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 Quality Improvements Within Reach For Providers

Barriers to improving quality in the nursing care setting are many, but providers that take steps to bring more progressive tactics and systems into their long term care facilities will see positive results, said Keith Kanel, MD, chief medical officer for the Jewish Healthcare Foundation and member of the Pittsburgh Regional Health Initiative.
Speaking recently at the Medicaid Congress event in Washington, D.C., Kanel outlined the importance of improving quality at nursing facilities at a time when payment and care systems are being revamped, notably under the accountable care organization (ACO) model presented by the Centers for Medicare & Medicaid Services.
He said the U.S. health care system cannot "meaningfully address the issues around ACOs without addressing nursing homes." How nursing facilities are utilized and the flow of patients to and from hospitals

are vital to getting it right in terms of caring for patients and residents and cutting the costs of health care delivery, Kanel said. 
In talking with physicians in a focus group, the thing that most concerned doctors was the bounce back from nursing facilities to emergency departments and the lack of information about these patients upon entry to the acute-care setting, Kanel said.
Nearly half of all nursing facility visits to emergency rooms result in an admittance, and the flow from facilities to emergency rooms is "brisk," especially for Medicaid patients, he said
There are unique barriers standing in the way of more drastic quality improvements in the nursing facility setting, Kanel said. Among these is the simple fact it is much more difficult to engage patients in a facility, given age, frailty, and Alzheimer’s factors.
Other barriers are the minimal involvement of commercial payers in nursing care, the absence of compelling outcome measures, the slow pace of electronic health record use, staff turnover, and the immense amount of documentation that nursing facilities must file.
"There really are barriers in keeping up with all the documentation," Kanel said, noting the 37-page minimum data set as one example.
The drivers behind high transfer, admission, and readmission rates at some nursing facilities include the complexity of patient illnesses, the lack of primary care physician involvement in care, unavailability of medical information at the point of care, the lack of off-hour lab testing and radiological services, and liability issues, Kanel said.
Through his work in Pennsylvania, data from hospital admissions departments has shown the biggest reasons for bounce backs to hospitals are infections, leading some experts to call for mandatory infection control practices at nursing facilities.
For Kanel, the way to "raise the bar" for quality starts with standardized communications; the development of standing orders for residents; the assurance of basic diagnostic capabilities available at all hours; establishment of advance directives; and the consideration, not requirement, of an infection control practitioner.
Staff should also consider the hospital transfer as a last resort, he said, and be trained in system-based quality improvement practices, like the Lean system, in which all staff think of themselves as problem-solvers.
"These steps are not beyond the realm of any nursing homes," Kanel said, noting the positive experience he has witnessed in facilities teaching the Lean methods.
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