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 Specialty Services In Nursing Homes: A Crucial Component Of Quality Care

Providers are starting to look at offering on-site services such as optometry, dentistry, audiology, and podiatry.

 Contributing Editor

A 90-year-old resident of Samaritan Bethany in Rochester, Minn., who suffered from both Parkinson’s disease and dementia, was having multiple health problems, and no one could figure out the underlying problem. She had intermittent fevers, was hospitalized a couple of times, and was treated for a bladder infection. Her behavioral issues made assessing her difficult, and she would become agitated whenever anyone tried to clean her mouth or wash her face.

Seeking Help

One day a geriatrician and geriatric fellow from the nearby Mayo Clinic were at the facility seeing certain patients. Susan Knutson, the facility’s administrator, had been trying for a long time to get a dentist into the facility to examine the residents—as required by federal regulation—but without success because of inadequate Medicaid funding, lack of portable equipment, and lack of expertise in geriatric dentistry in the area.
 
Staff knew about Knutson’s efforts, and one of them asked the geriatrician if she would examine the teeth of the resident who was having so many problems. The Mayo Clinic geriatrician was embarrassed to admit that she rarely looked into the mouths of patients with dementia and behavioral problems because she wasn’t sure if she would be bitten, and because she was lucky if she could get a tongue depressor in their mouths.
But with the help of the geriatric fellow and staff, a flashlight was found and, with a great deal of effort, they managed to get the resident to move her tongue so they could see her teeth. They found numerous swollen areas with draining pus.

Finding A Dentist

It was a dilemma—the resident badly needed a dentist, yet Knutson hadn’t been able to find one that would accept Medicaid patients. So, first, Knutson tried to get the Mayo Clinic to treat the resident, but they refused care because she was on Medicaid. Then Knutson sent her to an area medical center, but they wanted to perform $10,000 to $15,000 worth of tests prior to working on her, none of which would be covered by Medicaid.
 
“Finally, after calling pretty much every dentist in Rochester, we found one who was willing to pull two teeth at a time,” Knutson says. Having found a dentist was a victory, although the resident suffered a great deal from the stress of being repeatedly transported to a strange place where a strange person would pull her teeth, even though family members went along to reassure her. Further, she wasn’t a good candidate for anesthesia, and the family members had to work hard to keep her calm during the procedures.
 
But after nine teeth were pulled and the remaining teeth were cleaned, all of those mysterious health problems ceased, as did the behavioral symptoms.
 
“If it hurts and you can’t tell them it hurts, you do act out,” says Knutson.

The Mayo Clinic geriatricians were tremendously impressed at the change in the resident, and so was Knutson. If only she could find a dentist willing to treat all of her Medicaid residents.
 
A staff member mentioned a company called Apple Tree Dental, a nonprofit group that provides dental care on-site at long term care (LTC) facilities, and did so for patients regardless of their payer source. Apple Tree, which is based in the Minneapolis-St.Paul area, didn’t have a program in Rochester, but Knutson and the Mayo Clinic geriatricians felt so strongly about what they’d witnessed that they weren’t going to let it drop. Ultimately, the geriatricians convinced the Mayo Clinic Foundation to be the major donor, along with several other contributors, of an effort to start a branch of Apple Tree in the Rochester area.
 
Knutson signed up Samaritan Bethany to be on Apple Tree’s client list right away, and since that time, all of her residents have received top-notch care, including those with dementia or other behavioral issues that would daunt many another dentist.
 
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Specialty Services Critical

Inadequate dental care can result in a host of health problems for the elderly. Providing on-site dental services—to alleviate the distress experienced by frail individuals being transported and to provide care for bedridden and unconscious residents as well—can make a world of difference not just in the health and happiness of the residents, but perhaps even in the costs associated with not treating those problems.
Other medical specialty services, too, like podiatry, vision, and hearing services, can have a huge impact on residents’ health and quality of life.
 
A minority of LTC providers offer these services, as numerous studies show, but studies also document the many barriers to offering such care, including medical specialty providers who are unwilling to accept Medicaid or who don’t feel comfortable providing care outside of their well-equipped offices; states that have drastically cut Medicaid coverage of such services or don’t cover them at all; and professionals who are not trained in or don’t feel comfortable providing care for medically complex, frail individuals.
 
On the other hand, many medical specialty providers who do deliver on-site services say caring for LTC residents has been so rewarding that it transcends the hit they take on reimbursement rates, and providers appear to be increasingly aware of the benefits of making such services available to their residents. If only public and private partnerships could be formed to fund these services, providers say, the well-being of residents across the country could improve dramatically, and payers and taxpayers would reap the financial rewards of preventing more serious health conditions.
 
Sandra Fitzler, senior director of clinical services for the American Health Care Association (AHCA), is well aware that residents need and too often don’t receive a number of medical specialty services. “Vision, hearing, and podiatry services are very much needed for our population,” says Fitzler, but aside from the American Dental Association (ADA) (go to providermagazine.com, Current Extra News Online), as far as she’s aware, no organized effort is being made on a national level to get these services into facilities.
 
Click HERE for information about finding location dental, optometry, or podiatry services.

Hearing Services

Half of adults aged 75 and older have a hearing impairment, according to the National Institutes of Health, and 80 percent of nursing facility residents do, says Janice Trent, a clinically certified geriatric audiologist who owns a private practice in Bowie, Md., and also cares for LTC residents, citing a book called “Geriatric Audiology,” by Barbara Weinstein, published in 2000. Other studies place that percentage between 53 percent and 77 percent, higher for residents with dementia.
 
Nearly 40 percent of nursing facility residents have hearing loss due to ear wax impaction—something that’s easily reversible by an audiologist or a nurse with appropriate training in how to irrigate ears. One study showed that 81 percent of nursing facility residents had neither been screened for hearing loss nor had ear wax removed. When Trent irrigates ears, she first does a case history and then talks with the resident’s physician. “Behind the ear could be an infection or perforated ear drum, so some contraindications” do exist to performing an irrigation, she says.
 
Hearing loss can result in confusion, withdrawal, and disorientation and can be mistaken for dementia. It negatively affects independence, communication skills, and functional abilities, Trent says. A large national survey found that elderly individuals with untreated hearing loss were more likely to report sadness and depression, worry and anxiety, paranoia, less social activity, irritability, and fearfulness. The greater the hearing loss, the more severe these negative effects were.
 
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Optical Care

Visual impairment is much higher for nursing facility residents than for people of the same age living in the community—studies indicate the rate is between three and 15 times higher for nursing facility residents. One study found that 57 percent of facility residents had poor vision that was untreated, compared with between 10 percent and 20 percent of elderly individuals living in the community.
 
Yet another study found that 68 percent of residents had untreated cataracts, and 17.5 percent had untreated age-related macular degeneration. Studies also found that two-thirds of residents’ vision impairment could be corrected with eyeglasses or cataract surgery.
 
Optometrists can discover undiagnosed diseases through an eye examination. “They may have some double-vision problems that might indicate diabetes, or a side vision problem that may indicate a stroke,” says Kerry Beebe, an optometrist practicing in Brainerd, Minn., who makes rounds at a nursing facility once a month. “It’s not rare in that population to see an embolism in a retinal blood vessel that would indicate a blocked carotid artery. It’s common to find other conditions during an eye exam.”
 
Beebe cites a study that said 80 percent of nursing facility residents never received eye care once they entered a nursing facility, and that figure “absolutely” holds true in his experience. Another study put that number at 66 percent, with only 12.6 percent receiving services on-site.
 
Untreated glaucoma and cataracts lead to blindness. Poor vision is linked to falls, depression, and confusion, resulting in an accelerated loss of independence. And poor vision reduces the ability to read, watch TV, and communicate effectively, thus reducing quality of life.

Foot Problems

When Kirk Geter, chief of podiatry at Howard University’s College of Medicine in Washington, D.C., first started providing podiatry services at LTC facilities, he found a lot of conditions that would have been preventable if residents had received podiatric care sooner. One of the more common problems Geter ran across was pressure ulcers on residents’ heels.
 
Other common problems include ingrown nails, fungal infections, bunions, deformities of the toes, limited movement of the ankle joints, corns and calluses, swelling, flat feet, and just things like the resident hitting a toe on something, causing lasting pain. With proper education for staff on providing good daily foot care, he says, a number of these conditions can be reversed or treated.
 
Pressure sores on residents’ heels can develop into an infection that requires surgery. People who cut themselves while trying to cut their own nails can develop infections—something especially dangerous for people with diabetes, who have trouble with healing and fighting off infections, says Geter. Toenails that go uncut and dig into the tender skin of the toe and other foot problems can cause falls. Fungal infections can develop into bacterial infections, he says.

Dental Care

Most nursing facility residents have some kind of oral health problem, says Michael Helgeson, DDS, chief executive officer (CEO) and co-founder of Apple Tree Dental. He cites a study of the initial oral health status of 3,479 Apple Tree clients from 36 nursing facilities that nearly 75 percent of residents who still had natural teeth had significant oral problems requiring routine or emergency care.
 
Two-thirds of residents without teeth also had oral health problems requiring care. Nearly one-fifth of the teeth requiring follow-up care were in such bad shape that only a root tip remained—something that looks like a dark stub in a resident’s gum. Root tips indicate inadequate oral care over an extended period.
 
Further, the elderly are seven times more likely than younger people to be diagnosed with cancer of the lip, oral cavity, or pharynx, according to the Centers for Disease Control and Prevention (CDC). The chance of surviving these cancers improves when diagnosed early on, but people with early-stage oral cancer rarely have pain or other symptoms, making that annual oral exam especially crucial for the elderly.
 
Yet, according to one study, only 13 percent of nursing facility residents have had even one dental visit and, according to another study, only 16 percent received daily oral health care from certified nurse assistants (CNAs), who spent an average of 16.2 seconds providing that care.
 
“As people age, the nerve chamber inside the tooth shrinks and calcifies, and teeth become less and less sensitive,” Helgeson explains. “So by the time a geriatric patient has a toothache, it has often become an abscess. They also have much less sensitivity in the nerves around their bones and jaws, so pain is just a really late symptom for an older adult. So the need to have a well-trained pair of eyes looking and getting X-rays to avoid tooth loss and costly downstream health care is really high.”

The Apple Tree Experience

Helgeson is one of the few dentists nationally who has the equivalent training of a specialist in geriatric dentistry. He’s a past-president of the American Society for Geriatric Dentistry and is on the American Dental Association’s National Elder Care Advisory Committee.
 
Roughly 70 percent of Apple Tree’s patients are in a public program like Medicaid. The organization has one program in the Twin Cities and four other programs targeted in rural areas. Last year, Apple Tree conducted about 70,000 dental visits and delivered $12 million in dental services, about half of those using its mobile delivery systems. It has a year-round regular schedule to provide services in elder-care facilities, group homes for adults with disabilities, and other settings. Each dentist has his or her own patients in order to maintain continuity of care.
 
The mobile units can provide nearly all dental services with the exception of some forms of anesthesia. “But I would say we have the most advanced mobile dental clinics in the country,” says Helgeson. “We can do digital radiography, surgical procedures, crowns, bridges—we can do most everything on-site.” Along with local anesthesia, they use oral sedation, which is the dominant form used for their LTC population. “Generally, geriatric patients already have oral medications that are used for behavior issues, and they’re typically administered by the nursing staff,” Helgeson says.
 
One reason for treating residents on site at the facility is to avoid behavioral problems. “You just don’t see the same type of behavior problems at the facility, partly because they’re more comfortable there, and partly because familiar caregivers can be with them the whole time, and they don’t have to go through a disruptive transportation event,” says Helgeson.
 
Patients are much calmer when dentists are seeing them in a familiar environment, he notes. When Apple Tree contracts with a facility, they take on the role of a dental director, similar to the role a medical director or pharmacy director would play. “We take responsibility for having an oral health program at the facility, and the intention is to make sure that every person there is getting appropriate oral health care.”
 
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Specialty Care Underfunded

Nationwide, states are underfunding nursing facility care at an average of $14.17 per patient day, says Fitzler, referring to a 2009 study conducted for AHCA by Eljay, a research firm, which also reported that the nursing facilities went without funding for Medicaid allowable costs totaling about $4.6 billion that year. The outlook for 2010 and 2011, the report said, was “bleak. It is worse than any other year in the past seven … due to unprecedented state budget deficits and expiration of federal stimulus funds at the end of 2010.”
 
The underfunding isn’t just limited to traditional LTC services; medical specialty services are also underfunded. In most states, for example, Medicaid doesn’t cover adult dental benefits at all, according to ADA, and in those that do cover it, the coverage is grossly inadequate.
 
“Sometimes nursing homes are required to pay for oral health care, or the family is, and a lot of residents don’t have family to pick that up,” says Cindy Luxem, president and CEO of the Kansas Health Care Association. This raises some questions: If a resident needs dentures, but reimbursement doesn’t cover the whole cost, how much will the dentist accept as payment? How much is the nursing facility required to pay to ensure the resident gets needed services?
 
“I absolutely believe federally mandated funds should be available for these services,” says Molly Forrest, CEO of the Los Angeles Jewish Home for the Aging, which offers multiple medical specialty services to its residents. “I can’t think of anything worse than being elderly and not being able to eat because your teeth hurt, or not be able to see your plate, or hear” the conversation at the table.
 
Even with Medicare cross-subsidization of Medicaid, nursing facilities see a loss, especially in 2010, due to Medicare payment reductions of about $16 per Medicare patient day.
 
Residents who are private-pay with private insurance aren’t necessarily in better shape when it comes to having their dental care covered. Most insurance policies don’t have dental health benefits, notes Luxem. “It’s often a side policy that you have to subscribe to.”
 
Despite all this, nursing facilities are increasingly taking on the responsibility of ensuring all residents receive the medical specialty services they need. But in the case of dental care, for example, that can be hard when so many dentists don’t take Medicaid.

Paying For The Service

Apple Tree helped change Minnesota laws so that its hygienists can complete the oral health assessments and write a daily oral care plan that becomes part of the resident’s care plan. If the resident already has a dentist, the hygienist helps make sure he or she goes to see the dentist when necessary. Residents who don’t have a dentist, can’t travel, or are on Medicaid can choose to sign up with Apple Tree.
 
The dentist visits regularly with the mobile unit and stays the entire day providing needed care. In addition, Apple Tree staff are on call 24 hours a day, seven days a week, in case of an emergency. For these services, Apple Tree charges each facility a monthly fee. Although some facilities are put off by the monthly fee, none of the assessing, preparation of care plans, or filling out of the MDS is reimbursable.
 
But Apple Tree has to recoup its costs somehow. It’s a nominal fee, says Helgeson; “If they have to pay for one person’s lost dentures, that’s going to cover our annual cost.”
 
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A Success Story

The Los Angeles Jewish Home is a stunning example of success in LTC. With almost 1,000 residents and another 500 on a waiting list, the organization offers far more medical specialty services than the vast majority of LTC facilities. This menu goes beyond the usual to offer dermatology, cardiology, oncology, psychiatry, urology, radiology, and lab services, and the list goes on for a total of 17 medical specialty services in all.
While those services aren’t necessarily the reason residents chose the Los Angeles Jewish Home over its competitors, half of its residents do say upon admission that quality of care is why they chose the organization, which offers independent living, assisted living, and skilled nursing on two campuses, as well as an acute psychiatric hospital and hospice services in the community.
 
The medical specialty services are offered in two on-site clinics and can also be provided in a small examination room in the nursing facility that has the dementia care unit, or even at the bedside if necessary.
Providing the services in the facility that is home to residents with severe dementia has been so successful that the center has had literally no incidents of residents being disruptive during treatment, says Forrest.
 
The reason the Jewish Home opened the clinics was to provide better health care for its residents, but staff found that having services on-site reduced their costs as well. Because their residents have an average age of 90 and therefore tend to be more frail, they can’t just be transported to a doctor’s office and dropped off. The facility also couldn’t use volunteers for this because the residents had to take their medical records with them and bring them back. So the Los Angeles Jewish Home was spending a lot of money sending CNAs with them.
But now, having all records and all of the doctors in one place means that most residents can be accompanied by a volunteer most of the time.
 
Forrest also believes providing medical specialty services, and the resulting improved health and postponement or elimination of more serious health conditions, is part of why the average length of stay for residents is eight years, despite the older average age. “We exceed all the averages substantially,” says Forrest. “We believe that the residents’ health and quality-of-life improvements are seen in the results both in the length of stay and in what I would call some negatives that are positives,” she says. “We’ve never had a lawsuit related to quality of care in the history of the home. In this modern age you hesitate to put that in print, but we work very hard on measuring results and outcomes. If somebody has a problem, we want to be the first to know. So we try to address issues early on and find ways to prevent anything from coming up.”

Recruiting For Resources

Being big isn’t the reason Jewish Home was able to make it happen, though. Forrest says that smaller facilities in smaller communities have an advantage because they tend to be seen as integral to the community. She remembers when she started out in LTC almost four decades ago, she worked in a small facility that was privately owned.
 
The owner, who cared very much about residents’ health, would go to Rotary meetings to connect with health care professionals and offer them the opportunity to do good by volunteering to provide these kinds of services to his residents.
 
In fact, before the Los Angeles Jewish Home opened its clinics in the 1990s, that’s exactly how it got residents’ needs met on-site—through volunteer professionals. It still relies on a core of about 400 volunteers who, among other things, help transport residents to on-site clinics, though staff are needed to assist the frailer residents.
 
A resource that might be available to some other facilities is where the Los Angeles Jewish Home gets its eyeglasses: the California women’s prisons, where prisoners make eyeglass lenses. Forrest says the residents’ glasses are actually quite stylish and don’t look at all institutional. Residents still get to pick out their frames, and the cost is about $30 in all.
 
Forrest learned about this opportunity from a group of retired optometrists. “All of the professionals have organizations and associations, and many times they have connections that we may not be aware of,” Forrest says, recommending that providers ask health care professionals they come in contact with for similar ideas. These providers are in their profession because they care about people’s health care and can be tremendous resources, she says.
 
“Long term care is always a balancing act between what do you get and what does it cost, and does the outcome justify the expense,” notes Forrest. “Whenever we find a challenge financially or organizationally, we have a sit-down meeting and say, ‘Okay, what are the issues? Where can we ask for help?’”

Benefits Are Many

Overall, the focus on providing medical specialty services on-site has a number of benefits, such as improving resident and family satisfaction levels and differentiating them from other facilities in the area. But Forrest thinks providers are increasingly turning to providing medical specialty services for their residents.
“I think facilities are investigating doing these services,” she says. “I don’t know anyone in long term care who doesn’t want to do a good job, but it takes time and energy to find partners in caring who will indeed come to your facility and help you start a new service. I think every facility would welcome it; it’s just having the time and understanding of how you can make your overall business dovetail with it.”
 
Kathleen Lourde is a freelance writer based in Manassas, Va.​ 
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