Becoming a Nurse – Brief Requirements List

For all the prospective medical caregivers, here is a brief list of the basic requirements needed to obtain a nursing degree or certification to get you started. This outline is meant to serve as an overview of what kinds of requirements may be needed to become a health practitioner. Please note that while these requirements listed here are specific to nursing, many are in fact national level exams and accredited courses or degrees.

General Requirements

High school diploma

Associate Degree for Registered Nurses

This is generally a 2 year degree that is considered the “entry level” for the industry. Generally the most schools that award this degree teach you fundamental anatomy, physiology, biology, and foundational nursing skills. In addition to that you will study pharmacology in your first year. Students spend most of their second year getting invaluable experience in clinical actual clinical settings by participating in nursing rotations with university and city hospitals.

Pass the NCLEX-RN exam (National Council Licensure Examination for Registered Nurses Exam)

The test will measures the nursing student’s understanding of how to administer quality health care, and the application of social and nursing sciences in a hospital setting or patient care environment.
Pass the TMJE exam (Texas Medical Jurisprudence Examination for Registered Nurses)

The test will measure the student’s understanding of the various legal concerns that are associated with being a registered nurse. The Texas Board of Nursing will not issue a permanent RN license until the student passes this important exam. This exam is provided to the nursing student when he or she applies for licensure.

Finally submit your completed application for licensing to the Texas Board of Nursing.

Students must then submit nursing school transcripts and the exam results from the NCLEX-RN and the TMJE exam.

While this list is representative for those wishing to become a nurse, it is indicative of the basic requirements for Texas and the United States as a whole. This list is intended to provide an outline only and serious nursing school students and those wishing to pursue this and related occupations should obtain a much more detailed list of requirements from the prospective nursing schools’ website or the official state medical examination website of the state they are interested in being licensed under.

It is also worth noting that requirements for nursing schools as well as the availability of funding can change on a quarterly basis. You are always advised to check with your state education board for latest requirements.

Child Development and Children of Trauma: Transitioning From Home to School

Child Development Ages Six to 12 Years

Those early school years, when children ages 6 to 12 are transitioning from a caregiving environment to an educational environment, are challenging from a child development standpoint. Children are learning academic skills, socialization (how to get along with others), structure and boundaries (how to follow rules) and, perhaps for the first time, are influenced by adults other than their own parents.

Primary or elementary school is a time to find out about how people are different in so many ways: race, ethnicity, gender, physical abilities, culture, upbringing, values, etc. A child’s self-esteem develops based on academic and social successes or failures. Adult expectations for responsible behaviors increase as children are expected to need less adult interactions to maintain established routines at home and school.

The adult world looks upon this transition from home to school as a natural part of what it takes to grow into a competent, capable, responsible adult. It is a time to learn what to do and how to do it. Most children make the transition easily, get into alignment with learning and do what is expected of them with the usual glitches or hiccups along the way. This is normal in the world of child development.

Children of Trauma React Differently

For other children, those who have undergone some sort of trauma in their lives, the transition is a nightmare not only for them but also for their caregivers and parents. Trauma for these children wasn’t a single-incident trauma; they had experienced multiple traumas that had been ongoing their entire lives. They come from families of intergenerational abuse, alcoholism, drug addiction, neglect, physical and sexual abuse, frequent moves, absent fathers, mothers who were depressed or had to work two or three jobs, poverty, and emotionally-absent caregivers. Some children eat only when they are in school. On weekends and in the summer they may get to eat once a day.

This was the population of children I worked with in a small east Texas rural community in a drop- out prevention program. Beginning with pre-K and ending in high school, the children I worked with taught me what I knew, what I didn’t, and what I needed to learn.

I was surprised at the intense behavioral issues of the children who were referred to me in pre-K to fifth grade. For those of us who love to learn and read, it is difficult at first to understand children who refuse to read or do their work. Compounding that are those children who are aggressive, defiant and hostile to teachers. “I would have never thought of doing any of that when I was growing up,” is what I said to myself and what you’re probably thinking right now.

As I got to know these children, heard their stories and listened to their parents, I learned it wasn’t that parents didn’t love their children. They had been traumatized as well and did not know how to give their children what they never got. This kept them from being able to meet basic attachment and emotional needs. If that foundation has not been met minimally, a child has difficulties with social and emotional issues in groups, which shuts down their ability to learn.

Over time, I came to learn more about what these children have been going through for years at home. It’s difficult to view life from their perspective and relate to the number of stressors they experience every day at home and at school, yet that is exactly what we must do to help them succeed.

Trauma Reactive Behaviors in School-Age Children

The following is a list of trauma reactive behaviors you may observe in early school-age children:

Regressive behaviors: clinging, crying, baby talk
Competitive and jealousy with younger siblings or peers
Hyperactive or always on guard; can’t sit still
Anxiously talking
A child who has been compliant may become irritable, aggressive or oppositional
Uncharacteristic fears of people, place, objects
Drops in school performance
Staying off task, withdrawn, shut down
Day dreaming, Spacey eyes, Pupils dilated
Sexual acting out behaviors with siblings, peers, or in play
Difficulty concentrating or paying attention
Appearing confused
Uncoordinated and clumsy
Acting emotionally younger than their age.

Children who have undergone trauma feel like no one understands them, that they are not loved and that they are failures. Imagine day in and day out going somewhere that only reflects how much you have failed, all that you do wrong, and the vast difference between you and your peers. You don’t fit in.

That is what these children feel. How could they not?

Acute Care in the Law Enforcement Community

I remember It well. It was July, 1986. A patrolling county sheriff squad car drove by my house while I was mowing my lawn. I asked myself: With all the training I have had in counseling, would there be a way to serve my community? The next day I mentioned this to a police officer who was then a student of mine at Bethel Theological Seminary where for 21 years I have taught pastoral care. On the following morning, a St. Paul Police Department lieutenant recruited me to serve as a volunteer police chaplain. I have been doing it ever since. I have done dozens of death notifications, attended to families where fatal accidents, homicide, suicide, SIDS, natural death, or other emotional trauma has occurred. At this writing, in the last month and a half I have attended five deaths. It almost goes without saying that even on my own campus, I am asked periodically to intervene in a crisis situation. Examples would be suicidal students or spouses, domestic disputes, psychotic breaks, or deaths.

*A Recent Intervention*

Recently, I was asked by a local police department to attend to the family and to the child care personnel where a SIDS death occurred. Together with the police officer, I met the mother as she arrived at the scene and informed her of the death of her three-month-old boy. She reacted very strongly, of course, ending up vomiting, hyperventilating, and needing oxygen more than once. As the father, the grandparents, and the parent’s siblings and their spouses came, the crowd of grievers grew. I called for another chaplain to deal with the child caregiver, who was also in a critical emotional state. When I discovered that the family had good church connections, I summoned their pastor, who came immediately and was immensely helpful.

The police officer and I prepared the family for viewing the body of the baby as soon as the medical examiner was through with his investigation. We encouraged holding the baby and passing him around to the various family members. The whole process (from being paged to when I left) took almost three hours. I drove away saying to myself, I can do without another SIDS death for a long time to come! I wept later that night as I held my own grown married daughter, who happened to drop in for a visit, saying I needed to do that for my own healing.

*Making Ourselves Available*

Over these past 12 years in this service, I have come to believe strongly in the Importance and necessity of Christian counselors and pastors being available for critical scenes. God reached out to us before we knew him (Rom. 5:8). In our desire to reflect that initiative-taking love, we also reach out to people in trauma and crisis.

Pastors, church workers, and lay caregiver are all expected to be present at situations of crisis. As a caregiver(but not as pastor) in my local church, I visit people in the hospital who suffer from heart attacks and strokes or face surgery. One couple from my church called me to come immediately to an ER when their son was found unconscious in a ditch suffering from an alcohol overdose. Being part of the body of Christ means we are in some sense all responsible for care giving. It’s arguable that every counseling client comes for help out of some sense of crisis. However, there are crises that crash in upon us in such a way that we become immobilized and feel helpless to manage. It is that kind of situation that I want to address.

*Officers Who Are in Crisis*

As a police chaplain, police administrators sometimes call me to attend to officers who are in crisis. For example, just days ago, an off-duty officer in his own car was hit by another car. The other driver died. The chief called me to debrief the officer. In almost 700 hours of police squad ride-along, I have talked through shooting scenes with officers, talked about their divorces, deaths of children, grief over colleagues deaths as well as the routine struggles with supervisors, raising children, and conflicts with spouses.

I was summoned in August, 1994, to attend to the families of two officers killed in the line of duty. During that 14-hour day, I led the police chief in prayer for Gods help and wisdom at the operating room door, helped spouses view the dead bodies of their loved ones, and debriefed officers who were involved in a sweep to find the shooter. There were a half dozen police chaplains involved in that terrible day full of sorrow and shock. We often saw on the police officers faces the famous thousand mile stare.

*Training for Crisis Intervention*

Pastors and counselors can obtain special training for such ministry from several sources. One well known training organization is the International Critical Incident Stress Foundation, Inc.1 Another is the International Conference of Police Chaplains.2 There is also a firefighters chaplains group.3 These organizations hold annual training seminars regionally, nationally, and in Canada. Training in crisis intervention and critical stress incident management is a regular part of their programming and certification process. It’s Imperative for anyone who gets involved in this kind of ministry to:

* develop a network and interpersonal support in order to stay emotionally and spiritually healthy;

* obtain specialized training for critical scenes and how to work with the agencies involved, e.g., police, fire, disaster teams, social workers, Red Cross, FEMA, hospitals, and to avoid transgressing the turf of the emergency workers on the scene, emergency medical services, and coordination authorities;

* shift from ones role as pastor of church so-and-so or counselor from such and such a clinic to the role of community helper, where denominational frameworks or clinical identities do not apply. When we represent the whole community, we must leave our localized identities behind;

* attend to one’s own emotional needs following such events, since there often is high emotional cost to responders on such scenes. At the 1995 International Conference of Police Chaplains annual training events, in Bismarck, North
Dakota, Police Chaplain Harold Elliott shared his own emotional pain. As a police chaplain, he worked with the morgue personnel following the Waco, Texas fire in the Koresh compound.

For months afterward, the last thing he would see just as he was drifting off to sleep each night was the burned body of a small girl, with her little shoes sitting on the gurney beside her head. Those of us who get involved in disaster and crisis must face the fact that we will pay a high emotional price for such work. Thorough debriefing and subsequent self-care are Imperative for any of us who work with disaster scenes. Here is therapist directory for your help.

What Is EVV for Home Health And Why Should You Care?

If you are in the home health business, chances are you’ve at least heard of EVV. So, what is it and why should you care?

EVV stands for Electronic Visit Verification. Essentially, it is a technology that verifies where and when a caregiver begins services for a client and when they clock-out. This provides a breadcrumb trail that provides the basis for billing.

The need arose from abuse from some providers inflating and making up timesheets. It became too easy for an unethical agency owner to pencil in false service times and then bill Medicaid / Medicare for the services. The result was that billions of dollars were being fraudulently or inappropriately collected by agencies.

Now with EVV technology, there is no disputing that a caregiver is in the location they checked in from (via GPS or registered land lines). You can imagine the millions of dollars this has already saved the healthcare system.

New Regulations Require EVV

Many states have already begun requiring electronic visit verification for registered agencies, but the EVV requirement is about to become a national mandate. In the last couple months of President Obama’s time in office, he signed the 21st Century Cures Act, which contained a lot of legislation.

Pertaining to home health, the Cures Act will require that all home health agencies and personal care services that accept government reimbursements will have to have an EVV solution in place by the end of 2019 for personal care and 2023 for home health agencies.

State Mandates Coming Your Way

Some states like Texas and South Carolina had mandated EVV long before this issue was ever a part of federal home care legislation. Most states did not even have it on the radar. Now that there is a national mandate in the near future, many states are in the process of creating EVV policies right now.

We’ll discuss some of the warnings and successes of different state EVV mandates.

Warnings of Single Vendor Systems

In Louisiana, the state mandated a single system in 2013, then a different one in 2015. They ended up cancelling both. Through that process both the state and providers wasted a tremendous amount of money, time and energy. Yet they have another mandated approach that is being implemented this year.
Connecticut is currently suffering a class-action lawsuit for its single EVV implementation from a group of some of the largest providers in the state.
Texas experienced major interruptions in care and reimbursements when its “preferred vendor” was forced to pull out of the state. Providers that were using that vendor had to migrate all of their data from one system to another and train their staff all over again on a new system.
South Carolina and Tennessee have providers that operate across state lines having to use more than one EVV vendor. This causes an operational headache for those providers. Some of them have had to hire additional staff just to manage those different EVV systems.
WHAT-IFs. What if that single vendor goes out of business? What if their systems go down for an extended period of time? What if the data quality cannot be trusted with no oversight?

In contrast, other states such as Missouri allowed providers to choose an EVV vendor that worked best for them as long as the vendor complied with Medicaid regulations. Well over 600 providers have implemented EVV in that state. We believe the risks of litigation, one company reliability and uptime, vendor business continuity and the satisfaction of stakeholders outweigh any benefits gained from having a single vendor system that does not allow competition in the marketplace. A multiple vendor solution is simpler, easier and more cost-effective for all parties involved.

Finally, there are three potential ways that a state can implement a multiple vendor approach.

Provider Choice. Providers choose their EVV of choice and ensure that all standards are met. Additionally, a common format export of data may be required by the state.
State Overseer. State overseer of EVV in an open choice model. An organization (state or private sector) with no conflicts of interest will verify and oversee the data and quality of data coming from the various EVV vendors in a single database or data warehouse, and provide data insights to the state.
Approved Vendor List. The state creates an approved vendor list. The list should not be static, but rather allows for different vendors to either be rewarded or punished for good or poor performance and design.

Providers Have a Say! Step Up

In the Cures Act legislation, the electronic visit verification mandate requires that states consult providers on a solution and that the solution is “minimally burdensome”. Let’s say that you’ve already spend the time, money and energy on creating a software solution for your company, including EVV. It works for you, and now you don’t even have to think about it.

What if all this sudden, you had to switch EVV vendors? You have to now get all of the data out of your current EVV system and migrate it over to the new EVV! What if the new mandated EVV is not reliable and breaks frequently (a common complaint from many providers in one-vendor mandated state)? Not to mention, this will cause many wasted hours of training time for your staff to learn a new system.

You are called to have a say in this matter in your state. Reach out to your associations and legislators to let them know that a provider choice solution is best for everyone involved.

Don’t Fight EVV, Embrace It

Some providers have been resistant to the idea of EVV, and like it or not, it’s coming. However, it’s not a bad thing, and it can actually make your business more profitable and efficient.

EVV allows you to automatically eliminate paper time sheets, record visits, and create billing / payroll data at the push of a button. Additionally, if an audit comes your way, you won’t have to worry about digging out stacks of paper, you can just download your data in minutes.

Most providers that use EVV find ways to save hours of admin time, cut overpayments, and find ways to increase revenue. So embrace the technology, it’s good for you.

What types of EVV Technologies Exist?

Originally, EVV started out as a landline telephony technology that recorded the time called in and out at the client’s home. That method is still widely used today. However, with the advent of smartphones, more and more visits are being verified through smartphones using GPS location. This is by far the fastest growing method. Also, computers and tablets can be used for verified visits.

Additional technologies include non-smartphone cell service triangulation, fixed-device check-ins, and now voice-bot check-ins. The non-smartphone method occurs when a caregiver calls through a non-smartphone, and then the cell carriers use the towers to locate where the caregiver is. With a fixed-device, some areas don’t have cell service or a landline, so caregivers will scan a barcode, record a number or scan an RFID card to clock-in/out.

Cellphone Triangulation
Computer or Tablet

While you may not need all of these technologies, some states are requiring multiple technologies in an EVV solution. Make sure that at the very least there is both telephony and mobile visit verification in your EVV solution

Austin Museum of Art

This is truly a museum for the casual and creative Austinite. With two locations and loads of interesting exhibits and programs, AMOA is a great cultural destination for students, adults, and even parents and caregivers of young children.

The downtown location is a sleek and modern space, while the Laguna Gloria campus, AMOA’s original home, is housed within a 1916 Italiante villa. The primary home of the AMOA Art School, Laguna Gloria is located on property once owned by Stephen F. Austin, and was the residence of the legendary Clara Driscoll. Overlooking Lake Austin, and with 12 acres of beautiful grounds and gardens, Laguna Gloria is worth a visit purely on historical merit. Both locations have permanent and changing exhibits, and both have space available for private functions.

One of the hallmarks of both AMOA locations is the informal structure and feel. No stuffy, hallowed grounds here – instead you find welcoming, easy to navigate floor plans full of surprising and interesting exhibits. You can tour at your own speed, reading the descriptions that are mounted next to each exhibit, or you can book a gallery tour, which are available with different age groups in mind. The compact size of the exhibit space adds to the experience – the visitor can spend time with each exhibit, getting more from the experience than one where you rush through to make sure you see it all. The exhibits are right out there – something to keep in mind when you bring kids – there are no barriers between fast little critters and the actual exhibit.

Still, the AMOA makes a point to be accessible and interesting to children as well. In addition to offering a number of free events for families, the museum has a permanent FamilyLab. The FamilyLab is a fantastic experience for kids of all ages. It is a hands-on, interactive place to make art with creative and colorful items supplied by the museum. They also have children’s books on hand, along with bean bag chairs, in case your little one just needs a cuddle. The mirror tunnel is endlessly fascinating, and all activities in the FamilyLab are offered at no additional cost to museum admission. The second Saturday of every month AMOA offers a reduced admission for families, with art instructors leading families in creating art projects to take home.

AMOA offers art classes for children and adults, with a limited number of scholarships available. Class themes include ArtPlay, ArtABCs, Life Drawing, Watercolor, Children’s Book Illustration, and many, many more. They have for the Art School. They offer periodical education programs for teachers, docents, adults, children, and groups. They offer a myriad of interesting events, sometimes pairing visual arts with music, both for their valued members and for the public. Events include their annual fundraisers, the Art Ball in June, and their fantastically popular international food and wine tasting event, La Dolce Vita. Their museum store offers cups, shirts and other items with their distinctive logo, as well as art-inspired gifts.

How to Buy a Hearing Aid

Behind-the-ear hearing aids, in-the-ear hearing aids, completely in the canal hearing aids, binaural hearing aids…and the list goes on. With so many types and hundreds of brands to choose from, what is a senior to do? First and foremost, don’t go it alone. Too often, seniors are wooed by a catchy ad or a pushy salesman and wind up with an expensive hearing aid that they shove in a drawer and never use. Work with a qualified audiologist who can conduct a thorough hearing evaluation, determine the type and degree of hearing loss and recommend the appropriate hearing aid, says Dr. Phillip L. Wilson, Au.D., Head of Audiology at Callier Center for Communication Disorders, University of Texas at Dallas.

The first thing the audiologist will do is to perform some basic hearing tests, including:

Pure tone air conduction audiometry. Patients listen to a range of beeps and whistles (called pure tones) and indicate when they can hear them, by pressing a button or raising their hand. The softest sounds they can hear (hearing thresholds) are then marked on a graph called an audiogram.

Pure tone bone conduction audiometry. This test helps determine where in the ear the hearing problem lies. If in the middle ear, the hearing loss can usually be treated medically. But inner ear hearing loss means the sensory cells are not working properly, and that problem is permanent.

Speech audiometry. Patients are asked to repeat words and sentences in quiet and in noise to help the audiologist understand the practical affect of the hearing loss.

Tympanogram. A test of how well the middle ear system is functioning and how well the eardrum can move.

After conducting the tests and isolating the hearing problem, if a hearing aid is the right solution, Wilson says an audiologist should perform a lifestyle needs analysis to determine the type of hearing aid that will work best for your loved one. Some questions the doctor should ask your loved one:

How active are you?
Do you have trouble communicating in noisy places?
Do you live alone? In an apartment? In a large home?
Do you talk on the telephone a lot? Watch TV often?
Do you regularly go out to eat at restaurants?
Do you have trouble hearing certain family members such as women or children?
Do you have trouble hearing at religious services, at lectures and at movies?

Features to look for

Hearing aid technology is constantly improving, and new products are being introduced all the time. To understand what your loved one needs, you first must know how a hearing aid works.

A hearing aid has three basic parts: a microphone, amplifier, and speaker. The hearing aid receives sound through a microphone, which converts the sound waves to electrical signals and sends them to an amplifier. The amplifier increases the power of the signals and then sends them to the ear through a speaker. The hearing aid can be programmed on a computer to customize the amplification specifically for your hearing loss.

According to Dr. Wilson, here are some of the newest advances in hearing aid technology that you can discuss with your audiologist:

Open fit aids. A common complaint among people with hearing aids that fit into their ear is that they hear distractions, such as an echo when they speak; or hearing themselves chew. A new class of hearing aids addresses this issue. Called “open fit”aids, these hearing aids sit behind the ear, with only a wire and tiny loudspeaker going into the ear.

Digital feedback reduction. New hearing aids have good feedback reduction, to reduce or eliminate another common hearing aid complaint: whistling noises.

Digital noise reduction. Using complex algorithms, this feature is making hearing aids “smarter” and able to tell the difference between speech and background noise.

Directional microphones. The directional microphone allows the user to focus on whoever is directly in front with reduced interference from conversations behind and to the sides.

Automatically adaptive. With this technology, the hearing aid changes the way it works when the user walks from one place to another. The hearing aid detects sounds exceeding a certain loudness level, and then self-adjusts to reduce the amplification. For example, in a quiet place, volume level will increase. In a noisy environment, directional mics will kick in as well as noise reduction features.

Bluetooth compatible. The user doesn’t have to hold the cell phone up to their ear, which alleviates the feedback some people hear when they answer the phone. When a call comes in, it rings through the hearing aid itself, instead of ringing from the phone. To answer, the wearer simply presses a button.

Even after selecting the right hearing aid, don’t expect your loved one to adapt immediately. Wilson says it often takes a month or more for patients to get used to their new device.

“Often, people who are using a hearing aid for the first time will be startled at how loud the world is,” he says. “Sounds may seem loud and disturbing. Suddenly, the refrigerator makes a roar, the newspaper rattles, even the turn signal in the car becomes disruptive. I recommend that people wear the hearing aid all day, every day. If you wear it only sporadically, you will never get used to the volume of new sounds, and the brain will be confused. It takes at least several weeks for the brain to put those new sounds into perspective.”

So be patient. It requires time to adjust to hearing aids. Your loved one’s listening skills should improve gradually as he or she becomes accustomed to amplification.

The FDA requires that manufacturers provide a 30 day trial period for all hearing aids, so take advantage of it. Ensure your loved one uses the hearing aid for more than a few days, especially since there’s no risk involved. It can be returned for up to 30 days. Being an effective “matchmaker” does take time. But it’s time well spent.

Benefits of Home Care and Payment Options

Whether you live near your parents, are a caregiver to them, or live miles away realizing they need assistance but you can’t be there, what do you do?

Home care, also called referred to as non-medical in-home care and personal assistant services (PAS) just might be your answer. Home care allows a person with special needs to remain in their home vs. moving to a care facility. It’s often more affordable too. Home care services can include medication reminders, bathing, dressing or hair washing as well as homemaking services such as meal preparation, light housekeeping, laundry, yard work, grocery shopping, transportation to medical appointments, errands and companionship. This can include card playing, taking walks or simply reminiscing. Home care also provides caregivers with some respite to ‘regroup’ by going to a movie or simply taking an uninterrupted nap.

Trained and experienced caregivers provide care wherever ‘home is’ including an assisted living facility, nursing home or hospital, as well as a private residence. Most offer specialized training in caring for individuals with Alzheimer’s and Parkinson’s. It’s important to verify the company is licensed, bonded and insured and that they perform multiple background checks and driving records (including auto insurance coverage) should their caregivers be using the family car for doctor appointments, errands, etc.

Paying for Care

There are few ways to pay for home care; privately, taking out a reverse mortgage or through long-term care insurance. If purchased a head of time, LTC insurance can pay for home care, often from the first day it is needed. It will pay for a visiting or live-in caregiver, companion, housekeeper, therapist or private duty nurse up to seven days a week, 24 hours a day (up to the policy benefit maximum). It’s important to check the person’s policy regarding the coverage they have.

For low and fixed income seniors home care services are often provided through local state agencies (such as the Area Agencies on Agency) or through various local non-profit organizations. While they typically do not charge for their assistance they are often under-staffed and unable to provide adequate long-term care due to the supply and demand issue.

If your parent has low-income and few assets (other than the house they live in), he or she might qualify for Medicaid. If so, a program run by Medicaid in your state might be able to pay your parent directly for care at home, which your parent could then use to pay you to provide that care. In some states, this kind of cash assistance is possible even if someone has slightly too much income or assets to qualify for Medicaid. The arrangement works through a state-run program called Cash and Counseling, or a similar program

Another resource is the Medicaid Personal Care Assistant (PCA) Services. This program is an optional statewide service (so you need to check to ensure your state offers such a program) for their Medicaid recipients who are experiencing some functional impairment and need a personal care assistant to help them with some aspects of daily living, such as dressing or bathing. The purpose of the program is to accommodate long-term chronic or maintenance health care, as opposed to short-term skilled care as is provided under Medicaid’s home health program. PCA services are non-emergency health related tasks done by qualified staff in a medically eligible beneficiary’s home.

Normally, if a Medicaid beneficiary is eligible for regular in-home care, Medicaid provides it through a certified home care agency. But this special program directly pays the person in need of care the same amount Medicaid would pay an aide from an agency. The person needing care can spend this money on anyone he chooses to take care of him. They can also use some of the money to make home improvements for safety or comfort, or to buy personal care items. In order for you and your parent to take advantage of such an arrangement, your state has to be offering this Cash and Counseling or similar cash assistance program.

The Importance of Early Childhood Education

The best predictor of a good ending is a good beginning. The old adage is a true today as when it was first uttered so long ago that no one can clearly say who first spoke those words. When it comes to the education of young children this proverb has such tremendous relevance that it is hard to overstate its importance. All learning and life experience is moulded by what happens to the child in the early years of his or her life. The influence of the family is of major importance but the influence of the educational opportunities offered to young children is just as powerful and, in some ways, more powerful. For it is the impact of early childhood education that determines the attitude a child will take to formal schooling at primary or secondary level.

The world today is a troubled place. We seem to be getting better at hating one another. We seem less and less able to accept people who are different from us. In a world riddled with violence, crime, bullying, chaos and unpredictability we have to ask some important questions. Why is it that some children

Do not become violent?

Do not become bullies?

Do not become depressed?

Do not loath themselves and others?

Do not despair and give up on life?

These may not be the most profound questions being posed in today’s world but they are among the most important. Where can we turn to discern the answers to these questions? What do we know that can help us unpack the issues embedded in them and come to a vision of how to raise and educate young children?

The answers to these and other questions about children are emerging from new research about how the human brain grows and develops. Although we are a long way off knowing exactly who we can prevent violence and depression we have learned a good deal about how to foster the brain’s potential as an organ to help children grow to become contributing and productive members of society. Before we explore some of the implications from this research we need to briefly review the five areas of development that all children pass through during childhood.

Understanding Child Development

There are five areas of development that children undergo as they grow to be young adults. These steps appear in a rather predictable sequence, one after the other. They are not like steps of a ladder leading to higher and higher levels. Rather, they are like a spiral of stages through which a child cycles endlessly as they grow and mature. At some point the highest level of attainment may not be reached in a given area but that does not mean the child cannot progress to other areas of the spiral.

The five areas of child development are:

They can be easily remembered by the use of the rather unfortunate acronym “PILES”.

Physical Development

This area of child development is no doubt the easiest to understand and observe. Physical development includes: gross motor skills, fine motor skills, motor control, motor coordination and kinaesthetic feedback. Let’s explain each of these briefly.

oGross motor skills are those movements of the large muscles of the legs, trunk and arms.

oFine motor skills are the movements of the small muscles of the fingers and hands.

oMotor control is the ability to move these large and small muscles.
oMotor coordination is the ability to move these muscles in a smooth and fluid pattern of motion.
oKinaesthetic feedback is the body’s ability to receive input to the muscles from the external environment so the person knows where his body is positioned in space.

Intellectual Development

This area relates to the level of intelligence of a child in general and to the various aspects of intelligence that influence overall level of general ability. Among these many aspects are:

oVerbal skills-our ability to communicate with words our ideas, attitudes, beliefs, thoughts and emotions.
oNon-verbal skills-our ability to use visual and spatial-perceptual skills to interpret the world around us.
oAttention span-the ability to sustain a focus on a stimulus for a sufficient period of time to interpret it and understand it.
oConcentration-our ability to utilise attention to juggle stimuli into various permutations as necessary to analyse it accurately.
oVisual-motor skills-the ability to coordinate the movements of the eyes and hands to manipulate objects effectively.
oVisual-perceptual skills-the ability to analyse stimuli visually without necessarily manipulating them manually.
oMemory-can be auditory or visual (or even kinaesthetic as in the case of remember dance steps) and can be divided into some important sub-types:
– Immediate recall-ability to hold input long enough to recall it straight away if required to do so
– Short-term memory-ability to hold input over a longer period of time, perhaps minutes or hours
– Long-term memory-ability to store input and recall is well after it has been perceived, perhaps days or months, even years later

Linguistic Development

Linguistic development refers to language usage. Like other areas of child development it can be divided into sub-types.

oReceptive language-our ability to understand spoken language when we hear it
oExpressive language-our ability to use spoken language to communicate to others
oPragmatic language-the ability to understand humour, irony, sarcasm and know how to respond appropriate to what another has said or asked as well as know when to wait and listen
oSelf-talk-the ability to use internal, silent language to think through problems, cope with difficulties and postpone impulses
oReasoning-the ability to think through problems, usually with self-talk but at other times aloud, create plans of action using words
oCreative thinking-although not strictly a linguistic function I include it here because many people use language creatively, in new and inventive ways (e.g. Joyce, Beckett)

Emotional Development

This aspect of development, along with social development, is probably one of the most underrated but yet most important aspects of learning how to live in the world. No matter how excellent intellectual, physical and linguistic development may be we are doomed to live lives of frustration and difficult if we have not gained satisfactory emotional development. It includes:

oFrustration tolerance-the ability to cope effectively when things do not go the way we want or expect
oImpulse control-the ability to think before we act and not do everything that comes into our head
oAnger management-ability to resolve conflict without recourse to verbal or physical violence
oInter-personal intelligence-understanding the attitudes, beliefs and motivations of others
oIntra-personal intelligence-understand our own attitudes, beliefs and motivations

Social Development

oSharing-knowing how to ask to use the materials that belong to another
oTurn-taking-knowing when it is your turn to do something and when to ask if you can do it
oCooperation-the skills of working with others towards a group goal of task
oCollaboration-the ability to communication your input in a meaningful way when working with others.
Again it is necessary to repeat that emotional and social development play a hugely important role in our ability to live lives of dignity and respect. They also largely determine how well we will get along with workmates, bosses and loved ones including life-partners.

When we recognise that all children pass through each area of development we design educational programme for them that are developmentally appropriate. Most pre-schools have done just that. Unfortunately many early years settings succumb to pressure and push children towards academic goals and objectives, sometimes almost obsessively. Indeed, the curriculum in our junior and senior infant classes is largely developmentally inappropriate. It is far too teacher and parent-centred and far too little child-centred. Regardless, appropriate or inappropriate, it is not enough to focus on child development alone in our work with young children. We must begin to recognise the inborn potential locked within the child’s brain.

The Human Brain

Locked inside the brain are the potentialities that make us human. We are born with the potential for:

oLove Hate
oPatience Mistrust
oTenderness Violence
oHope Despair
oTrust Suspicion
oDignity Corruption
oRespect Revenge
It is the responsibilities of adults to unlock the positive potentialities of the brain and prevent the negative from appearing.

All educational experiences of children in the early years, indeed all educational experiences of children across the entire school years, must place an emphasis on releasing the positive potential that lies within the brain. Recent brain research, much of it conducted by Dr. Bruce Perry in Texas, has illuminated six core strengths, each of them related to brain growth and development that must be a focus in development appropriate educational programmes for young children.

The Six Core Strengths

Bruce Perry and his colleagues at the Child Trauma Academy in Texas have identified six strengths that are related to the predictable sequence of brain growth and development. These six strengths, if nurtured and fostered appropriately, will help a child grow to become a productive member of society. They are:


The first of the six core strengths occurs in infancy. It is the loving bond between the infant and the primary caregiver. Early attachment theorists’ conceiver of the primary caregiver as the mother but it is now recognised that it could as well be the father, grandparent or any loving person. The primary giver, when providing consistent and predictable nurturing to the infant creates what is known as a “secure” attachment. This is accomplished in that rhythmic dance between infant and caregiver; the loving cuddles, hugs, smiles and noises that pass between caregiver and infant. Should this dance be out of step, unpredictable, highly inconsistent or chaotic an “insecure” attachment is formed. When attachments are secure the infant learns that it is lovable and loved, that adults will provide nurture and care and that the world is a safe place. When attachment is insecure the infant learns the opposite.

As the child grows from a base of secure attachment he or she becomes ready to love and be a friend. A secure attachment creates the capacity to form and maintain healthy emotional bonds with another. Attachment is the template through which we view the world and people in it.


Self-regulation is the capacity to think before you act. Little children are not good at this, they learn this skill as they grow if they are guided by caring adults who show them how to stop and think. Self-regulation is the ability to take note of our primary urges such as hunger, elimination, comfort and control them. In other words, it is the ability to postpone gratification and wait for it to arrive. Good self-regulation prevents anger outbursts and temper tantrums and helps us cope with frustration and tolerate stress. It is a life skill that must be learned and, like all the core strengths, its roots are in the neuronal connections deep inside the brain.


Affiliation is the glue of healthy human relationships. When children are educated in an environment and facilitates positive peer interactions through play and creative group learning projects they develop the strength of affiliation. It is the ability to “join in” and work with others to create something stronger and more lasting than is usually created by one person alone. Affiliation makes it possible to produce something stronger and more creative than is accomplished by one alone. Affiliation brings into the child’s awareness that he or she is not an “I” alone but a “We” together.


Attunement is the strength of seeing beyond ourselves. It is the ability to recognise the strengths, needs, values and interests of others. Attunement begins rather simply in childhood. A child first recognises that I am a girl, he is a boy. Through the early years of education it becomes more nuanced: he is from India and likes different food than I, she is from Kenya and speak with a different accent than I. Attunement helps children see similiarities rather than differences because as the child progresses from seeing different colour skin and different ways of speaking he or she begins to recognise that people are more similar than different. That brings us to the next core strength.


When the child develops the core strength of attunement it learns that difference isn’t really all that important. The child learns that difference is easily tolerated. Through this learning the child develops the awareness that is difference that unites all human beings. Tolerance depends on attunement and requires patience and an opportunity to live and learn with people who at first glance seem “different”. We must overcome the fear of difference to become tolerant.


The last core strength is respect. Respect is a life-long developmental process. Respect extends from respect of self to respect of others. It is the last core strength to develop, requires a proper environment and an opportunity to meet a variety of people. Genuine respect celebrates diversity and seeks it out. Children who respect other children, who have developed this core strength, do not shy away from people who seem different. An environment in which many children are grouped together to learn, explore and play will foster the core strength of respect.

How the Brain Grows

The brain grows from the bottom to the top. Each of the core strengths is related to a stage and site of brain growth. In infancy attachment bonds are acquired and lay down emotional signals deep within the brain. At the same time the brain stem is seeing to it that bodily functions can be self-regulated. Later on in childhood the emotional centres of the brain come under increasing control so temper tantrums disappear and the child controls their emotional life. In mid-childhood the child’s brain begins to develop the capacity to think and reflect on the external environment. It is at this stage when the frontal areas of the brain begin to mature and it is at this stage in brain growth when the core strengths of affiliation, attunement, tolerance and respect can mature as well.

The Classroom and the Brain’s Core Strengths

The education of young children must be undertaken with the core strengths in mind. Classrooms where there is peace and harmony among a wide variety of children will create opportunities for affiliation, tolerance and respect to develop. These classroom must be characterised by play, creative exploration of objects, lessons which are activity-based not teacher-lectured. There must be challenge to the brain in the form of innovative lessons and teaching methodologies. Cooperative learning activities must be part of the school day. The classroom should occasionally consist of an opportunity to engage in cooperative, mixed-ability groupwork. There must be an opportunity for long-term, thematic projects to be explored. The teacher should be a guide, always teaching with the core strengths in mind, always observing children and noticing which of them need more structure and guidance as they grow through the core strengths. The teacher must also be a person the children perceive as predictable and caring, patient and kind; a person who will not obsessively focus on mistakes.

What Is the Cost of Child Care?

Looking for someone to care for your toddler is an excruciating job. Finding the right person to trust is even harder. You want only the best for your precious one and a child care provider can offer a secure, warm and fostering environment. And in this modern world where finances are tight, learning the costs of child care is imperative to help you plan for the extra expense.

Important Factors

Where You Live

Child care varies from city to city. Hence, your geographic location is the number one factor in determining the cost of child care. Rates are based on a certain city’s cost of living, the population, annual salary income, unemployment rate and modernism. States with the least expensive child care costs are Alabama, Idaho, North Dakota, South Carolina and Texas. While states with very expensive child care costs are California, Illinois, Maryland, Minnesota, New York, Pennsylvania, Washington D.C. and Wisconsin.

A Toddler’s Age

Age is another consideration. Child care costs for babies from 0 to 11 months old are more affordable since lesser work is required in a child care provider. All the caregiver has to do is to feed, bathe, change the diapers and put the infant to sleep. For toddlers from ages 1 to 4 or for those in their preschool years, the cost is higher. At this point, taking care of children is a bigger obligation since caregivers have to prepare meals, help with your toddler’s homework and stay up late to wait for you to come home. Plus, it is not an easy job to run after a hyper child and manage other household duties at the same time.

Operating Hours

Whether your little one’s provider is a stay in or a stay out caregiver, an establishment or a relative, the hours put into looking after your toddler is meticulously observed. Some providers may have a fixed salary while others may not. This depends on the agreed schedule of the parents and the provider.

The Type of Child Care Provider

Day Care Centers

The cost of day care still depends on where you live and the quality of the day care center. In most cases, a day care center costs anywhere from $10 to $40 an hour. Since it is a professional center, you do not only pay for the caregivers’ services but you also pay for the day care’s operating cost and their reliability.

Typically, day care centers for infants and toddlers are very expensive since children at this age entail more hands-on care and one-on-one attention. Plus, a day care center accepts 25 to 30 children in a single class which requires more caregivers. The average rate in a day care ranges from $975 to $2,000 a month.

Day care centers for preschoolers are technically lower as toddlers are more self-sufficient. Child care costs are between $333 to $1,000 per month.

Home Day Care Centers

A home day care is located within the neighborhood so rates are more affordable. This child care provider is a smaller establishment than a day care so a maximum of 7 children are accepted and only 2 caregivers are employed. Average cost ranges from $300 per month. However, for a licensed home day care center, standard rates can go as high as $1,500 to $2,000 a month.

Relative Care

This type of caregiver is tricky as you do not want to offend your relative by paying her services. Basically, you do have to pay for relative care. But if she refuses to accept your payment, the cost of child care is free. In most cases, a relative is more willing to accept any token of appreciation. For example, gift certificates to her favorite boutique, salon or spa, movie or Broadway passes, grocery baskets or even a simple thank you card will do. Giving her a day off once a week is also good.

Nanny Care

Nanny care is the most expensive child care provider. Under the law of the U.S. government, a nanny is a legal employee and you are her employer. If she is a full-time nanny and lives with your family, a typical salary ranges from $400 to $700 a week. A part-time or stay out nanny’s salary averages between $350 to $650 per week. Aside from her monthly salary you have to pay for her taxes, health insurance, vacation leave, sick days and even open a bank account for financial aid.

Caregiver Stress – It Can Sneak Up on You!

I ran into my friend Mary yesterday, and found her in the middle of a crisis. Mary is 75 years old, and although she is active and relatively healthy for her years, she’s had some fairly serious health issues these last few years. But that hasn’t stopped her from taking on caregiving her ex-husband!

Perhaps it’s because he’s the father of her 3 children, who are dispersed across the US. Or maybe it’s knowing he has no one else nearby to care for him. None of her children live near enough to help their father as he ages, encounters serious health issues and is being moved from home to home, as facilities are not able to meet his needs. So that leaves Mary.

She looked exhausted, haggard and totally stressed! My first thought was… “Mary, why doesn’t he move to Texas, where your daughter lives, or to where one of your sons live? After all, he is their father. Shouldn’t they be taking care of him instead of you?” Mary’s reply. “Oh no, I don’t want to burden my daughter or sons with this.”

How do we get caught up in this kind of thinking? Why is Mary willing to risk her own health to take care of an ex-husband? Hard to say, but it’s oh so common.

Self Care Comes First

Having gone through this myself, when my mother was ill, I realize the stress and how easy it is in the middle of everything that’s going on, to forget to pay attention to yourself. After all, didn’t I get seriously ill within 6 months after she passed away? So I warn her… “be careful Mary, you don’t want to get sick like I did. Then your kids will have two parents to worry about!”.

It’s easy to loose track of yourself, as you scramble to keep up with another person’s life. But no matter how important this person is to you, you must remember that if you get too stressed and fall ill, you become the recipient of care rather than the caregiver, and are no help to anyone.

It’s OK to Put Yourself First

A wonderful process in dealing with overwhelming situations is to prioritize. First focus on taking care of yourself, then worry about taking care of others. It makes sense that when you take care to protect your own energy, you have more left to give to others. Caring ceases to be a good thing when it’s at the expense of your own health.

If you find yourself in a major caregiving role and you’re all alone, remember to reach out for some help. Help comes in many forms: friends, family, pastors, churches and support groups. Whatever you do, don’t take it all on by yourself!

Some of the ways you can minister to yourself and relieve some of the stress of caregiving, is to remember to make time to do the things that bring you joy and relaxation. My friend Mary regularly attended an exercise class, and she loved it. But over the 6 months since she’d taken on helping her ex-husband, she had not attended one class. As a friend, I made her promise me she’d be at the very next class. She was immediately less stressed once she agreed.

Warning Signs That You’re Overdoing It…

Loss of energy or joy of life
Emotional or physical exhaustion
Health problems
Disturbed sleep – not enough or sleeping too much
Changes of appetite – not eating or eating too much
Marital problems
Family problems
Alcohol or drug abuse
Neglect or abuse of the older person

Strategies to Better Manage Stress

1. Have realistic expectations
2. Ask for help
o get your family involved
o find support groups
o consult professionals
3. Take are of yourself
o Talk with someone about how you’re feeling
o Mind your own health
o Put aside time for yourself to do things you enjoy
o Eat nutritious meals
o Exercise regularly
4. Keep up your social contacts

Providing care for an elderly loved one can certainly be stressful, but there are ways to reduce the stress. Becoming aware is the first step. It’s necessary to realize your situation and start paying attention to yourself and how well you’re managing, before you can begin to do something about it.

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