434
Letters to the Editor / JAMDA 16 (2015) 433e437
9. van Harten PN, Matroos GE, Hoek HW, et al. The prevalence of tardive dystonia, tardive dyskinesia, Parkinsonism and akathisia. The Curacao Extra pyramidal syndromes Study. Schizophr Res 1996;19:195e203. 10. Nobutomo Y, Toshiya I. Dystonia secondary to use of antipsychotics agents. In: DystoniaeThe Many Facets. Croatia: InTech; 2012. p. 55e62. 11. Vasilyeva I, Biscontri RG, Enns MW, et al. Movement disorders in elderly users of risperidone and first generation antipsychotic agents: A Canadian population-based study. PLoS One 2013;8:e64217. 12. Tachikawa H, Suzuki T, Kawanishi Y, et al. Tardive dystonia provoked by concomitantly administered risperidone. Psychiatry Clin Neurosci 2000;54: 503e505. 13. Duggal HS, Mendhekar DN. Risperidone-induced tardive pharyngeal dystonia presenting with persistent dysphagia: A case report. Prim Care Companion J Clin Psychiatry 2008;10:161e162. 14. Vercueil L, Foucher J. Risperidone-induced tardive dystonia and psychosis. Lancet 1999;353:981. 15. Fdhil H, Krebs MO, Bayle F, et al. Risperidone-induced tardive dystonia: A case of torticollis. Encephale 1998;24:581e583. 16. Fahn S, The Tardive syndromes. Phenomenology, concepts on pathophysiology and treatment. A comprehensive review of movement disorders for the clinical practitioner. Clin Neuropharmacol 2003;20:181e265. 17. Tarsy D, Kaufman D, Sethi KD, et al. An open label study of botulinum toxin A for treatment of tardive dystonia. Clin Neuropharmacol 1997;20:90e93. 18. Trottenburg L, Paul G. Pallidal and thalamic neurostimulation in severe tardive dystonia. J Neurol Neurosurg Psychiatry 2001;70:557e559.
Rebakah Sumalini Abel Boenerjous, MD William Zirker, MD, MPH Temple University Hospital Philadelphia, PA Crozer Chester Medical Center Upland, PA Suhas Masilamani, AB, MS, DNB Srikara Hospital Hyderabad, India http://dx.doi.org/10.1016/j.jamda.2015.01.090
Hospice in the Nursing Homes: Perspectives of a Medical Director To the Editor: For more than 3 decades I have practiced and taught geriatric medicine, mostly in the nursing home setting. For those not familiar with nursing home care in the early 1980s, it was almost entirely long-term palliative care, as rehab was carried out in the hospital setting. There were no do-not-resuscitate regulations, as it seemed clearly futile to try to resuscitate nursing home patients. When a patient appeared to failing, usually from multiple comorbid cognitive and physical issues, measures were put in place to ensure a comfortable and dignified death. Experienced physicians were a key factor in recognizing when patients would obtain little benefit from hospitalization and artfully communicated this to patients and their families. Hospice was in its infancy in the United States, having started in Great Britain a few decades earlier. Congress enacted legislation in 1982 for hospice benefits under Medicare A. Hospice care started for the terminal cancer patient in the United States, with the bulk of patients being treated in the home care setting. Hospice services, originally entirely from nonprofit entities, was invaluable in helping the dying patient remain at home, with inpatient units used for a small percentage who could not be cared for by family members. In the 1990s, some hospice patients started to enter nursing homes, being discharged from inpatient hospice
units, unable to return to their home environment. A higher percentage of patients also carried noncancer terminal diagnoses. The entry of hospice into the nursing home seemed to be extraneous to me at the outset. Although the concept of knowledgeable and compassionate care at the end of life was laudable, it wasn’t clear exactly what the role of the hospice staff was. After all, an RN is on duty 24 hours per day with support from LPNs and nurses’ aides. Unroe et al1 and her associates found approximately one-third of nursing home staff noted coordination problems with hospice. My personal experience would suggest that percentage is much higher among nurses. I found it interesting that both Unroe et al1 and Swagerty2 concluded that these data represented an opportunity for better coordination between hospice and nursing home staff. I would argue for the opposite view, that hospice, through a formal arrangement with an outside vendor, and the nursing home is inherently a poor match. Although there are several factors in play creating this mismatch, 3 are most important: (1) Basic philosophy and skill set of long-term care facilities, (2) evolution of the role of the hospice nurse over time, and (3) cost. The long-term care section of the nursing home, despite limitations, has been the model for palliative care. Physicians, nurses, nurses’ aides, and social workers have been practicing expert and compassionate care for many decades without using the word “hospice.” I would take issue with Dr Swagerty2 that this is difficult and expensive, as it is neither of those. What is simply needed is the proper attentiveness by all staff members. Typically, nurses and nurses’ aides notify the physician of a resident in declining status. After assessment and in consultation with the patient and family, the physician will put in place a variety of palliative orders. Discussions often take place among staff so comfort is maximized. Many dozens of times I have instructed nurses to stop worrying about hypotension and poor intake and be concerned only with the comfort of the patient. After seeing more than 200 state and federal nursing home surveys, I have never noted a nursing home cited for weight loss or other “declining status” issues when clear documentation was in place. On those occasions in which hospice was formally consulted, I have not noticed any improvement in the comfort in which a patient passed away; having now signed more than 1000 death certificates of former nursing home residents. Over the years, the role of the hospice nurse has morphed from being a nurse to being a prescriber. Thirty years ago, a hospice nurse would often say that a given patient seems to have more pain or more anxiety. Nowadays, I receive written medication “recommendations” for a variety of symptoms having nothing to do with pain. It is very unclear to me just when hospice nurses became unofficial nurse practitioners. Although hospice nurses have excellent training and expertise in recognizing pain, they have little formal training in the medication management of the patient with dementia. When hospice is formally consulted for a patient with a primary diagnosis of dementia, all rational pharmacologic management is thrown out. Geriatric physicians are at their best when each medication is carefully thought out as to the benefits and risks of its use. I rarely see hospice nurses concerned or knowledgeable about the side effects of medications they are “suggesting.” I also cannot honestly recall a single instance when a hospice nurse noted a toxic side effect and recommended the offensive medication be discontinued. Some recent cases I have had illustrate this: An elderly woman with dementia is put on sublingual lorazepam as-needed for new-onset seizures. She was getting toxic doses of a selective serotonin reuptake inhibitor, and the seizures stopped once the dose was lowered. A woman in her 90s was titrated up to 9 mg a day of Haldol over a 2-week period due to agitation. When I saw her, the hospice
Letters to the Editor / JAMDA 16 (2015) 433e437
nurse was unaware that the patient was having severe dystonia. A dying patient was thought to be more agitated; he had dilated pupils, hot skin, and severe delirium. The patient became far more comfortable after the anticholinergic drugs were discontinued. An elderly man stopped choking and became more lucid after his lorazepam was titrated off. I realize that for many busy physicians, having hospice take care of a nursing home patient may be expedient, but it runs the medical and legal risk of rubber stamping poor and unlicensed prescribing. Finally, and perhaps most importantly, is the cost involved. Unroe et al1 and Swagerty2 appear to be in favor of more funding and more involvement of hospice in the nursing home. The minimum daily rate that Medicare pays hospice is $159 per day, up to approximately $900 per day. As geriatric physicians, I believe it is crucial that we be cost conscious. The notion that, “Medicare pays,” is simply irresponsible. How many patients and their families would pay $159 to $900 per day for hospice services in the nursing home? Hospice is now a multibillion-dollar industry, with aggressive marketing in the nursing home setting. Whoriskey and Keating3 detailed the unscrupulous practices of many hospice companies in a Washington Post series entitled the “Business of Dying.” This has been and continues to be an area ripe with fraud and abuse. Personally, there are 4 separate hospice companies in my area that push their products far more aggressively than any pharmaceutical rep ever did. In an era in which Medicare funding to nursing homes is decreasing, hospice funding is increasing. Wouldn’t the funds going to nursing home hospice care be better spent going directly to nursing homes? Despite some negative attitudes among the public and the press about long-term care, many of us on the front line take pride in caring for the frailest segment of our society. The nursing home should and can be the center of excellence and a role model for palliative and hospice care. References 1. Unroe KT, Cagle JG, Dennis ME, et al. Hospice in the nursing home: Perspective of frontline nursing home staff. J Am Med Dir Assoc 2014;15:881e884. 2. Swagerty D. Integrating palliative care in the nursing home: An interprofessional opportunity. J Am Med Dir Assoc 2014;15:863e865. 3. Whoriskey P, Keating D. Hospice firms draining billions from Medicare. Washington Post. December 26, 2013. Available at: www.washingtonpost.com/ 4ff75bbe-68c9-11e3.
Matthew Raider, MD Geriatric Medicine, Middletown, CT http://dx.doi.org/10.1016/j.jamda.2015.01.091
Response To Dr Raider’s JAMDA Letter to the Editor To the Editor: Excellent palliative care can be provided with resources within the nursing home setting; however, we disagree with Dr Raider’s characterization that this is the current default standard, and that hospice providers are somehow redundant or undermining quality
435
nursing home care. In fact, one study of family members of deceased nursing home residents found that physicians failed to recognize and treat symptoms near the end of life, missed opportunities for advance care planning, and were not present enough in the nursing home to provide needed care.1,2 Although Dr Raider’s experience is interesting, evidence shows that hospice involvement has been generally beneficial for nursing home residents and their families. When hospice is involved, nursing home residents receive better pain and symptom management, unnecessary transfers are reduced, and families report greater levels of satisfaction with care.1,3e6 Additionally, based on our own findings, front-line nursing home staff members were generally very positive about hospice involvement in resident care. Importantly, nearly 80% of respondents in our sample of nursing home staff reported that hospice, either always or often, provides needed care at the end of life for nursing home patients and families.7 Opportunities exist to improve on the default standard of care for nursing home residents with palliative care needs, including those near the end of life.1,2 There are now promising models that promote palliative and supportive care in nursing homes, and, thus, that both complement and extend services provided through hospice.8e10 Delivering and coordinating such high-quality palliative and supportive care, as well as well-coordinated nursing home/ hospice care, is the responsibility of all nursing home providers. Considering the well-documented benefits of hospice care in nursing homes, hospice should not be summarily dismissed as an option for end-of-life care. In our opinion, nursing home residents who are eligible to receive hospice should be informed about the availability of hospice services, and enrolled in hospice if they so desire. Doing otherwise limits patient choice and sidesteps an evidence-based model for end-of-life care provision. References 1. Wetle T, Shield R, Teno J, et al. Family perspectives on end-of-life care experiences in nursing homes. Gerontologist 2005;45:642e650. 2. Shield R, Wetle T, Teno J, et al. Physicians “missing in action”: Family perspectives on physician and staffing problems in end-of-life care in the nursing home. J Am Geriatr Soc 2005;14:1651e1657. 3. Kiely DK, Givens JL, Shaffer ML, et al. Hospice use and outcomes in nursing home residents with advanced dementia. J Am Geriatr Soc 2010;58: 2284e2291. 4. Miller SC, Gozalo P, Mor V. Hospice enrollment and hospitalization of dying nursing home patients. Am J Med 2001;111:38e44. 5. Kuhn DR, Forest JM. Palliative care for advanced dementia: A pilot project in 2 nursing homes. Am J Alzheimers Dis Other Demen 2012;27:33e40. 6. Miller SC, Mor V, Wu N, et al. Does receipt of hospice care in nursing homes improve the management of pain at the end-of-life? J Am Geriatr Soc 2002;50: 507e515. 7. Unroe K, Cagle J, Dennis ME, et al. Hospice in the nursing home: Perspectives of front line nursing home staff. J Am Med Dir Assoc 2014;15:881e884. 8. Center to Advance Palliative Care (CAPC). Improving Palliative Care in Nursing Homes. New York, NY: Funded by the Fan Fox and Leslie R. Samuels Foundation; 2008. 9. Comart J, Mahler A, Schreiber R, et al. Palliative care for long-term care residents: Effect on clinical outcomes. Gerontologist 2013;53:874e880. 10. Unroe K, Nazir A, Holtz L, et al. The optimizing patient transfers, impacting medical quality, and improving symptoms: Transforming institutional care approach: Preliminary data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project. J Am Geriatr Soc 2015;63:165e169.
Kathleen T. Unroe, MD, MHA Indiana University Center for Aging Research Regenstrief Institute Inc Indiana University School of Medicine Indianapolis, IN John G. Cagle, PhD University of Maryland-Baltimore School of Social Work Baltimore, MD
Letters to the Editor / JAMDA 16 (2015) 433e437
9. van Harten PN, Matroos GE, Hoek HW, et al. The prevalence of tardive dystonia, tardive dyskinesia, Parkinsonism and akathisia. The Curacao Extra pyramidal syndromes Study. Schizophr Res 1996;19:195e203. 10. Nobutomo Y, Toshiya I. Dystonia secondary to use of antipsychotics agents. In: DystoniaeThe Many Facets. Croatia: InTech; 2012. p. 55e62. 11. Vasilyeva I, Biscontri RG, Enns MW, et al. Movement disorders in elderly users of risperidone and first generation antipsychotic agents: A Canadian population-based study. PLoS One 2013;8:e64217. 12. Tachikawa H, Suzuki T, Kawanishi Y, et al. Tardive dystonia provoked by concomitantly administered risperidone. Psychiatry Clin Neurosci 2000;54: 503e505. 13. Duggal HS, Mendhekar DN. Risperidone-induced tardive pharyngeal dystonia presenting with persistent dysphagia: A case report. Prim Care Companion J Clin Psychiatry 2008;10:161e162. 14. Vercueil L, Foucher J. Risperidone-induced tardive dystonia and psychosis. Lancet 1999;353:981. 15. Fdhil H, Krebs MO, Bayle F, et al. Risperidone-induced tardive dystonia: A case of torticollis. Encephale 1998;24:581e583. 16. Fahn S, The Tardive syndromes. Phenomenology, concepts on pathophysiology and treatment. A comprehensive review of movement disorders for the clinical practitioner. Clin Neuropharmacol 2003;20:181e265. 17. Tarsy D, Kaufman D, Sethi KD, et al. An open label study of botulinum toxin A for treatment of tardive dystonia. Clin Neuropharmacol 1997;20:90e93. 18. Trottenburg L, Paul G. Pallidal and thalamic neurostimulation in severe tardive dystonia. J Neurol Neurosurg Psychiatry 2001;70:557e559.
Rebakah Sumalini Abel Boenerjous, MD William Zirker, MD, MPH Temple University Hospital Philadelphia, PA Crozer Chester Medical Center Upland, PA Suhas Masilamani, AB, MS, DNB Srikara Hospital Hyderabad, India http://dx.doi.org/10.1016/j.jamda.2015.01.090
Hospice in the Nursing Homes: Perspectives of a Medical Director To the Editor: For more than 3 decades I have practiced and taught geriatric medicine, mostly in the nursing home setting. For those not familiar with nursing home care in the early 1980s, it was almost entirely long-term palliative care, as rehab was carried out in the hospital setting. There were no do-not-resuscitate regulations, as it seemed clearly futile to try to resuscitate nursing home patients. When a patient appeared to failing, usually from multiple comorbid cognitive and physical issues, measures were put in place to ensure a comfortable and dignified death. Experienced physicians were a key factor in recognizing when patients would obtain little benefit from hospitalization and artfully communicated this to patients and their families. Hospice was in its infancy in the United States, having started in Great Britain a few decades earlier. Congress enacted legislation in 1982 for hospice benefits under Medicare A. Hospice care started for the terminal cancer patient in the United States, with the bulk of patients being treated in the home care setting. Hospice services, originally entirely from nonprofit entities, was invaluable in helping the dying patient remain at home, with inpatient units used for a small percentage who could not be cared for by family members. In the 1990s, some hospice patients started to enter nursing homes, being discharged from inpatient hospice
units, unable to return to their home environment. A higher percentage of patients also carried noncancer terminal diagnoses. The entry of hospice into the nursing home seemed to be extraneous to me at the outset. Although the concept of knowledgeable and compassionate care at the end of life was laudable, it wasn’t clear exactly what the role of the hospice staff was. After all, an RN is on duty 24 hours per day with support from LPNs and nurses’ aides. Unroe et al1 and her associates found approximately one-third of nursing home staff noted coordination problems with hospice. My personal experience would suggest that percentage is much higher among nurses. I found it interesting that both Unroe et al1 and Swagerty2 concluded that these data represented an opportunity for better coordination between hospice and nursing home staff. I would argue for the opposite view, that hospice, through a formal arrangement with an outside vendor, and the nursing home is inherently a poor match. Although there are several factors in play creating this mismatch, 3 are most important: (1) Basic philosophy and skill set of long-term care facilities, (2) evolution of the role of the hospice nurse over time, and (3) cost. The long-term care section of the nursing home, despite limitations, has been the model for palliative care. Physicians, nurses, nurses’ aides, and social workers have been practicing expert and compassionate care for many decades without using the word “hospice.” I would take issue with Dr Swagerty2 that this is difficult and expensive, as it is neither of those. What is simply needed is the proper attentiveness by all staff members. Typically, nurses and nurses’ aides notify the physician of a resident in declining status. After assessment and in consultation with the patient and family, the physician will put in place a variety of palliative orders. Discussions often take place among staff so comfort is maximized. Many dozens of times I have instructed nurses to stop worrying about hypotension and poor intake and be concerned only with the comfort of the patient. After seeing more than 200 state and federal nursing home surveys, I have never noted a nursing home cited for weight loss or other “declining status” issues when clear documentation was in place. On those occasions in which hospice was formally consulted, I have not noticed any improvement in the comfort in which a patient passed away; having now signed more than 1000 death certificates of former nursing home residents. Over the years, the role of the hospice nurse has morphed from being a nurse to being a prescriber. Thirty years ago, a hospice nurse would often say that a given patient seems to have more pain or more anxiety. Nowadays, I receive written medication “recommendations” for a variety of symptoms having nothing to do with pain. It is very unclear to me just when hospice nurses became unofficial nurse practitioners. Although hospice nurses have excellent training and expertise in recognizing pain, they have little formal training in the medication management of the patient with dementia. When hospice is formally consulted for a patient with a primary diagnosis of dementia, all rational pharmacologic management is thrown out. Geriatric physicians are at their best when each medication is carefully thought out as to the benefits and risks of its use. I rarely see hospice nurses concerned or knowledgeable about the side effects of medications they are “suggesting.” I also cannot honestly recall a single instance when a hospice nurse noted a toxic side effect and recommended the offensive medication be discontinued. Some recent cases I have had illustrate this: An elderly woman with dementia is put on sublingual lorazepam as-needed for new-onset seizures. She was getting toxic doses of a selective serotonin reuptake inhibitor, and the seizures stopped once the dose was lowered. A woman in her 90s was titrated up to 9 mg a day of Haldol over a 2-week period due to agitation. When I saw her, the hospice
Letters to the Editor / JAMDA 16 (2015) 433e437
nurse was unaware that the patient was having severe dystonia. A dying patient was thought to be more agitated; he had dilated pupils, hot skin, and severe delirium. The patient became far more comfortable after the anticholinergic drugs were discontinued. An elderly man stopped choking and became more lucid after his lorazepam was titrated off. I realize that for many busy physicians, having hospice take care of a nursing home patient may be expedient, but it runs the medical and legal risk of rubber stamping poor and unlicensed prescribing. Finally, and perhaps most importantly, is the cost involved. Unroe et al1 and Swagerty2 appear to be in favor of more funding and more involvement of hospice in the nursing home. The minimum daily rate that Medicare pays hospice is $159 per day, up to approximately $900 per day. As geriatric physicians, I believe it is crucial that we be cost conscious. The notion that, “Medicare pays,” is simply irresponsible. How many patients and their families would pay $159 to $900 per day for hospice services in the nursing home? Hospice is now a multibillion-dollar industry, with aggressive marketing in the nursing home setting. Whoriskey and Keating3 detailed the unscrupulous practices of many hospice companies in a Washington Post series entitled the “Business of Dying.” This has been and continues to be an area ripe with fraud and abuse. Personally, there are 4 separate hospice companies in my area that push their products far more aggressively than any pharmaceutical rep ever did. In an era in which Medicare funding to nursing homes is decreasing, hospice funding is increasing. Wouldn’t the funds going to nursing home hospice care be better spent going directly to nursing homes? Despite some negative attitudes among the public and the press about long-term care, many of us on the front line take pride in caring for the frailest segment of our society. The nursing home should and can be the center of excellence and a role model for palliative and hospice care. References 1. Unroe KT, Cagle JG, Dennis ME, et al. Hospice in the nursing home: Perspective of frontline nursing home staff. J Am Med Dir Assoc 2014;15:881e884. 2. Swagerty D. Integrating palliative care in the nursing home: An interprofessional opportunity. J Am Med Dir Assoc 2014;15:863e865. 3. Whoriskey P, Keating D. Hospice firms draining billions from Medicare. Washington Post. December 26, 2013. Available at: www.washingtonpost.com/ 4ff75bbe-68c9-11e3.
Matthew Raider, MD Geriatric Medicine, Middletown, CT http://dx.doi.org/10.1016/j.jamda.2015.01.091
Response To Dr Raider’s JAMDA Letter to the Editor To the Editor: Excellent palliative care can be provided with resources within the nursing home setting; however, we disagree with Dr Raider’s characterization that this is the current default standard, and that hospice providers are somehow redundant or undermining quality
435
nursing home care. In fact, one study of family members of deceased nursing home residents found that physicians failed to recognize and treat symptoms near the end of life, missed opportunities for advance care planning, and were not present enough in the nursing home to provide needed care.1,2 Although Dr Raider’s experience is interesting, evidence shows that hospice involvement has been generally beneficial for nursing home residents and their families. When hospice is involved, nursing home residents receive better pain and symptom management, unnecessary transfers are reduced, and families report greater levels of satisfaction with care.1,3e6 Additionally, based on our own findings, front-line nursing home staff members were generally very positive about hospice involvement in resident care. Importantly, nearly 80% of respondents in our sample of nursing home staff reported that hospice, either always or often, provides needed care at the end of life for nursing home patients and families.7 Opportunities exist to improve on the default standard of care for nursing home residents with palliative care needs, including those near the end of life.1,2 There are now promising models that promote palliative and supportive care in nursing homes, and, thus, that both complement and extend services provided through hospice.8e10 Delivering and coordinating such high-quality palliative and supportive care, as well as well-coordinated nursing home/ hospice care, is the responsibility of all nursing home providers. Considering the well-documented benefits of hospice care in nursing homes, hospice should not be summarily dismissed as an option for end-of-life care. In our opinion, nursing home residents who are eligible to receive hospice should be informed about the availability of hospice services, and enrolled in hospice if they so desire. Doing otherwise limits patient choice and sidesteps an evidence-based model for end-of-life care provision. References 1. Wetle T, Shield R, Teno J, et al. Family perspectives on end-of-life care experiences in nursing homes. Gerontologist 2005;45:642e650. 2. Shield R, Wetle T, Teno J, et al. Physicians “missing in action”: Family perspectives on physician and staffing problems in end-of-life care in the nursing home. J Am Geriatr Soc 2005;14:1651e1657. 3. Kiely DK, Givens JL, Shaffer ML, et al. Hospice use and outcomes in nursing home residents with advanced dementia. J Am Geriatr Soc 2010;58: 2284e2291. 4. Miller SC, Gozalo P, Mor V. Hospice enrollment and hospitalization of dying nursing home patients. Am J Med 2001;111:38e44. 5. Kuhn DR, Forest JM. Palliative care for advanced dementia: A pilot project in 2 nursing homes. Am J Alzheimers Dis Other Demen 2012;27:33e40. 6. Miller SC, Mor V, Wu N, et al. Does receipt of hospice care in nursing homes improve the management of pain at the end-of-life? J Am Geriatr Soc 2002;50: 507e515. 7. Unroe K, Cagle J, Dennis ME, et al. Hospice in the nursing home: Perspectives of front line nursing home staff. J Am Med Dir Assoc 2014;15:881e884. 8. Center to Advance Palliative Care (CAPC). Improving Palliative Care in Nursing Homes. New York, NY: Funded by the Fan Fox and Leslie R. Samuels Foundation; 2008. 9. Comart J, Mahler A, Schreiber R, et al. Palliative care for long-term care residents: Effect on clinical outcomes. Gerontologist 2013;53:874e880. 10. Unroe K, Nazir A, Holtz L, et al. The optimizing patient transfers, impacting medical quality, and improving symptoms: Transforming institutional care approach: Preliminary data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project. J Am Geriatr Soc 2015;63:165e169.
Kathleen T. Unroe, MD, MHA Indiana University Center for Aging Research Regenstrief Institute Inc Indiana University School of Medicine Indianapolis, IN John G. Cagle, PhD University of Maryland-Baltimore School of Social Work Baltimore, MD
