| Balancing Technology and Humanity in Long Term Care | <p><img src="/Articles/PublishingImages/740%20x%20740/telehealth2.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />The integration of technology into long term care is revolutionizing the way we approach this delicate and crucial stage of life. Being an executive in the senior care space for decades, I've witnessed firsthand the profound impact that technological advancements can have on enhancing the quality of care, communication, and comfort for patients and their families. From innovative medical devices to sophisticated data management systems, technology is not just a tool but a transformative force that is reshaping the landscape of long term care.</p><p>This proactive approach to long term care not only improves patient outcomes but also alleviates the stress and anxiety often experienced by families, knowing that their loved ones are under constant, attentive care. Technology's impact will be significant on the efficiency of care delivery, but also in upholding the dignity and preferences of those at the end of their life, making the journey as peaceful and respectful as possible.</p><h3>Revolutionizing Patient Monitoring and Care Delivery</h3><p>Wearable devices and remote monitoring systems enable the continuous tracking of vital signs such as heart rate, blood pressure, and oxygen levels, providing health care providers with real-time data that can be crucial in detecting early signs of distress or deterioration. This level of constant vigilance allows for timely interventions, which can significantly improve patient outcomes and enhance their quality of life. For instance, a sudden drop in oxygen levels can be immediately addressed with supplemental oxygen or medication adjustments, preventing further complications and ensuring the patient's comfort.</p><p>Telehealth has also emerged as a game-changer in long term care, particularly in reaching patients in remote or underserved areas. Through virtual consultations, patients can access specialized care without needing stressful and often difficult travel. This not only provides them with the best possible medical advice but also ensures that they remain in the comfort of their own homes. Telehealth platforms enable continuous communication between patients, families, and health care teams, keeping everyone aligned and informed about the patient's condition and care plan.</p><h3>Enhancing Pain Management and Comfort</h3><p>Innovations such as smart drug delivery systems, which can administer precise doses of pain medication based on real-time assessments, are transforming traditional approaches to pain relief. These systems can adjust dosages automatically, responding to fluctuations in a patient’s pain levels without the need for constant manual intervention by health care providers. This ensures that patients receive the right amount of medication at the right time, minimizing pain while reducing the risk of overmedication and its associated side effects. </p><p>AI and machine learning algorithms are also being employed to predict and manage pain more effectively. By analyzing data from various sources, AI can identify patterns and anticipate pain episodes before they become severe. This proactive approach allows for preemptive adjustments in pain management strategies, ensuring that patients remain comfortable, and their pain is controlled. Additionally, virtual reality and other immersive technologies are being used to provide patients with non-pharmacological methods of pain relief and relaxation.</p><h3>Personalizing Long term Care through Data and AI</h3><p>The utilization of data analytics and artificial intelligence in long term care is paving the way for highly personalized and effective treatment plans. By harnessing vast amounts of patient data—from medical histories and genetic information to real-time health metrics—AI algorithms can identify unique patterns and trends that inform individualized care strategies. These insights enable health care providers to tailor interventions precisely to the needs and conditions of each patient, ensuring that care is not only more effective but also more respectful of the patient's personal preferences and medical history. For example, predictive analytics can help identify patients who may benefit from early palliative care interventions, thus enhancing their quality of life sooner rather than later.</p><p>AI-driven decision-support tools are also revolutionizing how care plans are developed and adjusted over time. These tools can process complex data sets to generate recommendations for symptom management, medication adjustments, and other critical aspects of care. They provide health care professionals with actionable insights that go beyond traditional clinical guidelines, allowing for more nuanced and responsive care. This level of personalization ensures that long term care is dynamic and adaptable, meeting the evolving needs of patients as their conditions change. Additionally, data-driven approaches can facilitate more meaningful conversations between health care providers, patients, and families about treatment options, ultimately supporting more informed and compassionate decision-making.</p><h3>Ensuring Ethical and Compassionate Care</h3><p>Incorporating technology into long term care necessitates a strong commitment to ethical standards and compassion. While technological advancements offer tremendous benefits, it is crucial to ensure that they are used in ways that uphold the dignity and autonomy of patients. Consent and privacy must be prioritized when collecting and utilizing patient data. Clear, transparent communication about how data will be used and the potential benefits is essential in building trust with patients and their families. Additionally, ethical frameworks must guide the development and implementation of AI and other advanced technologies to prevent biases and ensure equitable care for all patients, regardless of their background or socioeconomic status.<br><span><img src="/Articles/PublishingImages/2023/MelissaPowell.png" class="ms-rtePosition-2" alt="Melissa Powell" style="margin:5px;" /></span></p><p>Compassion must remain at the heart of long term care, even as we embrace technological tools. Technology should enhance, not replace, the human touch that is so vital during this sensitive time. Health care providers must continue to engage with patients and families personally, offering empathy, understanding, and emotional support. Technologies like telehealth can facilitate these connections by enabling more frequent and meaningful interactions. Still, the essence of compassionate care lies in genuine concern and respect for the patient's experiences and wishes. Balancing technological efficiency with ethical considerations and compassionate practices ensures that long term care remains holistic, humane, and centered on the patient's well-being.</p><p>As we continue to navigate this evolving landscape, our ultimate goal must be to provide care that is not only technologically advanced but also profoundly humane.<br><br><em>Melissa Powell is </em><em>the COO of Genesis Healthcare, a network of 250 facilities across 22 states.</em><br></p> | 2024-09-12T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/telehealth2.jpg" style="BORDER:0px solid;" /> | Technology;Management | From innovative medical devices to sophisticated data management systems, technology is not just a tool but a transformative force that is reshaping the landscape of long term care. |
| How NCAL Executive Director LaShuan Bethea Advocates for Residents and Communities | <p>When LaShuan Bethea entered the senior living industry after graduating high school, she had no idea she’d spend the next 25 years in it—let alone that she’d become one of its most important advocates in Washington, D.C., as executive director of the National Center for Assisted Living (NCAL). </p><p>“I never knew that that would be my long-term career option,” she recalled of her first job as an licensed practical nurses at a nursing home. “But I found that as I tried a whole bunch of different types of nursing, I kept coming back to long term care.”<br></p><p>It was the human element of the job that pulled her back over and over again: the opportunity not just to take care of residents, but to spend quality time with them. “I loved engaging with the residents, hearing their story, and getting to know them as individual people and their history,” she said. “There was no other environment where I was able to get that same type of joy. Working with residents and their families, you get this immediate return on the investment that you make in caring for them, because they truly appreciate the work that you do.”<br></p><p>The longer Bethea spent working as a clinician, the more she came to recognize a tension between the realities on the floor and the regulations determining what happens there. However well-intentioned various rules may be, she realized, there was still a gap between the world regulators envisioned and the world as it exists. <br></p><p>“One of the things that became clear to me is there’s this disconnect between the people who write the regulations and what happens when you work in the industry,” she reflected. “I would often find myself saying, ‘There’s no way that a person who worked in our industry could have ever written a rule like this.’ Because they don’t. There’s a disconnect between them and what is happening at the bedside, what’s happening in the day-to-day work that we do.”</p><h3>From the Bedside to the Beltway</h3><p>Instead of navigating around that disconnect, Bethea decided to get to work bridging it. After years working in various nursing home roles—direct care nurse, unit manager, staff development coordinator, assessment coordinator—not to mention earning a JD and an MEd along the way, she started working at Genesis Healthcare in 2007, where she eventually became the operator’s vice president of legislative affairs. The role empowered her to draw upon her time with residents as she worked directly with policymakers, ensuring that the regulations they drafted helped the people they were meant to help. <br></p><p>“It allowed me to take my experience as a nurse and educate the people who make decisions—who make the laws, who make the regulations—about how we do what we do and how the legislation they write impacts us,” she said. “I always saw myself as an educator: I was there to help let them know that we are a resource, we want to collaborate, and we all want the same things—quality care and great outcomes for our residents.”<br></p><p>Having served in a wide range of positions and settings, from the memory care unit to the emergency room, Bethea has seen again and again that there truly is no one-size-fits-all approach to care. No two nursing homes are the same, no two units are the same, and no two care plans are the same, because no two residents are the same. This perspective has long informed her approach to advocacy work on a variety of critical issues, such as the new minimum staffing rule, which she describes as a blanket solution to a complex set of problems that does nothing to address the structural issues causing those problems. In other words, it’s exactly the sort of one-size-fits-all strategy that completely misunderstands how nursing homes work.<br></p><p>“We need a more deliberate approach to how we determine staffing needs, based on the needs of residents in each setting,” she explained. “It’s not the same in every single nursing home, just like it’s not the same in acute care versus post-acute care. A person who comes up with this rule doesn’t recognize that there is a variety of different residents in each of the types of settings that we have.”</p><h3>Being an Effective Voice</h3><p>When Bethea joined NCAL in 2021, her top priority was to hit the road. At Genesis, she advocated for almost 250 facilities in 22 states; now she represented thousands of facilities across every state. To be an effective voice for communities, residents, and employees, she’d have to meet them face-to-face, gaining a deeper understanding of their experiences and needs. <br></p><p>“I wanted to make sure that my voice is reflective of what’s happening in the various settings that I represent,” she recalled. “An assisted living facility in Oregon is very different from one in California, very different from Texas and Maryland. Going into those communities allows me to take that firsthand experience to legislators in D.C., and to make sure they’re aware that you can’t take one piece of legislation and use it to kind of paint that broad brush across the industry.”<br></p><p>Another priority is helping policymakers (and everyone else) understand what assisted living is and how it works. While the industry has received more attention in recent years, Bethea acknowledged that this attention often focuses on negative stories, isolated as they may be. <br></p><p>On one hand, the COVID-19 pandemic helped people understand what distinguishes assisted living from other care settings, such as home health and skilled nursing. On the other hand, common misconceptions remain prevalent—like the notion that assisted living isn’t regulated. The fact that it’s regulated at the state level, Bethea pointed out, is why it’s so misguided for policymakers to approach the sector with a broad brush. “Because it’s different in every state,” she argued, “it’s better to have hands that are closer to what it looks like at that level, rather than make a rule that would apply across all 50 states.”</p><h3>Fostering the Next Generation of Leaders</h3><p>As a leader, Bethea also considers it her responsibility to help cultivate and mentor other leaders. She thinks back to a former mentor at Genesis Healthcare, Marie Quinn, who once gave her some valuable encouragement before an anxiety-inducing presentation to senior executives. <br></p><p>“She said, ‘There’s no one better positioned to present this information than you,’” Bethea recalled. “‘If you go in the room and present as if you are uncomfortable or not confident, then people will receive it that way. But if you go into the room and present this information based on your own experience, the research that you’ve done that you’re confident about, people will walk away from that meeting understanding that you are the person that they need to go to with any questions; that you are the most knowledgeable person on this issue.’” <br></p><p>The pep talk was a game changer. Not only did it inform the presentation she was about to give, it stuck with her throughout every meeting she’s walked into since. “It’s something that I share with other people,” she said. “When I’m doing leadership presentations, I tell them about that experience, because it was so powerful and impactful for me.”</p><h3>‘It Warms Your Heart’</h3><p>Despite the challenges ahead, Bethea is looking forward to the future. She’s especially excited about the potential for new technology, such as wearable health trackers and AI solutions, to transform the assisted living space, making care workers’ lives easier and improving patient outcomes. <br></p><p>“Obviously we need the human touch; it’s a vital part of what we do,” she stressed. “But there are ways that we can complement the staff to be more efficient, and we can do that with AI. I’ve been visiting communities around the country and seeing some of the things that they’re doing, and it’s extremely exciting. We’re just scratching the surface of how technology will help us support our existing workers in our field.”<br></p><p>And, of course, she’s excited to continue doing her favorite part of the job: traveling the country and meeting the people she represents. “When you go into the communities and the nurses and the nurse aides and the other caregivers, like the environmental service and the housekeeping workers—when you see how they engage the residents, it warms your heart,” she concluded. “You can envision your own mom and dad there, enjoying themselves and having the best part of their life being in this community.” <br><br><em>Steve Manning is a freelance writer from New York City.</em></p> | 2024-09-11T04:00:00Z | <img alt="" src="/Issues/2024/Fall/PublishingImages/NCAL.jpg" style="BORDER:0px solid;" /> | Caregiving | Having served in a wide range of positions and settings, from the memory care unit to the emergency room, Bethea has seen again and again that there truly is no one-size-fits-all approach to care. |
| How PharMerica Can Help Facilities Amid New Staffing Mandate Requirements | <p>The Biden Administration’s recently announced minimum staffing rule will require nursing homes to hire an estimated 102,000 nurses and nurse aides, costing approximately $6.5 billion per year. While AHCA/NCAL and other organizations are fighting to prevent the mandate from taking effect, long-term care providers across the country are readying themselves for the additional pressures it will place on their operations.<br></p><p>As a trusted partner to thousands of providers across the country, PharMerica understands that filling prescriptions is just one small part of its role. Its dedicated local account management teams, consultant pharmacists, and nurse consultants provide hands-on support for each client, offering training and resources, conducting monthly medication reviews, participating in QAPI meetings, and integrating themselves into their communities. PharMerica is well prepared to help providers contain costs, enhance efficiencies, and mitigate the negative impacts of new hiring requirements. </p><h3>Streamlining Onboarding and Training</h3><p><img src="/Issues/2024/Fall/PublishingImages/DalePadgett-Pharmerica.jpg" alt="Dale Padgett" class="ms-rtePosition-1" style="margin:5px;" />PharMerica has streamlined its client onboarding process and offers a comprehensive training program. “We not only engage direct stakeholders but also unit-level staff to ensure they understand how to order medications, use the EMR platform, communicate with the pharmacy, refill orders, and manage IVs,” Dale Padgett, senior vice president, client strategy and partnerships, explained. <br></p><p>“We provide essential training,” added Rebecca Wingate, vice president of clinical operations, “especially about pharmacy processes and medication management, policies and procedures, and compliance requirements with regard to anything from high-risk medications to specific disease states like diabetes, CHF, and hypertension.”<br>This training is especially important for facilities dealing with staffing shortages whose clinical infrastructure may be more interim or transitional in nature. PharMerica also enables facilities to address skills gaps among new hires with standard educational offerings that ensure inevitable workforce turnover doesn’t come with negative impacts. </p><h3>Identifying Savings Opportunities to Reduce Operational Costs</h3><p>Meeting new staffing requirements will force facilities to look at other areas to cut costs, and many could save up to 20 percent on pharmacy spend annually. PharMerica’s goal is to explore lower-cost alternatives that maintain equal efficacy, optimize medication usage in terms of dosage and duration, and design specific interventions based on its clients’ referral sources’ prescribing trends.<br></p><p><img src="/Issues/2024/Fall/PublishingImages/Creasy-Pharmerica.jpg" class="ms-rtePosition-2" alt="Stephen Creasy" style="margin:5px;" />PharMerica achieves this goal by developing a personalized approach for each partner facility, recognizing there is no one-size-fits-all approach. “We partner directly with the medical director and the prescribers in the facility, with our consultant pharmacist working hand-in-hand on ordering labs, recommending medication adjustments or gradual dose reductions, and providing education to nursing staff on whatever they may be challenged with,” Wingate said. “Since we’re a guest in that facility, we really try to build that trust and that ongoing collaboration.”<br></p><p>PharMerica develops customized solutions based on a client’s unique circumstances and other relevant factors. “We have a very robust therapeutic interchange program that we administer—where allowed by pharmacy rules and regulations—in which we’re looking for equally efficacious alternatives to higher-cost medications,” Stephen Creasy, senior director, clinical services, explained. “We’re constantly evaluating and looking for new opportunities because we do know how expensive some of these medications are.”<br></p><p>An important part of this approach is identifying and addressing a facility’s unique pain points. In one recent case, a client had a high number of residents using IV medications. “We needed to understand how they train their nurses, and they needed to understand how our nurses help support residents that have IVs,” Padgett recalled. <br></p><p>With 80 percent of nursing homes expected to have to hire more RNs to meet the 24/7 RN requirement, PharMerica’s cost-saving measures can be instrumental in enabling facilities to redirect funds to hiring to comply with the mandate. “By spending less money on medications when there are therapeutic equivalents or other alternatives, they can free up cash flow and regain efficiencies with the nursing staff,” Creasy concluded. “It’s about doing more with less.”</p><h3>An Eagle’s Eye for Compliance Issues</h3><p>In cases where facilities have larger staffing gaps at the nursing or unit levels, PharMerica steps in to help fill them. “We provide a variety of resources to make sure that the facility is able to continue operating compliantly,” said Padgett.<br></p><p><img src="/Issues/2024/Fall/PublishingImages/RebeccaWingate_Pharmerica.jpg" alt="Rebecca Wingate" class="ms-rtePosition-1" style="margin:5px;" />These resources include compliance recommendations, survey preparation and support, and detailed action plans to ensure compliance during transitions and turnover. Then there’s Illuminate, the online educational platform that PharMerica maintains for its partners. “We have webinars where we provide continuing education, clinical resources, quality digests, podcasts, newsletters, bulletins, guides, and comprehensive resources for compliance,” Wingate explained. “We’re very adept at staying ahead of the latest CMS changes and ensuring the success of our customers in regard to compliance changes.” <br></p><p>The regulatory landscape is in constant flux, forcing providers to navigate a complex and ever-changing web of rules and requirements. Last October, for instance, CMS imposed new requirements on the MDS coding of some high-risk medications—and it’s already updating these requirements effective this coming October. “We’re already modifying our reporting that will be available to our client facilities, so they will be able to do that portion of the assessment much quicker,” Creasy said.<br></p><p>By keeping abreast of developments at the state and federal levels, PharMerica helps ease the burden on its partners—an especially valuable level of support as they deal with the additional pressures of the new staffing rule. <br></p> | 2024-09-11T04:00:00Z | <img alt="" src="/Issues/2023/Fall/PublishingImages/Pharmerica.jpg" style="BORDER:0px solid;" /> | Workforce | PharMerica develops customized solutions based on a client’s unique circumstances and other relevant factors. |
| Suicide Risk in Older Men Is a Growing Challenge for LTC Providers | <p><img src="/Articles/PublishingImages/740%20x%20740/sad_senior_man.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />In late 2023, an assisted living facility in southeastern Pennsylvania was shocked by the suicide of an 81-year-old resident. No one had any idea that he was at risk of suicide. No one realized that four men aged 75 and older take their lives in that state every week, and well over 700 men aged 65 and over die by suicide in the United States each month.</p><p>In-house suicide risk among long term care providers is increasing with a steadily growing segment of residents. Men aged 75-85 and older have long had the highest suicide rates of any age group. This tragic distinction will persist and worsen in coming decades as Baby Boomers, a generation characterized by a high incidence of suicide across the lifespan, age out.</p><p>Suicide risk in older men must be acknowledged and aggressively addressed. Little suicide prevention targets the “oldest old” in general and less still focuses on the oldest men. More problematic is a comparable lack of awareness of the problem among those who serve and advocate for older adults. </p><h3>Know the Risk Factors of Suicide</h3><p>Providers must be familiar with the major risk factors for suicide in older men:<br></p><ul><li>Caucasian </li><li>History of suicidal behavior or self-injury</li><li>Physical/psychological harm/sexual assault/domestic conflict</li><li>Social disconnectedness and isolation</li><li>Financial loss/insecurity/exploitation</li><li>History or presence of psychiatric disorders</li><li>Chronic illnesses; disabilities; other impediments to independent living</li><li>Veteran; military service</li></ul><p>Suicidal thoughts may arise after a hospitalization that results in chronic pain, impaired mobility, reduced autonomy, or other conditions limiting self-care. </p><h3>Circumstances Conducive to Suicide Risk</h3><p>Providers must pay attention to conditions that may trigger suicidal thoughts in older men such as:<br></p><ul><li>Loss of spouse or partner</li><li>Depression and anxiety</li><li>Worsening of a long term chronic illness</li><li>Onset of comorbid medical/neurological illness</li><li>Feeling a loss of dignity and control</li><li>Pessimism and seeing life as pointless</li></ul><p>Providers should be alert to suicide risk in new residents. Giving up one’s home, community ties, and residing with a spouse or partner are disruptive and traumatizing experiences. These factors are aggravated when such life transitions occur because of an inability to manage activities of daily living or the death of a caregiver spouse. </p><h3>How Suicide Attempts Happen</h3><p>The prevailing theory of suicide posits two prerequisites to a potentially fatal suicide attempt: (i) an extremely strong desire to die; and (ii) the capability for lethal self-harm. Intent to die arises from a strong belief that one is a burden to others and/or the belief that one does not belong.</p><p>Negative self-perceptions can produce a desire to die. These may lead to a sense of entrapment and defeat. Burdensomeness follows from thinking that one’s death may be more valued than one’s life. A lack of belonging flows from an unmet need for social relationships and a belief that one is not cared for by relatives and friends. Internalization of ageist views may also foment suicidal thinking.</p><p>An ability for lethal self-injury must be present for suicidal desire to become suicidal action and override the instinct for self-preservation. Attempting suicide requires the capability for serious self-harm. This is fostered by an elevated pain tolerance, a diminished aversion to severe injury, and a reduced fear of death.</p><p>Exposure to hurtful, painful, or violent experiences such as self-neglect and self-injury, elder abuse, interpersonal violence, and other types of trauma promote suicide capability. Repeated physical abuse may bring about indifference to living and lower resistance to both thoughts and acts of self-harm.</p><h3>Warning Signs of Suicide</h3><p>Providers must recognize behaviors possibly signaling the presence of suicidality. Examples are statements about being a burden to spouse or family or that they would be better off if he were dead. Other warning signs include:<br></p><ul><li>Feeling useless, purposeless, and hopeless</li><li>Increasing alcohol use or misuse of prescription medications</li><li>Withdrawing from family, friends, or community activities</li><li>Major mood shifts</li><li>Onset of anxiety, agitation, and sleep problems</li></ul><p>Sadly, signs such as these appear all too evident after a suicide. They may be missed in older men who live alone, have minimal social connections, do not engage with caregivers or deliberately hide their feelings. </p><p>Immediate intervention (911) is necessary when imminent danger is indicated by:<br></p><ul><li>Threats of serious self-injury or suicide</li><li>Seeking lethal means such as weapons, medications, toxins</li><li>Voicing an actionable suicide plan giving the when, how, and possibly where </li></ul><h3>Screening for Suicide Risk</h3><p>Screening is a means of detecting thoughts or actions that may signal danger. It generally relies on a structured instrument that distinguishes where a particular individual stands in relation to selected suicide risk factors.</p><p>A suicide risk screener should be brief, easy to use, and have demonstrated validity. An example is the Columbia-Suicide Severity Rating Scale (C-SSRS), which is freely available online and does not require any special training. </p><p>The C-SSRS consists of six questions:<br></p><ol><li>Have you wished you were dead or wished you could go to sleep and not wake up?</li><li>Have you had any thoughts of killing yourself?</li><li>Have you been thinking about how you might do this?</li><li>Have you had these thoughts and had some intention of acting on them?</li><li>Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?</li><li>Have you ever done anything, started to do anything, or prepared to do anything to end your life?</li></ol><p>Suicide risk screening and assessment is not a “one and done” event in older men.</p><h3>Concluding Comments</h3><p><span><em><img src="/Articles/PublishingImages/2024/Tony%20Salvatore.jpg" alt="Tony Salvatore" class="ms-rtePosition-2" style="margin:5px;width:150px;height:184px;" /></em></span>Given the inherently high risk of suicide in older men, providers must accept that it may occur in their facility at some point. They must create a context for suicide prevention by making it a policy and practice. There must be ongoing suicide prevention training for all staff and routine resident suicide risk-screenings. Providers must accept that the emergence of suicidal ideation among residents is a hazard akin to falls and infection and treat it similarly. <br><br><em>Tony Salvatore, MA, is the director of suicide prevention at Montgomery County Emergency Service in Norristown, PA. He has a background in home care and long term care and has published several articles on older adult suicide prevention in those settings. He may be contacted at tsalvatore@mces.org.</em><br></p> | 2024-09-05T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/sad_senior_man.jpg" style="BORDER:0px solid;" /> | Caregiving | Suicide risk in older men must be acknowledged and aggressively addressed. Little suicide prevention targets the “oldest old” in general and less still focuses on the oldest men. |
| How to Put Medicare Advantage CY24 Changes into Action | <p><img src="/Articles/PublishingImages/740%20x%20740/dr_tech_medical.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:260px;height:185px;" />The evolving health care landscape continues to present new opportunities for skilled nursing facilities (SNFs) and Medicare Advantage (MA) beneficiaries to access necessary care. The powerful changes included in the Medicare Advantage Contract Year 2024 Final Rule, which took effect at the beginning of 2024, are reshaping how care is accessed and managed. As we navigate through the current year, these changes remain crucial for SNFs to leverage.</p><h3>Significant Changes Impacting SNFs</h3><p>The most impactful updates drastically affect prior authorization and medical necessity determination. The MA Final Rule specifies that prior authorization will only be used to confirm a diagnosis or other medical conditions. Once a diagnosis is confirmed, beneficiaries no longer need prior authorization from their MA insurer. For instance, a beneficiary admitted from the hospital with a confirmed diagnosis bypasses the need for prior authorization. Furthermore, once prior authorization is granted, it remains valid as long as medically necessary.</p><p>Medical necessity determination has also shifted. Now, it is based on a beneficiary’s prior medical history and the recommendation of the treating physician. Previously, the MA insurer’s medical director determined medical necessity. This change allows the treating physician to make the decision, improving beneficiaries' access to comprehensive care.</p><p>Additionally, MA plans are required to align coverage more closely with traditional Medicare, adhering to its benefit guidelines, Local Coverage Determinations, and National Coverage Determinations. When coverage criteria are undefined, MA insurers may use internal guidelines, which must be publicly available and summarized with evidence considered during development.</p><p>New network requirements for Medicare Advantage organizations (MAOs) mandate MA insurers to reimburse facilities at the PDPM rate when working out-of-network. Interestingly, providers working in-network are often paid less than their out-of-network counterparts.</p><h3>The Growing Impact of Medicare Advantage Plans</h3><p>Medicare Advantage is not just a passing trend; its influence is here to stay and grow. In 2023, more than 50 percent of all Medicare-eligible beneficiaries were enrolled in an MA plan. This trend is expected to continue, with enrollment rates rising in many regions across the United States. As MA plans become more dominant, SNFs must adapt to ensure they can effectively manage these relationships and maintain census levels.</p><p>Rate erosion should be a strong consideration for when forecasting future budgets and roadmaps. Providers may use their quality mix to determine financial success, but need to look closely at what payers make up that quality mix. Most MA plans pay less than the Traditional Medicare Default rate, with some plans paying as low as Medicaid rates. Many providers are still budgeting at a fee-for-service Medicare rate, when the patients they’re admitting are MA beneficiaries, with rates that could be up to 50 percent less than what was budgeted.</p><p>Given this substantial growth, it is vital for SNFs to understand and navigate the complexities of MA plans. Providers who fail to do so risk falling behind as the MA landscape evolves.</p><h3>Taking Action</h3><p>This progress empowers SNFs to reclaim control from MA insurers. However, challenges persist as some insurers resist complying with new requirements that may impact their financial interests. Often, information is not communicated effectively; MA case managers might be unaware of or misinterpret the MA Final Rule’s requirements.</p><p>Given that Medicare Advantage remains prevalent, with over 50 percent of Medicare beneficiaries enrolled in an MA plan, SNFs must strategically manage these insurers. Here’s how:<br></p><ol><li>Understand the MA Final Rule: Ensure familiarity with the rule’s specifics. Your case manager and admissions director should have a copy and be well-versed in its details.</li><li>Initiate Conversations: Proactively engage with MA case managers. Clearly communicate your understanding of the new requirements and set your expectations.</li><li>Address Non-Compliance: If insurers push back, inform them you will contact your CMS regional office. Highlight how their actions limit beneficiary access to care. Use key phrases such as:</li></ol><ul dir="ltr" style="text-align:left;"><li>“The MAO is limiting beneficiary’s access to care.”</li><li>“The MAO is not providing the same coverage as traditional Medicare.”</li><li>“The MAO is not following the current MA Final Rule guidelines.”</li></ul><p>CMS Regional Offices Contact Information<br></p><ul><li>Atlanta: (404) 562-7150 (AL, FL, GA, KY, MS, NC, SC, TN)</li><li>Boston: (617) 565-1188 (CT, ME, MA, NH, RI, VT)</li><li>Chicago: (312) 886-6432 (IL, IN, MI, MN, OH, WI)</li><li>Dallas: (214) 767-6427 (AR, LA, NM, OK, TX)</li><li>Denver: (303) 844-2111 (CO, MT, ND, SD, UT, WY)</li><li>Kansas City: (816) 426-5233 (IA, KS, MO, NE)</li><li>New York: (212) 616-2200 (NJ, NY, PR, VI)</li><li>Philadelphia: (215) 861-4140 (DE, MD, PA, VA, DC, WV)</li><li>San Francisco: (415) 744-3501 (AS, AZ, CA, GU, HI, NV, MP)</li><li>Seattle: (206) 615-2306 (AK, ID, WA, OR)</li></ul><h3><img src="/Articles/PublishingImages/2024/MaureenMcCarthy.jpg" alt="Maureen McCarthy" class="ms-rtePosition-2" style="margin:5px;width:150px;height:184px;" />Looking Ahead</h3><p>The future holds more changes. The CY 2025 MA Final Rule, released in April 2024, details new requirements for the MA appeal process. Effective January 1, 2025, MA beneficiaries will have access to a five-level system similar to traditional Medicare appeals. This change would involve independent reviewers from CMS-affiliated Quality Improvement Organizations (QIO) handling appeals of MA plan service terminations. Further, the CY 2025 MA Final Rule fully eliminates current regulations that require MA beneficiaries to forfeit their right to appeal a termination of services to the QIO when discharged from a SNF. <br><br><em>Maureen McCarthy is the CEO and Founder of Celtic Consulting, a long term care advisory firm that delivers operational, clinical, and financial support to health care providers. McCarthy can be reached at <a href="mailto:mmccarthy@celticconsulting.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">mmccarthy@celticconsulting.org</a> or 860-321-7413.</em><br></p> | 2024-08-29T04:00:00Z | <img alt="" height="398" src="/Articles/PublishingImages/740%20x%20740/dr_tech_medical.jpg" width="568" style="BORDER:0px solid;" /> | Medicare Advantage | The powerful changes included in the Medicare Advantage Contract Year 2024 Final Rule, which took effect at the beginning of 2024, are reshaping how care is accessed and managed. As we navigate through the current year, these changes remain crucial for SNFs to leverage. |
| Distinguish Quality Measure Exclusions from Clinical Standards in Long Term Care | <p><img src="/Articles/PublishingImages/740%20x%20740/senior_nurse_1.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:300px;height:211px;" />In the long term care profession, understanding the differences between Quality Measure (QM) exclusions outlined by the Centers for Medicare & Medicaid Services (CMS) and clinical standards of practice can be challenging.</p><p>For example, a nurse assessment coordinator (NAC) states, “CMS only allows two diagnoses for an indwelling catheter: uropathy and neurogenic bladder.” Although the NAC has identified the two diagnoses that can exclude a resident from the QM for indwelling catheter, he or she fails to recognize the other appropriate clinical indications for use.</p><p>The ability to distinguish between these two components is essential for ensuring proper care delivery and careful reporting in nursing home facilities. This article highlights the key distinctions between QM exclusions and clinical standards of practice and how putting the resident at the center of the care decisions can guide the NAC in the right direction. </p><h3>Quality Measure Exclusions</h3><p>When discussing QM exclusions, CMS does not mandate specific indications for medical interventions, such as the use of indwelling catheters. Instead, CMS identifies certain diagnoses or conditions that are beyond the control of the facility and, therefore, should not count against the facility for quality measurement. For instance, CMS outlines several QM exclusion criteria related to the long-stay indwelling catheter measure, including admission assessments or the 5-day assessment, missing catheter status, and specific diagnoses, such as neurogenic bladder and obstructive uropathy.</p><p>Here's another example: The long-stay QM for residents receiving an antipsychotic medication excludes residents who have missing data for antipsychotic medication use or a diagnosis of schizophrenia, Tourette’s syndrome, or Huntington’s disease from triggering this measure.</p><p>However, facility teams must recognize that CMS does not limit the facility to using these exclusionary diagnoses as the only appropriate diagnosis for the clinical condition. Teams must work with the primary physician to identify the clinical indication for each resident, regardless of the impact on the QMs. </p><h3>Clinical Standards of Practice and Clinical Indications </h3><p>Contrary to QM exclusions, clinical standards of practice offer guidelines for appropriate indications and the use of medical interventions like indwelling catheters in long term care settings. These standards aim to optimize resident care while minimizing risks and complications.</p><p>The <a href="https://www.cdc.gov/infection-control/media/pdfs/guideline-cauti-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Centers for Disease Control and Prevention’s (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections</a> lists clinical guidelines for appropriate catheter use.<sup>1</sup> Examples of correct indications for indwelling urethral catheter use according to this guideline are acute urinary retention, perioperative needs, wound healing assistance, prolonged immobilization, and end-of-life comfort care. Conversely, inappropriate uses of catheters are substituting them for nursing care, unnecessary urine collection, or prolonged postoperative usage without suitable indications.</p><p>Regarding clinical indications for antipsychotic medications, many conditions, in addition to those that exclude the resident from the antipsychotic QM, may still warrant a physician to prescribe an antipsychotic medication. One guideline for this decision comes from a <a href="https://www.ncbi.nlm.nih.gov/books/NBK519503/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">StatPearls article</a><sup>2</sup> that identifies several additional indications for antipsychotic medication use: acute mania, major depressive disorder with psychotic features, delusional disorder, severe agitation, borderline personality disorder, dementia and delirium, substance-induced psychotic disorder, Parkinson’s disease, Lesch-Nyhan syndrome, and pervasive developmental disorder. </p><p>Focusing on Resident Well-Being and Investigating QM Triggers for Accurate Reporting and Interventions<br>Although nursing home facilities must strive for continuous quality improvement, resident-centered care must be prioritized. By focusing on resident well-being and addressing the underlying causes of QM triggers, facilities can achieve more precise Minimum Data Set (MDS) assessments, care plans, and QM reporting.</p><p>To ensure the well-being of the resident, the team must identify current and active diagnoses correctly. In some instances, the medical record does not provide the details to support coding the specific diagnosis or the use of a medical device. Facility teams should query the physician to ensure the diagnoses represent the resident’s conditions accurately.</p><p>Consider a resident with prostate cancer who has an indwelling catheter for urine output due to his enlarged prostate that is likely causing obstructive uropathy. But the resident does not have this diagnosis in the medical record. Querying the physician in this situation will improve the accuracy of the medical record, support the use of the medical device, ensure an appropriate care plan, and lead to better QM reporting by appropriately excluding the resident.</p><p>CMS acknowledges that facilities have residents who trigger for different measures, and based on the resident population, they may do better in some measures than others. CMS does not expect facilities to prevent all residents from triggering any of the measures because clinical conditions require interventions like an indwelling catheter or antipsychotic medication administration. Therefore, the care team should focus on ensuring the appropriateness and the need for such interventions in individual resident care plans.</p><p>Unfortunately, some facility staff may feel pressured to seek out a diagnosis from the provider, even if the medical record does not support the diagnosis, just to improve QM outcomes. This type of practice prompted CMS to initiate the schizophrenia coding audits in January 2023. The <a href="https://www.cms.gov/files/document/qso-23-05-nh-adjusting-quality-measure-ratings-based-erroneous-schizophrenia-coding-and-posting.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">QSO-23-05-NH</a> memo stated, <br></p><p dir="ltr" style="text-align:left;">CMS is concerned that some nursing homes have erroneously coded residents as having schizophrenia, which can mask the facilities’ true rate of antipsychotic medication use. Therefore, CMS will conduct offsite audits of schizophrenia coding and, based upon the results, adjust the quality measure star ratings for facilities whose audit reveals inaccurate coding.<sup>3</sup></p><p>Regardless of QM outcomes, facility teams must always ensure the accuracy of diagnosis coding and not lead the physician to state a vague or imprecise diagnosis to change outcomes.</p><h3>Aligning Quality Measures with Resident-Centered Care</h3><p>The disparity between QM exclusions and clinical standards of practice highlights the importance of holistic resident care in long term care facilities. Facility teams must ensure the diagnoses and the MDS represent the resident fairly. This accuracy will result in a care plan that is resident-centered and QM outcomes that represent the resident’s care in the facility.</p><p>Consider a resident who has an indwelling catheter to promote healing for a Stage 3 pressure ulcer to the coccyx. Although this resident will trigger the indwelling catheter QM, the facility team must recognize that the catheter is medically appropriate and clinically indicated. The resident-centered care plan would reflect the catheter as an intervention to keep the skin dry while the wound is healing. The MDS, care plan, and QMs must all align to accurately represent the resident and the care provided.</p><p>Ultimately, the goal remains the same: to promote the highest practicable physical, mental, and psychosocial well-being of every resident in long term care. Through careful consideration of appropriate QM exclusions and clinically indicated practices based on the resident’s needs, goals, and preferences, the facility team can ensure QM and MDS accuracy while providing resident-centered care. <br><br><em>Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, is curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).<br></em></p><p><em><br></em></p><h4>References<br>1.    Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., Pegues, D.A., & Healthcare Infection Control Practices Advisory Committee. (2019). <em>Guideline for prevention of catheter-associated urinary tract infections 2009. Centers for Disease Control and Prevention. </em><br>2.    Chokhawala, K., & Stevens, L. <em>Antipsychotic medications.</em> [Updated 2023 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. <a href="https://www.ncbi.nlm.nih.gov/books/NBK519503/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK519503/#</a><br>3.    Centers for Medicare & Medicaid Services. (2023). <em>Updates to the nursing home Care Compare website and Five Star Quality Rating System: Adjusting quality measure ratings based on erroneous schizophrenia coding, and posting citations under dispute. </em><a href="https://www.cms.gov/files/document/qso-23-05-nh-adjusting-quality-measure-ratings-based-erroneous-schizophrenia-coding-and-posting.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https://www.cms.gov/files/document/qso-23-05-nh-adjusting-quality-measure-ratings-based-erroneous-schizophrenia-coding-and-posting.pdf</a></h4><p></p> | 2024-08-13T04:00:00Z | <img alt="" height="519" src="/Articles/PublishingImages/740%20x%20740/senior_nurse_1.jpg" width="740" style="BORDER:0px solid;" /> | Caregiving | This article highlights the key distinctions between QM exclusions and clinical standards of practice and how putting the resident at the center of the care decisions can guide the NAC in the right direction. |
| Health Care’s Value Revolution Focusing on Quality Over Quantity | <p><strong class="ms-rteForeColor-2">ADVERTORIAL</strong><br></p><p><span><img src="/Articles/PublishingImages/2024/Curana-Advertorial-Man%20with%20Provider.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" /></span>Provider financial returns have long been driven by the quantity of services provided, not the outcomes that were achieved. However, as we journey deeper into the 21st century, it’s becoming clear that this volume-driven approach is no longer sustainable, nor beneficial to patients.</p><p>The traditional fee-for-service (FFS) model can negatively impact patient care through a focus on quantity over quality, driving fragmented treatment plans while contributing to shorter clinician-to-patient interactions. This is especially true for seniors, who benefit the most from personalized, holistic care that takes their individual needs and quality of life into consideration.</p><p>In response, many skilled nursing facilities (SNFs) and assisted living facilities (ALFs) are making the transition from the traditional FFS model to value-based care: both to better serve their residents’ complex health needs and to share in the savings created by producing better outcomes.</p><p>A national leader in value-based care services and innovative payment models for senior living, <a href="https://curanahealth.com/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Curana Health</a> is proud to be at the forefront of health care’s value revolution. We’re also honored to support SNFs and ALFs on their own value-based care transitions. </p><h3>Understanding Value-Based Care</h3><p>Value-based care is transforming the health care financing system to prioritize patient outcomes over the number of services rendered, and by 2030, 100 percent of Medicare beneficiaries will be required to participate in a value-based care plan.</p><p><img src="/Articles/PublishingImages/2024/Jeremy-Dressen.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:109px;height:135px;" />“This model is built on a foundational principle that individual patient outcomes should be the ultimate goal of the health care system,” says Jeremy Dressen, president of Curana Health Plans. “Better health and quality of life are often not achieved in the most intensive care settings or through the highest number of billable events. We believe in empowering—and paying—providers to take the extra time to understand their patients’ needs and manage individual care plans that focus on preventive and holistic care, with the aim of keeping patients in their homes longer and avoiding unnecessary hospital visits.”</p><p>In addition to enabling better care for senior living residents, value-based models also provide new revenue streams for improving quality and reducing unnecessary costs.</p><p>“SNFs and ALFs can unlock meaningful financial incentives by jumping into value-based care,” says Jon Karl, vice president of value-based payment programs at Curana Health. “Investing upfront in data-driven, preventive care and putting patient outcomes first improves patients’ quality of life, reduces avoidable cost and utilization, and rewards providers with shared savings and performance bonuses through partnerships with accountable care organizations and Medicare Advantage plans.”</p><h3>The Case for Value Over Volume</h3><p>Transitioning to value-based care offers many benefits, including:</p><h4>1. Improved Patient Outcomes and Census</h4><p>At the heart of value-based care is the goal of improving patient health. When payments are made based on outcomes instead of actions, your residents benefit tremendously through:<br></p><ul><li>Improved management of chronic conditions and medications.</li><li>Reductions in avoidable hospitalizations and unnecessary emergency room visits.</li><li>Enhanced care coordination, ensuring that patients receive the proper care from the right clinician at the right time.</li><li>A strong focus on preventive services.</li></ul><p>“Overall, value-based care helps keep residents in their communities longer, something that is both beneficial to operators and the individuals who call the facilities home,” Dressen said. “Various studies have found that 40 percent or more of hospitalizations in the long-term care eligible population were potentially avoidable, which is on-par with the reductions Curana achieves in working with our clinicians and facility operators.”</p><h4>2. Cost Efficiency</h4><p>One of the most significant benefits of value-based care is its potential to reduce unnecessary health care costs. In a volume-driven model, the emphasis on performing more procedures and providing more services can lead to excessive and unnecessary spending that often does not improve the patient’s quality of life.</p><p>In contrast, value-based care models encourage and incentivize the delivery of efficient, coordinated care that eliminates waste and reduces health care spending long-term. Providers are rewarded through various incentive structures, including shared savings programs (where they receive a portion of the savings generated from reduced health care costs) and performance bonuses (which are awarded for meeting specific quality and efficiency benchmarks).</p><h4>3. New Revenue Streams </h4><p>By joining an accountable care organization, SNFs and ALFs collaborate with a network of health care organizations dedicated to delivering high-quality, coordinated care to their patients. This partnership allows participating facilities to earn shared savings by improving quality of care and reducing unnecessary costs for their residents.</p><p>By participating in Medicare Advantage plans, facilities can earn additional revenue by meeting or exceeding specific quality and cost benchmarks developed in partnership with the plan. Additionally, senior living organizations ready to dive headfirst into value-based care can develop their own Medicare Advantage plans, receiving the full capitation rate from the Centers for Medicare & Medicaid Services.</p><h4>4. Decreased Staff Burden</h4><p>In SNF and ALF settings, value-based care increases the on-site presence of physicians, nurses, and advanced practice clinicians. This is funded by the cost reductions anticipated or achieved through reducing avoidable and unnecessary costs.</p><p><span><img src="/Articles/PublishingImages/2024/Jon-Karl.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:109px;height:134px;" /></span>“This expansion of resources and focus on reducing unnecessary utilization can decrease the burden on your facility’s existing staff, reducing burnout and allowing for increased support for each resident under your care,” Karl said. “We’ve seen this across the board with our partner organizations. In fact, one of our ALF partners saw more than a 100-percent increase in employee happiness upon implementing value-based care in their facilities.” </p><h3><span><span><span><span></span></span></span></span>The Path Forward for Skilled Nursing and Senior Living Facilities</h3><p><span><span><span></span></span></span>The transition to value-based care represents a fundamental shift in the health care landscape. By prioritizing quality over quantity, SNFs and ALFs can not only improve their residents’ health, but also increase their revenue.</p><p><span><span></span></span>Today, skilled nursing and senior living facilities have the opportunity to be at the forefront of value-based care—why shouldn’t your organization lead the charge? </p><p><span></span><em>Jeremy Dressen is president of health plans for Curana Health. Jon Karl serves as vice president of value-based payment programs for Curana Health.</em></p><p><em>Driven by the mission of improving senior living residents’ health, happiness, and dignity, Curana Health is dedicated to advancing the adoption of value-based care and transforming the health care experience for senior living residents. Curana’s medical group offers primary, post-acute, and multi-specialty care to seniors in skilled nursing facilities, assisted and independent living communities, and memory care settings. Curana’s accountable care organizations and health plan partnerships support the medical group’s personalized, proactive, and coordinated clinical care model. Additionally, Curana Health’s owned and operated Medicare Advantage Special Needs Plans make care more accessible and affordable for residents, while also offering skilled nursing facilities and senior living operators enhanced operational capabilities and new financial opportunities aligned to improved clinical outcomes. Currently, Curana’s 1,000+ clinicians serve approximately 175,000 patients annually, spanning 34 states and 1,600+ senior living sites. To learn more, visit </em><a href="https://curanahealth.com/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank"><em>curanahealth.com.</em></a></p><p style="text-align:center;"><a href="https://curanahealth.com/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank"><img src="/SiteCollectionImages/logos/curana.jpg" alt="" style="margin:5px;width:250px;height:73px;" /></a><br></p> | 2024-07-30T04:00:00Z | <img alt="" src="/Articles/PublishingImages/2024/Curana-Advertorial-Man%20with%20Provider.jpg" style="BORDER:0px solid;" /> | Caregiving | Provider financial returns have long been driven by the quantity of services provided, not the outcomes that were achieved. However, as we journey deeper into the 21st century, it’s becoming clear that this volume-driven approach is no longer sustainable, nor beneficial to patients. |