENS-factories that change names every two years to avoid detection from government agencies for fraud.  These clinics, employ unlicensed PTs to treat dozens of patients a day and are in cahoots with a licensed therapist who comes in only once a week to sign documents to make the operation appear legal. I know this for certain as I have a couple friends verify this.

Insurance fraud such as this adds up to the bankruptcy that is facing the Medicare system in the face.  Many reforms have been introduced and as recently as October of last year, they introduced Manual Medicare Review (MMR), towards which they hired (I assume) non-healthcare professionals to assess, evaluate and approve or disapprove request for more therapy for patients who have reached their caps for the year.  A cap is the maximum amount of money that Medicare can pay for each patient receiving skilled therapy for the year. If the patient goes beyond cap, theoretically he has to pay out of pocket. Before the MMR, even if the patient reaches the cap, a therapist can write justification explaining why the patient would need more therapy despite having used up his money for the year.  With MMR, you are only allowed an evaluation once the patient reaches cap.  Then all the necessary documents pertaining to the patient will be sent out to the agency performing the MMR, on which the agency will have ten business days to decide and approve or deny the evaluation and need for therapy.  Their response will be sent out via snail mail back to you. 

I will say it up front.  The whole MMR process is a mess!  A big, and utter mess!  For starters, ten business days is two weeks from evaluation.  Add the days for completion of documents and the days for snail mail and you are looking at at least three weeks (or in my experience even two months!) before you get to know if you can start treating a long term care patient.  How in the fucking world can you expect the patient to stay at the same level, set the same goals for the patient after evaluating him a month ago? How in the world do you expect the patient not to have declined in that span?  For example,  I have a patient evaluated for a fall and I sent the patient's paperwork out for MMR.  The evaluators took their damn sweet time processing the papers and I received a reply more than a month later approving twenty treatments for the patient.  By that time, the patient has had fallen two more times and has now progressively weakened from the pain and the fear of falling again.  How in the world do they expect me to fix him now?  I'm pretty sure I need to re-evaluate him as his needs, level of function have changed.  But I can't!  Because if I do, I would have to wait for God knows how long again before I get their reply.  By then I'm not even sure if the patient would still be alive.

The inefficiency of those doing the MMR was so blatantly upsetting, that by the end of the year, three months after the MMR was introduced, I was left with only two patients to see.  Two patients mean I can only stay for work for a very short time thus leaving me broke by the new year.  Many other therapists who work in nursing homes also reflect the same sentiments.  And all the papers I sent out are just there awaiting nothing, no response from MMR whatsoever.  I have sent out at least ten patient evaluations and no response from them.  It was very frustrating and my fear is that this Manual Medicare Review might go on as the future of Medicare reform.  This does not bode well for the future of the healthcare practice and professionals.  But most of all, it does not bode well for the quality of life of patients.

It becomes a big irony when they tell you the need for PTs will continue to rise in the future as more and more baby boomers get older and need therapy but at the same time the politicians are looking at choking the lifeline of these same health care professionals and eventually driving them off the workforce.  We can only pray that they would know better and make better recommendations at health care reform.  Before we all drive ourselves and jump over a real cliff. 

Bond 2012: SKYFALL

I remember when I learned that Daniel Craig was to play the coveted role of James Bond several years ago, my first reaction was: Daniel who? I never heard of the guy and when the poster was shown I shook my head and dismissed the actor and the franchise to ultimate failure.  Daniel Craig did not look like the former James Bonds. They all used to share Sean Connery's tall, dark and handsome features. All of them dashing, smooth, debonaire.  Daniel, on the other hand, is not even good-looking.  He is also shorter than the other Bonds, is bulkier and more muscular and has blond hair.  So as one of the earliest naysayers, my foot is stuck in my mouth as Daniel Craig rose up to the plate and became the most bankable James Bond in history, probably even outdoing the feats of Sean Connery, Roger Moore and Pierce Brosnan. 

This movie, Skyfall, is set to become the highest grossing in the 50 year history of the franchise, and not surprisingly so.  The movie is great, the script intact and the cinematography superb.  I would like to commend its director Sam Mendes for doing a wonderful job at the helm.  The cinematography was also breathtaking particularly with the train crashing towards Bond in the tunnel and the fight scene on a Shanghai skyscraper. The actors themselves were very good at showing their vulnerability.  The script was almost flawless with a good injection of humor throughout the film.  This, in my humble opinion, is the best Bond film to date.

Since the first installment of Craig as Bond, the production behind the Bond series have intelligently transitioned to a more believable and more human depiction of the famous fictional English assassin.  They have done away with invisible cars, exploding fountain pens and weird disguises that fool no one.  Instead, the director has used Daniel Craig's eyes and sharp-lined mouth to make the viewers realize that Bond is not immortal.  Bond is a human being who hurts, who feels, who gets tired, who gets old.  It is with Craig that we have seen Bond tortured, wounded badly and almost die.  It is because Craig, despite not being good-looking, can pull off the hero-who-becomes-the-underdog-to-rise-and-become-hero-again stint. What's more, Craig is definitely believable to play the part.

The other cast members also performed very well.  

I am in awe of Berenice Marlohe, a French actress, who looked and played an Asian concubine/employee of antagonist Javier Bardem.  Not only is she stunningly beautiful, she was able to beautifully project deceit, fear, loathing and hope in rapid succession during her conversation with Bond at the casino.  Her hand trembled at the thought that Bond wanted to meet her boss.  She shook with fear, her mouth quivered as she told him: Be careful what you wish for.  And her eyes shone with hope when she asked him: Are you gonna kill him? 

Naomie Harris in the film, I think was confident and played the her role well as Eve a field agent who was mistakenly shot Bond as he struggled with another assassin on the train.  At the end of the movie, she is revealed to be the returning character Ms  Moneypenny, secretary to M.  In the Bond series though, her name is Jane not Eve.  I didn't think that she was as good as Marlohe in this film but yes she does have the better ass.  Yep, ass as in behind.  Go Ms Moneypenny!

Another great addition to the film is Ben Wishaw who played Q, a computer wiz who is at the helm of anything computer related within the MI6.  He played his character very well too, looking all dorky and unkempt but with the sarcastic verbose nature that all high-IQ nerds possess.  He was also able to project very well the short but plot-decisive virtual chess game with Javier Bardem.  

Judi Dench played her last role as M and will be replaced by Ralph Fiennes (aka Voldemort) in the upcoming films.  Both actors played their roles well although at times I felt veteran actress Dench looked stiff.  She did have to play a tough role though, to play an impassive and cold director of the MI6 who calls the shots and carries the burden of dead agents or failed missions at her behest all in the best interest of England.  I did expect more from her especially during her confrontation with Javier Bardem and during the opening scene when Bond was inadvertently shot by Eve upon M's command where she looked more lost than impassive. 

The most striking of all the actors though, including Daniel Craig, is Javier Bardem who was marvelous in his portrayal of Bond's nemesis as Silva, a former personal favorite of M, who was disgraced and eventually let go by the MI6.  He was portrayed as a power-hungry evil genius attracted to power and strength which birthed to his homo-erotic scene with Bond.  Silva returned as a devious and ruthless cybercriminal, fanatical in his desire for both revenge and acceptance from M.  His brilliance and cunning always put him a step ahead of Bond and the MI6 as he unleashed a wave of cyber and actual terrorism.  His portrayal of Silva in this film proves that his talent as an actor and his Oscar recognition is no fluke.  Plus, having a Penelope Cruz for a wife is a prize in itself.

This Bond movie has solidified the idea that in the world of espionage and covert operations, the concept of you-snooze-you-lose cannot be emphasized more.  This was also relayed by Liam Neeson in Taken when he confronted his former French friend at the dinner table with: That's what happens when you sit behind a desk for too long. You forget things! Like having a gun that's loaded and one that's not.  The skill and the instinct may be there, but the precision, dexterity and reflexes definitely slow down.  In this particular film, for instance, Bond retreated to seclusion and alcohol after his widely perceived death.  He returned a lesser assassin, who looked and moved like the shell of his former self.  And since I love David Morrell's (creator of Rambo) Brotherhood of the Black Rose book so much, I would like to imply again that between two equally skilled and deadly assassins in combat, the younger one always has a higher percentage of winning. The reason is the younger you are, the faster your reflexes are.  Bond, in this film, was shown as getting old with not-so-subtle hints of having him retired.  But, of course, like all protagonists, he persists and eventually triumphs over Silva and his goons but at the sad expense of M.  

As for the assassins themselves, it is clear that emotions and feelings are considered a great liability and bad for business.  The has been well-documented in the Bourne series and in Mr and Mrs Smith. Assassins are trained to kill without remorse, without doubt, with indifference.  But, no, like in all the Bourne series, Mr and Mrs Smith, Taken as well as the books of David Morrell, Daniel Silva, Frederick Forsythe and Tom Clancy, assassins are not without heart and at times risk their lives for that split-second moment of doubt or surge of regret or love.  This is the very first time in the history of chauvinistic, womanizing James Bond to have seen him at his most vulnerable.  For the first time since his parents' death, James Bond shed tears for his boss, M, Mom, the closest thing to a mother he had.  He openly wept for his love of country, his love of M and for his freedom from the dark memories of Skyfall.

P.S.  It seems that this movie can do no wrong.  Adele, the British vocal behemoth, who has inspired multiple eargasms with her soulful and bluesy vocals, has sung the hauntingly beautiful theme song of Skyfall, named as such.  Sometimes you just wonder if they made the movie just so she can sing its theme song.  It really captured the essence of the film.  I recommend that you watch it in theaters.  It will not do justice to this movie's perfection if you just download it and watch it on the small screen. 

Pictures II

Green Means Go

Shadow Over Apples

Orange Globe

Fruit of the Earth

Bounty

Shaded Beauty

Hiding from the Sun

And my favorite pic of the day:

Autumn Willow

Destination Anywhere

I have stumbled upon this documentary from one of the write ups of the opinion section of the Philippine Daily Inquirer.  It's opening line is like an uppercut to the diaphragm: Imagine a nation where the #1 career choice is leaving the country. Yes, it is talking about us, the collectively heralded heroes of the present, the overseas Filipino worker. 

The Pen Artist

Funny, I only realized that after my puberty was over, there were only two things that persisted: (1) my acne and (2) the fact that my best days of impassioned writing was over.  Yes, I still do write poems and essays such as this every now and then.  But I know not how I managed to conjure up an obra maestra of letters and verses in one sitting.  Where once I could sit and write a love poem in less than half an hour inspired by the works of Edgar Allan Poe and Maningning Miclat, I am now resigned to squeezing my brain to write even a single verse for my wife or to type a blog entry that probably only a couple people will read anyway.

I did not know when I lost the passion for writing.  Its slow but inevitable death probably has started when my mom told me I will not take up Creative Writing at UP Diliman.  She told me poetry and short stories will not feed a family.  You will live and die by the poverty that the pen can only bring.  She told me to pursue my passion for the arts yet remain grounded in the fact that too many artists died starving before a Picasso becomes priceless.  Keep writing she said, but make it a hobby not a career.  Now that I think of it, she made sense but it did bring the near-death of my writing passion.  I don't think I would have been recognized as a great writer anyway, a good one yes, but not good enough to be great.  I don't think I can play with words as well as Patricia Evangelista or Conrado de Quiros.  My essays are pretty much decent, but even I don't think they are special.

Yeah, yeah and you give me the litany of believe-in-yourself-believe-in-your-dreams-keep-dreaming-and-someday-you'll-achieve-it bullcrap.  There are hundreds of thousands of people told to follow their dreams no matter what other people say or no matter the odds.  Almost all of them died with eyes wide open and skin pressed deeply against their ribs.  Those who didn't die chose a day job way different from their first passions.  To think of  it, how many people try and try again and fail to produce a Michael Jordan or a Michael Phelps or a Michael Jackson? There are literally thousands upon thousands of cabaret and bar singers who at one point in their lives really thought they stand out and that they would make it.  The world is hard on artists, that is a fact, and when the truth comes crashing down it dawns on you that you have been strumming that guitar for twenty years now, writing that novel for fifteen years now, or playing in some random rundown theater for ten years now and still the break that you were looking for is far from your grasp.  How long will it be before you realize that nobody listens to your songs anymore, or your graffiti which drew oohs and ahhs from way before remain that?  How long before reality breaks you down and poverty transforms your creativity to despair?  At one point in their lives, artists of pen or brush or song will struggle. 
Struggle and the triumph over it is what defines each artist and will engrave his legacy.

Ah, but how wonderful it was when I was an impassioned writer.  How I miss the magic that my heartbreak brought or my desire to save the world can do.  Pain is what drove me.  Pain of an unrequited love.  Pain of adolescent rebellion.  The passion that rages in your chest and flows in your blood to the ink of your pen.  Life seemed more... vivid then.  And now I just chill.  As I stare into this entry that wasn't supposed to be an entry, I wonder what drives me now.  Now that the pain is gone and the heartbreak has healed a long time time.  Where do I get that fire? Where do I get the itch to pick up a pen and write down a story or a poem so spirited my blood will roll again into my canvass of letters.  The moment is now.  The time is now. But like all has-beens do, I'd say nay and put off the obra maestra till tomorrow or until probably forgotten. 

GRANDMA

My former boss sent me a text last Friday.  She rarely texts me other than news about Grandma.  I smile when I remembered her.  She was my former patient at my old facility.  Her name is Marion Rapalee.  She was born January 20 or 21st (not sure) 1919.  She is ninety-three years old but claims to be two hundred.  It doesn't matter how many times other patients tell her that she can't be two hundred it's impossible.  She strongly believes that she is and that is that.

I never knew anybody who didn't like Grandma.  She was sweet and kind and always looks at other people with empathy.  I remember one day we were in the gym exercising, and another patient rolled in in a wheelchair.  Grandma asked her what happened to her.  She told Grandma that she missed the chair when she sat, slammed her butt on the floor and broke a hip.  Grandma came close and gave her a hug and consoled her: Oh you poor thing.  Later, we found out why she was so compassionate about other patients.  Grandma Rapalee was a nurse her whole life.  She told us (over and over) again that she had been a nurse for sixty-three years (this too cannot be confirmed but we all know she had been one for a long time.) 

Grandma was also a wonderful singer.  She told us she sang in the choir and in church.  Everybody would amusingly hear her singing her heart out along corridors or in her room.  When you don't hear her sing, it means she's sick.  She belts out Somewhere Over the Rainbow again and again.  Or Someday my Prince Will Come.  She also likes Elvis' Blue Suede Shoes, Love Me Tender and Can't Help Falling in Love.  But because of her dementia, she makes up her own lyrics to the songs, admit that she's making them up and we'd all laugh about it.  Something like: Someday, my prince will come; Someday, I'll find my love; And the moment that he comes to me; I will hang him up the old apple tree...

I remember the first few times we met.  We were in the parallel bars and I asked her if she remembered who I was.  She told me no.  I told her: Well, Ms Rapalee. I'm the mayor of this town. Her eyes widened and looking all surprised she asked me: You're not.  I said: I am, really.  She replied: Wow! Then suddenly looking disinterested said: If you say so! Then, we both cracked up.
What I didn't realize is that she truly identified me as the mayor.  And she would talk to the nurses and other residents about meeting the mayor.  In the dining room, she would loudly introduce me to her table-mates as the mayor of the town much to my chagrin.  The name stuck though and some of them started calling me Mayor in jest.  I started calling her Grandma when she told me she will adopt me.  Apparently, she told a lot of people she will adopt them according to her family.  I've seen her daughter and granddaughter visit her several times a week.  Both of them were attractive older women who are about as sweet as Grandma.  One day while she was doing her therapy at the gym, they came to visit her.  Grandma insisted that they take her home immediately without delay.  They told her: But, Grandma, you're too old to go home. Nobody will stay at home with you all day. We work.  You're two hundred years old remember?  To which Grandma replied: Two hundred's not old.  It's not like I'm two-fifty!  I burst out laughing again right then and there.

Three weeks ago, the same former boss texted me to tell me that Grandma is back on caseload.  She had bowel obstruction and they picked her back up after hospital discharge.  Grandma remembered the Mayor and the therapist (my boss) who's seeing her as my step sister.  I told her to tell Grandma that I miss her a lot and she better get well soon.

Last Friday, she sent me a text again.  She told me Grandma was on a decline since last week and they finally sent her out to the hospital in the morning.  She told me, Grandma passed at the hospital.  It broke my heart.  Funny, how that same morning, I heard Somewhere Over the Rainbow being played on the piano by one of the residents.  I thought of Grandma then, just as I am thinking of her now.  It is amazing how God plans our lives.  There are some people who stay in your life for a long time and not leave a mark at all.  And yet there are some who pass for the briefest of moments and leave an indelible print in your being.

I will miss Grandma so very much.  And I thank God for giving me her for even just a short time.  I know who I want to be as a healer.  I know who I want to be when I grow old and gray.  She must be making all the angels laugh up there and making heaven an even happier place than it's ever been.  So I bid her adieu, until we meet again, somewhere over the rainbow.