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Nursing Facilities & Physicians: Working Togetherhttps://www.providermagazine.com/Issues/2010/Pages/0110/Nursing-Facilities--Physicians-Working-Together.aspxNursing Facilities & Physicians: Working Together<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>It’s 2 a.m., and a long term care facility resident has a fever and stomach pain. What happens next says a great deal about the relationship between facility staff and the attending physician.</p> <p>As the aging population grows and more physicians follow their community-based patients into assisted living and nursing facilities, administrators, nurses, and others must find ways to successfully establish and maintain relationships with clinicians who may have little experience working in the long term care continuum. At the same time, physicians must learn the unique policies, protocols, personnel, and communications systems of facilities that vary in size, type, and demographics. </p> <div>Fortunately for everyone, the answer to these challenges may be in reach and based on common sense. With strong communication, a culture that promotes teamwork and open discourse, consistent and ongoing education and training, and clear policies and procedures, positive relationships can result, and quality care is the ultimate outcome. </div> <h3 class="ms-rteElement-H3">Scope Of The Problem</h3> <div>In one recent study reported in the Journal of Patient Safety, nearly 400 nurses identified several barriers to effective nurse-physician communication in long term care. These included lack of physician openness to communication, logistical challenges, lack of professionalism, and language barriers. Authors Tija J, Mazor K, Field T, et al., identified two specific barriers—feeling hurried by physicians and an inability to reach doctors promptly. In the same study, qualitative interviews suggested overwhelmingly that nurses need to be brief and have current, accurate clinical information when communicating with physicians and that physicians need to be better listeners.</div> <div> </div> <div>Josh Allen, RN, chief executive officer (CEO) of California-based Caring Compliance Group, which specializes in assisted living staff training and education, says, “A common complaint I hear from nurses is that they can’t reach physicians in a timely manner.” This is especially challenging in assisted living, he says, because, “We don’t have standing orders, so we need new physician orders for everything. When you have to reach out for approval on everything, it can be frustrating when a physician can’t be reached.” </div> <div> </div> <div>It can help to develop an as-needed (PRN) authorization form to enable commonly used medications such as Tylenol to be available when residents need them. “With every resident in the building, we’ll get commonly prescribed PRN orders as appropriate and keep them on file,” Allen says.</div> <div> </div> <div>One challenge to good nurse-physician communications is that physicians might have different expectations. For example, according to Charles Cefalu, MD, CMD, a multifacility medical director in New Orleans, some physicians don’t want to be called for nonacute changes of condition. Others want more constant communication. </div> <div> </div> <div>As Karyn Leible, MD, CMD, chief clinical officer at Pinon Management, Lakewood, Colo., says, “I want to know if a patient is experiencing a decline over a period of days before he or she is admitted to the hospital.”<br> </div> <div>These disconnects can be addressed to some degree, says Cefalu, by training team members on how and when they should contact physicians. At the same time, facilities should address with physicians up-front how they want to be contacted when there is a problem. </div> <div> </div> <div>Facilities also need to let physicians know what is expected of them and when and why staff will need to contact them. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div><h3 class="ms-rteElement-H3">Successful Models, Innovative Ideas</h3> <div>A successful model for good facility-physician relationships includes overall collaboration and mutual respect and trust, says Robert Bales, administrator of the John J. Hainkel, Jr., Home and Rehabilitation Center in New Orleans. His facility has implemented several successful measures to maximize physician-nurse relationships. </div> <div> </div></div> <div>For example, he says, “We use a monthly Performance Improvement Committee meeting that is physician-led and chaired by the medical director. We focus on patient care concerns specifically and don’t let the group get sidetracked by other issues. If there is a new protocol, such as one for wound care, we make sure to get physician input as we develop them.”</div> <div> </div> <div>It is important to get physicians involved in such committees so that they feel connected to the facility and have an opportunity to get to know all the players. “We attempt to get attendings [attending physicians] involved on committees, and we rely on their expertise,” says Cefalu. “We ask them what their interests are and get them involved accordingly. Getting their input on new programs, policies, and so on is important.”</div> <div> </div> <div>Cefalu suggests getting physicians involved on formularies so that they can have input on medications and other products on the lists. “Things like this—that reduce unnecessary work and paperwork—save the physicians time. When you do things that make their lives easier and make it more pleasant for them to come to the facility, they appreciate it. And they think and act more like active team members,” he says.</div> <div> </div> <div>Another way to involve physicians and improve relationships is to create educational and communication opportunities that are convenient. Cefalu suggests, “Have a ‘dine and dash’ and invite physicians in to educate them about a new policy, protocol, or product or to have them sign records.” He explains, “It can be challenging to get physicians to complete and sign medical records, especially when you have a lot of attendings. Having something like this makes it a little easier and more palatable.”</div> <div> </div> <div>Making physicians’ lives easier can score points with them. For example, billing and coding for long term care can be a challenge, especially for physicians who are new to this care setting. Helping them and their staffs understand these issues can strengthen partnerships. </div> <div> </div> <div>“As part of the medical staff meeting, you could have their billing people come in and update them on coding issues. This would help [physicians] a great deal, and they likely will be very appreciative,” Cefalu says.</div> <div> </div> <div>It also can help some physicians realize that long term care actually can be a profitable care setting for them. “Billing codes have increased 5 to 7 percent per year in recent years, and overhead is very low,” Cefalu says. However, he adds, “The downside is that these patients require a great deal of care. Of course, physicians can utilize nurse practitioners to help provide this care.”</div> <div> </div> <div>It also is helpful to make sure physicians get the information they need about patients—when possible, without asking. For instance, says Cefalu, “Offer to provide attendings with the face sheet of the admission form for their patients when they come into the facility. You can arrange to fax it automatically so that they have it before their first visit.”</div> <h3 class="ms-rteElement-H3">How To Contain Quantity Of Calls</h3> <div>One complaint physicians often have is the number of phone calls they receive. So the Hainkel Center has a “problem book” at the nursing station that lists nonacute problems. Physicians can elect to use this book instead of getting phone calls about these issues. <br><br>When they come to the facilities, physicians can check for any problems or issues related to their patients. “This can prevent the physician from getting calls two to three times a day about nonemergent problems. However, for this book to work, physicians must commit to coming into the facility once or twice a week consistently,” Cefalu says.</div> <div> </div> <div>Bales and his team also developed a protocol for communicating with physicians after hours, which also helps reduce unnecessary calls. The AMDA also has such a document, which addresses about 100 conditions and what information will be necessary when contacting a physician (see box).</div> <div> </div> <div>“Such protocols help make sure that nurses know precisely what information physicians will expect when they call about a patient problem. This ultimately makes the nursing staff feel more comfortable and confident when they make these calls; physicians are happy because they only get calls that are necessary, and they get all the information they need to make decisions,” says Cefalu.</div> <div> </div> <div>To help reduce the call volume to physicians, Bales also suggests differentiating between common, recurring problems and isolated incidents. Either type of problem must be addressed promptly, but a problem that suggests a trend or a common situation requires special attention and a long-term solution. “After you’ve addressed something, go back and see how it’s going. Check to see if everyone is satisfied with the resolution,” says Bales. He adds, “The main thing is to close the loop and get feedback.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Build Mutual Respect</h3> <div>Of course, it also is important to have a culture where physicians and nursing staff have mutual trust and respect. “We have created a culture where physicians rely heavily on nurses’ input, and this yields the best results,” says Bales. “It is important to have a person-centered culture where people understand the importance of communication and people feel comfortable bringing up concerns without fears of retaliation.” </div> <div> </div> <div>To help, his leadership team creates lists of potentially problematic issues and discusses them regularly with unit managers, including medical staff. </div> <div> </div> <div>When everyone has the residents’ best interests at heart and team members respect each other, says Bales, resolving issues actually can be easy and stress-free. For example, he recalls a situation where a new physician was ordering numerous STAT lab tests, which are very costly. “We sat down with the physician and said, ‘We may have missed this in the orientation, but we have a daily lab service,’” Bales recalls. The physician cooperated, and it solidified a positive relationship with the nursing staff.</div> <div> </div> <div>Facilities can help physicians by making sure that nursing and other staff have the skill sets to do their jobs and care for patients. “Physicians have to feel confident that staff can handle the complexity of patient care in the facility, and you need to have sound systems for hiring and training staff,” Bales says. “We are fortunate to have a medical director who enjoys teaching staff. This is a big plus for us.”</div> <div> </div> <div>Bales stresses the need to meet with physicians occasionally outside of the noise and distractions of the facility. “Whether it’s a conversation over breakfast or a cup of coffee in a nearby park, it gives them a chance to address their issues and concerns and talk about what the facility can do for them,” he says.</div> <div> </div> <div>It is essential for everyone to realize that respect and concern are a two-way street. “Staff have a tough job, and they appreciate a pat on the back sometimes. It means a lot to them to have physicians who see them as colleagues and respect the work they do,” Bales says.</div> <h3 class="ms-rteElement-H3">Assisted Living Challenges</h3> <div>Relationships with attendings can be more challenging in assisted living (AL) communities, where staffing, size, rules, and regulations may vary considerably. “There isn’t a requirement for medical care oversight as there is in nursing homes,” notes Leible. </div> <div> </div> <div>However, physicians who are new to the setting may not know this. They may assume that AL communities provide services similar to those found in nursing facilities. This can cause frustration and damage relationships.  </div> <div> </div> <div>AL facilities need to realize the benefit of good relationships with attendings, says Dan Haimowitz, MD, CMD, a multifacility medical director and AL attending physician in Pennsylvania. “If the AL facility really interacts with the physician, asks what he or she needs, establishes good contact patterns, and is able to get to know him or her, this can make a big difference,” he says. </div> <div> </div> <div>There is no requirement for attendings to see their residents onsite at the AL facility. “Some attendings go to the AL community, which benefits everyone, but some never go. If they don’t, they may not know what the facility is like, who staff are and what skills they have, and what services they can provide,” says Haimowitz. However, he adds that even when physicians go onsite, they may not get the information they need.</div> <div> </div> <div>“You may or may not get a good story about what is going on with the patient. Depending on when you go, you may or may not talk to a nurse, and the caregivers may or may not have the information the physician needs.” </div> <div>Nonetheless, Haimowitz notes that it is easier and less costly for residents to be seen onsite. He adds that it can benefit the physician as well. “If a physician starts going to the AL, he or she may get more patients. It can lead to more business and become a good source of income,” he says.</div> <div> </div> <div>While physicians shouldn’t compare AL communities to nursing facilities, they can take some ideas from skilled nursing and translate them to AL. “Physicians can spearhead such ideas as reduction of antipsychotic use in AL,” says Haimowitz. “These facilities may be able to take some sort of disease-state management programs and focus on concerns such as falls, wound care, and incontinence. Working with physicians on such programs can help practitioners understand the AL facility better and create collaborative relationships between physicians and staff.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>Residences should make sure that all attendings understand what AL can provide. “When the physician understands what the facility is trying to do, he or she is more likely to work with them to reach goals. Facilities need to help physicians understand the uniqueness of this setting. They have to work harder to establish relationships with attendings,” says Haimowitz.</div> <div> </div> <div>Because few AL residences have a medical director and most have limited nursing staffs, off-hours communication can be difficult. “Aides may not know about assessments or have training. At the same time, they may not have access to charts and other information. This makes for a multitude of communication problems,” says Haimowitz. </div> <div> </div> <div>Policies vary from community to community, and this can cause confusion and misunderstandings. </div> <h3 class="ms-rteElement-H3">When Physicians Are Unresponsive</h3> <div>Staff need training about communication, including what to tell physicians and when to contact them. At the same time, the physician needs to understand the importance of responding to calls from the facility promptly.</div> <div>Pat Giorgio, MPS, president and CEO of Evergreen Estates, a retirement community in Cedar Rapids, Iowa, says, “We need to make sure that our staff are very professional and that they have the information physicians need when they ask for it. Nothing is more cringe-worthy than when there is a fall and you don’t have the vital signs to report to the physician. We need to make sure that documentation is concise and complete. We can’t waste the attending’s time.”</div> <div> </div> <div>Since AL settings generally don’t have physician medical directors, staff can’t count on such a person to intercede when there is a problem. </div> <div> </div> <div>“If you start to see care issues and/or can’t get the attending to respond to calls, you have to find a way to address it,” says Leible. “Before you do anything, you need to reach out to the physician and try to find a mutually agreeable solution. If the situation continues, you may decide to discuss this with the family. If the issue is lack of response, you need to be prepared to offer specific examples of when the physician was unavailable.” </div> <div> </div> <div>Haimowitz agrees. “If a physician chronically doesn’t return phone calls or complete paperwork, a facility leader can go to him or her and talk in a friendly way about what the facility needs and how they can work together more effectively,” he says. “Ask what the physician needs from your facility and what his or her concerns are.” </div> <div> </div> <div>Ultimately, facilities can give residents the opportunity to choose a new physician, and they can suggest practitioners with a proven AL track record. However, they can’t force a resident to make such a change, and they should attempt to work with the nonresponsive physician before discussing a possible change with the resident or family members.</div> <div> </div> <div>It is important to realize, says Haimowitz, that the resident may not even know that the physician is being unresponsive. “How the physician interacts with staff may not be obvious to the resident, who may not realize that their doctor isn’t returning calls, signing forms, or completing paperwork.” </div> <div> </div> <div>It is helpful to discuss with new residents what the facility will need from their physicians and why a good relationship is important, he says. “It’s a slippery slope to discuss the physician with residents and families,” Haimowitz cautions. “You have to avoid looking like you’re playing favorites or bad-mouthing any physician.” </div> <div> </div> <div>One challenge, says Giorgio, is that “many attendings seem to prefer faxes to face-to-face interactions, and this can be problematic, especially when faxes go unanswered or require further clarification. We feel like the physicians who ‘really get it’ will come to the facility. Those who are willing to come out have a better grasp of what AL is and what resident needs are.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Be Proactive</h3> <div>Giorgio reaches out to physicians on a regular basis. “When we get a referral from a physician, we send him or her a formal thank you with a brochure, a coffee mug, and coffee. It lets them know we appreciate them, and it tells them about our philosophy of care and what services we provide. We try to build relationships this way,” she says.</div> <div> </div> <div>Giorgio suggests that AL communities not forget about the physician’s own nursing staff. “You really need to make sure you have a relationship with the attending’s nurses. You need to explain what you do and who you are. Offer your support and willingness to provide additional guidance as needed,” she says, adding, “Don’t hesitate to take an active role in educating nurses about assisted living.”</div> <div> </div> <div>Some facilities send out information packages to new physicians that detail what they are, what services they provide, and what they expect from the relationship. This can be helpful, but there is no guarantee that physicians will read the package even if they receive it.</div> <div> </div> <div>Another option is to arrange a personal meeting with the physician when he or she first comes to the facility. For example, the registered nurse can show the physician around, introduce him or her to various staff, and talk about the resident’s needs, how to share information, and what the practitioner should do if he or she has questions or concerns. </div> <div> </div> <div>“When an attending comes to the community, you need to be very welcoming. One physician said that nothing is worse than when he comes to the AL facility and no one can give him the information or support he needs,” Giorgio says. “Staff greeting visitors need to understand the importance of the attending and of finding the nurse to meet the physician.</div> <div> </div> <div>“My experience is that physicians are more inclined to listen to what another physician tells them. Facilities can ask experienced attendings to talk with other physicians and to educate their peers about assisted living through various meetings and presentations.” </div> <h3 class="ms-rteElement-H3">Still Tech-Challenged?</h3> <div>While some might think that technology is an easy answer for improving relationships and communication with attendings, it isn’t quite that simple. “Use of technology for long term care communication is still in its infancy, although it will be huge down the road,” says Kevin O’Neil, MD, CMD, FACP, medical director of Brookdale Senior Living, Brentwood, Tenn. “Few [assisted living facilities] have the technology to share information with hospitals or attendings. Hopefully, that will change in the future.”</div> <div> </div> <div>In the meantime, there are several challenges to be overcome. For example, there are many different software products available.  </div> <div> </div> <div>“Some places have great technology that physicians can access from anywhere and use to submit orders directly from their offices or homes, but other places have different—and often incompatible—systems. That is why so many physicians are hesitant to invest in technology products,” says O’Neil.</div> <div> </div> <div>In the meantime, he says, “We use e-mails, texting, and other means of communicating with physicians. We find that e-mail communication is a good way for the physician to interact with us. Additionally, we’ve offered some Web-based education for physicians.” </div> <div> </div> <div>As long term care settings attract more physicians to the fold, technology becomes more consistent and readily available, and staff have access to protocols and other tools, physician-facility relationships can only improve in the coming years. </div> <div> </div> <div>However, the changes won’t come easily. As Leible says, “Everyone has to put aside their egos and preconceived notions and focus on the common goal of providing great care for residents.” </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div>As more and more primary care physicians follow patients into facilities, staff must find ways to successfully communicate with them. 2010-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/Clip%20art%20doctor%20with%20hand%20on%20pocket%20and%20stethoscope.jpg" style="BORDER:0px solid;" />Caregiving;Management;WorkforceColumn1
Providers Agree: HIT Beats Paperhttps://www.providermagazine.com/Issues/2010/Pages/0110/Providers-Agree-HIT-Beats-Paper.aspxProviders Agree: HIT Beats Paper<p>One of the fundamental reasons for the slow uptake of health information technology (HIT) in nursing facilities and the long term care setting in general is the lack of data showing the benefits and costs of sinking valuable capital into such systems. </p> <p>A new government report starts to provide answers, at least in part, by offering case studies of eight technologically progressive nursing facility and home health agency sites profiling their experiences. </p> <p>Published by the U.S. Department of Health and Human Services (HHS), the study sought to:</p> <ul><li>Understand how HIT, including point-of-care and health information exchange tools, are being used in selected nursing facilities and home health agencies;</li> <li>Identify the types of costs and benefits associated with these HIT applications, including the entities to whom these costs and benefits accrue; and</li> <li>Develop a data collection and analysis plan to assess the magnitude of the costs and benefits.</li></ul> <p>A couple of main points came out loud and clear from the case studies, namely that once a long term care provider moved away from paper-based systems, there was no turning back, as long as they could handle the technical upkeep of the HIT system. </p> <div>This sentiment emerged even though none of the sites profiled in the HHS report had conducted a rigorous cost-benefit analysis of their HIT programs.</div> <h3 class="ms-rteElement-H3">Access To Data Critical</h3> <div>The profiled nursing facilities use HIT to assist with administration, operations, and electronic health records (EHRs), with EHRs as the most common tool.</div> <div>Steven Chies, senior vice president of long term care operations for Benedictine Health System, Duluth, Minn., a system cited in the report, says his organization has made advanced technology a key strategic tool for its 40 facilities. "Even though we are still in the midst of evaluation [of the costs and benefits], we have seen increased documentation of patient acuity, and that has probably been the biggest impact thus far,” Chies says. </div> <div> </div> <div>Benedictine will continue to explore new uses for HIT, he says, noting that some facilities are starting to use new video conferencing equipment with the ultimate goal of allowing more access to patients for “virtual” visits with family. </div> <div> </div> <div>The HHS case studies showed that nursing facilities and home health staff overwhelmingly listed the “anytime, anywhere” access to health information afforded by EHRs as the best benefit thus far. Being able to find the health record and communicate information to family members and physicians has proven invaluable.</div> <div> </div> <div>“This access to electronic records was sharply contrasted to locating and retrieving the single copy of the resident’s paper chart, which may be in use by another individual, requiring not only the time to find and retrieve the record” but also resulting in delays in waiting for the record to become available, the report said.</div> <div> </div> <div>HIT has also made it easier to meet administrative and federal requirements in long term care. EHRs integrated with clinical information help meet the complex web of reporting requirements, and patient billing can be automatically generated from clinical data, shortening the billing cycle and improving accuracy with automated edit checks, the report said.</div> <div> </div> <div>Minimum data set and home health care outcome and assessment information set data were also more accurate with the electronic systems. “Most providers also reported reductions in administrative staffing because of accrued time savings,” the report said.</div> <h3 class="ms-rteElement-H3">Tools Boost Tracking Capabilities</h3> <div>A third cited benefit was improved quality management through reports, alerts, and decision-support tools. As in the case of Benedictine, the case studies showed at least the potential for HIT to give staff the following tools: the ability to answer alerts for specific patient needs; methods for fall prevention; and mechanisms to track status, weight decline, skin breakdown, and hospitalizations. </div> <div>Though some of the tools are beyond the current capabilities of most long term care settings, the ability to improve patients’ activities of daily living is a recurrent result from even limited HIT implementation. </div> <div> </div> <div>The final benefit is the opportunity for a health information exchange that connects acute care with long term care and physicians. “Data exchange with physicians for order review and approval minimized duplicate data entry, and data exchange with hospitals facilitated patient admission and transfer processes,” the report said. </div> <div> </div> <div>So, why not more HIT in long term care? The hurdles are high, and, as Chies says, many providers are in a wait-and-see mode, what with the health care reform debate raging in Washington and the economic squeeze on budgets. </div> <div> </div> <div>The HHS report said case study sites described large financial outlays for servers and back-up systems, though the amounts varied widely depending on storage size and speed of the system and other factors, like how much was budgeted for labor, technical support, and clinician time for system and workflow redesign.</div> <h3 class="ms-rteElement-H3">Incentives May Be On The Way</h3> <div>Greg Alexander, professor at the University of Missouri Sinclair School of Nursing and researcher in HIT use in nursing facilities, says the acute-care setting has more support to handle HIT, thus giving such facilities a computer-savvy staff to maintain and improve the systems moving forward.</div> <div> </div> <div>“Nurses running the systems are not well-trained in HIT, and even administrators have little knowledge. The facilities get a lot of vendor support at first, but they eventually pull out,” Alexander says.</div> <div> </div> <div>The fact that HIT is not reimbursed is also a large barrier, he says, though that is changing with the incentives put in place by the economic stimulus package signed by President Obama in February 2009 that targeted the accelerated adoption of HIT across health care settings. </div> <div> </div> <div>In fact, the American Recovery and Reinvestment Act contains a measure that requires HHS to study the extent to which payment incentives should be made available to health care providers, like nursing facilities and home health agencies, which are receiving minimal or no payment incentives for implementing certified EHR technology.</div> <div> </div> <div>The HHS report said even though there is a need for more evidence on the costs and benefits of HIT in the long term care setting, there is enough proof from even small samplings that quality of care and efficient services improve with the use of such technology in these settings. </div>A government report offers case studies of eight technologically progressive nursing facility and home health agency sites profiling their experiences with HIT.2010-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/Clip%20art%20nurse%20at%20computer.jpg" style="BORDER:0px solid;" />Technology;QualityColumn1
Safe Handling In Long Term Carehttps://www.providermagazine.com/Issues/2010/Pages/0110/Safe-Handling-In-Long-Term-Care.aspxSafe Handling In Long Term Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>​<img width="157" height="162" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0110/Caregiving1.jpg" alt="" style="margin:15px;width:162px;" /><br>Safe-handling practices in nursing facilities and other long term care settings not only reduce injury-related costs, but also serve to improve the safety of staff and residents.</p> <p>Previously referred to as no-manual-lift, the concept of using lifting devices that help direct-care staff safely move and transfer residents has evolved into a more comprehensive approach now known as a safe-handling program.  </p> <div>Although long term care facilities have had access to mechanical lifts for a number of years, the technology has often been viewed as too cumbersome and impractical for everyday use. </div> <div> </div> <div>But in facilities where no-manual-lift policies have been initiated over the years, the impact on both the quality of patient care and the safety of health care workers has been significant.</div> <div> </div> <div>Safe-handling programs take this policy a step further by encompassing education and training of all employees and ongoing mentoring of caregivers. </div> <h3 class="ms-rteElement-H3"><div>Staff Buy-In Vital</div></h3> <div>Implementing a safe-handling initiative at a long term care facility requires enthusiastic cooperation from nurses and nurse assistants. It is also vitally important to reduce potential barriers that may cause resistance to the program among staff members. </div> <div> </div> <div>Some of the most common concerns voiced by nursing facility employees prior to implementation of a safe-handling program are that adequate lifting equipment is not available, the devices take too much time to use, residents refuse to use them, they don’t stay charged, they don’t always work, and the equipment is unsafe. </div> <div> </div> <div>The doubts stated above are critical challenges that must be resolved to ensure staff compliance with the change. </div> <div> </div> <div>Implementation and maintenance of a successful program first requires a commitment from all staff, and it must begin with the top managers. </div> <div> </div> <div>Some providers have utilized a train-the-trainer approach to implementing a program. Empowering direct-care staff to train colleagues can be an effective motivator, especially when there are staff members who express a willingness to be trained and work with others.</div> <h3 class="ms-rteElement-H3">Not Just Lifts </h3> <div>Of course, a safe-handling program requires handling devices. Although mechanical lift manufacturers continue to provide a wide spectrum of total and sit-to-stand lifts in varying weight capacities, there have been some developments during the past decade with handling device options. </div> <div> </div> <div>To address the challenging needs of repositioning residents in the bed, friction-reducing aids are being incorporated. Some facilities are using transfer/repositioning sheets that can stay on the bed and are readily available.</div> <div> </div> <div>Nonmotorized stand aids are used to help residents to a standing position or to assist them in toileting. Overhead ceiling lifts are also a new development in long term care, although they are a more expensive option. </div> <div> </div> <div>The benefits of having the equipment within reach of the task creates the most efficient and convenient option available. Nursing facilities should use handling devices that are easy to move, fit under low beds, straddle mattresses on the floor, lift high enough for whirlpools, have a wheelbase that fits standard bathroom doors, and have the capacity to pick residents up off the floor. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>There are two types of mechanical lift devices used with an effective safe-handling program: total lift and stand lift. </div> <div> </div> <div>The total lift device is used to transfer patients who are unable to assist in any way, while stand lift equipment is for those who can bear weight on at least one leg but who require a stand-pivot transfer. Any resident who can stand and ambulate is not considered a lift candidate. </div> <div> </div> <div>The sling, which attaches to the frame of a mechanical lift device, supports the weight of the resident during a lift-transfer. To accommodate a variety of individuals affected by age and disease, an adequate number and variation of sling styles are needed. Bilateral amputees, for example, require their own slings, while residents who weigh in excess of 250 pounds will require specialized slings. <img width="183" height="199" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0110/CaregivingPhoto2.jpg" alt="" style="margin:10px 15px;width:199px;" /></div> <h3 class="ms-rteElement-H3">Mentoring Makes A Difference</h3> <div>Caregiver compliance with the use of safe-handling practices is directly equal to caregiver competence. That said, the effective implementation of a safe-handling program is 10 percent design, 10 percent training, and 80 percent mentoring. </div> <div> </div> <div>Over the years, nurse trainers have come to the realization that training someone to use the equipment is not enough—mentoring and modeling appropriate use of the equipment and handling residents is a necessary element in competency. </div> <div> </div> <div>Many caregivers readily state that they leave a training session feeling confident in the use of the equipment; however, when faced with the realities of small resident rooms and residents who are contracted or combative, they realize there is more to the use of the device than just the operation. </div> <div> </div> <div>Expert-level nurses should mentor the proper use of equipment with actual residents who present unique challenges not covered in training. </div> <div> </div> <div>By modeling lifts, transfers, and repositions with residents who have different needs, the nurse trainer can support the caregiver learning process with the demonstration and reinforcement of best practices. Many caregivers say that once they have participated in this type of learning, their competency in using the equipment is boosted.</div> <h3 class="ms-rteElement-H3">Broad-Scale Education </h3> <div>Implementing and maintaining a safe-handling program involves almost every department in a facility. For example, the laundry department must be aware of the special handling of the slings. </div> <div> </div> <div>Cloth slings should be laundered at a temperature that meets infection control guidelines but does not include the use of bleach in the wash cycle. Training these employees in a way that illustrates how important their role is helps improve their appreciation of the importance of following the guidelines. In addition, a sling that shows signs of wear should be removed from service.</div> <div> </div> <div>Maintenance personnel must be trained to inspect the lifts and ensure their functionality on a consistent basis. </div> <div>The housekeeping department should be responsible for scheduling regular cleaning of the equipment, while admissions must notify new residents about the safe-handling policies and procedures.</div> <div> </div> <div>Training new hires and all caregivers annually on safe-handling practices is also crucial in maintaining the effectiveness of a program. New-hire training should include both didactic and hands-on equipment training. New caregivers’ skills should be observed and mentored to validate competency.</div> <div> </div> <div>All responsible departments should receive training on their roles and responsibilities initially and annually. </div> <div> </div> <div>After redesigning and creating all the necessary support processes and educating staff, patients, and patients’ representatives on the mechanics of the equipment, a facility can begin the process of initiating the safe-handling program. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Inform Residents, Families</h3> <div>It is important for caregivers to realize that progress may be slow going at first, until they become proficient at using the mechanical-lift devices.</div> <div> </div> <div>More than 10,000 nurse assistants in the United States have been asked how long it takes to become time efficient with this equipment, and the answers vary from “the first time I used it” to “six months.” Changing work processes involves time. Also important to remember is that all documentation, care processes, and enforcement of the relevant policies and procedures must be integrated within regulatory guidelines. </div> <div> </div> <div>A critical example is residents’ rights. Prior to implementation of a safe-handling program, the policies and procedures involved must be presented in writing to resident representatives and to residents themselves. </div> <div>Patients must be given ample time to discuss what the program provides and have an opportunity to view a demonstration of the function of the lifts. </div> <div> </div> <div>Educating residents is a key factor in reducing their resistance to mechanical lifts. </div> <h3 class="ms-rteElement-H3">Monitor Compliance </h3> <div>To reinforce and support lift use, training needs and support processes must be monitored on an ongoing basis. </div> <div> </div> <div>Monitoring requires an ongoing evaluation of equipment function and sling and accessory availability. All slings should be inspected for tears or signs of wear and removed from service if found. </div> <div> </div> <div>Caregivers, for example, must determine logistics for training direct-care staff on specialty slings, creating processes for difficult patients, assessing sling availability, gauging battery change schedules, and orienting new hires.</div> <div> </div> <div>Implementing and maintaining a successful program is possible, if not easy. The cost savings and the impact on quality of care reflect the benefits. There may soon be a day when all nursing facilities will no longer permit employees to manually lift or transfer patients.</div> <div> </div> <div>And although the awareness of the need for safe handling has increased dramatically in the past decade, there remains a lack of financial incentives for providers. With the increasing focus on new health care worker protection legislation, there is hope that some remedies will be offered. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0110/Benefits-Of-A-Safe-Handling-Program.aspx">HERE</a> for a list that describes the benefits of a safe resident-handling program.</div> <div> </div> <div><em>Betty Z. Bogue, RN, BSN, is president of Prevent, Hickory, N.C. (</em><a href="http://www.getalift.com/"><em>www.getalift.com</em></a><em>). She can be reached at (828) 261-0043.  </em></div>Safe resident handling is most successful when it incorporates training, mentoring, and the use of best practices.2010-01-01T05:00:00Z<img alt="" src="/Issues/2010/PublishingImages/0110/CaregivingPhoto2.jpg" style="BORDER:0px solid;" />Caregiving;WorkforceColumn1
SNF Ownership Successor Liabilityhttps://www.providermagazine.com/Issues/2010/Pages/0110/SNF-Ownership-Successor-Liability.aspxSNF Ownership Successor Liability<p>​​In this difficult economic environment, health care facilities unable to meet ongoing financial obligations may negotiate payment plans with their creditors or file for bankruptcy protection. Others may consider selling their assets to a new entity in order to get a fresh start, but leaving a facility behind does not guarantee a release from its liabilities.</p> <p>Under the common law of virtually all states, if one corporation is considered the successor to another, the successor is liable for the acts and obligations of the predecessor if ownership was acquired by means of a merger or consolidation. </p> <div>However, if the transaction is merely a transfer of assets to another entity, the assets may generally be transferred without also transferring liabilities. </div> <h3 class="ms-rteElement-H3">Exceptions To Liability</h3> <p>There are several exceptions to the general rule that could lead the buyer of a corporation’s assets to be liable as its successor: if the buyer expressly or indirectly agreed to assume the obligations of the predecessor, if the transaction is found to be a de facto merger or consolidation of the two entities, if the purchaser is determined to be a mere continuation of the seller, or if the transaction is fraudulently entered into to escape liabilities. </p> <div>If a creditor of the predecessor company can demonstrate that one of these four exceptions applies, a court could enforce the predecessor’s obligations against the successor company.</div> <div> </div> <div>The analysis becomes more complicated in situations where only certain obligations are assumed or where there is no express agreement for the assumption of liabilities, but the purchaser voluntarily pays certain debts of the seller. </div> <div> </div> <div>A creditor may argue that the voluntary assumption of some debts by the purchaser obligates it to assume others, but this fact alone will not be sufficient to find an implied assumption of liability in the absence of other factors.</div> <h3 class="ms-rteElement-H3">De Facto Mergers</h3> <div>If a transaction is not intentionally structured as a merger or consolidation by the parties, the successor corporation may nonetheless be held responsible for the predecessor’s liabilities if a court determines that the parties have engaged in a de facto merger or consolidation. </div> <div> </div> <div>This determination is based on an analysis of four independent factors under common law: whether there is continuity of management, employees, physical location, assets, and general business operations; whether ownership remains the same, such as shareholders of the seller corporation becoming shareholders of the purchaser; whether the cessation of ordinary business and liquidation of the seller corporation takes place as soon as possible; and whether the purchaser assumes the obligations of the seller that are ordinarily necessary for the uninterrupted continuation of the business of the seller.</div> <div> </div> <div>All four criteria need not be met in order for a de facto merger to be found to exist. Furthermore, there need not be a finding of fraudulent intent on the part of the parties.</div> <div> </div> <div>A “mere continuation” exception will apply when the acquiring company is deemed to be a continuation of the selling corporation in a different form, rather than only a continuation of the seller’s business. </div> <div> </div> <div>This applies when a purported asset sale is deemed to be, in effect, a form of corporate reorganization. In making this determination, a court will analyze whether the directors and shareholders of the acquiring company are basically identical to those of the seller, and whether the selling corporation ceases to exist after the transaction.</div> <h3 class="ms-rteElement-H3">Lifting Corporate Protections</h3> <div>A court may find that a successor company is responsible for the obligations of the predecessor company if it determines that the transaction was entered into fraudulently in order for the predecessor to escape certain liabilities. </div> <div> </div> <div>This determination requires a detailed factual analysis, including, among other things, whether there is a close relationship between the parties to the transaction, whether the purchaser paid fair consideration for the assets, and whether the seller retained any control over the assets after the transaction.</div> <div> </div> <div>The general rule and the exceptions outlined above will apply to a transfer of assets from one health care entity to another. If the predecessor company is a corporation or limited liability company that owns a nursing facility, home health agency, or similar facility, the individual equity owners of the predecessor company should have no liability for the obligations of that company unless one of the above exceptions applies or unless there is a legal justification for piercing the corporate veil—removing the protection it provides—and pursuing the individuals.</div> <div> </div> <div>The corporate veil may be pierced if the company, for example, failed to observe corporate formalities such as maintaining records and holding meetings, commingled its funds with those of its shareholders, allowed shareholders to use the funds for personal expenses, or purportedly operated while actually insolvent. </div> <div> </div> <div>If the corporate veil cannot be pierced, and none of the above exceptions applies, any outstanding liabilities of the predecessor company will be payable only from its own corporate assets. </div> <h3 class="ms-rteElement-H3">Personal Liability </h3> <div>The result may be different when a closely held health care practice closes its doors or sells its assets. If a professional corporation with a single physician shareholder is determined by Medicare to be liable for overpayments, the fact that the services were performed, or perhaps not performed, through a corporation will not shield the individual physician from liability for repayment.</div> <div> </div> <div>Under state law, it may be unusual for a court to pierce the corporate veil in the absence of fraud; however, when the U.S. Department of Health and Human Services seeks recovery of Medicare overpayments, federal law applies. Under federal case law, the corporate veil may be pierced, if necessary, to prevent circumvention of a statute or avoidance of a clear legislative purpose.</div> <div> </div> <div>Courts have held that the federal government’s goal of paying only the reasonable cost of Medicare services is a sufficient legislative purpose to justify piercing the corporate veil, in the case of a Medicare overpayment.</div> <div> </div> <div>In the case of United States v. Pisani, the federal government sought to recover from an individual physician Medicare overpayments that had been made to his single-shareholder corporation. The Third Circuit held that federal law controlled and pierced the corporate veil to hold the physician personally liable for the overpayments. </div> <div> </div> <div>In United States v. Normandy House Nursing Home, the court found that the defendant doctor was the alter ego of a nursing facility corporation, which again allowed the corporate veil to be pierced. </div> <div> </div> <div>While both cases involved the Medicare program, the relevant analysis would apply equally to overpayments under other federal programs or joint federal/state programs, including Medicaid, but not to cases brought by private insurance carriers.</div> <div> </div> <div>Consideration of whether to sell, purchase, or close a health care facility requires an analysis of issues that are more complicated than those affecting businesses in other industries. Careful planning will help ensure the maximum possible protection from potential liability for both sides. </div> <div> </div> <div><em>Leslie Levinson is a partner and chair of the Health Law Practice Group, and Eric Fader is counsel, with Edwards Angell Palmer & Dodge LLP, in New York City. They can be reached at <a href="mailto:llevinson@eapdlaw.com">llevinson@eapdlaw.com</a> and <a href="mailto:efader@eapdlaw.com">efader@eapdlaw.com</a>, respectively.</em></div>Selling your facility to a new entity in order to get a fresh start leaving a facility behind does not guarantee a release from its liabilities.2010-01-01T05:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Legal;ManagementColumn1

February

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A Bridge To Better Staffing In Long Term Carehttps://www.providermagazine.com/Issues/2010/Pages/0210/A-Bridge-To-Better-Staffing-In-Long-Term-Care.aspxA Bridge To Better Staffing In Long Term Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p><img width="343" height="653" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0210/Workforce2.jpg" alt="" style="margin:15px;width:238px;height:179px;" /><br>Cindy Lee Lamica would be on any long term care facility’s list of top employees. Originally on track to become a teacher, she ended up leaving college with three semesters left and went to work in geriatrics. After becoming certified as an activities director, she went to work in 2000 at Notre Dame Du Lac assisted living residence, Worcester, Mass., where her expertise in caring for people with memory impairment qualified her to direct its dementia care Harmony program.</p> <div>And then, as the saying goes, life happened. With a young teenage son at home and another child on the way, Lamica decided it was time to consider her next career move, including getting her degree to improve her earning power. “I loved what I did, but there was very little opportunity for advancement in my profession,” Lamica recalls. “And then they suggested that I apply to go back to college through the Educational Bridge Center.” </div> <h3 class="ms-rteElement-H3">An Idea Is Born</h3> <div>The Notre Dame Educational Bridge Center, located on the Notre Dame campus, evolved out of a labor crisis that began with certified nurse assistants (CNAs) and then grew to licensed nurses. It was a time of sign-on bonuses, extra vacation, and creative perks to lure licensed nurses into the facilities. But no sooner had they filled one vacancy when two more would open as nearby hospitals absorbed most of the available nursing pool. </div> <div> </div> <div>In 2003, Notre Dame Du Lac had tried every strategy its managers could think of, but no amount of perks or marketing could solve what had become a double-digit vacancy rate that was on the rise.</div> <div> </div> <div>Then, during a meeting of a consortium of 12 local facilities under the name of the Intercare Alliance, the solution suddenly appeared. Dean Messier, director of human resources for Holy Trinity Nursing and Rehabilitation Center, an alliance partner, listened carefully as the challenges were described. </div> <div> </div> <div>Short of inventing these nurses, there appeared no way out of a cycle that was depleting budgets with overtime and agency fees, sinking staff morale as a revolving door spun staff in and out of the facilities. <br>“Why don’t we grow our own,” said Messier. </div> <div> </div> <div>The idea of developing a pool of licensed nurses was intriguing for a number of reasons, the primary reason being to solve the nursing labor gap. There was also a considerable financial  incentive for Notre Dame’s collective 12 facilities to solve the problem as it cost collectively more than $1 million annually to pay for the agency nurses who filled in uncovered shifts.</div> <div> </div> <div>The churn of agency nurses and staff nurses who left for other jobs was also emotionally draining for other employees and residents, who the company felt would benefit from greater stability in its CNAs and licensed nursing staff. </div> <h3 class="ms-rteElement-H3">A Bridge Is Built</h3> <div>At the heart of that strategy was the Educational Bridge Center, rooted in the tradition of the Sisters of Notre Dame, a teaching order committed to “educating for life,” which understood that education was the path to a better life for its employees and, by association, its residents. </div> <div> </div> <div>Investing in employees began as a strategic answer to a daunting problem but quickly became a cultural shift in the facilities.</div> <div> </div> <div>Word soon spread that the company was offering to raise employees from entry-level positions into a better-paying and more permanent career. Competing with hospitals for the same labor pool was over because the nursing candidates were Notre Dame’s own employees who had already expressed a preference for working in long term health care.</div> <div> </div> <div>Jo-Ann Desjardin, Notre Dame’s director of human resources, recalls the noticeable shift that occurred within two years of the start of the program. “The first days were tricky, and then word started to get around that we had a program where we would pay for everything,” she says. “Now, nine out of 10 people who come here know about the program, so it didn’t just expand the career ladders for existing employees; we had extended that ladder to pull even more people into the profession.”</div> <div> </div> <div>After structuring a unique arrangement with nearby Quinsigamond Community College, the Intercare Alliance applied for and received grant funding from state and private funding sources to prepare staff members. The program launched its first class in 2003.</div> <h3 class="ms-rteElement-H3">Overcoming Challenges</h3> <div>There were some challenges along the way. For example, there was the practical problem of how—and where—these candidates would get the prerequisite courses they needed before they attempted college-level course work.</div> <div> </div> <div>The selected candidates had the requisite passion and commitment for a career in nursing, but most had not pursued a license on their own because they lacked education or language skills, making career advancement daunting if not impossible.</div> <div> </div> <div>The Educational Bridge Center quite literally became the bridge for these candidates by offering employees of the alliance facilities convenient access to classroom facilities on the Notre Dame campus for pre-college courses; General Educational Development, or GED, test preparation; and computer training. Thus, the center had filled the educational gaps that kept many candidates from realizing their dreams. </div> <div> </div> <div>What is truly remarkable about the alliance program is embedded in the center. It is here, says Desjardin, where a once unattainable dream of going to college and earning a license in nursing takes shape and becomes real.</div> <div> </div> <div>Most of our students who went on and earned their LPNs [licensed practical nurse certification] are now going on to the RN [registered nurse] program. It has changed their lives and their family’s lives,” says Desjardin. “Ninety percent of the candidates would never have had the opportunity to achieve what they have accomplished. I think that pride goes out of the building, they wear it everywhere they go, and it has spread like wildfire.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>The foundation for what has become the very successful Grow Your Own Nurses program in central Massachusetts is the collaborative effort of the Intercare Alliance, whose members shared the same intractable problem. </div> <div>  </div> <div>Budget concerns have also been alleviated. Notre Dame was spending tens of thousands of dollars every month to shore up its depleted ranks with agency staff and had nothing to show for it. Now, for about $10,000 per student for all tuition, fees, uniforms, and clinical equipment, they have a nurse who is not only solving a labor problem but has become the best advertisement for the opportunity of working in long term care. </div> <h3 class="ms-rteElement-H3">Dreams Are Realized</h3> <div>For Lamica, whose mother, sister, and aunt were all nurses, this is a profession that makes her feel that her life is in balance. The Bridge program, she says, was the key, as she spent all her available time there preparing for and completing her course work. </div> <div> <img width="379" height="422" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0210/Workforce3.jpg" alt="" style="margin:15px;width:273px;height:205px;" /><br>In 2007, Lamica graduated Phi Beta Kappa. Her unfulfilled dream of become a nurse while managing the dementia program at Notre Dame has now been realized. “You look at it and then say to people, ‘Look at what my employer is doing for me.’ You feel more relaxed, and I realized that I want to be here for a very long time.”</div> <div> </div> <div>Concern that the home-grown nurses would leave after their two-year commitment has also not materialized. More than half of the LPNs from the first graduating class in 2004 are still on the job, while 82 percent of the class of 2006 are also still working in their LPN positions or have gone on to earn their RN degrees.</div> <p>And now they are joined by a new class of graduates who were pinned last June in a ceremony at Quinsigamond before a packed auditorium of family and friends.</p> <p>“Whether they stay or not after their two-year commitment,” says Desjardin, “at the end of the day we have developed a nurse who is dedicated to the mission of long term health care. We started out to solve a labor problem, but what we have created is a work and learning environment that is not only transformational for employees but also gives our residents a sense of continuity of care.” </p> <p><em>Katheerine Lemay, RN, MS, is chief executive officer/administrator of the Notre Dame Long Term Care Center in Worcester, Mass. Patricia Campbell is director of the Notre Dame Educational Bridge Center.</em></p>A dozen providers join forces to create the Notre Dame Educational Bridge Center, which evolved out of a labor crisis that began with CNAs and then grew to licensed nurses. 2010-02-01T05:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0210/Workforce1.jpg" width="150" style="BORDER:0px solid;" />WorkforceColumn2
Aquatic Therapy For Residents With Cognitive Impairmentshttps://www.providermagazine.com/Issues/2010/Pages/0210/Aquatic-Therapy-For-Long-Term-Care-Residents.aspxAquatic Therapy For Residents With Cognitive Impairments<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​<img width="163" height="160" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0210/CaregivingPHOTO-01_thumb.jpg" alt="" style="margin:10px 15px;height:163px;" />Residents with memory impairments make up the lion’s share of many long term care facilities, but wellness programming continues to suffer from a dichotomy of activities that benefit higher-functioning residents while alienating those needing a heavier standard of care. </p> <p>Senior Living Communities (SLC), a long term care provider based in Charlotte, N.C., is addressing this double standard through the integration of aquatic programming into the framework of its person-centered operating initiatives. </p> <div>Instead of reinventing the wheel, many communities can benefit from tailoring their resources to fit the needs of their residents. Even the smallest of steps can make a big impact on the quality of care a community delivers.</div> <h3 class="ms-rteElement-H3">Utilizing Resources</h3> <div>SLC used this approach to develop a program called Waves, which helps reduce or alleviate symptoms associated with cognitive decline in residents suffering from Alzheimer’s disease and dementia.</div> <div> </div> <div>Since eight of SLC’s 10 communities have pools for resident use, Vice President of Member Services Kelly Stranburg utilized the community-wide resource as a starting point in the process before testing the program at Summit Hills, a community located in Spartanburg, S.C.</div> <div> </div> <div>Waves combines the therapeutic benefits of warm water with low-impact aerobic exercise to ease symptoms associated with memory loss such as increased anxiety or wandering behavior. With on-site wellness coordinators leading training sessions under Stranburg’s direction, program implementation was both straightforward and inexpensive.</div> <div> </div> <div>In conjunction with recently designed “neighborhoods,” where residents benefit from the consistency of assigned caregivers, the Waves program promotes a strong relationship between staff and community members.</div> <div> </div> <div>“The program is really about personal relationships,” Stranburg says. “That’s why it fits perfectly into our larger, person-centered operating initiatives. Yes, there are physical and emotional benefits, but the amount of trust and understanding required from both caregivers and residents when they get into the water is at the heart of the program’s future success.”</div> <div> </div> <div>After training, primary caregivers join residents in the pool, guiding them through a variety of slow, methodical exercises. </div> <div> </div> <div>Despite severe memory loss and the risk of anxiety brought on by strange surroundings, residents benefit from the familiar face of their assigned caregiver, who understands that individual’s preferences and personality.</div> <h3 class="ms-rteElement-H3">Positive Results</h3> <div>The benefits residents receive from the activity are well worth the effort, Stranburg says. “Increased activity promotes emotional well-being, improves appetite, reduces stress, and can even help residents rest easier at night. “</div> <div>Although the short-term objective for Waves is to increase resident engagement and participation while improving self-esteem and personal worth, the long-term objective includes a reduction in the amount of care members need in their everyday lives. </div> <div> </div> <div>“The idea is not that we reduce care for those who truly need constant monitoring,” Stranburg says. “Rather, we believe residents who require a heavy standard of care should be treated like family members, not hospital patients. If we can reduce their dependence on a caregiver by increasing their physical strength or minimizing anxiety, we can help our residents maintain their dignity throughout an extremely challenging chapter of their lives.”</div> <div> </div> <div>Compassionate care is at the heart of the Waves program. During training sessions, caregivers are required to play the part of both the assistant and the resident, so they can gain an appreciation for the challenges residents may face when performing the exercises. </div> <div> </div> <div>Summit Hills Wellness Coordinator Tonya Ray says the program benefits staff members as well as residents. “Caregivers are able to step out of their daily routine and experience something new,” Ray says. “It makes ‘just another day on the job’ something to look forward to.”</div> <div> </div> <div>The beauty of the program lies in its ability to nurture the whole person while simultaneously strengthening the bond between residents and caregivers. Preliminary results from several of SLC’s communities suggest that Waves is well on its way to breaking ground on a new standard of care. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>One Summit Hills resident reports he is “less agitated” after participating in the program, while Ray has observed an increase in lower body strength among participants. Some residents who were unable to stand for long periods of time have been able to improve their mobility and walk for short distances around the community. </div> <div> </div> <div>Lower body strength and mobility are key determinants when evaluating quality of life and resident independence, Stranburg says. Her goal is to increase or maintain what residents are able to do on their own through their participation in Waves.</div> <div> </div> <div>The results are measurable and can involve something as simple as being strong enough to don clothing unassisted. Although small, these quality-of-life improvements can make a significant impact on a resident’s self-esteem. <img width="180" height="170" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0210/CaregivingPHOTO-03_thumb.jpg" alt="" style="margin:10px 15px;width:230px;height:230px;" /></div> <div><h3 class="ms-rteElement-H3">A Team Effort</h3></div> <div>Using existing resources in an innovative and creative way, SLC was able to introduce a viable, sustainable wellness program to a traditionally underserved population. But, like so many other great ideas, Waves was the result of hard work and research.</div> <div> <br>The idea of expanding aquatic activities to include memory-care patients was the result of a story Chief Operating Officer Mary Bowers read in an industry publication about a community implementing a similar program. </div> <div> </div> <div>Moved by the story and the residents’ success, Bowers assembled a team of experts to bring the project </div> <div>to fruition. </div> <div> </div> <div>Headed up by Stranburg, who oversees wellness coordinators at all 10 communities, Waves has blossomed into a full-fledged, person-centered example of how wellness programming can improve outcomes for all residents, no matter their individual challenges.</div> <div> </div> <div>In a year’s time, Stranburg hopes to oversee a total of five Waves programs throughout the system, with the remaining communities coming on board as soon as training is completed. Optimistic about the program’s future success, she encourages other long term care providers to follow suit.</div> <div> </div> <div>She hopes that others will be inspired by the success of the program. “There is no magic bullet or one-size-fits-all mentality when it comes to person-centered programming for all levels of care,” Stranburg says. “But sharing our success is something we should do, so others can take our ideas and improve the lives of their residents, whether they live with us or not.” </div> <div> </div> <div><em>Katie Huffstetler, director of public relations for Senior Living Communities (SLC), Charlotte, N.C., can be reached at khuffstetler@senior-living-communities.com. Kelly Stranburg, M.Ed., CSCS, vice president of member services for SLC, can be reached at kstranburg@senior-living-communities.com.</em></div>A long term care provider utilizes its pools to create a person-centered program for residents with cognitive impairments. 2010-02-01T05:00:00Z<img alt="" src="/Issues/2010/PublishingImages/0210/Caregiving-PHOTO-2_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalColumn2
Long Term Care Documentation Made Easierhttps://www.providermagazine.com/Issues/2010/Pages/0210/Long-Term-Care-Documentation-Made-Easier.aspxLong Term Care Documentation Made Easier<p>​<img width="504" height="336" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0210/TECH-Photo1.jpg" alt="" style="margin:10px 15px;width:208px;height:139px;" />When one thinks of warehouses, health care probably is not the first thing that comes to mind. But a technology that began in supply-chain management has made its way to long term care, and providers are utilizing it to improve resident care and ease documentation. Known as voice-assisted technology, it first landed in long term care, but has since expanded into acute care.</p> <p>Voice-assisted technology is typically utilized by caregivers who are equipped with personal headsets designed to recognize voice commands and provide detailed information. Each headset is wirelessly networked to a central computer system that records and stores the information. The technology allows its users to hear individual residents’ personalized care plans, to silently page other staff members for assistance, and to document care tasks, all through the headset and without having to access paper records. </p> <p>Proponents of the technology say that it helps staff deliver person-centered care profitably, simply by talking and listening. </p> <p>During the American Health Care Association/National Center for Assisted Living 60th Annual Convention & Expo, held in Chicago in Oct. 2009, executives from several long term care companies participated in a panel discussion about how voice-assisted technology is helping them improve resident care, facility operations, and revenue. </p> <div>In particular, improvements include better financial performance of six and seven figures per facility, higher resident and family satisfaction through better clinical outcomes, better survey results and compliance, and improved communication across care delivery teams.</div> <h3 class="ms-rteElement-H3">Caregiving Benefits</h3> <div>Caregivers benefited from dramatically improved communication across delivery teams, the panelists reported. Because documentation is completed as the user speaks into the headset, there is no lag time and no guesswork in charting, providers reported. </div> <div>This saves time and eliminates copycat charting, which is a major problem in traditional documentation systems. </div> <div> </div> <div>One panelist tested several documentation systems before making the investment in one. A remote wireless voice-activated system simplified documentation for the nurse assistants better than another system that required the use of a computer to “convert their actions into documentation.”</div> <div> </div> <div>The investments required to set up the system included renting the equipment and fitting the facilities for wireless capability. </div> <div> </div> <div>The ease of use and immediacy of voice-assisted technology also gives team members quick, simple access to accurate, updated records and care plans for residents. This, in turn, increases survey results and compliance, another challenging area for facilities using other forms of documentation. </div> <div> </div> <div>When a panelist was in jeopardy of being written up by a surveyor because the care plan had not been updated, a staff member spoke up and suggested they take a look at the voice-assisted system. “A care plan isn’t just necessarily that piece of paper in the chart that no one looks at, when in fact, [the technology] drives the care plan out to the end users,” he said. The surveyor agreed, and the provider was able to demonstrate that they had, in fact, actually modified a care plan to meet the needs of this resident. “We had been providing the right care, and it had been documented. And so she didn’t cite us.”</div> <div> </div> <div>Preferred Care Partners Management Group, Plano, Texas, which represents 66 communities in Texas, Arizona, Florida, Iowa, and Kansas, reported that after piloting a voice-assisted system in two buildings, the average activities of daily living score increased from 11 to 15.65. </div> <div> </div> <div>Others reported that its silent paging feature increases staff efficiency by enabling them to page one another for assistance right from the resident’s bedside. This eliminates the need for staff members to leave a resident unattended while they physically go to look for help in lifting a resident or administering medication. </div> <div> </div> <div>In addition to streamlining work processes and increasing efficiencies, the silent paging feature eliminates noisy, disruptive overhead announcements and pages, thus creating a more peaceful environment inside the facility. </div> <div> </div> <div>The panelists reported that voice-assisted technology brought with it unexpected benefits, such as improved teamwork, a new sense of pride, and increased levels of professionalism among the staff. </div> <div> </div> <div>Executives found that since team members at every level needed to learn how to use the technology together, a collaborative bond developed among the whole staff. They also reported improved communication among staff members, which translates into a better working and better care environment.</div> <h3 class="ms-rteElement-H3">Revenue Boosted</h3> <div>Increasing reimbursement and reducing operating costs are two challenges facing nearly all long term care facilities. The idea of implementing a new charting and communication system, with its requisite technology needs, initially may seem overwhelming and cost-prohibitive.</div> <div> </div> <div>However, facilities that have implemented voice-assisted technology reported that just the opposite is true. In fact, the cost savings for operators is profound, with many facilities showing superior financial performance of six or seven figures in each building after implementing the technology. </div> <div> </div> <div>The technology helps to save costs and increase revenue in several ways, providers reported. First, it increases facility revenue by enabling more thorough and complete documentation, which results in higher reimbursement. </div> <div> </div> <div>One provider with 10 communities reported an increase of $5.00 per day in its Medicaid rate and an increase of $50.00 per day in its Medicare rate after implementing voice-assisted technology. When these increases were annualized for one building, they equaled more than $1 million of additional reimbursement compared with the previous year. <img width="127" height="298" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0210/TECH-Photo2.jpg" alt="" style="margin:10px 15px;width:200px;height:230px;" /></div> <div> </div> <div>Another provider suggested that the implementation of the system is helping them capture the services that are actually rendered. “Nurse aides sit down and spend all their time writing little initials in little boxes on flow sheets for 30 minutes or an hour out of their seven-and-a-half-hour day,” one panelist said. “And those things are not accurate…but if the nurse aide only has to communicate, this is a tremendous system. They use this little tiny headset,  and it captures all that wonderful information in 1.6 seconds or something like that. You can’t help but win.”</div> <div> </div> <div>Voice-assisted technology can also reduce or eliminate the need for overtime shifts. One company reported that its overtime shifts practically disappeared. <br></div> <div>The decrease is the result of employees using voice-assisted technology to chart as they go, which eliminates time spent completing paper forms or waiting to access another type of documentation system. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0210/Long-Term-Care-Documentation-Made-Easier.aspx">HERE </a>for tips on how to implement voice-assisted technology.</div> <div> </div> <div><em>Susan LupPlace is director of clinical services at Preferred Care Partners Management Group, Plano, Texas; Troy Baumann is chief operating officer of Community Eldercare Services, Tupelo, Miss.; and Jim Quasey is president of Vocollect Healthcare Systems, Pittsburgh.</em></div>A technology that began in supply-chain management has made its way to long term care, and providers are utilizing it to improve resident care and ease documentation.2010-02-01T05:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0210/TECH-Photo1.jpg" width="225" style="BORDER:0px solid;" />Technology;ManagementColumn2
Rooting Out Fraud In Long Term Carehttps://www.providermagazine.com/Issues/2010/Pages/0210/Rooting-Out-Fraud-In-Long-Term-Care.aspxRooting Out Fraud In Long Term Care<p>​Nov. 22, 2009, marked a significant milestone for Tamar Abell. It was the end of a 10-year ordeal that cost her family’s skilled nursing facility business more than $2 million in settlement costs and legal fees, not to mention numerous sleepless nights and hundreds of hours of paperwork.</p> <p>It began in the spring of 2000: After three decades of successfully owning and operating nursing facilities, one of Abell’s properties was hit with an investigation prompted by the allegations of a “whistleblower” who recently had been fired from the company.</p> <p>The U.S. Health and Human Services (HHS) Office of Inspector General (OIG) spent four years investigating the facility before a lawsuit was filed. Each of the business owners—Abell, her husband, brother, and father—were sued by the federal government under the civil False Claims Act (FCA) and placed under a quality-of-care corporate integrity agreement (CIA) that required federal officials to monitor each of of the company’s facilities for a period of five years. </p> <p>It never occurred to Abell that she would be sued. “I considered myself to be a ‘typical’ mom and pop provider,” she says. “I thought everything was going well. I thought this only happened to the big companies."</p> <p>Making matters worse, the facility under investigation had been managed by Abell’s company for only 16 months when at least a dozen federal officials marched into the lobby with subpoenas in hand. What’s more, the facility itself was unlike any other she had managed before. Having “grown up” with skilled nursing facilities, this particular building, which served inner-city young adults with mental illnesses, was a very different ballgame.</p> <p>“We knew going in that this was not going to be easy, but we did make improvements, and we had just had a good survey,” says Abell. </p> <p>But by the time they pulled out of the facility, just 18 months in, it was too late. </p> <p>Abell’s story does have a happy ending, but it serves as a cautionary tale of how earnest the federal government has become in its efforts to crack down on fraud, waste, and abuse in the Medicare and Medicaid programs. OIG and the U.S. Department of Justice (DOJ), as well as the Office of the U.S. Attorney General (AG), the Centers for Medicare & Medicaid Services (CMS), and most of the states have intensified their efforts in unprecedented ways to recoup overpayments, prevent billing errors and upcoding, and snag more onerous perpetrators in the act of billing for services never rendered or for deceased beneficiaries.</p> <h3 class="ms-rteElement-H3">Turning Lemons Into Lemonade</h3> <div>Implementing the CIA was arguably one of the most challenging aspects of her family’s entire calamity, says Abell, but it was also one of the best things that has happened to her business. “The OIG monitors were extremely helpful throughout the entire process,” she says. “They really helped us grow; they were really unbelievable consultants.” </div> <div> </div> <div>In fact, says Abell, her business has never before run as well as it does now. A CIA is typically negotiated as part of the settlement agreement with OIG in cases brought against health care providers under the FCA.</div> <div>In some cases, OIG will agree to allow a provider’s continued participation in Medicare and Medicaid in exchange for the imposition of a CIA, which is what Abell did. </div> <div> </div> <div>In addition to writing quarterly or monthly reports to OIG, CIAs may require providers and their staff to undergo rigorous training and education. In Abell’s case, her CIA required all direct care workers in each of the company’s facilities to be trained within the first 120 days of the program and annually thereafter.</div> <div> </div> <div>But tracking and monitoring the training programs for so many employees became unwieldy for Abell. So she created a solution that eventually became a separate—and successful—business. </div> <div> </div> <div>“I couldn’t figure out how to manage training all those people, so I developed an online training and tracking system that records who has been trained, when they were trained, and what tests they took,” she says. As she likes to say, “I made lemonade from lemons.”</div> <div> </div> <div> In 2009, Abell launched Upstairs Solutions, a company that helps senior care facilities educate staff to ensure compliance and mitigate risk. Abell has also recounted her harrowing experience to other long term care owners and operators in an effort to raise awareness about how susceptible providers are to government investigations. </div> <div> </div> <div>“There isn’t an operator in the country who can’t be the next one. I don’t care how big, how small; everybody’s vulnerable and accountable,” Abell says. But because she took advantage of OIG’s help and implemented a company-wide compliance program, the likelihood of her facing another OIG investigation or lawsuit has been minimized. </div> <h3 class="ms-rteElement-H3">Now Is The Time</h3> <p> As a result, Abell is now a strong advocate of every nursing facility adopting a corporate compliance program (CCP) “before someone else makes you put [one] in place.” Hers is one of many examples driving defense attorneys’ efforts to implement CCPs for their nursing facility clients.</p> <div>Why the urgency? “There are some very real dangers to health care companies out there, and there are some very real benefits to the protections provided by a corporate compliance program,” says Dan Small, a trial and health care partner with the Boston and Miami offices of Holland & Knight.</div> <div> </div> <div>According to nearly any expert with knowledge of the long term care industry, CCPs are the best defense against government accusations of fraud.</div> <div> </div> <div>Small says some studies of CCPs have found that nursing facilities with strong compliance programs are better run, have reduced capital costs, and have less expensive liability insurance rates. In fact, he says, the government has used some cases where there is either a lack of a compliance program, or a deficient one, to demonstrate that “any company that is in the health care industry and does not have a compliance program, is almost, per se, recklessly disregarding their obligations under the law.”</div> <div> </div> <div>OIG also favors the idea. A recent guidance document suggests that all long term care providers should establish and maintain effective compliance programs with the goal of improving quality of care and services.</div> <div>Resistance to adopting a CCP most likely comes from two sources, says Small. Some have a hard time believing that an industry that is as highly regulated as nursing facilities would need yet another layer of regulation on top of it. </div> <div> </div> <div>“The truth is, you have to layer on a compliance program precisely because we’re one of most heavily regulated industries in the country,” he says. </div> <div> </div> <div>The other hurdle to getting providers to implement compliance programs is cost. Owners and operators often see a CCP as an expense rather than an investment. “But it’s one of the best investments a facility can make,” says Small.</div> <div> </div> <div>Both whistleblowers and the government will use any violation of those regulations as evidence that someone is committing fraud, he adds. “It puts people that don’t have a compliance program in a very dangerous situation.”</div> <div>Small also touts an additional benefit for facility owners who are selling a property. “Acquiring parties are taking a strong look at a compliance program during the due diligence process,” he says. “Because if you buy a facility that has poor compliance practices, you’re buying the unknown: investigations and potential FCA risks.”</div> <h3 class="ms-rteElement-H3">Focus Is On Fraud</h3> <div>Driving the heightened interest in CCPs is the government’s renewed fervor to root out wasteful spending, overpayments, overbilling, and criminal activity.</div> <div> </div> <div>In an effort to recoup dollars back into the system, state and federal watchdogs have turned their attention to nursing facilities, home health agencies, and durable medical equipment suppliers with an eye on the tremendous potential for cost savings that preventing and prosecuting fraud can bring.</div> <div> </div> <div>Behind the eagerness to ferret out and return funds to the government is the fact that fraud has become big business for criminals—so big, in fact, that organized crime leaders have gotten into the game. </div> <div> </div> <div>Although no one is certain what the exact figure is, the National Health Care Anti-Fraud Association estimates that some $60 billion, or about 3 percent of total annual health care spending, is drained from the Medicaid, Medicare, and other government-sponsored health care programs each year thanks to fraud, waste, and abuse.</div> <div> </div> <div>In testimony before a Senate committee hearing last May, Malcolm Sparrow, a professor at Harvard’s John F. Kennedy School of Government, asserted that the “units of measure for losses due to health care fraud and abuse in this country are hundreds of billions of dollars per year. We just don’t know the first digit. It might be as low as one hundred billion. More likely two or three. Possibly four or five. But whatever that first digit is, it has 11 zeroes after it,” he said. </div> <div> </div> <div>Sparrow, who is considered to be a leading expert on the topic, emphasized that reining in such losses “warrants a great deal of serious attention.” He advised committee members that defeating fraud would take drastic measures, including the use of “surveillance, arrest, or dawn raids.”</div> <div> </div> <div>With the potential for savings and recoupment so great, pressure has also come from the executive branch in the form of promises. During a joint session of Congress last year, President Obama pledged to fight health care fraud and alluded to using the recoupments to cover the cost of health care reform.</div> <h3 class="ms-rteElement-H3">Heightened Activity</h3> <div>Federal agencies are also working together in new ways to ramp up their data sharing and enforcement activities in an effort to better detect and identify fraudulent providers. HHS, for example, recently joined forces with the Office of the U.S. Attorney General last May to launch the Health Care Fraud Prevention and Enforcement Action Team, or HEAT, which deploys “top-level” DOJ and HHS officials to both prevent fraud and enforce current anti-fraud laws around the country. </div> <div> </div> <div>HEAT has made some headway in its early stages, according to Tony West, assistant U.S. attorney general, who testified last October before the Senate Judiciary Committee. </div> <div> </div> <div>“We are actively analyzing data in unprecedented coordination between our two agencies, and in as real time as possible, to identify fraud ‘hot spots’ and expand Strike Force operations to those areas where there is the most need,” West said. </div> <div> </div> <div>Already under way is enhanced training of prosecutors and investigators on enforcement measures; increased compliance training for providers to prevent honest mistakes and help stop potential fraud before it happens; and efforts to educate the public about ways they can assist DOJ in detecting, preventing, and prosecuting fraud.</div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0210/A-Tidal-Wave-Of-Anti-Fraud-Activity.aspx">HERE </a>to learn about how the various agencies have joined forces to fight fraud in Medicare and Medicaid.</div> <div> </div> <div>OIG investigators are also implementing “state-of-the-art” technology to identify and analyze potential fraud with unprecedented speed and efficiency, said West. </div> <div> </div> <div>According to OIG, the use of this technology has enabled federal law enforcement officials to obtain “electronic evidence” that previously took months to analyze using traditional investigative tools.</div> <h3 class="ms-rteElement-H3">Consider A Compliance Program</h3> <div>Industry advocates like the American Health Care Association (AHCA) have kept track of this flurry of anti-fraud efforts over the past few years and concluded that its members would benefit from more guidance about how to implement a CCP. As a result, the organization launched a series of Webinars aimed at guiding providers through the process of planning, implementing, and maintaining a compliance program. </div> <div> </div> <div>At least one dozen presentations on AHCA’s Web site illustrate the importance of adopting a CCP and drive home the idea that planning and developing one is key to its effectiveness. CCPs need to be well-implemented and monitored on a regular basis, and they must be embraced by the company’s leadership, according to Ken Burgess, a health care attorney with Poyner Spruill in Raleigh, N.C., who worked closely with AHCA to develop the Webinars.</div> <div> </div> <div>Effective compliance programs take the commitment of the company owners, managers, and board of directors as well, he says. “Whether your company and facilities are owned by a single individual, a partnership, or corporate shareholders, and whether your managing body is small or large, those folks have to dedicate sufficient resources to the program on a daily basis.”</div> <div> </div> <div>Burgess likens the implementation of a CCP to “designing, building, maintaining, and repairing a house.”</div> <div>“The construction of any house begins with a planning and design process,” Burgess says. “So does an </div> <div>effective compliance program.” </div> <div> </div> <div>A CCP should be viewed as two separate components, he adds: the physical structure—the elements that govern the operation of a CCP—and the furniture and appliances inside the house—the substantive laws and policies that ensure compliance. </div> <h3 class="ms-rteElement-H3">Mitigating Factors</h3> <div>Chris Myers, a partner at Holland & Knight and editor of “The Corporate Compliance Answer Book 2009,” says one of the first things a nursing facility operator should do when creating a CCP is to review the OIG guidance documents that identify risk areas for long term care providers. “This guidance identifies risk areas that should be addressed and walks through the elements of an effective compliance program,” says Myers.</div> <div> </div> <div>Another important document to review is published by the U.S. Sentencing Commission. It was originally designed for use in criminal sentencing, but is now used by organizations hoping to avoid being investigated for, or convicted of, criminal activity, according to Myers.</div> <div> </div> <div>“[It] is beneficial to providers because it provides guidelines on factors that may be considered either mitigating or exacerbating in determining the appropriate sentence,” he says. The manual contains a series of calculations, based on the seriousness of an offense, “and the most favorable mitigating factor [in sentencing] is whether or not you have an effective corporate compliance program,” says Myers. “It uses a detailed outline of what an effective compliance program should look like.” </div> <div> </div> <div>Another important element of a CCP, says Myers, is that it be risk based. “It should be designed and implemented to address the particular legal and regulatory compliance risks that affect a business,” he says. “And so for nursing facilities, since Medicare billing regulations are high up on the list, a compliance program needs to address those things.”</div> <div> </div> <div>Myers says that most well-run compliance programs begin with a risk assessment whereby the facility identifies the legal and regulatory provisions that affect the business and how it is conducted. </div> <div> </div> <div>“Providers also should look at their relationships with various government agencies, whether it’s Medicaid or Medicare or private insurance,” he says. “You need to list the various regulations that affect your business and determine if you have or need to develop special policies and procedures that will help you comply with that particular set of regulations.”</div> <div> </div> <div>Once a facility has a written set of policies and procedures, the staff must be trained, Myers adds. “They need to know what they’re supposed to do, how to comply with the policies, and where to go for questions,” he says.</div> <h3 class="ms-rteElement-H3">A Word About The False Claims Act</h3> <div>An effective, well-implemented, and well-run compliance program is the best defense against one of the most powerful tools the government has to fight fraud—the civil FCA.</div> <div> </div> <div>The statute imposes liability on persons who knowingly present—or cause to be presented—false or fraudulent claims to the United States, knowingly make false records or statements to get false or fraudulent claims paid, or conspire to defraud the government by getting a false or fraudulent claim paid. It also provides for treble damages plus penalties of $5,500 to $11,000 for each false claim.</div> <div> </div> <div>It has been a very potent weapon in the government’s arsenal against fraud, Myers stresses, and it presents some “extraordinary challenges to long term care facilities because any disgruntled employee who believes that there has been fraud in billing or any other related areas can bring one of these cases,” he says.</div> <div> </div> <div>The bad news is that the FCA just became more powerful, thanks to the passage of the Federal Enforcement and Recovery Act last year.</div> <div> </div> <div>Myers advises providers to be “very concerned” about the amendment. First, it expands the presentment of claims component to cover claims submitted to government contractors or grantees, as long as they are paid with federal money. Since Medicaid is a joint federal and state program, claims presented to Medicaid may now be subject to the FCA.</div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0210/Enforcement,-Investigation,-Prosecution.aspx">HERE</a> for more information about the government's various fraud, waste, and abuse prevention and prosecution strategies under the Medicare and Medicaid programs.</div> <h3 class="ms-rteElement-H3">Other Changes</h3> <div>Another major change to the FCA pertains to how DOJ shares information with a qui tam whistleblower’s counsel within the context of an FCA case.</div> <div> </div> <div>“It used to be that DOJ would hold things close to the vest,” Myers says. “Now they are expressly permitted to share information with the [whistleblower’s] counsel and with state and local health care agencies that want to get involved.”</div> <div> </div> <div>Yet another FCA amendment worth noting is something called “reverse false claims.” This means that if a nursing facility discovers a billing inaccuracy that results in receiving an overpayment, even if the mistake that led to the overpayment was completely innocent, the facility must return the money or be subject to an FCA suit. </div> <div>“Even if you didn’t do anything fraudulent, it entitles the government to bring a reverse false claim suit,” </div> <div>Myers says. “It makes it easier for whistleblowers to proceed but makes it more difficult to defend against these kinds of claims.”</div> <div> </div> <div>The qui tam bar is “all excited about these changes because they think it will increase liability and increase their opportunities to bring cases,” Myers says.</div> <div> </div> <div>Also related to the FCA is a growing trend among the various agencies to pay attention to quality-of-care issues, Myers says. “Nursing facilities in particular are vulnerable to these kinds of claims. For example, if a nursing home bills for services and the residents receive poor quality of care, DOJ now uses that situation to assert false claim liability.”</div> <div> </div> <div>Abell’s case was among the first quality-of-care FCA suits to be brought against a small nursing facility.</div> <div>Additional FCA amendments pertaining to long term care providers are as follows:</div> <ul><li>Allows for government complaints, for the purposes of the statute of limitations, to “relate back” to the filing date of the complaint originally made by the whistleblower;</li> <li>Expands whistleblower protections to include contractors and agents, in addition to employees; and Allows for designees of the attorney general to issue a civil investigative demand, which is similar to a subpeona.</li></ul> <div>States are also collaborating more and more often with federal entities to bring suits against nursing facilities </div> <div>and other health care providers, says Myers.</div> <div> </div> <div>The Deficit Reduction Act of 2005 encourages states to enact an FCA law that is as stringent as the federal one. Once a state has done so, it can retain an extra 10 percent of recovered Medicaid funds. As a result, 32 states and the District of Columbia have enacted false claims acts. </div> <div> </div> <div>The government’s many and varied efforts to step up health care fraud-fighting capabilities must not be taken lightly by long term care providers, both Small and Myers stress. “With nursing homes, you have an industry that is so heavily regulated and is now facing another tidal wave of regulation,” says Small. </div> <div> </div> <div>“And part of the problem more globally here is that with everyone talking about health care reform and talking about how much money will be saved by fighting fraud against Medicare and Medicaid, it puts an enormous amount of pressure on the agencies to develop the kinds of programs we’re talking about,” he says. </div> <div> </div> <div>“People have to understand that this is not going away; the government is going to put a lot of time and money and energy into these programs because of a commitment at the highest levels, and it’s been promised at the highest levels that they would yield extraordinary results.”</div> <div> </div> <div>For more information: Go to AHCA’s compliance website at:  <a href="http://www.ahcancal.org/facility_operations/complianceprogram/pages">www.ahcancal.org/facility_operations/complianceprogram/pages</a>.  </div> <div> </div> <div><em>Meg LaPorte is </em>Provider's <em>managing editor.</em></div>Under the government’s microscope now more than ever, providers must take steps to ensure compliance under Medicare and Medicaid.2010-02-01T05:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Policy;Legal;Survey and CertificationColumn2

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EMRs Enhance Retention, Recruitment In Nursing Facilitieshttps://www.providermagazine.com/Issues/2010/Pages/0310/EMRs-Enhance-Retention,-Recruitment.aspxEMRs Enhance Retention, Recruitment In Nursing Facilities<p>​<img width="259" height="385" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0310/tech1.jpg" alt="" style="margin:10px 15px;width:218px;height:164px;" />Caroline Rich decided some years back that the Brooklyn, N.Y., nursing facility she runs used entirely too much paper. She couldn’t get past what she saw: reams of paper being purchased for charting patients, keeping administrative records, and even for staff-to-staff communications, despite the fact most of her personnel had access to e-mail.</p> <p>Rich and other managers at the Four Seasons Nursing & Rehabilitation Center pondered steps to reconcile their desire for less paper and corresponding hope for significant cost savings and efficiencies, not to mention improved care for their nearly 270 residents.</p> <div>“About that time, there was the emergence of some national companies developing software for long term care, and then the grant from the QCOC fell into our laps,” Rich says, remembering what now has been a fortuitous turn of events for Four Seasons. </div> <h3 class="ms-rteElement-H3">Grant Opportunity Opens The Door</h3> <div>QCOC is the Quality Care Oversight Committee of the 1199 SEIU (Service Employees International Union) Greater New York Worker Participation Fund, which was at that time looking for facilities to participate in a long-range study on the effect of electronic medical records (EMRs) on employment and labor relations in nursing facilities. </div> <p>Rich’s facility joined 19 other New York centers that comprised the testing ground for the EMR study and eventually resulted in the release of a comprehensive 118-page report late last year detailing their mostly positive experiences in a “paperless” world. Rich’s take on the experience is more than positive. </p> <div> </div> <div>In addition to the study’s installation of new software, between June 2007 and spring 2008 Rich undertook a sweeping review of the existing technology at the facility and made relatively easy and logical changes. </div> <div> </div> <div>“We already had technology not being utilized, like internal e-mail,” she says, detailing how she got her own staff to avoid making lists on paper and use the fax machine’s scanning function to e-mail necessary documents instead of printing them out. </div> <div> </div> <div>“It was about raising awareness. I mean, we use cell phones and other devices so why not use [technology] in our business?”</div> <div> </div> <div>Meanwhile, while Rich was raising the bar on reducing paper through her home-grown initiatives and the new software, the overall study was focused on the larger issues of what it meant to bring technology to the seemingly neglected long term care sector. What the researchers eventually found was that many myths about nursing facilities and EMRs melted away under closer examination.</div> <h3 class="ms-rteElement-H3">Myths Dispelled</h3> <div>​What myths? Well, the one that nurses and certified nurse assistants would object to paperless systems by either quitting or not using the computers, or be unable to adapt to the technology. </div> <div>“EMRs did not affect the ability of the nursing homes to retain their employees; attrition rates were identical in the treatment homes and the control homes,” the report said. </div> <div> </div> <div>Of the 20 facilities taking part, 15 were upgraded with EMRs and five remained in traditional mode to allow researchers to compare and contrast the two.</div> <div> </div> <div>In fact, the adoption of EMRs actually attracted workers, the report concluded. Other positives were that employees in EMR facilities reported fewer conflicts with colleagues, experienced better communication with supervisors, were able to devote more time to resident care instead of paperwork, and noted fewer medical errors and near misses.</div> <div> </div> <div>Report authors—David Lipsky of Cornell University and Ariel Avgar of the University of Illinois at Urbana-Champaign—summarized that the evidence they compiled showed excellent results, with the vast majority of facilities using electroni<img width="365" height="300" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0310/EMRInfluence_tech.jpg" alt="" style="margin:10px 15px;height:309px;" />c documentation at rates of more than 90 percent.</div> <div> </div> <div>“The demonstration project, judged on technical grounds, was a remarkable achievement,” the report said. The results did caution, however, that positive outcomes depended greatly on a cooperative style of management at the individual homes, namely, in getting workers to buy into the notion of a mostly paperless world.</div> <div> </div> <div>Rich says the Four Seasons has millions of reasons to want to stay paperless, as in the number of dollars she estimates the five-year software lease will provide her facility. “Our return on investment should be around $4 million,” she says (Four Seasons is two-and-a-half years into its software lease), noting that number could be higher when all is said and done. These cost savings come from not having to buy as much paper, time savings for workers, elimination of newly unnecessary staff for maintaining paper medical records, redirected staff resources and equipment, and pharmacy costs.</div> <div> </div> <div>“We can now see, through the software tracking, what medications new admits use and see how that compares with our formulary and avoid unnecessary and excessive medication. These are quality-of-life issues,” Rich says. </div> <h3 class="ms-rteElement-H3">For More Information</h3> <ul><li>To read more about the long-range study on the effect of EMRs on nursing staff and their job satisfaction, including an executive summary and other information, go to: www.ilr.cornell.edu/conflictRes/research/nursingHome.html.</li></ul> <p><em>Patrick Connole is </em>Provider's <em>senior editor.</em></p>A New York EMR demo exceeds nursing facility's expectations.2010-03-01T05:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0310/tech3.jpg" width="225" style="BORDER:0px solid;" />Technology;QualityColumn3
SNFs Break The Infection Chainhttps://www.providermagazine.com/Issues/2010/Pages/0310/SNFs-Break-The-Infection-Chain.aspxSNFs Break The Infection Chain<p>Now, more than ever, disinfection of the resident’s environment is a key component of the infection prevention and control process in the long term care setting. One of the most critical interventions that can be routinely performed to decrease the risk for cross transmission and development of health care-associated infection is routine cleaning and disinfection of the health care environment. </p> <div>Cross contamination can occur in a variety of ways, but an environmental surface often becomes contaminated and then serves as a reservoir for microbial growth. The hands of either the health care provider or the patient come in contact with this contaminated surface, and contact is made with another device or surface, thereby contaminating it as well. Thus the chain of infection transmission begins.</div> <h3 class="ms-rteElement-H3">Clean Surfaces First</h3> <div>The ability of microorganisms to successfully survive and reproduce on environmental surfaces has never been greater. Organisms such as Methicillin-resistant Staphylococcus aureus, Escherichia coli, Clostridium difficile (C-diff.), and Mycobacterium tuberculosis can survive on surfaces for several months. C-diff. and other organisms, such as Vancomycin-resistant Enterococci, continue to plague the long term care environment.  Because of the resilience of these microorganisms, it is important to routinely disinfect potentially contaminated surfaces to reduce the risk of transmission. <img class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0310/HowInfectionSpreads.jpg" width="347" height="535" alt="" style="margin:10px 15px;width:375px;height:556px;" /><br><br>Before effective disinfection can occur, it is important to thoroughly clean visibly soiled environmental surfaces to allow for the full efficacy of the chosen disinfectant product. Cleaning—as defined by the latest Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, released in 2008—is “the removal of foreign material, such as soil, and organic matter, from objects, and is normally accomplished using water with detergents or enzymatic products.” </div> <div> </div> <div>CDC also emphasizes that thorough cleaning is essential before conducting high-level disinfection and sterilization “because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.” </div> <div> </div> <div>Cleaning removes bioburden—the number of bacteria living on a surface before it is sterilized—from the affected surface by reducing the number of microorganisms that must be inactivated. Removing bioburden from the surface prior to application of the disinfectant will result in increased disinfectant efficiency. </div> <div> </div> <div>It is also important to apply friction to the area being cleaned and disinfected in order to remove more resistant forms of microorganisms such as spores and C-diff. from the surfaces that may not be readily inactivated by the disinfectant. This will decrease the risk for development of multidrug-resistant organisms.</div> <div> </div> <div>High-touch surfaces such as blood pressure cuffs, stethoscopes, and glucometers require frequent disinfection to prevent cross-transmission between residents. The physical number of microorganisms present on any given surface is influenced by a number of factors, including the amount of moisture present on the surface, the amount of activity taking place in the immediate environment, the number of people having contact with the environment, and the type of environmental surfaces present and their ability to support the growth of microorganisms.  </div> <h3 class="ms-rteElement-H3">Critical And Noncritical Items</h3> <div>The primary focus of a thorough environmental disinfection program should be on those items that are used with multiple residents and/or procedures. E.H. Spaulding created a standardized approach to disinfection in the health care environment that consists of three categories: critical, semi-critical, and noncritical. </div> <ul><li>Critical items are those that will enter sterile tissue or the vascular system or areas in which blood flows would be sterile. The objective with disinfection of these items is complete sterility, which can be achieved through a variety of techniques such as ethylene oxide sterilization, gas hydrogen, chemical, or steam sterilization. Examples of critical items include intravenous catheters, implant devices, needles, urinary catheters, cardiac monitoring catheters, and surgical instruments. </li> <li>Semi-critical items are those that will come in contact with mucous membranes and/or intact skin. The objective for disinfection with these items is to eliminate all vegetative microorganisms, including viruses, bacteria, fungi, and mycobacteria. These items require high-level disinfection through  use of chemical disinfectants. </li> <li>The most frequently used items in the long term care facility are noncritical items, such as wheelchairs and bedside tables, because they have contact with intact skin, but not sterile body tissues or mucous membranes. These items require the use of a low-level disinfectant. With the recent migration of electronic medical records in many acute care facilities, disinfection of noncritical items such as computer keyboards is important to reduce transmission of microorganisms throughout the entire environment. Hand hygiene in these circumstances is still the most critical intervention to break the chain of infection, but routine disinfection of these potential reservoirs for microbial growth is also a key component. It is critical to have a complete set of policies and procedures identifying each individual’s and department’s responsibility in the cleaning and disinfection process. Careful collaboration with the environmental services team is necessary in order to ensure that all surfaces are routinely disinfected by the appropriate personnel. Educational programs are available through organizations such as the Association for Professionals in Infection Control and Epidemiology (APIC) or the American Society for Healthcare Environmental Services. Involvement of all staff members, including executive management and nurse leaders, is critical to the success of an environmental disinfection program. </li></ul> <h3 class="ms-rteElement-H3">Waiting Room Breeds Bacteria</h3> <div>Educating health care staff is key to minimizing risks associated with using any disinfectant product. Staff members should be trained on the appropriate indications for use of the product; the instructions for use, including total overall contact time required to effectively inactivate the microorganisms on the product’s efficacy label, known as the material safety data sheet; and the appropriate use of personal protective equipment as required by the Occupational Safety and Health Administration’s Bloodborne Pathogens Standard. </div> <div> </div> <div>Training on the appropriate use of the chosen product will ensure the product’s effectiveness and protect end users from adverse reactions. </div> <div> </div> <div>The waiting room of any a long term care facility is an excellent place for bacteria to breed due to the high-traffic nature of these unique environments. Residents also frequent these locations to visit with other residents, family members, and visitors. This creates an opportunity for transmission of infection between the resident and visitor, as well as between any environmental surfaces. </div> <div> </div> <div>One of the most efficient and economical ways to prevent infection transmission is to provide visitors and residents hand hygiene products for use immediately upon entering the facility. This simple intervention will prevent most microbes from entering the facility and being transmitted to residents and staff. It is also critical to properly educate visitors entering the facility about infection prevention standards for hand hygiene and isolation to ensure compliance with all current policies and procedures. </div> <div> </div> <div>Environmental services staff should thoroughly disinfect the waiting room and all items within each and every day with a facility-approved disinfectant to prevent microbial growth as a result of contamination. </div> <div> </div> <div>It is critical to involve all parties, including residents as well as visitors, in the infection prevention process to ensure success. A thorough cleaning and disinfection program combined with careful selection of the most appropriate hospital-grade disinfectant will dramatically improve the daily fight against health-care-associated infections. </div> <div> </div> <div>For More Information</div> <ul><li>APIC and Professional Disposables International have created a toolkit for educating health care facilities on proper infection prevention techniques and solutions. To request a free copy, which includes a facilitators guide; motivational posters in English and Spanish; case studies on hand hygiene, surface disinfection, and skin antisepsis; a resource guide; and a motivational video, go to: ww.pdipdi.com/champions_kit.aspx.</li></ul> <div><em>J. Hudson Garrett Jr., PhD, is director of clinical affairs at Professional Disposables International, Orangeburg, N.Y. He can be reached at hgarrett@pdipdi.com.  </em>​</div>Disinfecting medical equipment and environmental surfaces in nursing facilities is vital to stopping the spread of harmful microorganisms. 2010-03-01T05:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Caregiving;Quality;ManagementColumn3
Social Media In Long Term Care: Everybody’s Talking About Ithttps://www.providermagazine.com/Issues/2010/Pages/0310/Social-Media-In-Long-Term-Care-Everybody’s-Talking-About-It.aspxSocial Media In Long Term Care: Everybody’s Talking About It<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>​Joni Morrissey, the granddaughter of a resident at The Worthington, likes to look in on the Brick, N.J., assisted living facility’s Facebook page to see what’s happening at the facility and in the lives of her grandmother and her grandmother’s friends and also to chat with and be supportive of the community of “friends” of the page.  </p> <div>“It’s a great way to actually see on a regular basis what is going on,” says Morrissey. “My relatives in Texas and Florida can see my grandmother ‘in the flesh,’ so to speak, and comment on goings on. We can pass condolences and well wishes to the families of other residents if there is a death or illness. We even joke around, too!” </div> <h3 class="ms-rteElement-H3">Measures Protect Privacy</h3> <div>“Opening families up to this type of media gives true meaning to an open door policy,” says Morrissey. “What’s nice als<img width="197" height="250" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0310/coverstory2.jpg" alt="" style="margin:10px 15px;width:209px;height:157px;" />o is that Julia [the administrator] keeps tabs on who our members are so that our loved ones are not out there in cyberspace for all to see.” </div> <div> </div> <div>Julia Fraser, administrator of The Worthington, controls who’s allowed to become a “friend” of the page—only residents, family members, and real-time friends—so residents’ privacy isn’t violated. She developed a permission slip for residents or their family members to sign before a photo of them is ever posted on the Facebook page. Fraser likes to post photos of residents involved in a craft or other activity and can post a caption under the photo using the resident’s own words to send a message to family members—and other “friends”—electronically.</div> <div>Fraser and her staff are “extremely diligent” about keeping families involved in life at the facility, and the Facebook page is an extension of that effort. “I send out a family letter every month, we call families all the time for good and bad things, e-mail, text, etc.,” says Fraser. “After I myself joined Facebook and realized how easy it was to keep up with [my own] friends and family, it seemed like a perfect tool to add to The Worthington’s efforts in open communication.”</div> <div> </div> <div>Fraser says the top three drivers of satisfaction are communication, communication, and communication. “Any tool you can use to safely communicate with your families—use it. We scored huge in the [Summit, N.J.-based parent company Chelsea Senior Living’s] customer satisfaction survey because we communicate like mad.”</div> <h3 class="ms-rteElement-H3">What Is Social Media?</h3> <p>Social media is a conversation, a give and take, as opposed to the monologues of television and the printed word. It is communication that informs, but then goes beyond that to spark a discussion. Personalities emerge from the profile, the status update, tweet, photo, blog, or video. Acquaintances become “friends,” friends become “family,” and family become more closely bound—all because of frequent communication that ranges from trivial to earth-shaking, just as life does.</p> <div>Social media is a term that covers an array of computer platforms, the most popular today being Facebook, YouTube, MySpace, Twitter, LinkedIn, and Flickr.</div> <div> </div> <div>“Social media is the term for Web sites that publish user-generated content,” says John Cruickshank, an attorney with Alaniz & Schraeder, a labor relations legal firm based in Houston. “Most experts describe the rise of social media as Web 2.0, [a term that] was coined to identify the shift in the production of Web site content from large corporations to individuals.” Now, many of the large corporations have incorporated user-generated content to their Web sites, adding blogs, social networks, or discussion boards for feedback. </div> <div> </div> <div>Most sites are growing at a tremendous pace, says Cruickshank. </div> <div> </div> <div>Scott Testa, a professor of business at Cabrini College in Philadelphia, has conducted research into social media. “The fastest growing [social media sites] at this point are Facebook and Twitter,” says Testa. “MySpace is starting to lose members or is stagnant. LinkedIn continues to grow, and there are some other smaller niche sites that are gaining momentum.” Facebook alone has 350 million active users as of September 2009. </div> <div> </div> <div>“It’s not just a fad, and it’s not just teenagers,” says Beverly Macy, chief executive officer (CEO) of Gravity Summit, a Beverly Hills, Calif.-based organization that educates companies on how to use social media in their marketing efforts. “A fundamental shift of how we communicate has happened due to social media,” she says.</div> <div> </div> <div>Social media offers up an array of possibilities to long term care providers, provided they go about the process of immersing themselves in it in the right way. And because front-line staff are likely already familiar with it, the usual barrier to incorporating new technology to the workplace—resistance due to unfamiliarity—isn’t there.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">But Would Residents And Family Use It?</h3> <div>Interviews with numerous long term care providers revealed that many believe that not only would their residents never use social media, but that their baby boomer children, who often make the decision to place a resident in a particular facility, don’t use it and wouldn’t be effectively reached through social media. “The idea that older adults are not using social media is false,” says Cruickshank. “Facebook currently has over 10 million users aged 55 and over. That number will only go up—especially as grandparents realize how easy it is to communicate with their grandkids on Facebook and MySpace.” <img width="251" height="283" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0310/coverstory1.jpg" alt="" style="margin:15px;width:216px;height:162px;" /><br><br>Further, research indicates baby boomers and the younger members of the previous generation are turning to social media to help them make purchasing decisions and to find health care information.</div> <div> </div> <div>“Social media sites are how these decision makers will make their decisions,” says Cruickshank. “They will want to read the reviews and comments of other people describing their experiences” with the long term care facility, he says. </div> <div> </div> <div>Macy agrees. “Fifty to 65 is a very active online audience for health care research and understanding what they want to do with their parents,” she says.</div> <div> </div> <div>A study conducted in June 2009 by Cable & Telecommunications Association for Marketing found that 71 percent of seniors aged 65 and older go to the Internet to look up health and medical information, among other things, and that 39 percent of baby boomers regularly go to social networking Web sites, forums, message boards, and chat rooms. </div> <div> </div> <div>A study published a year earlier conducted by New York City-based ThirdAge, which researches the media and marketing habits of baby boomers, found that 97 percent of boomers go to the Internet for health care information. In making decisions, their findings indicate boomers value word-of-mouth recommendations, expert opinions, and trusted brands. “They relate to people sharing a similar life phase—and they trust those who have walked in their shoes,” said ThirdAge CEO Sharon Whiteley.</div> <div> </div> <div>A more recent ThirdAge study, conducted between July and August 2009, found that the Internet is playing an increasingly important role in the lives of boomers caring for sick or elderly loved ones. A majority indicated that they seek or plan to seek resources and information on caregiving online; 20 percent said they would turn to social networking sites dedicated to this topic.</div> <div> </div> <div>“This is an important measure of where people seek information, support, and advice and shows that today’s midlifers are proactively seeking solutions online, even for these sensitive, emotionally charged family health care issues,” said Whiteley in a statement.</div> <div> </div> <div>Marketing and public relations directors at long term care communities are taking note. “It’s an amazing phenomenon, and it’s something we all need to be part of because that’s where the conversation is taking place,” says Bonnie Polishuk, director of marketing for the Los Angeles Jewish Home.</div> <h3 class="ms-rteElement-H3">Many Providers Cautious</h3> <div>Despite the increase of social media use by baby boomers, many long term care companies are cautious about using the sites to reach decision makers. “The use of social media in the seniors housing industry is in its infancy,” says Liz Bush, senior vice president of marketing and sales at Life Care Services (LCS), Des Moines, Iowa. Using social media in a variety of ways is under discussion at LCS, but has yet to pass the discussion stage. “Use of or work with social media to promote communities is limited to a few pioneers,” she says. </div> <div> </div> <div>Macy thinks long term care companies will increasingly turn to social media to reach their stakeholders. She likens it to websites. Ten years ago, companies weren’t sure that they needed one, but “then there was a tipping point where everybody had a Web site. And now it’s a regular business process,” she says. “We’re at this place where there’s a real transition occurring, and it’s very exciting.” </div> <div> </div> <div>Most of those who see the value in using social media are proceeding with caution. “We really just got our main Web site where we want it within the last year or so,” says Tom Kranz, public relations director of Chelsea Senior Living. “The company’s been kind of slow moving in that area. In terms of social media, the approach will be slow and careful. Privacy and security of our residents comes first; marketing comes second. I think we’ll do more [with social media], but we’re not rushing into it.”</div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0310/Revamp-Policies,-Training.aspx">HERE</a> for more information about how providers can educate staff to ensure the privacy of its residents.</div> <div> </div> <div>Those who ignore social media do so at their peril, say experts, and long term care providers are beginning to heed the warning. “These networks are changing the way people learn and make decisions,” says Michael Smith, corporate director of public relations for ACTS Retirement-Life Communities, a not-for-profit aging services organization. “Your brand is no longer what you say it is, it’s what others say it is,” he points out. “And social media helps you learn a great deal about your stakeholders and their priorities—how they make decisions and what they value.”</div> <div> </div> <div>Smith says some people at ACTS were a little skeptical at first about using social media, “and that’s natural. Any time something new appears there’s a little skepticism involved as far as what the impact will be,” he says. “But now that social networking has gone mainstream, it’s seen more as a necessity and embraced as a marketing tool.”</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">Start With A Strategy</h3> <div>So social media is a good tool for reaching baby boomers who will, at some point, likely need to look for a long term care facility of some kind for their parents. But should a company just start setting up accounts with the various platforms?</div> <div> </div> <div>Start with a plan, experts advise. Providers should “build a [social media] strategy just as any marketing strategy, and understand that these are simply new distribution [forums] for the branding message,” says Macy.</div> <div> </div> <div>Begin with learning about social media and how it works. Answer questions such as who are you trying to reach, what are you trying to accomplish, how are you going to accomplish it, who is going to do the work, what sort of policy or guidelines do you need to develop to keep everyone on track and protect the company legally, and how are you going to measure your effectiveness?</div> <div> </div> <div>Eric Schubert, vice president of communications and public affairs for Ecumen, a faith-based provider of seniors housing from independent living to long term care based in Shoreview, Minn., says asking those questions is essential. “Why do you want to use it, and how are you going to use it?” says Schubert. “We just threw a Facebook page up there and didn’t answer those questions,” and the page was not successful.</div> <div> </div> <div>When determining who to reach through social media, certainly include families and baby boomers, but consider other stakeholders, too, such as informal caregivers, people with disabilities, referral sources, potential donors, residents, current and potential employees, the media, and legislators, experts say.</div> <div> </div> <div>ACTS’ strategy involved “creating goals, creating content, measuring our efforts, understanding challenges and risks in managing social media, and having some guidelines in place for our employees when posting on behalf of the corporation,” says Smith. “We want to drive traffic back to our Web site where people can learn more about our company and the services we provide, and ultimately be a lead generator,” he says. </div> <div> </div> <div>“The key point I wanted to make is we view social media as a complement to the other forms of outreach,” Smith says. “It doesn’t replace other means of relationship-building with residents, families, and other stakeholders; doesn’t replace the personal visits, e-mail, direct mail, ads, events, and public relations efforts,” he says. “The key is integrating the benefits of engagement and listening and dialog that these networks provide with a broader communications strategy.”</div> <div> </div> <div>Also important to consider is who will be doing the work of maintaining the social media sites. To be effective, someone will have to consistently and frequently post content to these sites. </div> <div> </div> <div>“It does take time to maintain and to use,” says Schubert, “and so I think it’s helpful to really figure out who’s going to be operating that and how does it fit into your overall strategy.” </div> <div> </div> <div>Macy recommends going to an expert when it comes to rolling out the company’s presence in social media. “You’ve spent thousands of dollars, maybe millions of dollars, building your brand. Don’t turn [social media efforts] over to an intern.” </div> <div> </div> <div>But many long term care companies, like Ecumen, prefer to keep that work in-house. </div> <div> </div> <div>The Jewish Home has hired a full-time employee whose sole focus is social media, says Polishuk. This employee will maintain the Facebook and Twitter pages. He’ll send out tweets (messages) and news releases and come up with strategies to generate traffic and interest.</div> <h3 class="ms-rteElement-H3">Learning How To Use Social Media</h3> <div>Before launching any content on social media sites, spend some time getting familiar with the various sites and determining who will be best reached by which site. </div> <div> </div> <div>For example, if the purpose is to recruit professional staff, look at LinkedIn, which is a social networking site for professionals. With LinkedIn, after creating a profile an approach might be to join long term care-related groups to begin to foster relationships that may result in an optimal hire. </div> <div> </div> <div>If the purpose is to make senior staff available as subject matter experts, an approach might be to start a blog. Readers of the blog may ask questions that the expert could answer. But before starting a blog, spend time reading what’s already out there. Figure out how to differentiate the company’s blog, or make it more valuable than what’s already available. See how blogs are written and how reader comments are handled. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0310/Social-Media-Tips-And-Terms.aspx">HERE</a> for more information about social media tips and terminology.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>Blogs are also a great tool for communicating with residents and families, says Brian Purtell, an attorney and director of legal services for the Wisconsin Health Care Association. “I don’t think people know how simple it is to set up a blog that would allow them to give residents and family members real-time updates about facility news and information,” he says. Newsletter information “isn’t particularly relevant by the time it comes out.” </div> <div> </div> <div>Compare that with a blog that family members subscribe to—and to which access is limited—in which a provider can, for example, remind family members of an event like a family picnic that is going to happen in the very near future, he says.</div> <div> </div> <div>If the purpose is to keep staff at a number of facilities informed of what’s going on in the profession, maybe Twitter would be an option. Content on that particular site must be limited to 140 characters, so “tweets” could share links to articles of interest on the Web, for example, along with encouraging brief conversations among staff to make them feel more like a community.</div> <div> </div> <div>If the goal is to keep family members informed of what’s happening at a facility, The Worthington’s experience shows that Facebook or MySpace may be a good option, and they have the added benefit of introducing family members to each other and allowing them to create community amongst themselves. “Families really like it,” says Kranz.</div> <h3 class="ms-rteElement-H3">Going The Group Route</h3> <div>Fraser recommends that administrators—or the designated social media person—set the page up as a “group” rather than as an individual or fan page. “I first tried to set it up as a ‘person,’ but then there were warnings from Facebook that ‘if you are a business and sign up as a person you’ll be in big, big trouble,’” says Fraser.</div> <div> </div> <div>“So I tried as a fan page, but realized that anyone could access your page and post comments. With the way team members come and go in this industry, the thought of sour employees posting bad things was too risky. So I found the ‘group’ arena and set us up as a closed group with permission needed to join or access it.” </div> <div> </div> <div>To encourage family members to join the group, Fraser sent out a flyer with her monthly “family packet” and mentioned it in three consecutive family letters. “Now I mention it every couple of months, and we include it in our family orientation packet,” she says.</div> <div> </div> <div>If the purpose is to get people to actually look at the facility so they can see how nice it is, then Flickr, a photo-sharing site, or YouTube, a video-sharing site, may be the best bet. Those sites are also good for publicizing images of a recent event. </div> <div> </div> <div>To connect family with residents more effectively, consider using Skype, a free video call application using the Internet. “We can enhance quality of life by having laptops available so [residents] can do a Skype call” with their loved ones, says Purtell. To reach baby boomers, do a Google search on “social media sites for baby boomers,” which will pull up a list of such sites, like Eons.com, targeted directly to this population, she says.</div> <div> </div> <div>Whatever the goal, chances are a social media site or application exists that will meet the need. If Cruickshank could give providers one piece of advice about social media sites, it would be, “Don’t be afraid of them. Many people, especially those who grew up before the age of the Internet, are worried that this medium has already passed them by,” he says. “They couldn’t be more wrong. Social networking sites are designed to be simple. Starting a Facebook page takes a mouse, a keyboard, and about four minutes. Don’t be afraid of something that is designed to be easy. Try it out. You might even like it.”</div> <h3 class="ms-rteElement-H3">Taking The Plunge</h3> <div>Ecumen is significantly involved in social media and first got involved in it three years ago when it was still very new. Today, the company regularly posts on Twitter, Flickr, LinkedIn, and YouTube and has three blogs.</div> <div> </div> <div>Schubert had several reasons for getting Ecumen involved in social media, particularly blogging. “I’m kind of a media junkie,” admits Schubert. Back before launching the company into social media, he kept seeing so many “neat stories” on senior services and noticing the many interesting things that the profession was doing. He began “looking for an outlet to share that information [with] other people who might be interested in the subject. So blogging really seemed to be a good vehicle for us.” </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>The first blog the company launched on its website, “Changing Aging,” provides news, ideas, and opinions relating to innovation in senior services. Two years later, divisions within the company added another two blogs: one provided by their clinical consulti<img width="294" height="214" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0310/Top10onlinedestinations.jpg" alt="" style="margin:15px;width:374px;height:274px;" />ng division, which acts as a nursing facility help desk, and one produced by their development division, which is targeted to people who are considering developing seniors housing.</div> <div> </div> <div>The blogs also help cohesion within the company, which has 80 locations in five states. They “allow our employees to learn more about things that may be happening within Ecumen or the profession or aging and senior services.”</div> <div> ACTS is rolling out a new Web site in the first quarter of this year that will integrate a good deal of social media.</div> <div>The company currently is active with Twitter and plans to roll out Facebook, LinkedIn, a YouTube channel, podcasts, a blog, and lots of video and audio to coincide with the redesign of its Web site, Smith says. “Also in the works are portals with resident-generated content, offering the ability to connect with other ACTS residents and family members, view in-house television, and [other] content.” </div> <div> </div> <div>“We envision all of these platforms are going to help us have a dialog and a free exchange of ideas with our stakeholders, as well as greatly enhance our brand awareness and recruitment efforts,” he says. </div> <div> </div> <div>Most every business nowadays is looking at how social media can be used to market goods or services to consumers, referral sources, and peers, says Macy.<br><br>Macy didn’t have statistics on how effective social media marketing is for the long term care profession, but data are coming out about how social media marketing is doing for other industries, she says. “In the auto industry, JD Powers released at the end of 2009 [data showing that] social media is driving marketing for consumers more so than print ads, that word-of-mouth marketing is more powerful than ever.”</div> <div> </div> <div>Providers in the long term care profession are just beginning to evaluate advertising on social media sites.</div> <h3 class="ms-rteElement-H3">Social Media And Advertising</h3> <div>Kranz has just placed his first Facebook ad for Chelsea Senior Living. These are small ads that appear on the right sidebar of an individual’s Facebook page. “You pay per click on the ad, which then redirects the viewer to the main Chelsea Senior Living Web site,” says Kranz. “I went with a very low-budget plan, just to see initially what the response is.”</div> <div> </div> <div>Sherman advertises on Facebook because Facebook told her 80 potential people were out there who would be interested in her advertisement, but she only gets about two hits on her ad a month, she says. None of the hits have led to new residents. </div> <div> </div> <div>But according to Vicki Rackner, MD, president of The Caregiver Club, a Web-based social networking community for family caregivers out of Mercer Island, Wash., plenty of caregivers could benefit from appropriate information provided to them via social media sites, and, if done right, learn to trust the company that provides it. In getting the club off the ground, Rackner relied heavily on social media, especially blogs and videos. </div> <div> </div> <div>"I’ve been amazed at the results,” she says. “Last night I posted a little video. This morning it is No. 1 out of 3 million.” She thinks videos are particularly effective because she believes the country is moving toward being a video-based society. Rackner, a physician and an informal caregiver, has a good idea of what such caregivers want and need. She posted a video about how to talk to your doctor, and that video got more hits than millions of other similar videos. </div> <div> </div> <div>“If I can learn how to do this, anyone can do this. They can make their own videos. It’s so easy to buy the latest Kodak camera and upload the videos to YouTube and other sites,” Rackner says. “The Internet works beautifully for [caregivers] because they experience isolation, and it’s a chance to get connected."</div> <div> </div> <div>And it’s equally valuable for the people the caregivers are caring for, she adds. “Pain plus isolation equals suffering. Even if you can’t go out, [with social media] you’re not alone, and that’s hugely, hugely helpful for caregivers and the people for whom they care.”</div> <h3 class="ms-rteElement-H3">Benefits To Staff</h3> <div>Staff at far-flung facilities have something in common—the challenges and rewards of caring for people who are elderly or have disabilities. Social networking could provide them with a community from which they could learn and receive support. </div> <div> </div> <div>“Certain questions that may come up in one assisted care facility are probably common in a lot of them, so social networking would be a very good fit in these kinds of facilities,” says Testa. “It may be more efficient to communicate electronic-ally than it would be via telephone.”</div> <div> </div> <div>Another use for social media in long term care would be to set up a private social network—one to which only staff have access. One way it could be used is as a “central depository,” says Testa. “Say there’s some type of procedural list, anything the staff would have to turn to in paper form. It can be put into [a private] social media context. </div> <div> </div> <div>Let’s say there’s a list of procedures to follow when an injury occurs, and it’s kept in a three-ring binder at all the nurses’ stations. You could post that,” and key staff members could review it and add suggestions, video of correct procedures could be posted to it, and the facility could thereby develop something much more comprehensive than the original list. </div> <div> </div> <div>Social media could be valuable for quality care, he says. “It’s the middle of the night. You have a skeleton staff over the holidays. Someone falls. What’s the procedure to follow? That answer could be on your social network. The staff member could search on ‘fallen patient’ and it would pull up what to do with a fallen patient and a list of people who should be contacted with not only their cell phone number but also their chat address, and staff could have an electronic group discussion about the situation.”</div> <div> </div> <div>That may be in the future for most long term care facilities, but “the nice thing about the future is that it’s constantly being shaped by the people of the present,” says Cruickshank. “The more interesting question is: What do long term care companies want the future of social media to be? Let’s go from there.” </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla. </em></div>Providers are finding new ways to communicate with families, prospects, and other key players through Facebook, LinkedIn, and other sites.2010-03-01T05:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0310/coverstory1.jpg" width="199" style="BORDER:0px solid;" />Technology;ManagementColumn3

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Health Care Reform Saga Keeps Everyone Guessinghttps://www.providermagazine.com/Issues/2010/Pages/0410/Health-Care-Reform-Saga-Keeps-Everyone-Guessing.aspxHealth Care Reform Saga Keeps Everyone Guessing<p>​Anyone searching for a final answer to the question of whether major health care reform legislation will happen this spring is probably suffering from whiplash syndrome. It’s been that crazy trying to figure out a logical conclusion to a possible once-in-a-lifetime, trillion dollar overhaul of the health care system.</p> <div>Even for Washington insiders, there has been no certainty on what this spring would bring, just as there was no certainty concerning the issue over the past year. “Anyone who has said one thing has usually been proven wrong,” said a Senate Finance Committee staffer. </div> <h3 class="ms-rteElement-H3">How It All Began</h3> <div>President Obama swept into office on the heels of a mantra to bring change to Washington, to fix a wide range of disparate problems facing the country. In fact, health care reform was the key domestic policy issue for most of Obama’s campaign for the White House, at least until the economy blew up later in the summer and fall of 2008. </div> <div> </div> <div>Obama framed the health care situation as a crisis of its own, saying a major overhaul of the system was needed, not just piecemeal change, in order to provide health care to the 40 million some Americans without it and as importantly to rein in year-to-year premium cost increases crippling employers’ ability to provide employees insurance. He also declared a fix to health care vital to future economic growth, noting the size of the health care system in relation to the gross domestic product and the threat of continuing with no plan to save Medicare and Medicaid as the nation ages.</div> <p><br></p><p>The core of the plans passed in the House and Senate, and now Obama’s own plan, would extend health insurance coverage to 30 million uninsured Americans over 10 years with a first-time mandate for nearly everyone to buy insurance and a host of new requirements on insurers and employers. </p> <div>The package that is expected to hit the House in early spring will be less expensive than the $1 trillion House-approved bill from last year and will not contain a government-run insurance program to compete with private insurers. This may please moderates and upset liberals.</div> <h3 class="ms-rteElement-H3">Where It Stands Now</h3> <div>The best way to look at the unsettled situation may be to outline the political logic prevailing in Washington, as <em>Provider</em> went to press, with a warning that any element could change at a moment’s notice. </div> <div> </div> <div>President Obama is currently using all of his presidential influence, including making campaign-like appearances and personal cajoling on Air Force One, to win over recalcitrant Democrats in the House who are wary of supporting the Obama plan for philosophical and political reasons. </div> <p>Obama undertook this effort, and even delayed an overseas trip by a few days, knowing full well that the fate of his health reform plans rested on his ability to sway members of his own party to back not only his plan, but the parliamentary maneuvering being considered to get the legislation passed. The House vote is mere days away, and even though Democratic leaders say they will have enough “yes votes,” there is no guarantee that the president will win. </p> <p>Prior to what now appears to be an imminent conclusion to the reform effort, President Obama and selected congressional leaders from both sides of the aisle held a widely anticipated, televised health care summit. The public meeting put into focus the difficulties everyone has known about in private for getting a bipartisan reform package done anytime soon.</p> <p>Simply put, most Democrats want to proceed with some version of the two bills they passed along party lines in 2009, which would give Obama the massive overhaul of the system he promised during his campaign for the presidency.</p> <p>Republicans made it clear that despite some areas of agreement, the House and Senate reform packages are too massive, too expensive, and without the support of most Americans. Plus, they see possible political gain by denying its passage, as witnessed by successful Republican election results in gubernatorial and congressional votes in Virginia, Massachusetts, New Jersey, and elsewhere over the previous months.</p> <div>Rep. Eric Cantor, the up-and-coming Republican leader from Virginia, put this sentiment in its baldest form during the summit by declaring: “We just can’t afford this [reform].”</div> <h3 class="ms-rteElement-H3">The Obama Plan</h3> <p>Obama, for his part, has recently released his own reform plan, which looks a lot like the Senate health care reform bill that passed last year. This hasn’t pleased all Democrats in the House, but it is unlikely that if given a choice, Democrats will reject whatever the final Obama plan looks like, even if it strays from what liberals and moderate Democrats really want.</p> <p>So, what does all this mean? Without getting into the arcane rules of congressional bill making, it is possible that the Democrats will push through a legislative package consisting of the main Obama reform plan (primarily the Senate bill) and a separate bill including policy changes demanded by the House. </p> <p>The Democrats will have to do this by maneuvering parliamentary rules that allow for simple majority votes, called reconciliation, thus avoiding Republican filibustering, which would require 60 votes the Democrats no longer have to block.</p> <p>Neither bill approved in Congress is good news for long term care providers. The glimmer of better news is that Obama’s proposal is based on the Senate version, which includes $14.6 billion in Medicare cuts for skilled nursing facilities (SNFs). These cuts would go into effect in 2012 via a productivity adjustment of the market basket rate as dictated by the secretary of the Department of Health and Human Services. By comparison, the House plan includes $23.9 billion in such cuts.</p> <p>Francesca Fierro O’Reilly, senior director of government relations for the American Health Care Association (AHCA), says it is not clear what other policy changes currently in the Senate bill will survive. It all depends on how the situation plays out, and whether Democrats actually go ahead with the reconciliation option, but she expects it may come down to that. “I think that [reconciliation] is the vehicle, because they don’t have the votes otherwise in the Senate,” O’Reilly says.</p> <p>Bruce Yarwood, president and chief executive officer (CEO) of AHCA, said the organization is working to advance a “reconciliation strategy” that would seek to improve the current reform proposal, namely by including some form of Medicaid relief—as long as the Medicaid relief is not used to justify higher Medicare cuts, and proceed with implementation of the resource utilization groups (RUGs IV) on Oct. 1, 2010, in a budget-neutral manner.</p> <h3 class="ms-rteElement-H3">Proposals To Watch</h3> <div>Other key issues at play for long term care include:</div> <ul><li>Wyden MedPAC (Medicare Payment Advisory Commission) Amendment. This is part of the Senate bill and would require MedPAC to review and report on Medicaid funding when making recommendations about Medicare payments. This is viewed by industry supporters as an important first step in ensuring stable funding that will protect the quality of patient care.</li> <li>Medicaid Nursing Facility Supplemental Payment Program. This is supported by provider groups since it would add $6 billion in Medicaid funding for long term care services over the next four years. The provision is part of the House reform bill. Specifically, it recognizes the chronic underfunding of Medicaid SNF care, which results in an estimated shortfall of more than $4.6 billion a year, or $14.17 per beneficiary per day. Another important part of a related House provision would require state Medicaid programs to report to the Centers for Medicare & Medicaid Services (CMS) information on how provider payment rates for covered services are determined. </li> <li>Transparency. The House language to increase civil monetary penalties and other mandates is not favored by provider groups. The Senate plan for additional disclosure requirements is acceptable, long term care leaders say.</li></ul> <h3 class="ms-rteElement-H3">A Little History</h3> <div>Before looking ahead too far, it may be helpful to look back for a quick moment. It’s safe to say the previous 15 months have been a roller coaster ride for health care reform, and for providers tracking the goings-on in Washington, that ride seems to have no end. </div> <div> </div> <div>When last year started, Washington experts had good reason to think 2009 or 2010 would be “the” time for making major structural changes to a U.S. health care system plagued by high costs, the lack of coverage for millions, and uncertain government funding on a year-to-year basis.</div> <div> </div> <div>When the dust cleared after the November 2008 elections, newly elected President Obama and victorious congressional Democrats were emboldened to make sweeping reforms. After all, Obama had made change the theme of his campaign, and health care reform topped his domestic policy agenda; in the minds of many Americans, it was the one day-to-day issue they wanted addressed in a timely and thorough fashion.</div> <div> </div> <div>Little did anyone know that the 12 months between Obama taking the oath of office and the election of Republican Scott Brown to replace reform standard bearer Sen. Edward Kennedy (D-Mass.) would fail to yield a legislative proposal for Obama to sign.</div> <div> </div> <div>After Brown’s win, the fate of reform came down to simple math. Even with a 59-41 majority in the Senate, the Democrats could not push through their proposals in the normal legislative manner without winning over one more vote to get back their super majority status of 60 votes (to break filibusters and other maneuvering by Republicans). </div> <div> </div> <div>This fact put in doubt everything that was sketched out over the previous months and now leaves many questioning whether Obama and his congressional lieutenants can achieve their reform goals.</div> <h3 class="ms-rteElement-H3">Observers Comment</h3> <div>Edmund Haislmaier, senior research fellow in health policy studies, domestic policy, for the Washington, D.C.-based Heritage Foundation, firmly believes the Brown election was the signal event that derailed the chances for a comprehensive reform package.</div> <div> </div> <div> “The odds are against any major piece of legislation. There are a whole lot of these House Dems who would rather not have to vote for their own proposal,” Haislmaier says. </div> <div> </div> <div>He expects stand-alone bills to emerge from Congress over the next weeks and months as it becomes less likely for an Obama bill to pass. Areas for possible legislation include insurance market reforms and fixing the much-discussed preexisting condition situation. What about long term care? It’s back to the future, he says, with congressional hearings on the White House budget plan. “This will fall back to the normal pattern, with tweaks made to Medicare in Congress,” Haislmaier says.</div> <div> </div> <div>He notes that his prediction for the ultimate failure of the Obama plan is based mainly on the unexpected way the president ran the effort. “I was surprised how badly it was done. It was technically and politically incompetent. You had kind of campaign types spinning it,” Haislmaier said. He notes the most basic aspects of the Obama health care program remain incomplete, notably the fact that there remains no permanent CMS director as the administration works into its second year. </div> <div> </div> <div>Lee Goldberg, policy director, long term care division, Service Employees International Union, was more confident that Obama will prevail in the end. “We are still hopeful this will go through,” he says. The big picture of the overhaul is appealing, Goldberg says, noting his group’s backing of provisions in the Senate plan for the CLASS Act, which seeks to allow people to participate in a new long term care insurance program.</div> <h3 class="ms-rteElement-H3">Providers Waiting And Acting</h3> <div>Ted LeNeave, CEO of Roanoke, Va.-based American HealthCare, has been on a mission. Instead of just watching and waiting for results from the health care reform saga, LeNeave, his company’s employees, and patients and their families have blitzed congressional offices with direct appeals to minimize Medicare cuts for SNFs and also have worked on the state level for more Medicaid funding.</div> <div> </div> <div>“We started a grassroots effort many months ago, using all of our 16 facilities and 2,000 employees for a letter-writing campaign,” he says. An initial two-day blast of such direct lobbying produced 5,000 letters to Congress, and a second effort months later pulled in another 5,000. “That’s 10,000 letters from employees, residents, and residents’ family members voicing our concern about cutting Medicare funding,” LeNeave says.</div> <div> </div> <div>The point made in the letters, and in nearly every sentence uttered out of the CEO’s mouth, is that while he understands how tough it is to make decisions in Congress on health care matters, the results of tough decision making should not be based on cutting those that need the money most.</div> <div> </div> <div>“I don’t envy them in their job, but I continually get tired of them trying to pay for everything on the backs of the elderly,” he says. “These are the people who fought in our wars, passed civil rights [laws], and paid for the buildings and furniture where the lawmakers work.” </div> <div> </div> <div>Health care reform is not just something providers in the D.C. area monitor closely, because every Medicare dollar cut or policy changed puts the bottom line at risk for any operator, no matter its size or location.</div> <div> </div> <div>One of those wondering about the fate of her business, and living a bit further away from the Washington area, is Linda Black-Kurek, president of Liberty Health Care Corp. in Dayton, Ohio, which runs 15 Liberty Nursing Centers in the state.</div> <div> </div> <div>She is straight on what she wants to see happen, which is nothing along the lines of the remedies on the table now. “I would like to see health care reform delayed as it is currently outlined,” Black-Kurek says. “The cuts to existing providers in order to fund coverage for additional beneficiaries do not make sense for the system as a whole. It will be difficult to continue to provide the services that are currently being offered.”</div> <div> </div> <div>But what if reconciliation happens and the Obama plan becomes law? What keeps her up at night? “The Medicare payment cuts are of extreme concern. We have already experienced significant reductions in net payments on the Medicaid side, and to have additional cuts on the Medicare side would be very difficult,” Black-Kurek says.</div> <div> </div> <div>She says further analysis is also needed on the implementation of the RUGs IV system. “It is supposed to be budget-neutral, but I don’t think the data have been analyzed by the industry to verify that. In fact, we think the system and rates as currently outlined involve additional cuts,” she says.</div> <h3 class="ms-rteElement-H3">Medicaid Factors In</h3> <div>Working not far from LeNeave is Debbie Petrine, CEO of Commonwealth Care of Roanoke. She stresses the double whammy being pulled on providers from not only the continued threat of more Medicare cuts, but also the depressed state of Medicaid funding. “That’s a real concern,” Petrine says.</div> <div> </div> <div>While she sees major problems with the way the system works now, it is not something she sees being fixed by the current legislation. “It is too far-reaching. Changes do need to be made in the system. We have a problem and need to deal with it, but such a massive overhaul is a concern,” she says.</div> <div> </div> <div>Petrine has a different take on what concerns her about the proposals. Beyond Medicare cuts, she worries about the employee side of the equation and thinks any reform should include the opening of the interstate insurance markets. It’s all about costs and trying to provide employees with a benefits package to discover and retain talented workers.</div> <div> </div> <div>“Companies should be allowed to go over state lines to buy insurance. If you can open that up and foster competition, that would help in both our rural and metro facilities,” she says.</div> <div> </div> <div>“We pay a large percent of our employees’ coverage; they pay for family, spouse, children … we are continually looking for ways to keep these rates affordable,” Petrine says.</div> <div> </div> <div>Something that Sen. John McCain (R-Ariz.) brought up time and again at the recent health care summit rang true for Petrine, which was the need to close so-called carve-outs in the health care legislation to protect selected groups. “I am concerned about large groups being carved out, like labor unions,” she says. </div> <div> </div> <div>Obama seemed to agree with McCain over the need to eliminate any “deals” made for votes and to appease certain constituencies, but nothing has been hammered out in the proposals currently on the bargaining block.</div> <h3 class="ms-rteElement-H3">Preparing For,  Fighting Against Cuts</h3> <div>LeNeave wants to change the way nursing facilities and their residents are perceived in Washington and, for that matter, in the state capitals as well. He believes that the fight against potential Medicare cuts should put SNF residents front and center, when possible, in order to show lawmakers who it is that will be affected by reductions in funding.</div> <div> </div> <div>“Long term care has a stigmatism to it, but nursing homes have completely changed from years ago,” LeNeave says. “Look at the case of my mother. She went into a facility for rehab [after surgery] for two weeks, then back home. It was cheaper in the nursing home than in the hospital. Somehow, I think [lawmakers] look at nursing homes and the people in them as demented, with odor issues and eating problems,” he says. The truth is that nursing facilities provide great care, LeNeave says, and the people living in SNFs, assisted living facilities, and other care centers represent a range of demographics and health and care needs.</div> <div> </div> <div>“We would get a lot more [positive] attention if the actual person affected [nursing resident] was speaking up. Right now, it is the employers speaking up,” he says, which puts long term care at odds with how Congress works to understand issues.</div> <div> </div> <div>As better ways to influence the political debate are explored, providers say now has also been the time to review options for controlling costs ahead of possible sizable Medicare cuts, though the economic slowdown has also been a factor in such planning.</div> <h3>Belt-tightening Goes Only So Far </h3><div>Black-Kurek fears for the worst, noting that previous funding cuts and the current economy have already forced changes to the way her facilities operate. “We have cut expenses already to a minimum. If we face additional Medicare cuts, it will be difficult to find more areas to cut without further impacting patient care,” she says.</div> <div> </div> <div>Petrine echoes that sentiment, stressing that further cuts would force a review of other efficiencies, but there is a point at which enough is enough. “There is only so much you can do,” she says.</div> <div> </div> <div>Across all their facilities, Petrine says 20 to 25 percent of residents pay through Medicare, and 60 to 65 percent with Medicaid. She doesn’t know if the industry is being singled out this time around, but it is clear to her that lawmakers need to understand that diminishing the role of SNFs is not good economics.</div> <div> </div> <div>“Legislators don’t see how we are a lower-cost alternative to hospitals,” she says, adding that the rising number of seniors and increasing pressure on hospitals to move people out as quickly as possible make nursing facility care even more important than before.</div> <div> </div> <div>For LeNeave, the thought of Medicare cuts has forced some real soul searching about the way his facilities function. In a process that has taken some time already, he says the company has reviewed its staffing model.</div> <div>“Of course you want to hire more in good times, but when that ends, you have that extra staff still. You don’t want to let them go, so we started looking at where we are efficient and right-sizing the organization,” he says.</div> <div> </div> <div>His review showed that from a clinical perspective, there were no areas to make cuts. The areas where some layoffs occurred were in the corporate offices, the roles that have an indirect impact on patient care. Other cost savings have come from utilizing technological advances and going paperless in record keeping and related areas.</div> <div> </div> <div>A major change that has helped save money was investing in making improvements to facility common areas by bidding out remodeling contracts during the recession. “Contracted renovation is cheaper than ever with so many contractors looking for work in the recession,” he says. The improved look of the facilities in turn generates more interest from potential residents, boosting marketing efforts. </div> <div> </div> <div>The company also went to suppliers and renegotiated contracts to trim margins and save money. LeNeave says these talks “were hard conversations” that had to be undertaken.</div> <div> </div> <div>In the final analysis, he says, resident care rules cost-cutting decisions and will do so even if the Obama plan goes into law. “The cuts will not hurt the quality of care; residents will always get meals, of course, and other required services. But these cuts will affect quality of life, like our fine dining programs and activities,” LeNeave says.</div> <div> </div> <div>“The fine dining that you have is like what you have at a restaurant, and costs a few hundred thousand dollars a year, but these are the things that really get [residents] excited.”</div> <div> </div> <div>That is what pains providers, he believes: the thought of having to reduce the book readings, seasonal parties, and outings that make life special for residents. The crux of the matter is making quality more than basic care, making it extra attentive to the individuals entrusted to the facility’s care.</div> <h3 class="ms-rteElement-H3">Conclusion Seems Near</h3> <div>Legislative sources, who work behind the scenes on health care for various committees, think too much has happened for Obama and the Democrats running Congress to walk away from the effort now.</div> <div> </div> <div>“There is a real sense that this is it. The summit is over, and the attempt at looking bipartisan took place, so after a month or so, I think [the Democrats] will get this through on their own,” said a House staffer working for the Democratic side.</div> <div> </div> <div>And, maybe that is what Republicans want too—a resolution—because once health care reform passes or fails, all eyes start turning to the November congressional elections and how lawmakers up for reelection will fare with voters across the country.</div> <div> </div> <div>The doubters think the Democrats will pay this fall, after misjudging the country’s appetite for what they are being served. </div> <div> </div> <div>Whatever happens, the way health care reform has progressed through the months has not surprised many people. Provider Black-Kurek certainly expected it, since the nature of Washington and the political wars are hotter than ever.</div> <div> </div> <div>“It has not really been a surprise that the votes have been along party lines,” she says. “This has turned into a political battle.” And, expect more of the same; just don’t expect anyone to predict when it will end, one way or the other. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0410/What-The-Health-Plan-Entails.aspx">HERE </a>for a brief description of what the plan entails. </div>President Obama swept into office on the heels of a mantra to bring change to Washington, to fix a wide range of disparate problems facing the country. Providers are concerned about how passage of health care reform will impact care.2010-04-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/architecture_1.jpg" style="BORDER:0px solid;" />Policy;ManagementColumn4
The Healing Power Of Touch For LTC Residentshttps://www.providermagazine.com/Issues/2010/Pages/0410/The-Healing-Power-Of-Touch-For-LTC-Residents.aspxThe Healing Power Of Touch For LTC Residents<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​<img width="275" height="268" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0410/caregiving3.jpg" alt="" style="margin:15px;width:198px;height:132px;" /><br>There is growing awareness of the value of therapeutic massage and skilled touch for elders with dementia. More and more elder-care communities are incorporating the services of a licensed massage therapist, but caregivers of all kinds possess the power of touch to help manage behaviors and improve the quality of life of the elders they care for.</p> <div>Long term care providers are being challenged like never before to come up with innovative ways to care for the rising numbers of older adults living with Alzheimer’s disease and other forms of dementia.  </div> <div> </div> <div>In this era of cost consciousness, skilled touch is an inexpensive and non-invasive intervention that can easily be administered by both professional and lay caregivers.</div> <h3 class="ms-rteElement-H3">Human Touch In Caregiving</h3> <p>People are naturally drawn to comfort infants with touch. What about those elders living with severe dementia? Are caregivers as willing to comfort with the same kind of touch offered to a baby? Most likely not. It seems that in society today, the willingness to touch elders diminishes. There is a culture that deems the aged and ill as “untouchable” in many ways. </p> <div>Touch is one of the most basic human needs and remains constant for a lifetime. Elders with dementia are often deprived of nurturing touch and meaningful physical closeness that can help them thrive.</div> <div> </div> <div>Touch in the form of sensitive massage or attentive holding has the power to ease physical, emotional, and spiritual discomfort. In the words of anthropologist Ashley Montagu, the most important and neglected need is the need for tactile stimulation. “The elderly often have impaired hearing, visual acuity, mobility, and vitality problems that can make them feel helpless and vulnerable…it is through the emotional involvement of touch that one can reach through the isolation and communicate love, trust, affection, and warmth,” she said.</div> <div> </div> <div>Since touching the hands is so familiar, hand massage may be gladly accepted by elders in long term care. A simple way to ask permission to give the hand massage is to offer to put lotion on elders’ hands. </div> <div> </div> <div>The following simple five-minute hand massage protocol can easily be incorporated into care routines by staff or family caregivers. Following are some techniques:</div> <ul><li>Preparation. Hold the hand of the resident receiving the touch, creating a connection and helping the person become focused or centered.  </li> <li>Application of technique. Apply hypo-allergenic massage lotion. Give each of the fingers a few gentle squeezes from the base to the fingertip, pausing periodically to make circular motions. Turn the hand over and make tiny circular motions on the palm of the hand with the thumbs and massage the soft, fleshy areas on the palm. </li> <li>Closing. Finish by thanking the recipient while holding both of his or her hands and sharing eye contact.</li></ul> <div>Universal precautions are important in any hands-on care. Caregivers should wash hands before and after giving a hand massage. Use caution and proceed with care when any of the following conditions are present: thin, dry skin; impaired range of motion; fragile bones; and conditions that contraindicate even gentle hand massage, such as bruises, cuts or openings in the skin, severe pain, edema, and inflammation.</div> <h3 class="ms-rteElement-H3">Mutual Benefits</h3> <div>Even in a five-minute touch session there are mutual benefits for the elder and the caregiver.</div> <div>For the elder, focused touch and sensitive massage can do the following:</div> <ul><li>Ease aches and pains;</li> <li>Encourage greater joint flexibility;</li> <li>Provide sensory stimulation, resulting in increased body awareness;</li> <li>Induce a relaxation response, increasing feelings of calmness;</li> <li>Support psychosocial well-being and decrease feelings of isolation; and</li> <li>Acknowledge one’s worth regardless of the condition of the body or mind.</li></ul> <div>The caregiver may experience decreased feelings of helplessness, less resistance by the resident in assisting with personal care and mobility tasks, the ability to more easily engage the elder in activities, a nonverbal way to redirect behavior or actions and reassure the person who is confused, and greater feelings of satisfaction and meaning in the work of caregiving.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Research Supportive</h3> <div>While there is a need for further research, studies indicate that the use of some forms of massage are effective in managing challenging behavior often exhibited by elders living with Alzheimer’s disease and other forms of dementia.</div> <div> </div> <div>The Remington Study, published in Nursing Research 2002, examined whether modifying environmental stimuli by the use of calming music and hand massage affects agitated behavior in persons with dementia. The <img width="223" height="200" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0410/caregiving1.jpg" alt="" style="margin:15px;width:134px;" /><br><br>subjects were exposed to 10 minutes of either calm music, hand massage, a combination of the two, or no intervention. Results demonstrated that both calm music and hand massage reduced verbal agitation and that the benefit was sustained for up to one hour.</div> <div> </div> <div>A 1995 Geriatric Nursing study by Snyder, et al., explored the idea of whether administering hand massage before care activities that were often associated with agitative behaviors would reduce the frequency and intensity of these behaviors during care activities. </div> <div> </div> <div>A five-minute hand massage was performed on residents in the morning and afternoon for 10 days. Results showed that it decreased the frequency and intensity of agitated behavior during morning care routines, although not during evening care. Staff reported that reducing the intensity of the behavior made it easier to care for the elders.</div> <div> </div> <div>A study published in the International Journal of Nursing Practice (1998) explores use of hand massage in an adult day-care center. Hand massage and essential oils were applied by staff and family members. The results were increased alertness; improved sleep; and decreased agitation, withdrawal, and wandering among the residents who received the hand massages.</div> <div> </div> <div>Family caregivers also reported decreased stress, improvement in sleep, and less difficulty in managing the elder’s difficult behaviors.</div> <h3 class="ms-rteElement-H3">A Case In Point</h3> <div>A case study in Geriatric Times illus-trates the impact of incorporating skilled touch in the form of sensitive hand massage for an 81-year-old woman called Mary, who resided in a skilled nursing facility for seven months.</div> <div>Prior to admission to the facility, she was cared for in her daughter’s home. Mary had Alzheimer’s disease, anxiety, dementia with behavior disorder, insomnia, osteoarthritis, osteoporosis, and recurrent urinary tract infections.</div> <div> </div> <div>She also required a wheelchair and had increasing difficulty communicating her needs because she could not find the appropriate words to express herself. Mary had also recently begun to yell out and, at times, bang on her wheelchair for long periods of time. </div> <div> </div> <div>She attended group activities, but her behavior was upsetting to the others, so she often was removed from the group. She had difficulty sleeping and was often more anxious at night, which increased her yelling behavior.  </div> <div>The nurse assistants and activities staff administered hand massages to Mary three times per day. Each session was five to 10 minutes and typically took place in the morning after breakfast, before group activities, and in the evening. </div> <div> </div> <div>Mary was receptive to having lotion applied to her hands and was responsive to the one-to-one attention.</div> <div>Following one week, the activity director reported that Mary was able to remain in more group activities without disruptive yelling and only occasional banging on her wheelchair. She was more engaged during self-care activities, and she had decreased restlessness at night.   </div> <div> </div> <div>This scenario illustrates that focused touch and sensitive massage may be used by any caregiver as an easy-to-learn and effective tool in dementia care. </div> <div> </div> <div><em>Ann Catlin, OTR, LMT, is a nationally certified and licensed massage therapist, Compassionate Touch Practitioner, and a registered occupational therapist. Catlin directs the Center for Compassionate Touch, a training organization. She can be reached at <a href="http://www.compassionate-touch.org/">www.compassionate-touch.org</a>. </em></div>Massaging the hands of residents with dementia can be a powerful tool in helping them feel less stressed and more relaxed.2010-04-01T04:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0410/caregiving2.jpg" width="150" style="BORDER:0px solid;" />CaregivingColumn4

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Culture Change Picks Up Speed In LTChttps://www.providermagazine.com/Issues/2010/Pages/0510/Culture-Change-Picks-Up-Speed-IN-LTC.aspxCulture Change Picks Up Speed In LTC<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>Bill Thomas, MD, would like to clear up a misconception about his position on nursing facilities: He doesn’t want to eradicate them; he wants to eliminate the traditional, institutional model of care that was adopted by nursing facilities nearly 50 years ago. “I want to abolish the practice of institutionalizing frail, older people,” he says. “The old model of the nursing homes needs to go away and be replaced with new models.” </div> <div> </div> <div>Although he understands that doing away with institutionalization may take the rest of his career—maybe even the rest of his life—Thomas is certain that it will happen.</div> <div> </div> <div>For the uninitiated, Thomas is a well-known figure in the long <img width="338" height="405" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0510/coverstory5.jpg" alt="" style="margin:15px;width:261px;height:176px;" />term care field who established the Eden Alternative in 1991 with the mission of transforming institutional approaches to care into a community “where life is worth living.” </div> <div> </div> <div>Thomas’ passion is sometimes mistaken for a disdain of nursing facilities and their operators, he recognizes, but that is not the case, he says. “People sometimes confuse what I say; they think I want to padlock all nursing homes and walk away, and here’s why that’s not true: I remain a forceful advocate and supporter and leader of the Eden Alternative movement, which is dedicated to bringing culture change to nursing homes as they are today.” </div> <div> </div> <div>He emphasizes that his plan is not “some kind of silly turn-off-all-the-lights-and-walk-away idea.” No, he says, “that’s not what I want—I want us to deliberately plan to outgrow the nursing homes. Let’s go beyond something that was handed to us half a century ago; let’s embrace and develop and implement new models of care.”</div> <h3 class="ms-rteElement-H3">A Notable Shift </h3> <div>There is no denying that Thomas’ work in the culture change movement has helped the industry change the way it looks at long term care. Awareness and adoption of some components of culture change have gained considerable momentum in the past two decades and made even greater strides in the past several years. </div> <div> </div> <div>A Commonwealth Fund survey of health care opinion leaders in 2008 found that 66 percent of respondents were familiar with the culture change movement, a dramatic shift from a 2005 survey in which 73 percent of respondents were unfamiliar with the term.</div> <div> </div> <div>In a recent article in the journal Health Affairs, Commonwealth Fund President Mary Jane Koren credits the Centers for Medicare & Medicaid Services’ (CMS’) Eighth Scope of Work contract with the nation’s quality improvement organizations as one reason why providers have become more aware of culture change.</div> <div> </div> <div>However, the battle is not entirely won, Koren notes. The fund’s “2007 National Survey of Nursing Homes” found that only 5 percent of directors of nursing said that their facilities completely met the description of a nursing facility transformed through culture change, and only 10 percent reported that they had initiated at least seven or more culture change practices. </div> <div> </div> <div>“All told, about one-third reported adoption of some culture change practices,” Koren writes, “and another third said that they were planning to follow suit. But the rest of the respondents said that they were neither practicing nor planning to commence culture change.” </div> <div> </div> <div>The difficulties of “operationalizing and maintaining culture change remain daunting” but are not insurmountable, she says. Speculation about why more providers have not adopted culture change on a wider scale typically centers on cost, access to capital, and perceived barriers to implementation, such as regulations that conflict with the person-centered approach that is so central to the movement. </div> <div> </div> <div>Nonetheless, culture change has become a part of the long term care lexicon. The basic tenets of the movement—person-centered care, individualized treatment plans, and resident choice and autonomy—have become the standard by which quality care is measured.</div> <div><br>Click <a href="/Issues/2010/Pages/0510/Measuring-Culture-Change.aspx">HERE</a> for information about evaluation tools that help providers measure culture change in their facilities.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Influence Broadens</h3> <div>CMS has embraced many principles of culture change, which has led to significant changes in surveyor guidance and regulation clarifications, while a number of organizations born out of the movement have done their share to educate policy makers and the public about the need for a fundamental change in the way nursing facilities care for their residents. </div> <div> </div> <div>The Pioneer Network, a nonprofit organization that provides education and networking to long term care stakeholders, runs 34 state coalitions dedicated to advancing culture change in their respective states. Coalition participants include provider associations, quality improvement organizations, state long term care ombudsmen, state survey agencies, culture change training and consulting organizations, academia, and citizen advocacy groups.</div> <div> </div> <div>Further evidence of the powerful impact that culture change has had on the long term care industry are the recent changes to licensing requirements for nursing facility administrators and certification requirements for medical directors. Working with the Pioneer Network, the National Association of Long-Term Care Administrator Boards amended the study guide for licensed nursing facility administrators with new task statements in resident-centered care.</div> <div> </div> <div>AMDA also worked with the Pioneer Network to create a separate domain and core competencies related to person-center<img width="1137" height="1313" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0510/Golden%20North%20Carolina%20Kitchen.JPG" alt="" style="margin:15px;width:267px;height:178px;" />ed care. A similar curriculum will soon be released for licensed nurses. </div> <h3 class="ms-rteElement-H3">For-Profits On The Scene</h3> <div>Although the majority of culture change early adopters have been nonprofit organizations, for-profits are beginning to take on this trend as their own. Large multifacility providers, such as Golden Living and Genesis HealthCare, Kennett Square, Pa., have jumped onto the bandwagon with companywide, patient-centered care initiatives that could rival many early adopters. </div> <div> </div> <div>Fort Smith, Ark.-based Golden Living began its culture change efforts in 2002, with the implementation of the Resident-Centered Care Initiative (RCCI) in 10 pilot facilities in four states. By 2005, the RCCI concept expanded to 24 facilities in seven states. The following year, Golden Living initiated companywide education on the principles of culture change. </div> <div> </div> <div>Ed McMahon, Golden Living’s director of Alzheimer’s care and quality of life, says these and other “very successful” programs have spurred a more resident-focused attitude throughout the company. </div> <div> </div> <div>More recently, Golden created a 100-point scale that enables each facility to measure its level of adoption. The company has also introduced a new set of five domains that incorporate the principles of the Pioneer Network: individual empowerment, community involvement, staff empowerment, the home environment, and the dining experience.</div> <div> </div> <div>The decision to turn its culture change initiatives into a companywide endeavor was not a difficult one, McMahon says. Among the most compelling indicators that Golden’s resident-centered programs were working was its increased market share. “In almost every market where we have a really transformed culture, we did better than our competitors…and that’s held true from when we first looked at the data in 2006 through today,” he says.</div> <div> </div> <div>Golden facilities that have fully embraced culture change experience higher revenue across the board, as well as a dip in expenses per resident day, compared with its non-culture change facilities. Profits per resident day were also significantly better, he adds. </div> <div> </div> <div>Golden’s payer mix and occupancy rates also improved, with a “significant increase” in the company’s percentage of Medicare and private-pay days, a decrease in the percentage of Medicaid days, and an increase in overall occupancy in highly transformed cultures.</div> <div> </div> <div>“This really made the case for us to continue down the path of culture change,” he says, adding that companies that do not embrace culture change “will be left in the dust in the next several years.”</div> <h3 class="ms-rteElement-H3">Advocates Tout Evidence </h3> <div>The Pioneer Network is working hard to prove to providers that culture change initiatives can be successful, and even lucrative. Through a grant from the Commonwealth Fund, the organization has been working on a project aimed at illustrating the market viability of the model. </div> <div> </div> <div>The goal of the project is to accelerate adoption and support implementation and sustainability by articulating the operational linkages between person-directed care, quality of care, and financing.</div> <div> </div> <div>In addition to a number of case studies, the project has produced an examination of how adopter outcomes translate into more quantifiable metrics and a benchmark of those metrics with national data and tools that assist providers in planning and budgeting processes for implementation, including an investment model outlining areas of investment and returns on investment in culture change. </div> <div> </div> <div>Also in the works is the development of tools, measurements, and benchmarks that will help providers better understand the planning, decision-making, and budgeting of culture change to make it approachable and doable. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>With support from the Commonwealth Fund, Pioneer Network policy analyst Amy Elliot compared the occupancy rates and operating margins of “early adopter” facilities with those of providers that had not yet adopted culture change. The results showed that culture change adopters have statistically significant higher occupancy rates longitudinally than the national average. More specifically, Elliot found that facilities with a sustained level of culture change between 2004 and 2009 maintained, on average, occupancy rates that were seven points higher than the national mean. </div> <div> </div> <div>Adopters also experienced a boost in private-pay occupancy due in part to increased demand for culture change providers, according to the research. The process of implementing culture change initiatives was reported by adopters as a largely budget-neutral process, with costs in some areas of implementation offset by efficiencies in others. </div> <div> </div> <div>“So, for example, a provider may lose some efficiencies when going from a single dining room to multiple dining rooms in neighborhoods,” Elliot says. “However, providers gain efficiencies in reduced plate waste or even areas like neighborhood laundry where costs are reduced due to universal workers, increased revenue from occupancy, and lower costs in supplements.”</div> <div> </div> <div>Another bonus for culture change adopters, according to Elliot, was operating margins that were comparable to the national mean. </div> <h3 class="ms-rteElement-H3">Going For The Green</h3> <div>One model of culture change that is gaining momentum at a fairly rapid rate is the Green House Project, a model that breaks the mold of institutional care by creating small homes for six to 10 (and sometimes 12) “elders” who require skilled nursing or assisted living care.</div> <div> </div> <div>The homes, which are designed for the purpose of offering “privacy, autonomy, support, enjoyment, and a place to call home,” are a radical departure from traditional skilled nursing facilities and are considered to be the peak of culture change. </div> <div> </div> <div>Each elder lives in a private room, designed to receive high levels of sunlight and easy access to all areas of the house, including the kitchen, laundry, outdoor garden, and patio. </div> <div> </div> <div>According to the Green House Project Web site, the small size of a Green House home promotes freedom from the limitations of an institutional schedule. Meals are prepared in the open kitchen and served at a large dining table where staff, elders, and visitors enjoy pleasant dining. </div> <div> </div> <div>NCB Capital Impact, a nonprofit community development organization that is pursuing the “rapid replication” of the Green House model through a grant from the Robert Wood Johnson Foundation, offers technical assistance and predevelopment loans to providers that are dedicated to developing and operating Green House homes. </div> <div> <img width="427" height="421" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0510/coverstory4.jpg" alt="" style="margin:15px;width:227px;height:224px;" /></div> <div>When the first Green House homes were built in Tupelo, Miss., seven years ago, many observers were impressed but skeptical about how such a small, individualized, and expensive model could be sustainable.</div> <div>Over the past few years, however, much of the skepticism has dissipated and been replaced with enthusiasm about the possibility that Green House homes can be replicated on a larger scale. As of March of this year, there were 79 Green House homes open in 14 states, and another 132 homes are either in development or under construction in another 12 states. </div> <div> </div> <div>Robert Jenkens, director of the Green House Project at NCB Capital Impact for the past five years, says that in the early days providers were building just two to three homes per site. Today, however, projects are much bigger, some with 16-home campuses. </div> <div> </div> <div>What’s more, in just the past two months, Jenkens says, he has had a flurry of requests for more information about Green House homes from for-profit providers. </div> <div> </div> <div>“I think what’s happened is that it’s moved from something that people wanted to work and were comfortable testing in a small way, to something people now understand and believe works, and they’re willing to do full transformations,” he says. “I think it’s what we had hoped for. We broke through that nonprofit group into the for-profit, which had always been our hope.”</div> <h3 class="ms-rteElement-H3">A For-Profit Takes The Plunge</h3> <div>The first for-profit Green House campus opened last September in Magnolia, Ark., a small town in the southwest corner of the state that is home to Southern Arkansas University and the World Championship Steak Cook Off.</div> <div> </div> <div>Developed and operated by Summit Health Resources, the five Green House Cottages of Wentworth Place are clustered on a campus along with a 40-bed short-term rehabilitation facility. Summit President and Chief Executive Officer John Ponthie is passionate about the company’s latest venture; he views it as the future of long term care. </div> <div>“We believe it represents the wants and needs of elders going forward,” he says. Ponthie puts his money where his mouth is: Summit opened its second Green House campus in February, and a third campus will open its doors in May.</div> <div> </div> <div>The Magnolia campus is filled to capacity and has a waiting list, as does the second campus in Rison, Ark., about 85 miles northeast of Magnolia. </div> <div> </div> <div>Ponthie says he was sold on the small house model as soon as he saw the first-ever Green House home in Tupelo. “I was blown away,” he says.</div> <div> </div> <div>Ponthie, who also owns and operates traditional nursing facilities, admits that the upfront costs for his Green House campuses were approximately $2 million more than the cost of building a traditional facility. “But if you amortize over the useful life of a property, say 40 years—that’s our horizon—it will hold its value better,” he says. “Culture change is a marathon, not a sprint. We got to the point when we saw Green House homes and went ‘wow,’ it was an awakening for us.”</div> <div> </div> <div>Ponthie says his Green House homes are the culmination of his best business sense, “what we know to be the best living environment,” he says.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Sound Investment</h3> <div><br>The financial outlays for Green House homes may be higher than for traditional nursing facilities, but new research indicates that over the long term, the model is a sound investment.</div> <div> </div> <div>The first of two evaluation studies funded by the Robert Wood Johnson Foundation was written by Siobhan Sharkey, Sandra Hudak, and Susan Horn. It compared eight Green House homes with their legacy organization and a similar nursing facility within their community.</div> <div> </div> <div>The studies found more direct care time—23 <img width="2198" height="1814" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0510/Wentworth%20Place%20Street%20View.JPG" alt="" style="margin:10px 15px;width:349px;height:232px;" />to 31 minutes more per resident per day—spent on direct care activities in Green House homes; increased engagement with elders by more than fourfold, outside of direct care activities; and less job-related stress experienced by direct care staff.</div> <div> </div> <div>The study also found improved care outcomes among Green House residents—in the form of fewer in-house acquired pressure ulcers.</div> <div> </div> <div>A second study, conducted by Barbara Bowers from the University of Wisconsin, Madison, studied the relationships of Shahbazim (principal caregivers in a Green House home), nurses, and the models of care and communication. They found comparable quality of care by Shahbazim even when formal supervisory responsibilities were removed from the equation. </div> <div> </div> <div>The same study also revealed that the high level of direct care worker familiarity with elders led to very early identification of changes in condition, which led to timely interventions.</div> <div> </div> <div>If Thomas is more passionate about anything other than the culture change movement, it’s Green House homes. As the creator of the concept, he views the Green House model as “culture change all the way through.” </div> <div>He points to recent research, as well as his own experience, as proof that the model “puts more people, money, and more time at the bedside.”</div> <div> </div> <div>He argues that comparing the cost of building a Green House home to that of a replacement facility is an apples-to-oranges situation. “I can build a replacement for a nursing home for less than Green House homes; however, I’ll have nonprivate rooms, large industrial kitchens, with large congregate dining rooms, and I’ll have a loading dock—all the things that come with a nursing home,” he says. “It’s not the same thing.”</div> <div> </div> <div>In other words, building a lower-cost nursing facility would produce a facility that contains the same vestiges as the traditional model—complete with the institutional and impersonal environment, Thomas contends.</div> <h3 class="ms-rteElement-H3">Long-term Consideration</h3> <div>Thomas advises looking at the long term. “So, I’ve got my Green House homes over here, which are highly individualized, with loads of privacy, a family-style kind of dining experience and food preparation, and you’ve got an update of a 1960s building with double-loaded corridors, brick, single-story nursing home,” he says. </div> <div> </div> <div>“Let’s compare which model is more likely to succeed over the next 30 to 40 years while you’re paying off that mortgage—the Green House model or the standard nursing home replacement model.”</div> <div> </div> <div>Thomas contends that any provider that makes this kind of decision is taking a risk. “If you’re a business person and you really have to make these hard decisions about the future of your business and you’re going to spend $10 to $12 million on a bet about the next 30 to 40 years, wow, you really have to be a risk taker to build replacement nursing homes built on conventional designs.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>He points to Ponthie’s venture to bolster his argument: “Ponthie is going head to head with a brand-new nursing home [in Magnolia], and he’s doing extremely well,” he says. “My point is this: It’s increasingly clear from CMS and state governments, from academia, from professional associations, more and more people are understanding that culture change represents that next turn in the road for long term care. I know there are people who will still deny that, but more reasonable people who follow what’s going on agree.”<img width="304" height="357" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0510/coverstory2.jpg" alt="" style="margin:10px 15px;width:337px;height:227px;" /><br><br>Tabitha Health Services, Lincoln, Neb., opened the second Green House in the country in 2006. In July, it will open another one next door, and two more will be built across the street by next year. </div> <div> </div> <div>Joyce Ebmeier, Tabitha’s vice president of strategic planning, is happy to tout the model’s viability. She believes that the Green House model is the best product on the market. “Green House homes are clearly a leader of the market,” she says, adding that they easily attract private-pay residents.</div> <div> </div> <div>Even though Tabitha is a nonprofit organization, Ebmeier says that a mix of private-pay and Medicaid keeps it financially viable. “Don’t be afraid of it,” she says. “It works financially—it may not be a cash cow—but it works.” </div> <h3 class="ms-rteElement-H3">States Adapt To Green House Needs</h3> <div>For providers like Ponthie, who do take the Green House model all the way, NCB Capital Impact is there to guide them through the process. Ponthie, for example, didn’t fund the entire cost of the project alone. The state of Arkansas gave him a grant to help offset the costs of training, architectural fees, and construction. </div> <div> </div> <div>Carol Shockley, Arkansas’ director of the Office of Long Term Care in the Department of Human Services, worked with Jenkens and Ponthie on their project to push the new program through the legislature and change the regulations.</div> <div> </div> <div>Shockley’s journey with the Green House Project began when she was looking for a place to spend the state’s civil money penalty funds. It was important to her to find something that would have a lasting impact on long term care in the state. “I didn’t want to waste the money,” she says. </div> <div> </div> <div>After attending an Eden Alternative training session, Shockley says something clicked for her. “I thought the Eden principles were a value that we all needed to understand and employ when we’re looking at long term care in general.”</div> <div> </div> <div>Included in the training was a video that featured the first Green House campus in Tupelo. </div> <div>“I knew then that our civil money penalty funds could be used effectively if we could get the appropriate approval to spend it and change the laws that were in place regarding the funds and our staffing regulations to allow for universal workers,” Shockley says.</div> <div> </div> <div>Shockley eventually came up with the idea to create an incentive grant for facilities that were willing to build a Green House home.</div> <h3 class="ms-rteElement-H3">Provider Incentives</h3> <div>From there, Shockley says, she partnered with the Arkansas Health Care Association to draft two pieces of legislation, which were adopted and passed unanimously. “There was no opposition to the measures in any way,” says Shockley. “You have to consider that things are the right thing to do when you’re able to do it without a lot of opposition, and there was none on any front.”</div> <div> </div> <div>In addition to changing the staffing regulations specifically to fit the Green House model, the state’s surveyors examined the life safety code issues to ensure that they would not pose a barrier to building a Green House. Shockley says that as part of an incentive for providers, she initiated a state plan amendment with CMS so that the state could reimburse Green House providers $4 per day more for Medicaid beneficiaries. </div> <div> </div> <div>As an added bonus for culture change proponents in the state, Shockley invited NCB to train her surveyors in what a Green House is. As a result, about half of the state surveyors are now Eden associates, having completed a three-day training on the principles of the Eden Alternative. “We want them to appreciate the principles and that culture change can embrace a wide array of individual choices,” Shockley says. </div> <div> </div> <div>The state has seen yet another benefit to the Green House initiative: It has sparked providers’ interest in pursuing other culture change practices. “More than just trying to get buildings complete, I’m hearing more and more about subtle changes that people are doing in their architecture to incorporate culture change initiatives,” </div> <div>she says.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>If the result is that providers are leaving behind what had become a “cookie cutter approach” to architecture, “that’s wonderful," she says. She is happy to hear that people are embracing changes that can be made in staff recruitment and retention, “that people are paying attention to what culture change can be,” she says. </div> <div> </div> <div>“Those types of changes can be long lasting, and that’s what we wanted to spur out of our civil money penalty initiative.” </div> <div> </div> <div>Jenkens touts the Arkansas initiative as an excellent example of creating incentives for providers to build Green House homes. “For anyone who’s trying to build a new building, the capital piece is really tough if you serve a significant majority of Medicaid residents,” he says. “The Arkansas state plan amendment is really a model for any state and one that CMS is happy for other states to pursue.”</div> <div> </div> <div>In fact, Jenkens is happy to report, nearly all 50 states have policies that are conducive to building Green House homes. “Sometimes there is some little interpretive issues or some oddball physical pieces to work around,” he says. “But I would say we are pretty confident Green House will work in any state that you want to go into.” </div> <h3 class="ms-rteElement-H3">Promoting The Spirit Of Culture Change</h3> <div>As Jenkens and Thomas assert, the Green House model may not be for everyone, but if educating providers about it sparks ideas that carry on the spirit of culture change, then they have done something right. Golden Living’s initiatives are a good example. McMahon admits that while the Green House model is his strongest competitor, the company was simply unable t<img width="161" height="189" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0510/coverstory1_thumb.jpg" alt="" style="margin:10px 15px;width:207px;height:207px;" />o replicate it on such a large scale—so it did the next best thing.</div> <div> </div> <div>Having considered the Green House model, McMahon says, the company took the good points of the model and created their own. Golden renovated most of its existing buildings by adding neighborhoods, private rooms and baths, and shared dining and kitchen areas.</div> <div> </div> <div>“We converted space so we’ve given up beds to create that self-contained feeling of a community so [residents] have their own dining areas in the neighborhood they live in, and they have a kitchen and have accessibility to food,” McMahon says.</div> <div> </div> <div>Two of Golden’s newly constructed facilities, which opened last year, lean much more toward the Green House model. “It’s not a full Green House model, but we have smaller neighborhoods that we’re building with kitchens, dining areas, and living rooms so they can be shared. The difference between us and the Green House model is that we still share our housekeeping and dining services, which are done much more centrally, [but] neighborhoods are much more self-contained now,” McMahon says.</div> <h3 class="ms-rteElement-H3">Creating Neighborhood Ambience</h3> <div>Hal Garland is executive director at one of Golden’s newly built facilities in North Carolina. In designing the 70,000-square-foot building, Garland says he and his team created six distinct neighborhoods, each with its own 42” flat-screen television, a courtyard, a dining room, kitchen, and pantry. </div> <div> </div> <div>Each of the private bedrooms has its own bathroom and television as well, and two of the neighborhoods are exclusively short-term rehab units.</div> <div> </div> <div>“We stock each kitchen with the food each resident wants, and families are encouraged to use the kitchen because it belongs to them, and we mean that,” says Garland. “The response has been great.”</div> <div> </div> <div>The new building also boasts a new 4,000-square-foot therapy room with a Wii, a large flat-screen television, and a private entrance for the rehab patients. The only notable adjustment, says Garland, has been the addition of new supervisory positions to manage the six dining rooms."</div> <div> </div> <div>“We went from using food carts to not using them, and we added an evening supervisor, a day shift supervisor, an activities person, and a nighttime receptionist,” he says. “That’s it."</div> <div> </div> <div>McMahon believes it would be a mistake for any company right now not to go down the path of culture change, although being a privately held company has its advantages in this area. “Since we have become privately held we can take a much more long-range view of things, because we’re not going from quarter to quarter on earnings per share and reporting to the street,” he says. “It’ll be interesting how a publicly held company does it.” </div> <div> </div> <div>For More Information:</div> <ul><li>For a state-by-state listing of culture change incentives for providers, click HERE. </li> <li>To get more information about Green House homes, go to: <a href="http://www.thegreenhouseproject.org/">www.thegreenhouseproject.org/</a>   </li></ul> <p>Meg LaPorte is <em>Provider's</em> managing editor.</p>Awareness and adoption of some components of culture change have gained considerable momentum in the past two decades and made even greater strides in the past several years.2010-05-01T04:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0510/coverstory4.jpg" width="150" style="BORDER:0px solid;" />Quality;Culture Change;DesignColumn5
Loving Touch Makes A Differencehttps://www.providermagazine.com/Issues/2010/Pages/0510/Loving-Touch-Makes-A-Difference.aspxLoving Touch Makes A Difference<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​<img width="307" height="215" class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2010/PublishingImages/0510/caregiving3.jpg" alt="" style="margin:5px;width:276px;height:199px;" /><br>Traditional care offered in skilled nursing and assisted living facilities often fails to address the psychosocial and spiritual needs of residents in later stages of memory loss. Many residents with advanced-stage Alzheimer’s disease and related dementias cannot engage in a community’s daily activities like bingo, trivia, or sing-alongs. When not engaged in activities they may become agitated, depressed, apathetic, or withdrawn and are at an increased risk for falls.</p> <p>A program called Namaste Care, implemented in eight EPOCH Senior Living communities in Massachusetts and Rhode Island, offers an innovative approach to care that places residents with advanced dementia in a soothing environment with meaningful activities designed specifically for them.</p> <p>The term “namaste” comes from a Hindu statement that means “to honor the spirit within.” The program, which was first implemented six years ago, has been wildly successful and is surprisingly affordable. EPOCH’s management found it could address the needs of some of its most vulnerable residents and improve their quality of life without adding additional staff, purchasing expensive supplies, or setting aside a room exclusively for the program.</p> <p>“From the beginning, it was a very moving experience,” says Joanna Cormac-Burt, EPOCH’s chief operating officer. “We had agitated residents who, once they were interacting with a caregiver in a peaceful room with nice chairs and soft music, calmed down. Participants become more engaged in small ways, instead of being lined up in wheelchairs in front of the nurse’s station, or sitting alone with a television.”<br></p> <h3 class="ms-rteElement-H3">A Different Approach</h3> <div>EPOCH’s Namaste Care program provides a sense of structure and calm to residents who are unable to engage with the larger environment of their skilled nursing community. From the individualized greeting each participant receives at the start of a session to the peaceful environment where the program takes place, the individual resident is honored and cared for through a “loving touch” approach to activities of daily living. </div> <div> </div> <div>In EPOCH communities, Namaste Care—introduced by Joyce Simard, MSW, a private geriatric consultant and EPOCH’s Alzheimer’s specialist—is offered seven days a week for six hours a day in a designated Namaste Care room. </div> <div> </div> <div><img width="392" height="380" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2010/PublishingImages/0510/caregiving1.jpg" alt="" style="margin:5px;width:266px;height:200px;" />The daily program begins after most residents have finished breakfast and are toileted and groomed. Residents in the Namaste Care program are taken to the Namaste Care room, which features soft lighting, cushy, comfortable lounge chairs, soothing music, and the calming scent of lavender. </div> <div> </div> <div>Staff members greet residents according to their preferences. One resident goes by “Millie,” another prefers “Granny,” and a third might prefer the more formal “Dr. Powell.” </div> <div> </div> <div>If a resident is in a wheelchair, she is placed in a comfortable lounge chair. Namaste Carers remove uncomfortable shoes, wrap a quilt around each resident, and check to make sure each resident is comfortable. </div> <div> </div> <div>According to a recent study published in the American Journal of Alzheimer’s Disease and Other Dementias, each activity was offered in a slow, caring manner with the caregiver talking to the resident throughout the process. </div> <div> </div> <div>The study, conducted by Simard and Ladislav Volicer, MD, describes how residents responded to facial cleansing and moisturizing. “The women seemed to react favorably to the scent of Ponds Cold Cream, a product many of them used when they were younger. The men responded in the same manner to the scent of Old Spice.”</div> <div> </div> <div>The staff also offered residents in the program sips of liquid periodically. Since residents with advanced dementia rarely express thirst and take a long time to drink even small amounts of liquid, hydration is an integral part of the Namaste Care routine. </div> <div> </div> <div>Namaste Carers have several items on hand that can help residents interact with their surroundings, such as realistic stuffed dogs and cats. The residents often happily engage with their “pet.” They talk to, cuddle with, and sleep peacefully with the stuffed animals. </div> <div> </div> <div>Namaste Carers also provide clues about the seasons to bring pleasure to residents who rarely go outside. They use what nature provides: daffodils and tulips in the spring, roses and geraniums in the summer, pumpkins and colorful leaves in the fall, and snow or branches from fir trees in the winter. </div> <h3 class="ms-rteElement-H3">Implementing The Program</h3> <div>Each EPOCH community that introduced Namaste Care faced unique challenges. Some buildings had no unused space for a room to be designated just for Namaste Care. </div> <div> </div> <div>The pilot program, located in EPOCH’s community in Chestnut Hill, Mass., began in an empty room that had been a resident’s room. Simard and other staffers created a peaceful, homelike space using a bit of paint, some homelike curtains, a quilt hung over the call light system, used furniture, and a few pictures. As the program grew, staff moved the Namaste Care room to the former dining room, where as many as 20 residents could attend the program. </div> <div> <img width="217" height="169" class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2010/PublishingImages/0510/caregiving4.jpg" alt="" style="margin:15px 10px;height:185px;" /></div> <div>At EPOCH’s community in Norton, Mass., one of the first nursing facilities built in the state, the wing that cared for the majority of residents with advanced dementia had a single Day Room used for meals, activities, and family visits. Each day after breakfast, staff transformed the room. The Namaste Carer lowered the lights, started the soothing music, turned on the aroma diffuser, placed tablecloths on the round tables, and set china tea sets or centerpieces on some of the tables. When residents were taken back to the room, it felt like a different location. </div> <div> </div> <div>At EPOCH’s community in Weston, Mass., Administrator Adam Goldman introduced Namaste Care even while the building underwent renovations and the construction of a new assisted living memory care wing. The program started in one room and moved three times before being settled in a permanent room, improving residents’ quality of life, despite the construction. </div> <div> </div> <div>Namaste Care is surprisingly affordable. Communities already stock many of the supplies, such as nail clippers, basins, and emery boards. Face cloths and towels are provided by laundry, and beverages and snacks are available from food service. Namaste Care requires a few relatively inexpensive purchases, such as soft quilts, a compact disc (CD) player, CDs, lifelike stuffed animals, and an aroma diffuser. The largest expense is often a kitchen or tea cart on wheels that holds Namaste Care supplies. </div> <div> </div> <div>Some communities also budgeted for comfortable recliners that many homes have in the television room. Most communities did not have money for lounge chairs and used padded geri-chairs. More recently, EPOCH has begun investing $5,000 to $10,000 on lounge chairs when it creates a Namaste Care room. “It could probably be done for less, but we wanted to use high-quality, longer-lasting chairs,” Cormac-Burt says.</div> <div> </div> <div>EPOCH hired no additional staff members to launch Namaste Care, instead training one nurse assistant from each existing team and assigning them to the program. </div> <div> </div> <div>EPOCH’s administrators eventually added a Namaste Care position to each community’s budget at an added cost of $23,000. Over time, many employees at EPOCH have come to view being assigned to the Namaste Care room as a promotion or sought-after assignment.</div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">A Success Story</h3> <div>Namaste Care quickly became a key service offered by EPOCH. According to nurse reports, participants have fewer urinary tract infections and improved skin integrity, among other advancements. </div> <div> </div> <div>“Sometimes we see a resident who is very agitated until we place them in Namaste Care, and their whole demeanor changes,” Cormac-Burt says. “This has happened again and again, which is why it’s so effective.” </div> <div> </div> <div>Research now backs up this claim: The study found that residents attending Namaste Care for 60 days showed a decrease in the use of anti-anxiety medications, improved interest in their environment, and a decrease in indicators of delirium. </div> <div> </div> <div><img width="311" height="213" class="ms-rtePosition-2 ms-rteImage-2" src="/Issues/2010/PublishingImages/0510/caregiving2.jpg" alt="" style="margin:5px;height:223px;" />In addition, the minimum data set Challenging Behavior Profile was significantly decreased after enrollment in the Namaste program, indicating less impairment in social interaction.</div> <div> </div> <div>“For residents who are withdrawn or have reduced social interaction, the study showed that participating in the program had decreased some indicators of delirium and decreased the need for administration of anti-anxiety medications,” according to the study. </div> <div> </div> <div>Staff and family members find that residents are more verbal and aware of their environment. This is especially important to visiting family members. </div> <div> </div> <div>“The Namaste program opened up a whole new way for my mom and me to communicate in a loving and safe environment,” Damon Grew Syphers, the son of one resident who attended Namaste Care until her death, wrote recently. “We had periods of time when we could touch, hug, and kiss. I sensed a peace and tranquility that I had not witnessed before in my mother. Mom felt loved and wanted.” </div> <div> </div> <div>For more information, visit: <span lang="EN"><a href="/Issues/2010/Pages/0510/Study-Reveals-Value-Of-Advance-Directives.aspx">Study Reveals Value Of Advance Directives</a> or <span lang="EN"><div><a href="/Issues/2010/Pages/0510/New-Dementia-Care-Guiding-Principles-Available.aspx">New Dementia Care Guiding Principles Available</a>.</div></span></span></div> <div> </div> <div><em>Joyce Simard, MSW, a private geriatric consultant and Alzheimer’s specialist at Waltham, Mass.-based EPOCH Senior Living and author of “The End-of-Life Namaste Care Program for People with Dementia,” can be reached at joycesimard@earthlink.net. Joanna Cormac-Burt, EPOCH’s chief operating officer, can be reached at joanna.cormac-burt@epochsl.com.</em></div> <p> </p>A program called Namaste Care offers an innovative approach to care that places residents with advanced dementia in a soothing environment with meaningful activities designed specifically for them.2010-05-01T04:00:00Z<img alt="" src="/Issues/2010/PublishingImages/0510/caregiving1_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn5

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A New Look At Incontinence & MDS 3.0https://www.providermagazine.com/Issues/2010/Pages/0610/A-New-Look-At-Incontinence--MDS-3-0.aspxA New Look At Incontinence & MDS 3.0<p>According to the Centers for Medicare & Medicaid Services (CMS), the minimum data set (MDS) version 3.0 is designed to improve the reliability, accuracy, and usefulness of the instrument to include the resident in the assessment process and to apply standard protocols that are used in other settings.</p> <p>These improvements, CMS has said, will have “profound implications for nursing home and swing bed care and public policy.” </p> <p>Improvements notwithstanding, the MDS 3.0 contains numerous and substantial changes that represent a radical shift from the MDS 2.0. Some of the changes, however, can be turned into opportunities for incontinence management, especially when it comes to assessment and documentation.</p> <div>The new MDS 3.0, which will be implemented on Oct. 1, 2010, is reconfigured and supported by new material, definitions, and assessment processes. The Bladder and Bowel portion of the MDS—also known as Section H—now covers the following topics:</div> <ul><li>Appliances;</li> <li>Urinary toileting programs;</li> <li>Urinary continence;</li> <li>Bowel continence; and</li> <li>Bowel patterns.  </li></ul> <h3 class="ms-rteElement-H3">Review, Review, Review</h3> <div>Nursing facilities would be wise to have the entire clinical staff and the MDS nurse review the form in order to begin making sense of these changes. Comparing the MDS 2.0 to the 3.0 form and becoming familiar with the items, terminology, and coding requirements is a good place to start. </div> <div> </div> <div>Section H places an emphasis on the accurate assessment of urinary and bowel continence and the interventions used to manage incontinence. It is important to note that this section also centers on outcomes—the resident’s response to the trial toileting program. </div> <div> </div> <div>According to the CMS “Resident Assessment Instrument 3.0 Manual,” “each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment and services  to achieve or maintain as normal elimination function as possible.”</div> <div> </div> <div>Facilities must review chapter three of the manual, pages H-1 to H-13. This section provides details on each item in Section H of the MDS instrument, including the following topics: Item Rationale, Planning for Care, Steps for Assessment, Coding Instructions, and Coding Tips and Special Populations. Also included in this section of the manual are definitions for each appliance listed in Section H, such as an indwelling catheter, suprapubic catheter, and nephrostomy tube.</div> <div> </div> <div>Caregivers and assessment nurses should pay close attention to these definitions. Coding instructions are also listed for each appliance on pages H-1 and H-2, with specific directions for coding appliances used in the last seven days. These definitions are very specific and should be easy to comprehend.</div> <h3 class="ms-rteElement-H3">Get To Know MDS 3.0</h3> <div>Next on the new MDS form is Urinary Toileting Program. According to the MDS 3.0 manual, this section of the instrument centers on “an individualized, resident-centered toileting program [that] may decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence.”</div> <div> </div> <div>This terminology is very sound and represents current clinical thought as well as good clinical practice and quality of life for the elderly.</div> <div>  </div> <div>In order to comply with the intent of this terminology, nursing facilities should begin with a comprehensive plan to address residents’ needs, including an accurate assessment of the patient’s level of incontinence, then move to a toileting program or a retraining program. In addition, residents should be monitored to determine if the incontinence can be decreased or resolved.</div> <div> </div> <div>And, if the resident does not respond to the interventions, a program of supportive management should be instituted with the proper use of high-quality incontinence products and preventative skin care.</div> <div> </div> <div>The new MDS 3.0 utilizes three codes for this section of the MDS. The first code refers to documentation that the trial of a toileting program has been attempted on admission, reentry, or since the onset of the incontinence.</div> <div>The MDS manual describes all toileting programs, and the definitions are very specific. The new items are <strong>Habit Training/Scheduled Voiding and Check and Change</strong> programs.</div> <div> </div> <div> This is very positive. Not all residents are incontinent, and the definition in the manual for urinary incontinence is “the involuntary loss of urine,” which makes it very clear that residents with stress or postural incontinence will be coded as incontinent.</div> <div> </div> <div>The steps for assessment, as outlined on pages H-4 and H-5 of the manual, emphasize that individualized programs need to be established, communicated to the staff and the resident, and monitored through documentation and evaluations. The goal of these steps is to diminish the number of incontinent episodes and also to maintain the resident’s dignity, quality of life, and functional status. </div> <h3 class="ms-rteElement-H3">Combined Programs Work</h3> <div>Combined use of toileting programs and appropriate product use can and do work, so flexibility and individualization are the keys to success. The facility should work with vendors and suppliers that provide superior products, providing education and resources to staff, and tracking the outcomes of the toileting or retraining programs.</div> <div> </div> <div>The resident needs to be involved in the program, and it is imperative to document any and all successes in decreasing incontinent episodes and their impact on the resident’s quality of life. </div> <div> </div> <div>The manual has very specific coding instructions, as well as excellent examples, and should be used as part of a facility training program. </div> <div> </div> <div>What’s more, the manual’s definitions of the four urinary toileting programs should be consistent with facility policy and documentation standards.</div> <div> </div> <div>Page H-4 of the manual, Response To Trial Toileting Program, and page H-5, Current Toileting Program, are very specific outcome- and implementation-reporting items that were not part of the MDS 2.0 process. It is important to note that the data gleaned from these sections will enable regulators to monitor the use and outcome, or lack thereof, of toileting programs.</div> <div> </div> <div>On the other hand, facilities will also have the abilityto track these statistics for internal quality assurance </div> <div>processes. </div> <h3 class="ms-rteElement-H3">Importance Of Documentation</h3> <div>The Urinary Continence section of the MDS 3.0 manual, page H-7, asks the facility to document the level of urinary continence during the assessment period. It also outlines the devastating impact that incontinence can have on the resident, so the assessment must look at the level of incontinence over all shifts and throughout all documentation. </div> <div> </div> <div>All clinical staff members, including physicians and other members of the interdisciplinary team, such as the activities director and therapy employees, must understand the importance of documenting for all the shifts. The coding for this section must represent the resident’s experience over the entire assessment period.</div> <div> </div> <div>If the resident’s incontinence cannot be improved, then the staff must have a clear plan to protect the skin and the resident from unnecessary negative outcomes related to overall quality of care and quality of life. </div> <div>Properly sized products that have appropriate absorbency and wicking for the level of incontinence being treated is important. </div> <div> </div> <div>Many toileting plans and interventions need to be flexible and combine the use of treatment, interventions, and products to achieve the goal for the resident to improve quality of life, decrease the incontinent episodes, and decrease clinical risk.</div> <div> </div> <div>This is a big assignment since such a high percentage of residents have some level of incontinence when they enter the facility. </div> <div> </div> <div>More treatment options are available today, such as exercise, surgical interventions, behavioral programs, and combined nursing and therapy interventions. Product variety and sizing have also improved and give clinical staff the ability to establish truly individualized plans that work. </div> <h3 class="ms-rteElement-H3">Daunting But Worthwhile</h3> <div>In preparing to implement the MDS 3.0, the MDS nurse should review the facility’s current documentation process and compare it to the MDS 3.0 manual’s current practice and documentation. Educating and training staff is important, as is a complete assessment of all residents’ levels of continence, current interventions, and individualization of programs and plans. Once the plans are established, documentation must show that they have been delivered and evaluated for efficacy and outcomes.</div> <div> </div> <div>The MDS 3.0 manual contains numerous resources for training and preparation. Appendix C, Care Area Assessment (CAA) Resources, section six on Urinary Incontinence and Indwelling Catheter(s), contains a review of the causes of incontinence, the types of incontinence, and the factors that impact the level of incontinence. This reference should assist the facility’s care team in establishing the resident’s unique plan and documenting its outcomes.</div> <div> </div> <div>It may seem a daunting task, but preparation will pay off if clinical staff have learned more about the causes of incontinence and its successful treatment, as well as the variety of products that are available for residents to use during the retraining process.</div> <div> </div> <div>With a clear plan that includes targeted staff education and support products, staff can work together to successfully navigate the MDS 3.0. </div> <div> </div> <div>With consistent efforts, the MDS 3.0 also offers the facility a new opportunity to document and achieve success in this very important area of care and support the care planning process when urinary toileting programs do not solve the problem. </div> <div> </div> <div><em>Leah Klusch, RN, BSN, FACHCA, is a nurse educator, consultant, speaker, and executive director of the Alliance Training Center, an educational foundation that focuses on issues related to the care of the frail elderly. She can be reached at: LeahKlusch@sbcglobal.net.</em></div>The MDS 3.0 requires a new level of documentation and assessment, especially when it comes to incontinence management.2010-06-01T04:00:00Z<img alt="" height="740" src="/Issues/2010/PublishingImages/Web%20images/couple_bench_thumb.jpg" width="740" style="BORDER:0px solid;" />Management;QualityColumn6
Minimum Data Set Gets A Makeoverhttps://www.providermagazine.com/Issues/2010/Pages/0610/Minimum-Data-Set-Gets-A-Makeover.aspxMinimum Data Set Gets A Makeover<div>The minimum data set (MDS) 3.0 is set for implementation Oct. 1, 2010. As physicians, nurses, and others learn more about the changes to the instrument, they are thinking about how they will train staff, what the changes will mean to their data collection, and how MDS data will contribute to quality improvement opportunities. In anticipation of implementing and using MDS 3.0, there are mixed emotions, including anticipation and...fear. </div> <div> </div> <div>“Change is good, but change is hard,” says Tom Dudley, MS, RN, technical advisor in the Division of Chronic and Post Acute Care, Office of Clinical Standards and Quality, at the Centers for Medicare & Medicaid Services (CMS).</div> <div> </div> <div>“We knew that change is very difficult, and we didn’t want to make change just for the sake of change. We wanted to increase the clinical relevance for providers, and we wanted to honor the patient and family in the documentation process,” says Debra Saliba, MD, MPH. </div> <div> </div> <div>“If facilities are spending the time to collect data, getting something that is useful to them makes it a better investment,” says Saliba, who is director of the University of California, Los Angeles/Jewish Homes Borun Center and the RAND Corp. and Veterans Administration (VA) principal investigator for MDS 3.0 national development and testing.</div> <h3 class="ms-rteElement-H3">Designed For New Care Modes</h3> <div>MDS 3.0 was designed to introduce advances in assessment measures, improve accuracy and validity of data, improve user satisfaction, eliminate poorly performing items, redesign the form, and enable briefer assessment periods for clinical items. It also is intended to maintain the ability to use MDS data for quality indicators (QIs), quality measures (QMs), quality improvement, and payment.</div> <div> </div> <div>Perhaps the most important goal, however, was to increase the document’s clinical relevance to providers. But the new MDS version 3.0 not only is designed to improve resident assessment and the quality of clinical information for practitioners, it also pays tribute to the culture change movement by creating expectations for patients to be involved in providing information and input during assessments and have a role in decision making. </div> <div> </div> <div>The <a href="/Issues/2010/Pages/0610/MDS-3-0-Changes.aspx" target="_blank">changes to the MDS </a>were based on measurement science and guidance from stakeholders, users, and content experts. It has been 15 years since the MDS was last updated, and “that’s way too long,” Dudley says. CMS took the changes seriously and wanted to provide facilities with an instrument that would be useful and easier to use, he says.</div> <div> </div> <div>Saliba explains, “From the facility perspective, they invest a great deal in completing the MDS, and the content becomes the foundation for quality measures. Having better, more accurate data that gives facilities more information about changes over time can be immensely helpful.” </div> <h3 class="ms-rteElement-H3">Smooth Flying For Pilot Testing</h3> <div>Before finalizing MDS 3.0, CMS contracted with RAND Corp. and Harvard University to evaluate the proposed revisions. </div> <div> </div> <div>In total, 3.0 was tested in a national sample of more than 4,500 residents from 71 community nursing facilities in eight states and 19 VA facilities in six states.</div> <div> </div> <div>The national pilot showed that changes to the MDS produced a more efficient assessment and that better quality information was obtained in less time. </div> <div> </div> <div>Findings showed that MDS 3.0 items showed either excellent or very good reliability when used by both research and facility nurses; they also indicated that MDS 3.0 improved assessments while decreasing time to complete. The average time for completing 3.0 was 45 percent less than the average time for MDS 2.0.</div> <div>However, even before the national study, there was a smaller pilot. “We wanted to have the best instrument possible going into the national study,” says Saliba. “We made numerous changes at that point.”</div> <div> </div> <div>In the national study, CMS learned that there were some items in the section about preferences for daily activities that people said didn’t work. “So we took them out,” she notes, adding, “There also were some things that we tried that didn’t work better than what was in the MDS 2.0, so we didn’t implement those changes. We were adamant that there was no reason to make people change unless the changes were for the better and made a positive difference.”</div> <h3 class="ms-rteElement-H3">Nurses Give It A Thumbs Up</h3> <div>All of the efforts to test the instrument and solicit feedback clearly made a positive difference. Facility nurses testing MDS 3.0 generally were enthusiastic about the revised instrument. Not only did 81 percent say that it is more clinically relevant, but 85 percent said that they believed that it would help them identify problems that might not otherwise have been noticed. Additionally, 89 percent said that the MDS 3.0 items allowed for a more accurate report of a resident’s characteristics, 79 percent indicated that the revised instrument better reflects best practices and standards, and 85 percent said they found questions on 3.0 to be worded more clearly.</div> <div> </div> <div>During a recent MDS 3.0 train-the-trainer session, Dudley says, “Participants were overwhelmingly excited about it.” He adds, “We’ve received a lot of positive comments, although there are still some tweaks that need to be made.” Ultimately, he observes, “this instrument will give providers more information about the needs of residents and help them develop a [better] plan of care.”</div> <h3 class="ms-rteElement-H3">Big Change With Big Potential?</h3> <div>One of the most significant changes to the MDS—the inclusion of patient interviews as part of assessments—is implemented throughout the instrument, and it is causing some anticipatory anxiety for facility staff. But while this addition may create some worry for providers, it ultimately is designed to enrich the data and help the facility design care plans that address patients’ individual needs and issues. As Saliba says, “We’ve always been tasked to bring the resident into the process, and now we have a way to do this. It will help ensure a more </div> <div>transparent process for consumers.”</div> <div> </div> <div>While nurses and others have expressed some concerns about how the resident interviews would work and if they could be used effectively, the pilot study of MDS 3.0 described above showed that it successfully included resident voices. According to the nurses completing the instrument, the majority of residents were able to complete the interview section and that the items provided useful clinical insights.</div> <h3 class="ms-rteElement-H3"><div>Build Staff Interviewing Skills</div></h3> <div>Providing staff with adequate and consistent training on how to conduct interviews may increase their confidence, MDS planners say. The Picker Institute is developing a training video for that purpose that will enable staff to watch residents being interviewed.</div> <div> </div> <div>“We know that in teaching staff, a picture is worth a thousand words,” Saliba notes. “When I conduct trainings, I first try to help staff understand the why, then we talk about ways to make interviews go more smoothly. Then we show sample interviews and have people practice with each other.” She stresses that it will take time and experience for people to feel comfortable with the interviews. </div> <div> </div> <div>At a program session at the American Medical Directors Association’s annual symposium in March, Karen Leible, MD, CMD, said, “This is exciting as we’re moving forward in that we are talking to residents, interviewing them, and including them. It’s not just about subjective observations,” added Leible, who is chief clinical services officer at Pinon Management, which provides full-service operations for skilled nursing and assisted living.</div> <div> </div> <div>Facility nurses in the national pilot study seemed to share Leible’s enthusiasm. In fact, 84 percent said that the structured interview sections—on cognition, mood, customary routine, activities, and pain—improved their knowledge of residents’ health </div> <div>conditions. </div> <div> </div> <div>The involvement of residents and families in the assessment process seems to mirror CMS’ commitment to promoting resident-centered care. As Saliba notes, “We hope this is a useful tool for facilities to move forward on person-centered care. I think that having these questions will give facilities something to facilitate person-centered assessments. This, hopefully, will be useful to leaders in culture change and more recent adopters of person-centered care.” The patient interviews are not the only aspect of MDS 3.0 that has caused initial anxiety for some. “The most common comment is about MDS 3.0’s length—38 pages,” says Dudley. </div> <div> </div> <div>However, he stresses that the type font is much larger to increase readability, the page breaks are more practical and user-friendly, and definitions and other information that people need as they complete the assessments are right there on the page. “It is not really longer; instead, it is more efficient and clinically relevant,” he says.</div> <h3 class="ms-rteElement-H3">New Assessments, Quality Data</h3> <div>One significant change to the MDS is that Section V is now titled, “Care Area Assessment (CAA) Summary,” instead of “Resident Assessment Protocols (RAPs).” The 20 CAA problem areas are the same as the 18 RAPs—with the addition of “Pain” and “Return to Community Referral.” Instead of a standardized care plan, triggers will identify areas that need a care plan, and the facility will have the ability to develop one based on the facility’s clinical practices.</div> <div> </div> <div>For example, the mood care area is triggered if any of the following is elicited during the interview: </div> <ul><li>The resident’s response indicates that he/she has had thoughts that he/she would be better off dead or has had thoughts of hurting him/herself; or</li> <li>The staff assessment of resident mood suggests that the resident feels life isn’t worth living, wishes for death, or attempts to harm self.</li></ul> <div>Dudley notes that “the actual algorithm is a bit more complex, but basically the resident’s response triggers the need for the facility to intervene through the development of an individualized plan of care specifically addressing areas of concern impacting that person’s well-being.”</div> <div> </div> <div>There are several areas of the MDS where changes involve more personal and direct assessments designed to increase resident input and encourage more individualized care planning. One of these is Section C (Cognitive Patterns). Added here is the use of the Brief Interview for Mental Status (BIMS). This involves the repetition and recall of three words—sock, blue, and bed. “My facilities already have instituted the BIMS as a standard test,” said Leible. “We get better data from this tool versus others. We so often think that [residents with dementia] can’t tell us anything, but we can get information from them.” </div> <div> </div> <div>In fact, in the national pilot study 90 percent of residents were able to complete the test. A vast majority of nurses (78 percent) said they prefer this new assessment method, and 88 percent reported that the BIMS enabled them to get new insights into residents’ cognitive abilities. </div> <div> </div> <div>Also in Section C, the Confusion Assessment Method replaces old delirium items. This tool includes two parts—an assessment instrument that screens for overall cognitive impairment and a second part that includes only those four features found to have the greatest ability to distinguish delirium or reversible confusion from other types of cognitive impairment.</div> <div> </div> <div>In Section D (Mood), the MDS 3.0 includes the Patient Health Questionnaire (PHQ-9) for screening depression. This is a checklist of nine symptoms of depression that is completed via resident interview. “This tool brought out emotions when nurses tested it. One told me that she cried when she interviewed one patient. He had always seemed so happy, and no one had realized he was depressed. The interview was able to elicit feelings that he had kept concealed from staff and others. This is something of real value,” says Dudley.</div> <h3 class="ms-rteElement-H3">Data Collection: Just The Beginning</h3> <div>Of course, as with all components of the MDS 3.0, there are options to use observations in making assessments. If a resident is unable to be interviewed, then staff can document observations about signs and symptoms over a two-week period.  </div> <div> </div> <div>Once the information is collected, says Saliba, “You need a strategy about how to use it for ongoing monitoring so that it is part of your facility’s flow of activities. </div> <div> </div> <div>“One challenge with assessments is that you will find out something about a patient, and you need to know what you will do with this information. If you conduct an assessment and learn that something is important to the person, you need to determine how you will act on that information.”</div> <div> </div> <div>Saliba stresses that facility leaders need to help staff feel more comfortable thinking through how assessments and discoveries will fit in with work flow and interdisciplinary action plans.</div> <div> </div> <div>“That is where the physicians and all interdisciplinary team members come in—determining how we will integrate data into meaningful action and care plans,” she says. </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em>​</div>The new SNF tool is designed to improve the quality of clinical information and increase its relevance to residents.2010-06-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Caregiving;Reimbursement;Policy;QualityColumn6
Vitamin D Gains Favor In LTChttps://www.providermagazine.com/Issues/2010/Pages/0610/Vitamin-D-Gains-Favor-In-LTC.aspxVitamin D Gains Favor In LTC<p>​A growing number of studies have documented the importance of vitamin D for elderly patients, and many experts are supporting regular supplementation for long term care facility residents. The benefits are numerous and the cost minimal. Yet, inadequate vitamin D intake—and even deficiency—is too common in this population.  </p> <div>With a few simple steps, facilities can take huge leaps ahead in ensuring that their residents get enough vitamin D and enjoy its benefits, such as decreased falls and fewer fractures.  </div> <h3 class="ms-rteElement-H3">Why Vitamin D?</h3> <div>That vitamin D has benefits is not news, but only recently have studies documented how high a dose is necessary to have a positive impact on the elderly. “Basically, people have not realized the importance of high doses of vitamin D,” says John Morley, MD, physician and Dammert professor of gerontology, director of the Division of Geriatric Medicine, and acting director of the Division of Endocrinology at Saint Louis University School of Medicine. “They thought that as long as patients got some vitamin D supplement, they were getting enough.”</div> <div> </div> <div>Vitamin D is essential for bone growth and bone remodeling. It also is necessary for promoting calcium absorption and maintaining adequate serum calcium and phosphate concentrations to enable normal bone mineralization and prevent hypocalcemic tetany. </div> <div> </div> <div>Without sufficient vitamin D, bones can become thin and brittle. Adequate calcium intake, coupled with vitamin D sufficiency, help protect older adults from osteoporosis. However, in recent years, studies have shown that vitamin D can have a positive impact on a wide variety of diseases and ailments that affect the elderly, including diabetes, infections, and cancer.</div> <div> </div> <div>The best indicator of vitamin D status is serum concentration of 25(OH)D, which reflects vitamin D both produced naturally and obtained from food and supplements. However, it is important to note that serum 25(OH)D levels do not indicate the amount of vitamin D stored in body tissues. Circulating 1,25(OH)2D is not a good indicator of vitamin D status because it has a short half-life of 15 hours, and serum concentrations are not closely regulated by parathyroid hormone, calcium, and phosphate. Levels of 1,25(OH)2D generally do not decrease until vitamin D deficiency is severe. </div> <div> </div> <div>Many sites in the body recognize or synthesize vitamin D, including skeletal muscle, the brain, the heart, the prostate, dermal capillaries, keratinocytes, macrophages, vascular smooth muscle, leukocytes, the pancreas, and the colon.</div> <div> </div> <div> The Food and Nutrition Board (FNB) at the Institute of Medicine defines 15 nanograms per milliliter (ng/mL) or higher as an adequate or normal vitamin D level. In his book, “The Vitamin D Solution,” Michael Holick, MD, PhD, notes that currently “many experts agree that both children and adults need a minimum of 1,000 International Units [IU] of vitamin D a day (and preferably 2,000 IU a day) to maintain a blood level of 25-vitamin D that we consider to be healthful.”</div> <div> </div> <div>He adds, “It’s a bit of a shame that even though all this fascinating and alarming research has emerged since 1997 to change our perspective on vitamin D, the government continues to advocate subadequate daily allowances.” For example, FNB defines adequate daily intake of vitamin D for people aged 51 to 70 as 400 IU and 600 IU for those aged 71 and older. </div> <div> </div> <div>The Columbia, Md.-based American Medical Directors Association’s “Clinical Practice Guideline: Osteoporosis and Fracture Prevention” is one long term care-specific document that supports a higher dosage. The guideline defines 800-1,000 IU/d or 50,000 IU monthly of vitamin D3 as acceptable supplementation of vitamin D for long term care facility residents.</div> <div> </div> <div>F. Michael Gloth III, MD, FACP, associate professor of medicine at Johns Hopkins University School of Medicine and corporate medical director at Mid-Atlantic Healthcare in Baltimore, actually supports even greater daily amounts of vitamin D, including input from sunlight. “We have learned that the amount of vitamin D needed to normalize the vast majority of individuals actually is much higher—approximately 4,000 IU daily,” he says.  </div> <div> </div> <div>Low vitamin D levels are associated with many problems, including falls, fractures, and reduced physical functioning. One study has linked low vitamin D with cognitive impairment. </div> <h3 class="ms-rteElement-H3">Getting Past The Myths</h3> <p>While it is true that many are touting vitamin D as a miracle product because of its potential to have a positive impact on many diseases and conditions, until recently some studies led people to believe that vitamin D supplementation really didn’t produce significant benefits.</p> <div>As Gloth explains, “Studies were coming out that used low dosages of vitamin D and showed little impact. Also, many involved patients who were younger and spent more time outdoors. Old standards often were used in studies, and we now know that the doses used were way too low to enable people to respond adequately.</div> <div><br></div><div>“Studies using higher doses in populations demonstrated to be deficient have shown benefits in many arenas, including falls and fractures, certain infections, seasonal affective disorder, strength, functioning, balance, and even multiple sclerosis,” he adds.</div> <div> </div> <div>In adults, Holick says that vitamin D reduces the risk of Type 2 diabetes and may improve outcomes with some types of cancer. “We know that prostate cancer is associated with vitamin D deficiency, and one study has shown that vitamin D intake is associated with a reduced risk of breast cancer. It also can help reduce upper respiratory infections significantly,” he says. “If you are vitamin D deficient, you are at higher risk of having and dying from a heart attack. And we are just beginning to appreciate vitamin D’s impact on the autoimmune system.”</div> <div> </div> <div>There also are many myths and misconceptions about vitamin D that continue to perpetuate, and these may keep practitioners and others from fully appreciating its benefit for their patients. For example, Holick notes, “There is a myth that elderly people can’t absorb vitamin D as well as younger people. While it’s true that they can’t make as much vitamin D as their more youthful counterparts, older people can still benefit from vitamin D exposure.”</div> <h3 class="ms-rteElement-H3">Sunshine, Milk Aren’t Enough</h3> <div>Holick notes that while osteoporosis has gotten much attention, people seem to forget about vitamin D deficiency. “Physicians are taught that if you have a well-balanced diet, you won’t be vitamin D deficient, but nothing could be further from the truth. And this condition can have some serious consequen-ces for elders.” It causes people to lose phosphorus in the urine, he says, and it doesn’t permit collagen to be mineralized. People with vitamin D deficiency may have severe bone pain. However, once they receive adequate vitamin D and their levels rise to normal, Holick says, “They have dramatic improvements in terms of pain and feelings of well-being.”</div> <div> </div> <div>While it is true that sunlight is the best, most natural source of vitamin D, it often is not feasible for nursing facility residents to spend time outdoors. And there are some misconceptions about sunlight that can prevent older people from getting enough rays to get the vitamin D they need. For example, Gloth says, “Many facilities have solariums or sun rooms, and residents sit in these for hours getting the light of day. However, the glass blocks out positive rays, so this exposure does nothing to impact vitamin D status.” </div> <div> </div> <div>Staff may be concerned about skin exposure and send residents outdoors only with sunscreen coverage. While this may benefit their skin, it doesn’t help their vitamin D absorption. And the truth is that short exposures can make a positive difference in terms of vitamin intake without subsequent skin damage. As Holick says, “If arms and legs are exposed a couple of times a week, that helps.” Morley notes, “You just need about 20 minutes to get adequate vitamin D, and there are little data showing that 20-30 minutes creates much skin damage.”</div> <div> </div> <div>While foods such as milk are a good source of vitamin D, most experts agree that it is not realistic to rely on dietary intake to get enough vitamin D. As Todd Goldberg, MD, CMD, a West Virginia-based physician, says, “You would have to drink four to eight glasses of milk or more daily to get a minimum daily requirement that still likely would be too low.” He adds, “I certainly encourage people to drink milk, but they shouldn’t count on it as their only source of vitamin D.” </div> <h3 class="ms-rteElement-H3">Supplements, Supplements</h3> <div>Since it isn’t practical for elderly long term care facility residents to get adequate vitamin D from sunlight and diet, supplements usually are necessary. Gloth recommends 50,000 IU capsules, two capsules once monthly. “This comes out to between 3,000 and 4,000 international units per day,” he says. </div> <div> </div> <div>There are two options to get vitamin D in such a large dosage. Vitamin D2 (ergocalciferol) comes from irradiation of yeast and the plant/plant sterol ergosterol. This is a prescription-only product and has a half-life of eight to 10 days. Vitamin D3, an over-the-counter product, comes from oily fish and cod liver oil and has a half-life of 25 to 30 days.</div> <div> </div> <div>“Most people think of large doses of vitamin D as a prescription product, and it’s easy to see why people have been confused,” says Gloth. In fact, until recently, high-dose vitamin D was only available in a prescription form as vitamin D2. Even now, there are only a few companies manufacturing the over-the-counter high-dose vitamin D3, and many pharmacies don’t carry it. </div> <div> </div> <div>Gloth says that he recommends vitamin D3 for several reasons. “We think that vitamin D3 is the preferred source of vitamin D if patients are going to take it on a monthly basis. We find that if you take vitamin D2, levels of hydroxyvitamin D rise but taper off rather quickly within a week or so. With vitamin D3, those levels stay up there for a month.” </div> <div> </div> <div>Some facilities implement standing orders for vitamin D. “All facilities where I work have this standard in place,” says Gloth. “I think this largely is dependent on the medical director or if the facility is in an area where there are experts on aging and bone disease. I don’t see any negatives to making vitamin D a standard. Some people express concerns that people may get toxic, but 4,000-5,000 IU won’t cause toxicity in any of our older patients.” </div> <div> </div> <div>The benefits of vitamin D supplementation outweigh any burdens, experts concur. “For one thing, it is dirt cheap. You can go online and get 100 capsules of vitamin D3 for $30. It literally costs pennies a year to treat someone,” says Gloth. He notes that some people may want to take vitamin D2 because it is a prescription product that is covered by their drug plan. However, he notes, the cost may be higher than the cost for vitamin D3. </div> <div> </div> <div>Holick adds, “The cost for D3 is about 25 cents a pill, compared to $7 for the prescription vitamin D2. They are equally efficacious, but the over-the-counter product is more cost-effective. In fact, it is the most cost-effective way of improving health in the elderly.”</div> <div> </div> <div>For residents who can’t or won’t tolerate a pill or capsule, Holick notes, “You can empty the capsule into juice or milk, and it works fine. Or you can get a liquid form.” Additionally, while oral dosing is recommended, it is possible to administer vitamin D2 or D3 intramuscularly or intravenously—although some data suggest that the IM route may not be as effective.</div> <div> </div> <div>Vitamin D can be administered daily, weekly, or even monthly, which simplifies medication administration and doesn’t increase the burden on nursing staff. However, Goldberg notes, “it does make a difference when in the day you take it. It is fat-soluble, so it makes sense that it has better absorption with a big meal instead of on an empty stomach.”</div> <h3 class="ms-rteElement-H3">To Measure Or Not To Measure</h3> <div>The 25-hydroxyvitamin D test is the most accurate way to measure vitamin D levels in the body. Blood is drawn and tested, and a range of 30 to 74 ng/mL is considered normal, according to researchers F.L. Weng et. al, whose study of risk factors for low serum 25-hydroxyvitamin D concentrations was published in the American Journal of Clinical Nutrition.</div> <div> </div> <div>While the test is useful, it isn’t always necessary. As Holick explains, “I don’t recommend screening for my nursing facility residents. I believe that all residents should get 50,000 units of vitamin D once a week for eight weeks. This is easier than daily supplementation, and we know it works.” As stated earlier, fears about vitamin D toxicity (defined as having levels of 25-hydroxyvitamin D above 150 ng/mL with high blood calcium) in the elderly are generally unfounded, although only vitamin D supplementation—and not diet and/or sun exposure—can cause toxicity.</div> <div> </div> <div>As Goldberg explains, “I have had a handful of patients who tested for high levels of D after going on supplementation, but they didn’t experience any noticeable harm.” In the rare instance of toxicity, however, there are serious implications such as nausea, vomiting, loss of appetite, constipation, and weight loss. In more serious cases, toxicity could cause seizures, spasms, or heart problems. However, Holick stresses, “Vitamin D toxicity is extremely rare and happens only in unusual circumstances.”</div> <div> </div> <div>There are some residents whose vitamin D levels should be monitored once they go on supplementation. These include people with diseases related to malabsorption such as Crohn’s disease and those taking certain anti-epilepsy drugs. Patients who are obese may need higher dosages. Additionally, patients with tuberculosis and sarcoidosis should have their vitamin D levels monitored, as should bypass patients and individuals who are obese. In general, however, “there is no need to broadly screen elderly patients,” says Gloth.</div> <h3 class="ms-rteElement-H3">Vitamin D: The Facility’s Friend</h3> <div>The word about the value of vitamin D is spreading rapidly, and more facilities are making high-dose vitamin D a key part of routine care. As Morley says, “Over the last two to three years, many more facilities have begun to make this a standard of care. There will always be early ‘uptakers’ of ideas, and eventually others start to recognize the value and follow suit.” </div> <div> </div> <div>Most clinicians agree that the benefits of vitamin D—reduced falls and fractures among them—are well worth the low cost. And the flexibility of dosing reduces any additional medication administration time or effort. Clearly, vitamin D’s benefits outweigh any burdens. Morley says, “Once you exclude people with high blood calcium, there is no down side to vitamin D supplementation for our residents.” </div> <div> </div> <div>Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. Available at http://ods.od.nih.gov/factsheets/vitamind.asp.</div> <div>  </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa. </em></div>​A growing number of studies have documented the importance of vitamin D for elderly patients, and many experts are supporting regular supplementation for long term care facility residents. 2010-06-01T04:00:00Z<img alt="" height="740" src="/Articles/PublishingImages/150x150/women_window.jpg" width="740" style="BORDER:0px solid;" />Column6

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Customer Service Can Boost The Bottom Linehttps://www.providermagazine.com/Issues/2010/Pages/0710/Customer-Service-Can-Boost-The-Bottom-Line.aspxCustomer Service Can Boost The Bottom Line<div>​The long term care industry has many challenges ahead, particularly in three areas that are sure to impact bottom-line results: compliance with the new Centers for Medicare & Medicaid Services (CMS) quality-of-life requirements, implementing resident satisfaction initiatives, and achieving high levels of satisfaction among the ever-increasing short-term care population.</div> <h3 class="ms-rteElement-H3">The New Realities</h3> <div>Complying with new quality-of-life requirements could be a significant challenge for many long term care providers. Issued last year, the requirements encompass 12 F-tags and are focused on resident-centered care, with a particular emphasis on quality of life. This means that surveyors will pay closer attention to how nursing facilities create homelike environments that enhance quality of life in accordance with resident preferences.</div> <div> </div> <div>This leaves the facility with the responsibility of actively seeking information about resident preferences and choices and attempting to accommodate them. If a facility has not done so, surveyors will require them to provide an explanation. Moving from a facility-centered environment to a resident-centered culture could be a major challenge for some providers.</div> <div> </div> <div>The second challenge for providers is implementing programs and practices that increase resident satisfaction. There is a very real possibility that facilities will be required to undergo satisfaction surveys by an outside vendor. CMS may consider integrating resident satisfaction data into the Five-Star Quality Rating system and making the data public. If that happens, the data would enable consumers to decide which long term care facility they will ultimately choose.</div> <div> </div> <div>Nursing facilities have worked hard to develop clinical and professional standards, but they have not focused on developing quality service standards that will be necessary to meet and exceed customer expectations. In order to be effective, quality service standards need to be developed and integrated into all systems, processes, and procedures within a facility.</div> <div> </div> <div>The third challenge for nursing facilities is improving the satisfaction level of the short-term resident. Although related to the second challenge, the nature of the population makes this challenge quite different. </div> <h3 class="ms-rteElement-H3">The Short-Term Stay Factor</h3> <div>There has been a significant increase in the growth of this group over the past 10 years. These short-term residents bring with them a whole new set of criteria in terms of achieving high levels of customer satisfaction. </div> <div>They are, for the most part, younger and more discriminating in terms of what it takes to satisfy them and their family members. It is likely that their family and friends will be at the facility more often and will be in a position to evaluate service quality more critically. </div> <div> </div> <div>In turn, they will be making more of their decisions about choosing a facility based on the recommendations of family and friends, which places a greater demand on a facility that wants to increase market share to implement proven programs that will improve quality service. </div> <div> </div> <div>All three of these challenges have the same thing in common: changing the organizational environment from a facility-centered to a resident-centered culture. </div> <h3 class="ms-rteElement-H3">Long Term Care Versus Hospitality Industry </h3> <div>Fortunately, there is a direction in which to go. The long term care industry must examine the best practices that have been put in place and tried and tested over the years in the non-health-care sector. Long term care can borrow practices and experiences from the hospitality industry, restaurants, hotels, and virtually any organizations that have direct customer interaction as an integral part of what they offer their customers.</div> <div> </div> <div>When looking at the best non-health-related businesses, they have a lot in common with long term care. They are looking to gain the competitive edge and increase market share through repeat and referral business. </div> <div> </div> <div>But there are major differences as well. For example, most customers in this sector want to purchase their products and services, unlike long term care, in which customers are typically forced to make a choice in a very short period of time.</div> <div> </div> <div>In addition, the interactions with non-health businesses can be measured in terms of minutes, hours, or sometimes days. Whether it is going into a department store, a restaurant, or hotel, the time factor is relatively short.</div> <div> </div> <div>In long term care the challenge is much greater for just the opposite reasons. First, and probably the greatest, is that customers of long term care typically do not want to be there. Couple that with the fact that residents are there 24 hours per day for days, weeks, months, or longer, and the number of interactions they will have is countless. This just makes achieving a resident-centered culture more difficult.</div> <h3 class="ms-rteElement-H3">Manage Moments Of Truth</h3> <div>What does industry do in terms of best practices for achieving high levels of quality service? First, it looks at its delivery of the service, not from what it does but from what the customers experience. Managing these experiences in a way that will meet and exceed customer expectations is key.</div> <div> </div> <div>It is important to note that the physical environment in which the services take place, the personal appearance of employees, interaction with the employees, and processes that interface with all contribute to residents’ levels of satisfaction.</div> <div> </div> <div>In addition, many of the customers’ experiences happen in a fairly predictable way, with a defined starting point and a predictable end point. This can be called the “customer experience cycle.” For example, when one dines in a restaurant, the experience cycle may start with making a reservation, followed by arriving at the restaurant, and then all of the intermediate steps in between, ending with paying the bill. </div> <div> </div> <div>In a quality-service-focused restaurant, management has carefully studied and put in place the small, individual but important elements to make the dining experience live up to customers’ expectations. </div> <div> </div> <div>From the initial greeting by the host to meeting the wait staff, all have been looked at one “moment of truth” at a time, with a moment of truth being defined as any incident in which the customer forms an impression of the quality of the restaurant’s services. </div> <div> </div> <div>Moments of truth are formed by what the customer sees, hears, or experiences in the course of receiving a service. They are neither positive nor negative on their own. It is what is done at that moment that makes it a plus or a minus. It is all of these moments of truth, taken together, that form the customers’ score cards and ultimately their levels of satisfaction.</div> <h3 class="ms-rteElement-H3">Quality Service Standards</h3> <div>Do these concepts apply to the long term care environment? Absolutely. For example, when the resident is first admitted, does she experience a predictable series of events, from arriving on the nursing unit, being taken to her room, and being assessed and oriented by nursing personnel? After this occurs, the new resident is visited by an array of staff from various departments who further the assessment and orientation process.</div> <div> </div> <div>How does a long term care facility manage the customer experience in a way that meets and exceeds her expectations? It does it in the same way as the non-health-care sector does it, one moment of truth at a time.</div> <div> </div> <div>As with any other entity that has a service component to its business, long term care providers need to identify their quality service standards—those actions that must be built into how service is delivered. Identifying these standards and implementing them will take a concentrated organization-wide effort and the senior management team leading by example.</div> <div> </div> <div>Once these standards are developed, the facility needs to study its customer-experience cycles and build in these standards, which should be integrated into every aspect of the organization: job descriptions, job-specific performance standards, training programs, screening and selection practices, performance evaluations, orientation, and monetary and nonmonetary reward and recognition programs, just to name a few of the important areas.</div> <h3 class="ms-rteElement-H3">Staff Satisfaction Paramount</h3> <div>One other major factor that cannot be left out of this equation is the satisfaction and commitment level of the employee who is delivering the service. To be effective, an employee must be both satisfied and committed to provide high-quality service. Rarely has an employee who is unmotivated or disgruntled ever delivered high-quality service.</div> <div> </div> <div>That circles back to the management of the facility and how the employees are treated and valued as internal customers. Employees need to fully understand what is expected of them, and quality service standards need to be built into all aspects of their jobs, much the same way that clinical standards are. </div> <div> </div> <div>Managers need to provide feedback and recognition to the employee and create an environment that helps them feel motivated to deliver high-quality service. A strong emphasis on resident satisfaction needs to be a major focus for long term care and must be built in as an integral part of the strategic planning process. </div> <div> </div> <div>Service quality is one of the most important parts of the customer value package, along with clinical quality and price. Having one or two of these alone will not be enough to maximize repeat and referral business and market share. All three are essential to success. </div> <div> </div> <div><em>Norm Burns is founder and president of Organization Dimensions (ODI), a consulting firm focused on helping clients find solutions that contribute to their productivity, customer satisfaction, and bottom line. He can be reached at (352) 588-0890 and at normburns@odiconsultants.com. </em></div>As resident-centered and short-term care becomes more widespread, providers must focus on pleasing the customer.2010-07-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/customer_service.jpg" style="BORDER:0px solid;" />Management;Quality ImprovementColumn7
Focus On: Employee Credential Verificationhttps://www.providermagazine.com/Issues/2010/Pages/0710/Focus-On-Employee-Credential-Verification-.aspxFocus On: Employee Credential Verification<p>According to a landmark study conducted by Verifile, a United Kingdom employee screening company, the United States has become the phony degree capital of the world. </p> <p>Highlighted in the January-February 2010 journal of the National Association of Professional Background Screeners, the report claims to have identified 1,762 bogus “institutions” and is still investigating another 1,545 that are currently perceived as “suspicious.” The United States’ share of the confirmed phony institutions: 810.<br>In times past, an employer could get a copy of an applicant’s degree and pretty much rely on its authenticity if all the text was spelled correctly and in the proper fonts, if it had decipherable signatures, and if it was produced on the right kind of paper. </p> <p>Not so, today. With the advent and confluence of personal computers, scanners, laser printers, and Internet marketing, employers must verify the authenticity of degrees and the accreditation of the institutions that offer them by looking up and contacting not only the schools themselves, but also the appropriate accreditation agency in order to verify that both the degree and the school are legitimate. </p> <p>Diploma mills provide authentic-looking degrees in virtually any field of study, without the need to actually attend any classes or lectures or even peruse any textbooks. Some of these mills market the diplomas as legitimate degrees based on the “life experiences” of the students. </p> <div>Charges for these degrees range from under $100 to as much as $1,000. Of course, transcript, bibliography, and verification services are available for additional fees. Needless to say, employers also cannot rely on simply using verification phone numbers or even online services provided by these purported institutions any more than they can rely on the authenticity of a diploma based on its appearance. </div> <h3 class="ms-rteElement-H3">Health Care Vulnerable</h3> <div>It is hard to imagine a profession more susceptible to harm due to phony credentials than health care. Alarmingly, a recent Government Accountability Office study found that more than 11 percent of bogus degrees go to the health care field and include doctors, nurses, and other health care practitioners.  </div> <div> </div> <div>One phony doctor was responsible for hastening the death of a teenage cancer patient, while another was convicted of rape. In addition to the needless suffering of the victims, the blame and liability for these bad acts will fall on the shoulders of the employer. Notwithstanding the potential for economic damages, the reputation of the facility could suffer irreparable harm, and the loss of accreditation is a real risk. </div> <div> </div> <div>Some may feel that just relying on a job applicant or employee’s statement of education credentials puts the onus for liability back on the individual. But a plethora of negligent-hire lawsuits have proven that not to be the case. </div> <div> </div> <div>Consider the California county that hired an individual based in part on his false statement that he held a PhD in public administration. He was put into a position with access to Medicare funds, and when accounting irregularities began to surface, the ensuing FBI investigation determined that the individual would not have been hired if a check of his credentials had been conducted. The county was then held liable for negligent hiring and fined $20 million by the federal government.</div> <h3 class="ms-rteElement-H3">New Incentives For Screening</h3> <div>Another recent development, this time coming from the Federal Trade Commission (FTC), provides incentive for health care providers to implement more rigorous screening processes.</div> <div> </div> <div>FTC issued new rules last year that will hold financial institutions and creditors—including nursing facilities—accountable for implementing formal programs for preventing identify theft. In this case, nursing facilities will be responsible for ensuring that residents are protected.</div> <div> </div> <div>The rules require that any consumer account, or other account for which there is a reasonably foreseeable risk of identity theft, develop and implement an identity theft prevention program (ITPP) for combating identity theft in connection with new and existing accounts. </div> <div> </div> <div>Additionally, the creditor’s board of directors or appropriate individual/owner must certify that all ITPP processes will be effective in preventing or reducing the chances of identity theft, periodically review the ITPP for updates, and ensure that all appropriate staff are properly trained. </div> <div> </div> <div>These rules, which have been delayed several times, are set to go into effect on Dec. 31, 2010.</div> <div> </div> <div>Attempting to find information on individuals through social network sites such as Facebook, MySpace, or even Google can sometimes do a lot more harm than good. For instance, it is very hard, if not impossible, to determine if information on the site is accurate or even that it actually belongs to, or is properly attached to, a particular individual, as opposed to someone with the same or similar name. </div> <div> </div> <div>Additionally, accessing these sites for employment purposes may expose information such as age, marital status, race, religion, and other information protected by Title VII of the Civil Rights Act or the Americans With Disabilities Act, which may not legally be considered in making employment decisions. </div> <div> </div> <div>Courts have come down with decisions that say, for the most part, “you can’t unring a bell.” And if an employer has been exposed to certain information, it may be very difficult to prove it was not a factor in the employment decision-making process, thus making the employer susceptible to being sued for unlawful discrimination.</div> <div> </div> <div><strong>Outsourcing An Option</strong></div> <div>The U.S. Department of Education and the Council for Higher Education Accreditation are probably the most legitimate accreditation bodies in the United States. However, many bogus institutions use names very similar to the real ones and even falsely add legitimate schools to their lists of accredited members, making it very difficult to be sure what’s real and what’s not. </div> <div> </div> <div>There are currently no reliable shortcuts to determining the authenticity of education credentials. The personnel performing verifications need to be dedicated to the task and be as suspicious as a detective.</div> <div> </div> <div>Outside assistance is one way to reduce the possibility of hiring or retaining an individual with bogus credentials. Organizations that employ fewer than 1,000 skilled personnel will usually achieve more efficiency by outsourcing. Every company that requires education and/or training credentials for employment purposes should always verify those credentials to the best of its abilities. </div> <div> </div> <div>What’s more, checking the references and credentials of screening firms is as important as checking the credentials of job applicants.</div> <div> </div> <div><strong>Screening In Other Countries</strong></div> <div>According to Verifile, international background screening is becoming more critical to businesses as borders open up and the battle to hire the best talent intensifies. A large number of direct care staff in nursing facilities are foreign-born U.S. citizens, and facilities must effectively verify credentials to ensure potential employees have been honest and truthful in their applications. </div> <div> </div> <div>To start, screening them in each of the countries in which they have lived is necessary. Verifile recommends criminal record searches to verify that the prospective staff member does not have a record. Each country has its own system for collecting and releasing criminal record data, and it is important to take local regulations into consideration. </div> <div> </div> <div>Rules on the release of consumer credit information also differ from country to country. </div> <div> </div> <div>In the United States, obtaining credit information through a credit bureau is normal, legal, and widely understood, but in countries such as Italy or Malaysia, credit information is not available for preemployment screening purposes even though credit bureaus do operate there. </div> <div> </div> <div>In the United Kingdom, South Africa, and Australia, credit bureaus will only provide for preemployment screening purposes basic information on court judgments and bankruptcies. Although employment verification in the United States often takes place through a verbally conducted check, this is very different from the rest of the world. Verifile notes that in Europe, written requests for employment references are preferred.</div> <div> </div> <div>The reality is that many people are willing to pay for, and will jump at the chance to take, a shortcut to further their careers and bolster their images. </div> <div> </div> <div>This, coupled with the billions of dollars to be made by those who are happy to sell them the bogus tools with no regard for the potential consequences, means that this is going to be an ongoing and ever-worsening problem. </div>Phony websites and unreliable data are making it harder for long term care employers to screen job candidates.2010-07-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/staff_laptop_2.jpg" style="BORDER:0px solid;" />Management;WorkforceHuman Resources7
Nursing Facilities Embrace Short-Stay Residentshttps://www.providermagazine.com/Issues/2010/Pages/0710/Nursing-Facilities-Embrace-Short-Stay-Residents.aspxNursing Facilities Embrace Short-Stay Residents<p>​“Everybody wants to go home.” That statement has never been truer for long term care providers that have adjusted their caregiving and bottom-line priorities to include short-stay patients as well as traditional nursing residents in response to demographic shifts, new technology, economics, and the preferences of the aging baby boom generation.</p> <div>As with the burgeoning culture change movement that is revamping the way skilled nursing facilities (SNFs) look and feel—the Eden Alternative, Green House designs—providers are now bolstering their rehabilitation (rehab), therapy, and temporary housing offerings to tap new revenue streams, while bucking stereotypes of what SNFs do.</div> <h3 class="ms-rteElement-H3">SNFs Take On New Look</h3> <div>Scores of SNFs are extending their business lines into short-stay arrangements for residents whose stays are measured in days and weeks as opposed to months and years, or the rest of a lifetime. These new type of residents are often in their 60s or early 70s versus typical nursing facility clients who may be closer to their low to mid 80s. </div> <div> </div> <div><img class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0710/coverstory%20chart%201.jpg" width="243" height="299" alt="" style="margin:10px 15px;width:290px;height:384px;" /><br>The short-stay patients are not necessarily frail or elderly and may simply require physical, occupational, or speech therapy following time in an acute care hospital before they return to more independent living.</div> <div> </div> <p>The focus on these new patients revolves around the “everybody wants to go home” line, which came in a conversation with Parker Jones, administrator of the 164-bed Heritage Hall Nursing and Rehabilitation Center (American HealthCare) in Leesburg, Va., one of a number of such facilities in Virginia. The Leesburg campus Jones operates is like many across the country, as it seeks to fill beds and fill new needs. Jones notes that his facility was built in 1979 but has evolved in many ways since that time.</p> <p>“Folks do what they need to do and then go back to an assisted living facility [ALF] or independent living. Since January, 58 percent of our residents have been discharged and gone home or to assisted living, and that is fairly typical,” Jones says.</p> <p>While noting that his facility is 91 to 92 percent occupied, Jones says the average length of stay for “therapy people” is around 28 days. This compares with the two-year-plus national average for a resident’s length of stay in a nursing facility. </p> <div>“The short-term rehabilitation folks are a positive for us,” he notes, saying facility staff are emotionally satisfied that their work has resulted in success for the patient, while the patient is happy to be feeling better and going back home, and the patient’s family is gratified as well. “Everybody wants to go home,” Jones reiterates.</div> <h3 class="ms-rteElement-H3">SNFs Enter Market</h3> <div>There is not much mystery as to why SNFs are eyeing short stays, since the patients in short-term situations represent a higher-paying client base than long-term stays. Medicare pays two to three times more for rehabilitative services than Medicaid does for long term care, pushing SNFs in the direction of expanding their rehabilitation units to attract higher reimbursement and stabilize their finances.</div> <div> </div> <div>By treating “younger patients” in a post-acute care setting, SNFs are also looking to benefit from a push by the Medicare program to limit the number of enrollees who can receive care at higher-cost rehab hospitals. Medicare recognizes nursing facilities as a lower-cost resource for the scores of patients who need weeks or months in a rehab setting to convalesce following hip or knee replacement, stroke, or the like.</div> <p>Estimates put these lower SNF costs at up to one-third to one-half of what a rehab hospital charges for what typically is a one-month stay for post-operative care.</p> <p>What you are seeing is that there are a lot more short-stay acute cases [at SNFs], and this has been happening for a long time as nursing facilities offer more than just long term care,” says Irene Fleshner, senior vice president for strategic nursing initiatives at Kennett Square, Pa.-based Genesis HealthCare, a noted leader in the rehab and therapy space.</p> <p>“The traditional nursing home is a dinosaur, yet we are still regulated and paid that way,” she says, noting that even though there will always be the need for 24/7 care, the future appears to be more assisted living for those who used to inhabit nursing facilities and more room for SNFs to take on major structural changes to attract short stays.</p> <p>Mary Jane Koren, assistant vice president for the Picker/Commonwealth Quality of Care for Frail Elders Program at The Commonwealth Fund, says the market, as always, is ruling the decision-making process on where to put resources in the long term care sector.</p> <div>One of the things going on is that skilled nursing facilities are seeing increased competition from assisted living, so they are reaching out to new populations to help fill those beds. They are finding a new service they can provide to a community and are trying to use this as a new revenue stream,” Koren says.</div> <h3 class="ms-rteElement-H3">Health Reform Law Has Impact</h3> <p>Robert Kramer, president of the Annapolis, Md.-based National Investment Center for the Seniors Housing & Care Industry, says when a SNF adds a specialty rehab unit, the quality mix of nursing care in the community immediately improves.</p> <p>“This is particularly true in an area where you have older skilled nursing properties,” Kramer says. </p> <p>He sees the trend for more rehab and therapy patients headed to SNFs and says the reasons are based on the economics of long term care and related moves by investors, SNF companies, and related entities to attract more business by updating aging buildings and infrastructure.</p> <p>“The skilled nursing setting is the lowest-cost facility setting for providing this type of care,” Kramer says. If properly staffed and operated, these rehab units will be very attractive to managed care companies who will be looking to take advantage of opportunities to bundle services. “This makes for a very attractive post-acute care-bundling scenario” with the low-cost SNF and the new rehab and therapy emphasis, he says.</p> <p>Kramer says the new health care reform law, when implemented over the next few years, will be focused clearly on figuring out cost efficiencies. “There is a lot of discussion going on with [Health and Human Services Secretary Kathleen] Sebelius and the new leaders of CMS [the Centers for Medicare & Medicaid Services] on finding the best quality and clinical outcomes at the lowest-cost setting. They have a lot on their plate, but this is a key area of cost savings by reducing rehospitalizations,” Kramer says.</p> <p>He thinks it will take CMS the rest of this year to plan guidelines and funding mechanisms to support pilot programs for bundling services, and actual programs will not emerge until 2011, with start dates in 2012.</p> <div>The shifting economics for SNFs factor in the fact, according to Kramer, that nursing facilities have lost the private-pay customers to ALFs and home-based care, leaving opportunities elsewhere to revamp and remodel and attract the “younger” rehab market. </div> <h3 class="ms-rteElement-H3">Investments Required</h3> <div>To attract the new breed of patient/resident, SNFs are putting money into plant restructuring and equipment purchases, along with the most important factor of finding and retaining the skilled therapists and nurses necessary for quality care, or contracting out to companies to get the job done. </div> <div> </div> <div>Heritage Hall’s Jones points to a number of enhancements to the rehab programs at his 31-year-old facility, including purchases of modern equipment to help improve results and shorten stays. </div> <div> </div> <div>Some examples of the capital expenditures are the purchase of ACP Omnicycle and NUStep machines for endurance and strength, ultrasound technology for pain relief, Megapulse II Diathermy for pain management and edema control, E-Stim Omnisound 3000 for pain management, and a QualCraft Exerciser for physical rehab. </div> <div> </div> <p>Jones says electric beds and mechanical lifts have been added for resident comfort and convenience as well as resident and staff safety. There have also been plant upgrades, with the addition of outdoor siding to keep the facility “looking good and presentable to our clients,” he says. </p> <p>Many nursing facilities have taken the upgrade of their rehab and therapy spaces further, to the point of separating the short-term residents from the long-term, traditional clients, including the use of separate entrances and exits and even changing the facility’s branding to get the words rehab or therapy in the title.</p> <p>For Jones and his Virginia SNF, the changes are not so dramatic, as all residents enter and leave from the same entrance and exit, but there are distinct differences inside the building related to staffing and logistics.<br>“We haven’t done [separate entrances]. Everybody comes in the one entrance, but the short-term residents are kept in one unit. This is usually easier for us because our staffing is heavier in the acute units,” Jones says.</p> <p>Heritage Hall has the equivalent of 10 full-time therapists on staff, but they have distinct skills apart from the nurses and nurse assistants working in the acute wings, Jones says. He notes the occupational, physical, and other therapies are offered six days a week, and a seventh day is possible if an insurance company issues an order for such service.</p> <p>In Miami, the management at Miami Jewish Health Systems (formerly Miami Jewish Home and Hospital) took a look at the market for its range of long term care services and saw a potentially explosive opportunity in the rehabilitation and short-stay space, noting the expanded demand for a new style of nursing facility care that stresses temporary and targeted therapy over permanent residency. </p> <div>Blaise Mercadante, chief marketing and communications officer with Miami Jewish Health Systems, says the company markets its rehabilitation services to doctors and hospitals to show the quality of their services and to demonstrate “we’re not just a skilled nursing facility.”</div> <h3 class="ms-rteElement-H3"><div>Rehab CARE AT the Right Time</div></h3> <div>The unique method behind the Miami Jewish take on short-term stays is its use of extensive data collection to match the resident/patient/client with the right care based on outcomes measures for assessing what care worked best.</div> <div> </div> <div>The company’s marketing focuses on the “right” mantra. “Our systems are designed to a ‘right program, at the right time, i<img class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0710/coverstory2.jpg" width="248" height="286" alt="" style="margin:10px 15px;width:213px;height:140px;" />n the right place’ approach,” Mercadante says. “Whether the individual wants to remain at home, requires short-term therapy, longer-term care, or specialized services, Miami Jewish Health Systems offers quality programs to help maintain their independence and control of their life.”</div> <div> </div> <div>Miami Jewish’s Rehabilitation Center at Douglas Gardens employs Aegis Therapies to direct physical, speech, and occupational therapy. Aegis Therapies operates in 37 states nationwide by helping patients connect with specialists who operate in nursing facilities, assisted living residences, and their own homes.</div> <div> </div> <div><img class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0710/coverstory3.jpg" width="432" height="287" alt="" style="margin:10px 15px;width:217px;height:144px;" />An example of the sweeping number of services offered at Douglas Gardens includes electric stimulation, pain management, physical therapy, pneumonia treatment, occupational therapy, speech therapy, and therapeutic recreation. The list goes on to cover administration of intravenous medications, blood transfusions, cardiac monitoring, and diagnostic imaging.</div> <div> </div> <div>Miami Jewish Health Systems serves around 3,700 people in Miami-Dade, Broward, and Palm Beach counties and lists its clients as being from all age ranges. Chief Executive Officer Jeffrey Freimark says the newly rebranded company’s goal is to ensure quality of care and to expand the range of services for short-term stays and other residents by partnering with managed care stakeholders to compete for post-acute care dollars. </div> <h3 class="ms-rteElement-H3">Don’t Over-Promise</h3> <div>Providers say they understand the difference between making promises on available services and delivering on them and stress that finding quality staffers has been a priority of theirs for years, if for long-term or short-term residents. Jones notes that his facility has been able to staff at a higher level in terms of expertise and quality because of the recognition by entrants to the workforce of the opportunities in long term care. The economy, of course, has helped to make workers more readily available, but maintaining the quality of therapy staff is ongoing.</div> <div> </div> <div>“SNFs have to be careful they are able to provide the level of service they are advertising,” Koren notes. </div> <div> </div> <div>Marketing efforts to the general population or to discharge planners at hospitals are often taking the form of claims from SNFs that they can deliver comparable service as a hospital, which could be a recipe for trouble if the staffing, facility, and planning are not up to par. “You really need to have enough staff—physical and occupational therapists,” she says.</div> <div> </div> <div>Fleshner says SNFs cannot compete with hospitals also vying for skilled workers on a salary range basis, so nursing facilities “should be careful” when marketing to the same customer base.</div> <div> </div> <div>“Some [providers] are overselling,” she notes, adding that hospitals are equipped with emergency rooms, labs, and pharmacies for a reason, because they are the higher-cost option with much higher overhead. She did stress that SNFs can compete well for certain patients as they improve their clinical capabilities and develop an educated workforce. </div> <div> </div> <div>Koren says there is definitely a balancing act going on. On the one hand, managed care companies and others are looking to bundle their patients to send to SNFs, which offer the lowest cost alternative in the provider marketplace. “But how [SNFs] stay low cost” when trying to compete with hospitals and other rehab providers by staffing at a higher level and with modern equipment is another matter.</div> <div> </div> <div>“The bottom line is that they really have to provide high-quality care,” she says.</div> <div> </div> <div>What SNFs should be focused on, besides the obvious need for making their short-stay business thrive, is how success for the short stays can translate into an overall winning strategy for the future, experts say.</div> <h3 class="ms-rteElement-H3">Attract Future Residents </h3> <div>“Short stays are really opportunities for nursing facilities to market themselves to the community, and if they succeed, they will reap the benefits throughout the community,” Koren says. </div> <div> </div> <div>She notes that word of mouth is the most reliable way nursing facilities get business, so by pleasing the “younger” residents in rehab and therapy, they can build a bridge to these same people and their families when the time may come for permanent residency later on.</div> <div> </div> <div>“It’s like families asking: ‘Weren’t you there for your hip rehabilitation?’ and saying yes to the question of whether they want to put their mothers in there later. You have to make sure the staff is good, the food is good. Nursing facilities really have a great opportunity to capitalize on all the things they can do, and do well,” Koren says.</div> <div> </div> <div>The subject of marketing to short stays so they can become residents later on bridges into the culture change topic. The slightly younger groups in for rehab are expecting amenities that the more elderly may not. This demographic difference, catering to the beginning fringes of the baby boom generation, can translate into SNFs remodeling their short-stay spaces, to have the flat screen televisions available, the private bathrooms, and diverse food choices and preparation methods.</div> <div> </div> <div>It all goes together, providers say. The new look and feel and new clinical and care offerings make the old model for SNFs just that: old.</div> <h3 class="ms-rteElement-H3">Covenant Care: A Prototype For Success</h3> <div>Doug Shuck, vice president of operations-Midwest for Aliso Viejo, Calif.-based Covenant Care, offers his company’s Springfield, Ohio, long term care facility as a textbook example of what the future business model will look like for many in the long term care sector.<img class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0710/coverstory1.jpg" width="300" height="392" alt="" style="margin:10px 15px;width:211px;height:141px;" /><br><br>In 2005, Springfield was a very traditional long term care facility, enjoying a positive reputation for quality care and boasting an average occupancy of 92 percent. Its skilled nursing census averaged 18 patients.</div> <div> </div> <div>“However, we were facing some challenges to our traditional business model,” Shuck says. “Assisted living facilities were entering the market and siphoning most of the private-pay business. The demand for short-term rehabilitation services was increasing, and patients were demanding private rooms, modern amenities, and cutting edge therapy programs.”</div> <div> </div> <div><img class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0710/coverstory3.jpg" width="252" height="240" alt="" style="margin:10px 15px;width:209px;height:138px;" />Since typical consumers today are much better informed because of the online revolution, these new service demands were entering more and more into their decision making on where to put their long term care dollars.</div> <div>“Furthermore, the state Medicaid program was not paying us enough to cover our costs for caring for the state’s indigent patients,” says Shuck. “In addition, more Medicaid funds were being diverted to home- and community-based options under the state’s waiver program.”</div> <div> </div> <div>As many providers know and are fighting to correct, Medicaid reimbursement is also becoming unpredictable at best and severely lacking at worst. </div> <div> </div> <div>Shuck says based on unanticipated changes instituted in 2009 by Ohio’s Medicaid program, Covenant Care will see an estimated $1.2 million reduction in revenue to its Ohio facilities. “How can we make business decisions related to competitive wages and benefits or capital improvements for outdated buildings when we do not know if our reimbursement will be unexpectedly reduced? As a result, we found it necessary to reevaluate our business strategy,” he says.</div> <div> </div> <div>This is when the Springfield reinvention took place.</div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0710/Respite-Care-Offers-Options.aspx">HERE</a> to read about providers' efforts to offer respite care services.</div> <h3 class="ms-rteElement-H3">Investing In Rehab Therapy</h3> <div>“We made the decision to invest heavily in reinventing the Springfield facility into a state-of-the art rehabilitation facility as an adjunct to our traditional long term care business model,” Shuck says. </div> <div> </div> <div>“In May 2008, we opened a $2.1 million addition to the Springfield facility. This 8,210-square-foot facility includes 12 large private rooms, a dining room, and a 1,402-square-foot therapy gym.”</div> <div> </div> <div>As part of the expansion and remodeling, the company purchased $70,000 in state-of-the-art therapy equipment. The addition of the 12 private rooms also led to the creation of 12 more private rooms in the existing facility. In total, the Springfield facility has 30 private rooms, and the high demand keeps those rooms at 100 percent occupancy. </div> <div> </div> <div>Shuck looks back at 2005 and notes that Medicaid represented 69 percent of the Springfield patient mix and 52 percent of total revenue at that time.</div> <div> </div> <div>“In 2009, those numbers fell to 58 percent and 35 percent, respectively, as revenue from short-term rehabilitation services continued to grow at a record pace,” Shuck says.</div> <h3 class="ms-rteElement-H3">Rehab Therapy Partners</h3> <div>The Springfield facility, called Villa Springfield, employs 14 therapists, and Covenant Care partners with Select Therapies to fill these slots and keep updated on the latest technology available for its operations. Again, the goal is to admit patients with an eye to returning them home or to their previous living arrangements as soon as is feasible. </div> <div> </div> <div>“A patient’s best opportunity to return home begins when he/she is admitted to Villa Springfield for therapy services. We returned home 181 patients in 2009 out of 326 total admissions, or 55 percent,” Shuck says.</div> <div>Some 18 percent of the discharged patients from the rehab program were under 65, and 40 percent of all admissions in 2009 were former patients at Villa Springfield.</div> <div> </div> <div>The facility also offers a Transitional Living Unit that simulates a home living environment and includes a bedroom, small living area, efficiency kitchen, and full private bathroom. In some facilities, it may also have a washer and dryer.</div> <div> </div> <div>Shuck notes that outpatient services continue to expand as well, averaging 10 patients per month. Just last year, Villa Springfield received the company’s highest award, the Chairman’s Award, and a Better Business Bureau International Torch Award for Business Integrity that was presented in Washington, D.C., this past April.</div> <div> </div> <div>The range of ideas for short stays is broad, and the opportunities apparent to most SNFs looking beyond their traditional role. In the end, the nursing facility will always be a mainstay for the old and frail to spend their final years, but the baby boomers who are having surgery will need recuperation space, and that is an area for vast growth among SNFs eyeing the new market, experts say.</div>Temporary residents, rehab programs reshape facility operations.2010-07-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Management;Reimbursement;Quality Improvement;DesignColumn7
SNFs Embrace Intergenerational Activitieshttps://www.providermagazine.com/Issues/2010/Pages/0710/SNFs-Embrace-Intergenerational-Activities.aspxSNFs Embrace Intergenerational Activities<p>​As long term and elder care enter a new decade, the need for quality services continues to remain a central component of programming and administrative decisions. Coupled with this goal is the current economic situation, which calls for many organizations and agencies to continue or expand their care with the same, or in some cases fewer, budgetary dollars. </p> <p>Economic cutbacks and constraints have led many nursing facilities to create unique partnerships in order to maintain the quality care that is expected in their communities. </p> <div>In Cedar Falls, Iowa, the University of Northern Iowa and Western Home Communities have established a partnership that has led to intergenerational relationship building, event planning, and quality programming that the residents appreciate a<img width="319" height="182" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0710/caregiving2.jpg" alt="" style="margin:10px 15px;width:242px;" />nd look forward to throughout the year.  </div> <h3 class="ms-rteElement-H3">An Idea Is Born</h3> <div>At Northern Iowa’s Leisure, Youth, and Human Services Division, nearly 200 students are required to take a leadership class as part of their education. Ten years ago, a faculty member approached Jerry Harris, chief operating officer of Western Home Communities, with an idea that would benefit both organizations: Groups of students from the leadership class could design and implement evening special event activities for the residents. <br> </div> <div>Programs of this type are known in the field of gerontology as intergenerational activities, which, according to the National Council on Aging, are “planned and ongoing activities that purposefully bring together different generations to share experiences that are mutually beneficial.” </div> <div> </div> <div>In preparation for the events at Western Home Communities, student groups meet with Western Home’s program director, tour the grounds, and learn about the facility and its residents. </div> <div> </div> <div>The students then begin work on creating the evening special event activities, each of which must include a theme. Students are also required to use resources at the facility or bring in their own. </div> <div> </div> <div>The groups are responsible for marketing, setting up for the special event, leading the various activities, and cleaning up the facility or area once the event is over. The evening activities must be designed for all ability levels, and students are tasked with making adjustments, if necessary, that enable all residents to participate. </div> <div> </div> <div>For the leadership class, students must complete an assignment that addresses a number of items related to the evening special event activities, including the logistics of the event, examples of effective and ineffective leadership, and what they learned working with the residents. </div> <h3 class="ms-rteElement-H3">A Win-Win Situation</h3> <div>Over the past 10 years, the student groups have designed and implemented unique activities that leave a lasting impact on them, while the clinical and social setting provided by Western Home Communities allows the students to gain valuable insight and experience in the field of geriatrics. </div> <div> </div> <div>Many students appreciate this leadership opportunity and have continued to volunteer and intern with the organization. As one student said, “The impact of doing the special event at Western Home opened my eyes to opportunities in the leisure field and that I can make a difference in a person’s life, even if I am only with them for a short while.”</div> <div> </div> <div>Many students had not worked with elder populations before, but as activities and programs in the leisure field cater more and more to this group, the benefits of this experience will extend to the students’ future career aspirations. The collaborative effort between the University of Northern Iowa and Western Home Communities benefits staff as well. The special events that occur provide new, fresh ideas for future usage by permanent staff workindg at the facility.</div> <div> </div> <div>One semester, a student group used a Wii video game system as part of its evening special event activities. The residents enjoyed the opportunity to actively participate, and Western Home Communities went on to purchase multiple Wii video game systems for the residents to use regularly. </div> <div> </div> <div>A student from that group volunteered to show the staff how to set up the video game systems and demonstrate how to use them so staff could show the residents. </div> <h3 class="ms-rteElement-H3">Multiple Benefits</h3> <div>The residents benefit from participating in the special event activities in a variety of ways. They continually ask the staff when the “UNI students are coming back” to do activities with them. </div> <div> </div> <div>Many of the residents express how much they love the students’ energy and creativity, as well as enthusiasm for doing things with them. Residents will often participate in new activities, such as putting together a memory quilt or creating decorative door hangers, while others revisit existing skills, such as carving pumpkins. </div> <div> </div> <div> There is also a greater benefit from the activities—the time spent allows two generations to connect and learn from each other.</div> <div> </div> <div>One student group designed an evening special event celebrating Veterans Day. Since many residents at Western Home are military veterans or spouses of veterans, this opportunity allowed the students to learn firsthand about daily life when the United States was involved in a global war.</div> <div> </div> <div>During the activities, residents and students engage in conversations that are thought-provoking and informative. There is an intergenerational link between the two groups, and the students often inform the faculty member how educational their time was with the residents.</div> <div> </div> <div>The residents, meanwhile, appreciate the opportunity to share their life experiences with the students as a means of educating. </div> <div> </div> <div>The residents were informally engaging in “generativity,” or demonstrating a concern for establishing and guiding future generations. The residents hope that by imparting their knowledge and experiences to the students, it will have a positive impact on them. </div> <div> </div> <div>In addition, learning takes place because the students and the residents have positive viewpoints of each other. </div> <div>By engaging in effective leadership and fellowship, both the students and residents benefit from this collaborative effort. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0710/Wisconsin-Intergenerational-Program-Has-Staying-Power.aspx">HERE</a> to read about a University of Wisconsin program that has generated more than 175,000 student visits to nursing facilities.</div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0710/Resources-for-college-based-Programs.aspx">HERE</a> for a list of websites that offer resources on starting an intergenerational program in a nursing facility.</div> <div> </div> <div><em>Christopher Kowalski, EdD, is assistant professor, Leisure, Youth, and Human Services Division, University of Northern Iowa. He can be reached at: <a href="mailto:Kowalski@uni.edu">Kowalski@uni.edu</a>. Jerry Harris, chief operating officer of Western Home Communities, can be reached at Jerry.harris@westernhome.org.</em></div>Visits from college students have a powerful impact on residents and students alike.2010-07-01T04:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0710/caregiving1.jpg" width="150" style="BORDER:0px solid;" />Caregiving;QualityColumn7

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Dementia Care Refresherhttps://www.providermagazine.com/Issues/2010/Pages/0810/Dementia-Care-Refresher.aspxDementia Care Refresher <h3 class="ms-rteElement-H3">A Toolkit For Success</h3> <div>To find a way through these challenges and provide cost-effective, quality care, a few of the points included in the Alzheimer’s Disease Bill of Rights from “The Best Friends Approach to Alzheimer’s Care,” by Virginia Bell and David Troxel, can help build a dementia toolkit that will arm staff members with the instruments to be successful. </div> <div> </div> <div>The foundation of the toolkit focuses on each team member’s skills, knowledge base, actions, awareness, and involvement. It requires that each member of the staff recognize that he or she is expected to have a daily relationship in providing care and that to advance that relationship, training will be provided and expected—from orientation and throughout the term of employment. </div> <div> </div> <div>For the toolkit to work, each individual team member must be skilled in his or her respective discipline, have a professional understanding of the disease, have a care plan that emphasizes person-centered care, and be trained in the methods of communicating with residents. </div> <div> </div> <div>All team members must be involved in maintaining resident function and engagement in social activities throughout the day. Most importantly, all members of the team must feel confident that they can learn from and lean on the team as a whole in order to build and use the “perfect” toolkit. </div> <h3 class="ms-rteElement-H3">Knowledge And Skills</h3> <div>A dementia care facility should hire only caregivers who have prior education and training on how to do their jobs. Although these individuals might not be experts in dementia care, they should know how to provide quality care to the aging population and be able and eager to pursue additional education and experience for working with residents who have dementia.</div> <div> </div> <div>The best-suited personality for this job is someone who demonstrates a sense of calmness, speaks in normal tones and speeds, is flexible and understanding, and is able to easily recall and use coping strategies in difficult situations. </div> <div> </div> <div>Continuing education about caring for residents with dementia and facility-specific policies and procedures need to be provided both at the time of hire and periodically throughout the year. </div> <div> </div> <div>In order to care for their residents, staff members in a dementia wing need to learn and periodically be reminded of the difference between normal aging and dementia-related changes. For instance, the aging person with or without a dementia diagnosis at times displays forgetfulness, or “senior moments.” Staff must learn to differentiate common behaviors of aging from the more complex memory losses of early dementia. </div> <div>Staff must also understand that dementia may be reversible since it can be caused by a brain tumor, depression, dehydration, nutritional deficiencies, medication side effects, or infections. </div> <div> </div> <div>Some dementia is irreversible due to Alzheimer’s disease, Parkinson’s disease, Huntington’s chorea, Lewy body dementia, and Pick’s disease. </div> <div> </div> <div>Often the reversible diagnoses must be eliminated before an irreversible cause can be determined. Irreversible dementia is defined in stages, and knowledge of each stage is extremely helpful in planning the care interventions that will be most effective. </div> <div> </div> <div>Early-stage dementia’s recognizable symptoms include short-term memory loss and forgetfulness, difficulty concentrating or disorientation, personality changes or anxiety, difficulty finding words, withdrawal, and exhibiting poor judgment. </div> <h3 class="ms-rteElement-H3">Know The Symptoms</h3> <div>A resident at this stage benefits from staff members providing reminders and verbal cueing, but allowing the resident to accomplish tasks rather than taking over. Visual demonstrations of what is desired from the resident and then requesting that he or she try to duplicate it can be helpful during this process. </div> <div> </div> <div>Staff members need to tell residents what they can do and refrain from simply doing tasks for the resident. In addition, staff members should avoid telling residents what they cannot do.</div> <div> </div> <div>Middle-stage dementia symptoms demonstrate the advancement of the disease with short- and long-term memory loss, including no longer remembering friends and family members; exhibiting poor attention span; needing care 24 hours per day to stay safe and to meet activities of daily living (ADL) needs; increased behavioral episodes; and increasing restlessness. </div> <div> </div> <div>Late-stage dementia is the final stage of the disease. A resident in this stage displays severe short- and long-term memory loss, loss of most if not all of his or her comprehendible vocabulary, increased sleep, total incontinence, loss of chewing or swallowing ability, and loss of motor skills. </div> <div> </div> <div>Staff members can use this knowledge to adapt what the resident has been able to do in order to allow him to participate in the functional ADL processes.</div> <h3 class="ms-rteElement-H3">Emphasize Person-Centered Care</h3> <div>Eric Haider, founder of the person-centered care model, explains it as representing a philosophical shift from the care and protection of the body by the staff to caregivers encouraging residents to participate as much as they are able in meeting their own needs and better living lives of personal satisfaction. </div> <div> </div> <div>The person-centered care approach gives personal attention to the people who live in seniors housing and empowers staff members to be resident advocates. A caregiver’s knowledge of each resident’s pre-dementia story is essential to be able to gain the attention of that resident quickly when his or her behavior needs to be redirected. </div> <div> </div> <div>The culture of care changes from the staff predetermining the residents’ lives to the residents directing their wants and needs with varying degrees of support as they move through the stages of dementia.</div> <div> </div> <div>The foundation of this tool is built on the fact that the resident with dementia is right. Behavior problems are common in people with Alzheimer’s and related dementias, but it is important to realize that these are symptoms of the disease and not something the person is doing on purpose. </div> <div> </div> <div>All behaviors have meaning. A resident may be communicating fear, pain, fatigue, or an inability to express an unmet need or is feeling overwhelmed by inappropriate expectations.  </div> <div> </div> <div>Click <a>HERE </a>for more about the importance of effective communication.</div> <h3 class="ms-rteElement-H3">Whole Staff Approach</h3> <div>A dementia toolkit cannot be successful without the involvement of every employee in the facility. Each staff member needs to have training in meaningful activities for residents with dementia. The activity department must be considered a staff group that supplements the activity-focused care provided by other departments. </div> <div> </div> <div>All team members can be trained in reminiscing techniques using events that happened long ago, sensory stimulation such as massaging the hands or scalp, discussions of smells in their environment, reading a story, or normalization tasks like sorting silverware, folding towels, addressing envelopes, winding yarn, and organizing drawers. </div> <div> </div> <div>To ensure a superior quality of life for all residents, a facility’s administrator can set the tone by setting goals for each staff member and recommending visits with one resident or small groups each day to directly assist them in engaging with the world. </div> <div> </div> <div>Caring for residents with dementia adds stress to each caregiver, especially when many of the staff members believe that care issues belong only to one small group or department. This attitude generally leads to burnout, higher turnover, staff tension, and, in a few cases, staff retaliation toward an abusive or argumentative resident. </div> <div>A commitment to focusing on socialization and safety gives caregivers the tools they need to provide quality dementia care—improving outcomes for both the residents and staff. </div> <div> </div> <div>Click <a>HERE </a>for the Alzheimer's Disease Bill of Rights, from "The Best Friends Approach To Alzheimer's Care."</div> <div> </div> <div><em>Barbara Peterson, business development director for Risk Management Solutions (RMS), a health care consulting firm headquartered in Columbus, Ohio, <a href="http://www.rmsol.com/">www.rmsol.com</a>. Terri Odom, registered occupational therapist for Therapy Alliance/Ohio CEUS, a company providing therapy services, interim staffing, and consulting services, <a href="http://www.ohioceus.com/">www.ohioceus.com</a>.</em></div>Successful dementia care has many facets, including knowledge, skills, awareness, involvement, and action.2010-08-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_man_thinking_3.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;QualityFocus on Caregiving8
LTC Pharmacy Relationships Scrutinizedhttps://www.providermagazine.com/Issues/2010/Pages/0810/LTC-Pharmacy-Relationships-Scrutinized.aspxLTC Pharmacy Relationships Scrutinized<p>In November 2009, Omnicare, the nation’s largest long term care pharmacy provider, agreed to pay $98 million to settle several claims under the federal anti-kickback statute and the False Claims Act (FCA), including claims that the company provided consulting services to long term care facilities at prices below cost and below fair-market value to win pharmaceutical contracts. </p> <div>The settlement came one year after the Department of Health and Human Services’ Office of Inspector General (OIG) published its “Supplemental Compliance Program Guidance for Nursing Facilities,” cautioning that free goods and service arrangements, such as “pharmaceutical consultant services, medication management, or supplies offered by a pharmacy,” are suspect and warrant careful scrutiny.</div> <h3 class="ms-rteElement-H3">Heightened Scrutiny</h3> <div>The Omnicare settlement and the OIG guidance suggest that the relationships between long term care facilities and pharmacy providers will likely be subject to increased government oversight and enforcement in the near future, resulting in a need to revisit pricing structures.</div> <div> </div> <div>The anti-kickback statute prohibits the knowing and willful offer, payment, solicitation, or receipt of goods or services of value in order to reward or induce the purchase of goods or services paid for by a federal health care program. </div> <div> </div> <div>According to the whistle-blower, a former employee of Omnicare, the company violated the anti-kickback statute by offering pharmacy consultant services at below-market rates, which the government later alleged were also below cost, to long term care facilities to induce them to enter into contracts allowing the company to provide drug products to patients and to bill Medicare, Medicaid, and other payers. The whistle-blower alleged that this practice was used by Omnicare in connection with obtaining pharmacy services contracts with thousands of facilities.</div> <div> </div> <div>The claim was filed in 2002 under the FCA, which allows qui tam relators—also referred to as whistle-blowers—to bring actions on behalf of the government. The government intervened in the relator’s claim and consolidated four other pending cases against Omnicare in 2009, resulting in the multi-million dollar settlement.</div> <div> </div> <div>Citing OIG’s 2008 guidance, the settlement agreement stated that the “consultant pharmacist services contracts between Omnicare and nursing homes implicated the anti-kickback statute because, inter alia [among other things], they involved the provision of services at below cost and/or below fair market value.” </div> <div> </div> <div>In addition to the settlement agreement, Omnicare entered into a corporate integrity agreement (CIA), which provides for a contracts database and process for setting the terms of new arrangements, new policies and procedures, training, and other compliance program requirements, as well as a federal monitor to oversee the company’s compliance activities and new contractual arrangements.</div> <h3 class="ms-rteElement-H3">A Ripple Effect</h3> <div>The allegations in the complaint and the settlement agreement reflect the application of long-standing theories of the government. </div> <div> </div> <div>In 1999, OIG took the position in two advisory opinions that the provision of below-cost services can be a form of improper inducement under the anti-kickback statute. Given this climate, service contracts and other financial arrangements within the long term care facility and pharmacy provider industries are likely to be an area of continued focus of government enforcement agencies.</div> <div> </div> <div>Indeed, in the wake of the Omnicare case, prosecuting U.S. Attorney Michael Loucks declared that the settlement “provides a strong message to [long term care] pharmacies, as well as to pharmaceutical companies and nursing homes, that the government will not tolerate the payment of kickbacks [that] can distort proper medical judgment and put profits ahead of good medical care.” </div> <div> </div> <div>Moreover, by targeting the largest long term care pharmacy provider, the government may achieve a ripple effect in the market. Pursuing high-visibility providers in an effort to change industries is a tactic previously used by the government. </div> <div> </div> <div>Over time, the Omnicare case could have the effect of changing the market rates that pharmacy providers charge for consulting services so that, at a minimum, those charges reflect the pharmacy’s cost of providing the consulting services.</div> <div> </div> <div> </div> <div> </div> <div>Indeed, some facilities that obtain pharmacy services from Omnicare have already seen price increases for pharmacy consulting services, since, as required under its CIA, Omnicare reviewed its agreements and determined that pricing for certain of its consulting services contracts had to be increased to ensure compliance with the anti-kickback statute. </div> <div> </div> <div>If parties choose to ignore this warning shot regarding free or below-cost pharmacy consulting services, pharmacies are not the only entities at risk of enforcement actions. </div> <h3 class="ms-rteElement-H3">Reevaluate Relationships</h3> <div>Long term care facilities that receive such consulting services from pharmacies are equally at risk of enforcement actions themselves, as the anti-kickback law applies to both the giver and receiver. </div> <div> </div> <div>To date, the government has not brought charges against the facilities that had consulting relationships with Omnicare before the settlement, but it is unclear whether qui tam relators have filed complaints under the FCA, as such complaints are often sealed. </div> <div> </div> <div>Another set of allegations in the Omnicare case is similarly illustrative of the risks to long term care facilities. The government also pursued claims against both Omnicare and two nursing facility chains, alleging that Omnicare offered improper cash payments in order to induce the companies to sign long-term, 15-year pharmacy agreements. The two nursing facility companies and some of their principals, as individuals, settled with the government for $14 million in February 2010. </div> <div> </div> <div>Given this new climate, long term care facilities and pharmacy providers should reevaluate their relationships and revise their agreements. </div> <div> </div> <div>The government’s position in the Omnicare matter means that both long term care facilities and pharmacies must not only ask the question, “What is the going rate for this service in our area?” but must also consider whether the rates charged for consulting fees cover the pharmacy’s cost of providing the services.</div> <div> </div> <div>Facilities and pharmacies that do not move quickly to ensure that consulting pharmacy charges are consistent with fair-market value and the pharmacies’ internal costs, risk being the focus of government enforcement and whistleblower actions in years to come. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0810/Safe-Harbor-Protections.aspx">HERE</a> for information about safe harbor protections--provisions that can protect providers from penalty or liability.</div> <div> </div> <div><em>Timothy McCrystal is a partner and Mira Burghardt and Sarah Ferranti are associates in the health care practice group of Ropes & Gray.</em></div>OIG shines a spotlight on provider relationships with long term care pharmacies and scrutinizes contract pricing structures.2010-08-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/medications_3.jpg" style="BORDER:0px solid;" />Legal;ManagementColumn8
LTC Providers Revamp Dining To Please The Palettehttps://www.providermagazine.com/Issues/2010/Pages/0810/LTC-Providers-Revamp-Dining-To-Please-The-Palette.aspxLTC Providers Revamp Dining To Please The Palette<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>When Cindy Dahl began her career as a nutritionist, it probably never occurred to her that she would one day be a judge in a culinary competition—a la “Top Chef”—tasting five-star-worthy dishes like Chilean sea bass with nested linguine and salmon in red chili sauce with garlic-piped potatoes at a nursing facility.</p> <p>But for the past two years, Dahl, who heads up quality nutritional services for Plum Healthcare in San Diego, has done just that as part of the company’s Top Plum Chef competition, inspired by the popular television show. </p> <div>After searching for a way to revamp resident dining programs in the company’s 18 nursing facilities, Dahl came up with the “Top Chef” idea herself, hoping it would spark the chefs’ imaginations and encourage them to take new recipes back to their residents. “I wanted to transform our kitchen services into dyna<img width="349" height="397" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0810/coverstory16.jpg" alt="" style="margin:10px 15px;width:297px;height:198px;" />mic, inspiring teams that produce creative results,” she says.</div> <div> </div> <div><h3 class="ms-rteElement-H3">Tables Are Turned</h3></div> <div>Dahl is one of many long term care professionals who are redefining resident dining and helping to reverse the poor reputation that nursing facilities have earned over the years for serving bland, tasteless fare that even staff members won’t eat. </div> <div> </div> <div>While it’s true that fine dining and nursing facilities are rarely, if ever, uttered in the same sentence, stringent regulations and a regimen of highly efficient systems of tray-served meals, as well as the rationale of “because that’s the way it’s always been done,” have contributed to this perception.</div> <div> </div> <div>With the momentum of culture change at an all-time high, however, and strong support from the Centers for Medicare & Medicaid Services (CMS) for resident-centered care initiatives, providers are rethinking many aspects of facility operations. </div> <div> </div> <div>The results are new dining programs that deliver delicious meals, attractive dining areas, and a broader range of choices for residents. For many facilities, one of the first steps to making this shift is the elimination of trays, which have been ubiquitous in nursing facilities for decades. Although the system has been relatively efficient, tray-served meals delivered to residents in their rooms hinder socialization and interactions that are so vital to quality of life. </div> <div> </div> <div>What’s more, trays represent an institutional vestige that harkens back 50 years or more.</div> <div> </div> <div>CMS’ support for more homelike options has been touted by culture change advocates as a signal that the agency means business when it comes to resident-centered care.</div> <div> </div> <div>Among other things, the guidance instructs surveyors to identify compliance and noncompliance in areas of resident choices about “daily schedule, visitation issues, homelike environments, food procurement, and lighting.”</div> <div> </div> <div>With regard to dining, CMS’ new guidance suggests that providers consider doing away with the following: trays during meal services, plastic cutlery and paper or plastic dishware, staff standing over residents while assisting them to eat, and staff interacting and conversing only with each other rather than with residents while assisting them.</div> <div> </div> <div>The guidance also promotes certain practices, such as the use of dishware that contrasts with the table and a tablecloth color to aid residents with impaired vision to see their food. </div> <h3 class="ms-rteElement-H3">Evidence Backs It Up</h3> <div>In addition to support from stakeholders and the federal government, some limited research on the topic indicates that providers are headed in the right direction. </div> <div> </div> <div>As it happens, culture change adopters are more likely to deinstitutionalize their dining programs, according to a 2007 survey conducted by the Commonwealth Fund. </div> <div> </div> <div>Nearly half (46 percent) of facilities that have adopted culture change have changed how meals are served, while only 22 percent of traditional homes reported they were making such alterations.</div> <div> </div> <div>Compared with earlier research, these data indicate providers are moving forward with new dining programs. Figures from a 2004 survey of nursing facilities conducted by the Centers for Disease Control and Prevention show that 89 percent of facilities in the United States used a pre-plated, tray-style food delivery service—that is, food prepared in kitchens, placed on trays, and delivered to residents. </div> <div> </div> <div>Six years later, the Commonwealth survey revealed that 29 percent, or three out of 10 nursing facilities, had implemented less institutional approaches to dining, such as restaurant, family, and buffet styles, and provided more dining times. </div> <div> </div> <div>Research on the impact of different dining styles also gives credence to the need for change. A study of family-style dining that also focused on staff giving encouragement and praise to people with dementia, resulted in higher participation in eating and improvement in appropriate communication.</div> <div> </div> <div>Another family-style dining study of persons without cognitive impairment reported improvements in quality-of-life measures, fine-motor functioning, and body weight.</div> <div> </div> <div>A Canadian study that examined the combination of steam table/buffet-style food service and a homelike dining environment found that it optimized energy intake in individuals at high risk for malnutrition, particularly those with low body mass index and cognitive impairment.</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">True Choices</h3> <div>Not surprisingly, proponents of culture change view dining as an essential ingredient to resident-centered care in nursing facilities. The Pioneer Network, a national culture change advocacy organization, deemed the topic important enough to host a day-long symposium focused solely on <a href="/Issues/2010/Pages/0810/Dining-Options-For-Nursing-And-Assisted-Living%20Providers.aspx">dining and culture change </a>last February.</div> <div> </div> <div>In addition, the organization’s state coalitions offer workshops that walk facilities through the process of enhancing the dining experience for all residents “using multiple approaches to focus on their needs and preferences.” Titled “Food For Thought,” the workshops are presented by Action Pact, a consulting company that specializes in culture change. </div> <div> </div> <div><div>Linda Bump, a licensed nursing home administrator, registered dietitian, and Action Pact consultant, advocates “true choice” when it comes to resident-centered dining. </div> <div> </div> <div>She discussed her philosophy and her recent paper, “The Deep-Seated Issue of Choice,” at the Pioneer Network’s dining symposium: “Simply speaking, it is all about choice. It is as simple as asking, ‘What does the resident want?’ ‘How did they do it at home?’ ‘How can we do it here?’” Bump says. </div> <div> </div> <div>Giving residents a choice of what to eat, when to eat it, where to eat, whom to eat with, and how leisurely to eat is a true choice, she says, “not the win-lose choice between a hot breakfast and sleeping to the rhythm of your day. Not simply the choice of hot or cold cereal, but also the raisins and brown sugar that make oatmeal a daily pleasure.” </div></div> <div><br>Bump contends that true choice in dining is exemplified in “point-of-service choice,” because, “how often do </div> <div>we know what foods will appeal most to us tomorrow, next week, in three weeks?” </div> <h3 class="ms-rteElement-H3">From Dull To Delectable</h3> <div>Bump’s position is reflected in MediLodge of Sterling Heights’ approach to resident-centered dining. The facility, located just outside Detroit, offers buffet meals and hotel-like room service that dishes up a range of meals and beverages throughout the day and night.</div> <div> </div> <div>Nabil Hawatmeh, the facility’s executive director of food service, began revamping the dining program about four years ago. Having worked in the restaurant and catering industries, he took a less conventional approach to creating better tasting and better looking cuisine for his residents.</div> <div> </div> <div>“When I saw the food here I knew I had to change it,” he says. “Every day, it was either chicken or beef, and it was slapped on a plate and put in front of you.”<img width="187" height="135" class="ms-rtePosition-1 ms-rteImage-0" src="/Issues/2010/PublishingImages/0810/coverstory13.jpg" alt="" style="margin:10px 15px;width:228px;height:173px;" /><br></div> <div>Hawatmeh says he went to the administrator to ask if he could test a buffet-style meal during the weekend. “So I moved the old steam table out of the kitchen and into the dining room and covered it with a nice skirt,” he says.</div> <div> </div> <div>He knew that buffet-style meals would bring enticing aromas into the dining room and whet residents’ appetites. A dining room makeover provided additional temptation with new flooring and wall hangings and a plasma television. </div> <div> </div> <div>Hawatmeh first tested his buffet plan during lunch and breakfast mealtimes. “For breakfast, residents had a choice of eggs cooked several different ways—scrambled, sunny side up, or poached,” he says. “We also had doughnuts, Danishes, bagels, muffins, pancakes, sausage, bacon, fresh fruit, and three hot cereals.”</div> <div> </div> <div>Before the buffet began, however, Hawatmeh had to convince staff and residents that the idea was a good one. “I went to the resident council meetings, the directors of nursing, nurse assistants, and nurses to explain it to them. I went to the day and night shifts to convince them that it was the right thing to do,” he says. </div> <div> </div> <div>In an effort to make the plan run as smoothly as possible, Hawatmeh also created a book that listed each of the 335 residents’ names and any information about their dietary restrictions, allergies, and assistance needs, if any, so staff could monitor them as they entered the dining room. </div> <div> </div> <div>In addition to creating a buffet for every meal and keeping the kitchen open 24 hours per day, Hawatmeh launched an always-available room service program, which, he says, “adds to resident satisfaction by allowing night owls to satisfy a sweet tooth or request a midnight snack.” </div> <div> </div> <div>Meals are served on china dishes and delivered to residents on a cloth-covered tray. Recognizing that presentation is almost as important as taste, Hawatmeh taught the cooks how to garnish plates with parsley, fruit, and other items to make the meals more appetizing.</div> <div> </div> <div>After ironing out a few glitches, the new system now runs smoothly and efficiently, Hawatmeh reports. </div> <div> </div> <div>More importantly, residents are happy with the new options and delicious food. A minimum of three to four entrees are served each day, in addition to standard items such as pizza, grilled panini sandwiches, homemade soups, and chili. “All of our soups are homemade,” says Hawatmeh, “as are most of the desserts.” </div> <div> </div> <div>He also serves some upscale dishes on special occasions. For example, he served lobster bisque, shrimp cocktail,  and filet mignon for Valentine’s Day. </div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">Mixing It Up</h3> <div>Like MediLodge, nursing centers run by Genesis HealthCare, Kennett Square, Pa., have taken on similar changes, such as new flooring, curtains, and homelike décor, in addition to decentralizing their dining programs.</div> <div> </div> <div>As part of a companywide adoption of culture change that began several years ago, nursing centers were given the green light to embrace trayless dining programs as well as other initiatives that have reportedly had a dramatic impact on residents’ quality of life.</div> <div> </div> <div>As a result, most centers have tossed the trays in favor of utilizing steam tables in the dining room; preparing and cooking meals outside the kitchen, where residents can see cooks work; and hiring chefs to create palette-</div> <div>pleasing selections. </div> <div> </div> <div><img width="720" height="480" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/0810/coverstory15.jpg" alt="" style="margin:10px 15px;width:320px;height:213px;" />“In a traditional model, you prepare the food, put it on a tray, put it on food carts, and send them down the halls,” says David Almquist, Genesis’ regional executive vice president. “Our goal is to take the food out to the patient, and whether it’s a café or whether it’s a place that does strictly trayless dining and serves all the food right there in the dining rooms, we wanted to create environments that are different.”</div> <div> </div> <div>Genesis did not dictate a model for its centers to follow; rather, they were free to make the changes at their own discretion. The result is a variety of programs that reflect the individual needs of the centers. Some have built cafes and remodeled their dining rooms, while others have created a tableside service that enables residents to sit at tables and socialize while staff wait on them.</div> <div> </div> <div>Another key component of Genesis’ dining transformation has been the hiring of culinary-trained chefs. “We felt like being culinary trained, knowing how to prepare and use fresh ingredients, would improve the quality of the food,” says Almquist. Ninety-nine culinary-trained chefs have been hired to serve 74 Genesis centers in 13 states. The company now boasts a total of 144 chef managers.</div> <h3 class="ms-rteElement-H3">Everything But The Kitchen</h3> <div>Hammonds Lane nursing center in Brooklyn Park, Md., opened its newly renovated dining room about eight months ago. The modifications began with the idea that kitchen staff and food preparation should not be hidden away inside the kitchen walls.  </div> <div> </div> <div>“We all agreed that everyone would be better served to get the kitchen staff out from behind the doors,” says Bill Tian, Genesis’ southern area director for food and nutrition.  </div> <div> </div> <div>One of many positive outcomes of Hammonds’ efforts is that residents and dining staff members have developed relationships that could not have been possible before. “It has changed the role of staff from being in the kitchen and now are outside interacting with residents and asking them what they want,” says Tian.</div> <div> </div> <div>Meals are served in a restaurant-style manner, with staff taking orders from residents, who choose from a generous menu of dishes that could rival a five-star restaurant. </div> <div> </div> <div>Hammonds’ menus change daily, but standard options such as sandwiches and soup are always available. Breakfast, which runs from 7:00 a.m. to 11:00 a.m., is made to order. “Residents can have whatever they want for breakfast: waffles, pancakes, omelets, or eggs sunny side up or poached,” says Tian. </div> <div> </div> <div>The move to the dining room from the kitchen was made smoother with the purchase of matching culinary uniforms for the dining staff. “It made a tremendous difference,” says Chuck Diffenderffer, Genesis’ southern area executive chef for food and nutrition. “It really brought them out as a team.”</div> <div> </div> <div>Tian says there is an additional benefit of the new system—meals in the dining rooms take no longer to turn around than the previously noisy and chaotic tray system did. Residents are happy with the change as well. “We have thousands of people coming to breakfast now across our southern region,” says Tian. </div> <div> </div> <div>The residents’ satisfaction is also reflected in the facility’s positive clinical outcomes: Weight at Hammonds has stabilized, “and it’s getting people moving around, which helps reduce pressure sores,” Tian says. </div> <div> </div> <div>Staff are also buying lunch and dinner at the facility, another bonus that has brought in additional revenue. Before the change, says Tian, staff were not interested in staying in for lunch. </div> <div> </div> <div>What’s more, the surveyors are happier and less focused on food service F-tags, while survey outcomes are consistently good.</div> <h3 class="ms-rteElement-H3">Fine Dining On A Dime</h3> <div>Beaumont Rehabilitation and Skilled Nursing Center in Northbridge, Mass., took a simpler, less expensive approach to altering its dining program, says Darrold Endres, the center’s food service director. “We got rid of all trays, and it’s now as near to restaurant style as a nursing home can get,” he says. </div> <div> </div> <div>Some areas around the central dining room were also remodeled to improve the work flow. Endres rolled the steam carts from the kitchen to the edge of the dining spaces, where staff now plate the meals as residents select them.</div> <div> </div> <div>The menu was expanded, and the dining room tables are now decorated with tablecloths, silverware, and china, while residents enjoy calming music as they dine.</div> <div> </div> <div>Endres notes that he and another staff member designed “from scratch” new clothing protectors, formerly referred to as bibs, and hired a tailor to make them. “The protectors were made with a high-quality cloth,” he says, adding that they resemble “something you would tuck into your shirt at a high-class restaurant.”</div> <div> </div> <div>“There’s a certain elegance to things,” he says. </div> <div> </div> <div>Another plus is the fact that the facility’s budget has remained virtually unchanged. “We did not have to change or advance our budget by much at all,” he says. </div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">Making It Work</h3> <div>Among the challenges for Endres was fitting all the pieces together. “To organize all the people, times, transportation, change rooms, and breakdown tables and making sure that it all goes smoothly was the biggest challenge.”</div> <div> </div> <div>Residents dine in seven different places, which makes the system somewhat complicated. Adding to the intricate process are meals that are individually tailored to <a href="/Issues/2010/Pages/0810/Dining-With-Dignity-For-Alzheimer%27s-Patients.aspx">meet the needs of residents with Alzheimer’s</a>.</div> <div>Endres says his food service contractor, Newton, Mass.-based Unidine, was instrumental in helping him transition to the new program. “Unidine helped us prepare the food items, menus, and orchestrate the system to make it flow well,” he says.</div> <div> </div> <div><img width="228" height="399" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0810/coverstory17.jpg" alt="" style="margin:5px 15px;width:263px;height:175px;" />Food service vendors are a common presence in the health care industry. Menus, meal preparation, and dining management are integral to a facility’s operation, and vendors offer a range of services that help the buildings run smoothly and free up time to focus on other tasks. </div> <div> </div> <div>The new dining trend has sparked some innovative responses from vendors, many of whom now offer consulting services, technical assistance, and fresh foods and ingredients that have never before been in the vernacular of health care facility food service. </div> <div> </div> <div>Cura Hospitality, a food service and consulting company based in Orefield, Pa., assisted Presbyterian Village at Hollidaysburg, a continuing care retirement community in Pennsylvania, in decentralizing its dining program about two years ago. A renovation of the campus included the construction of two additional kitchens in order to serve the different levels of care within the community, says Deb Larkin, director of food service at Hollidaysburg.</div> <div> </div> <div>The installation of country kitchens—a kitchen that opens up to the dining area—in the assisted living and skilled nursing levels “allows residents to see and smell the cooking as it happens,” she says. </div> <div> </div> <div>Also new are two dining rooms. Larkin says the company changed the dining style entirely and had staff trained in ServSafe, a food service safety training program. </div> <div> </div> <div>“Residents come in and dine whenever they choose,” says Larkin. “They can either seat themselves or a staff member will seat them. They are given a menu, which includes the special features for the day and the standard items available every day.”</div> <div> </div> <div>As she began procuring new items such as china and silverware for the dining rooms, Larkin also enlisted the residents’ help. “We had them sample the china and silverware to see how they held it, if it worked for them,” she says. </div> <div> </div> <div>The community purchased red Fiesta Dinnerware because it stimulates appetite and blue plates so that residents with visual impairments could better see the food. </div> <h3 class="ms-rteElement-H3">Pilot Offers Useful Advice</h3> <div>Culture change advocates in the state of California have been on board with resident-centered approaches to dining since 2007. Eager to test some models in a pilot project, a coalition that includes the California Association of Health Facilities (CAHF) and the California Culture Change Coalition theorized that motivating providers to alter their dining programs to more resident-centered approaches would promote the adoption of additional culture change initiatives within facilities.</div> <div> </div> <div>Jocelyn Montgomery, director of education for CAHF, was able to convince CMS’ Region IX to back a Culture Change Dining Pilot, which launched in February 2008. The 11 participating facilities were asked to adopt at least one of the following dining practices: restaurant-style, buffet-style, or an expanded snack program. </div> <div> </div> <div>At the conclusion of the pilot, which ran for eight months, the coalition released a guide, “The Person-Directed Dining Package,” which contains information about the pilot, a list of participants, and sample policies and forms. </div> <div> </div> <div>Plum Healthcare’s White Blossom Care Center in San Jose participated in the pilot and took on buffet-style dining. According to a summary of the facilities’ experiences, White Blossom’s installation of buffet dining improved residents’ socialization, encouraged them to participate in other activities, and stabilized their weight. </div> <div> </div> <div>Among the lessons learned: Teamwork is essential to setting up and cooking the meals, and support from the administrator and the director of nursing was imperative to getting the program off the ground.</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">Lessons Learned </h3> <div>As word has spread about the success of MediLodge’s buffet- and room service-style programs, Hawatmeh has been asked to speak to facilities and organizations in Michigan and surrounding states about his experience. </div> <div> </div> <div>State surveyors are also interested in what Hawatmeh has to say. Since he launched the dining program, he has presented at several of Michigan’s joint surveyor/provider training sessions. </div> <div> </div> <div>Some of Hawatmeh’s take-home <a href="/Issues/2010/Pages/0810/Dining-Interventions-Factors-To-Consider-Before-Making-A-Change.aspx">advice about making the transformation </a>is aimed at getting providers to understand that residents need to have greater control over their mealtime choices; they should be offered a variety of appetizing, nutritional food choices; and they should be given an enjoyable, upscale dining experience. </div> <div> </div> <div>Hawatmeh also emphasizes that excellent customer service is vital to the success of this program, just as it is to any business. He recommends listening to residents, quickly responding to any complaints, and training staff on the program’s importance. </div> <div> </div> <div>One testimonial about his program speaks to the importance of pleasing the residents: “The new dining program brought back the glamour of the resident’s younger days.” </div> <div> </div>Providers find that dining choices and flexibility lead to resident satisfaction and better outcomes.2010-08-01T04:00:00Z<img alt="" src="/Issues/2010/PublishingImages/0810/dining_thumb.jpg" style="BORDER:0px solid;" />Management;Quality Improvement;Culture ChangeColumn8
MDS 3.0: Setting The Stagehttps://www.providermagazine.com/Issues/2010/Pages/0810/MDS-3-0-Setting-The-Stage.aspxMDS 3.0: Setting The Stage<div>​What do quality care plans, purposeful assessments, accurate reimbursement, positive survey results, good public relations, and good quality measures have in common? The answer: a well developed and interdisciplinary approach to the minimum data set (MDS). It’s undeniable. MDS has become the backbone of the long term care industry. </div> <div> </div> <div>As such, a successful transition from 2.0 to 3.0 is mission critical. However, the word “transition” cannot be misconstrued. MDS 3.0 is not a revision of MDS 2.0. In fact, MDS 3.0 takes a radically different approach to resident assessments with extensive philosophical and practical changes. </div> <h3 class="ms-rteElement-H3">Backbone Of Long Term Care</h3> <div>MDS is the catalyst to ensure an accurate, thorough, and interdisciplinary approach to resident assessments for the purpose of improving care plans and delivering the best possible quality of care to every resident. However, the data collected through MDS have proven increasingly valuable for a number of other purposes throughout the long term care arena. </div> <div> </div> <div>Today, the majority of revenue for almost any long term care provider is driven by acuity level as captured through MDS. Prospective residents and family members examine publicly available quality measures that are derived from the MDS on the Centers for Medicare & Medicaid Services’ (CMS’) Five-Star Quality Rating System and Nursing Home Compare. </div> <div> </div> <div>The transition to MDS 3.0 presents the perfect opportunity to reexamine not just the resident assessment process, but also the organizational structure and culture as it relates to the significance of the MDS and a commitment to excellence. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0810/MDS-3-0-Significant-Changes.aspx">HERE</a> for a list of the significant changes found in the MS 3.0 and tips on how providers should prepare for the transition.</div> <h3 class="ms-rteElement-H3">More Than A Transition</h3> <div>MDS 3.0 represents a major shift in assessment philosophy from an observational approach to a focus on resident-directed care. One method MDS 3.0 uses to achieve this construct is through the required use of scripted interviews that incorporate the resident’s own voice into the assessment. Clinicians are required to interview each resident to assess cognition, mood, pain, goals, and preferences. </div> <div> </div> <div>Almost every section of MDS is altered from 2.0, affecting all interdisciplinary team members who contribute to the assessment process. </div> <div> </div> <div>Beyond changes to the assessment process itself, this transition will also eliminate access to CMS’ MDS-based outcomes measures—the quality measures and quality indicators—that so many care providers rely on for quality monitoring and improvement. </div> <div> </div> <div>In fact, CMS estimates that it may take one year before 3.0 measures and reports will be available. </div> <div>That is why it is critical for leaders to recognize its significance and take a holistic approach that considers organizational structure, processes, and outcomes. </div> <div> </div> <div>A successful transition needs to be orchestrated from the very top of the organization and driven by an interdisciplinary transition team that includes the facility administrator, director of nursing, dietitians, and the MDS coordinator, as well as representatives from therapy, social services, nursing, and the business office. </div> <h3 class="ms-rteElement-H3">Opportunity To Rebuild</h3> <div>A successful transition team will understand the key role MDS plays in terms of a facility’s overall success and approach this project as an opportunity to rebuild the function internally. From a leadership perspective, this will require a broad look at the organizational structure, job descriptions, and chain of command to ensure that this transition team has the resources, access, and, most importantly, the authority to build a foundation for success.</div> <div> </div> <div>To delineate responsibility for the implementation plan, consider creating teams for each MDS section. Each section team will document the current MDS assessment process, learn the MDS 3.0 requirements, and create a road map from 2.0 to the new 3.0 environment. Ultimately, this road map becomes the written action plan with detailed steps, accountability, and time frames for completion. </div> <div> </div> <div>To get started, have section teams examine current source documents, tracking sheets, and notes used for MDS 2.0 to make sure they align properly with 3.0. Keep in mind that data-capture tools and strategies in place for meeting 2.0 requirements may not work in 3.0, and review all the data-capture tools carefully. Section teams will also present recommendations for possible resource reallocation and training needs. </div> <div> </div> <div>During the implementation process, each section team should also recommend the appropriate MDS section facilitator. Ultimately, it is a section facilitator’s job to make sure that the assigned MDS section is completed accurately and in a timely manner. Facilitators are also responsible for ensuring multidisciplinary input. Too often, MDS access and input are limited to very few staff members, resulting in discipline silos where one person or discipline is “owner” of a section. </div> <div> </div> <div>These silos produce resident assessments that are incomplete and less reflective of the resident’s actual status. For example, through conversation or observation, a social worker may obtain valuable input from the resident regarding pain or incontinence yet might be untrained in terms of presenting that input during MDS assessment or care plan meetings. This transition is an ideal opportunity to educate and train all caretakers on how to contribute their observations into the MDS assessment and improve the collaborative nature of care plan meetings. </div> <h3 class="ms-rteElement-H3">Develop Interview Skills</h3> <div>Retraining will prove essential. At a minimum, two disciplines should be trained on each assessment section. Also, the development of new tools such as scripted interviews allows facilities to look beyond those currently responsible for assessing certain areas. </div> <div> </div> <div>For example, while social services may be the traditional assessor for the mood section, access to scripted interview tools allows a facility to revisit this practice and consider other alternatives, and certainly more than one. </div> <div> </div> <div>In any case, those selected to perform the interviews must be proficient and comfortable in that role. Accordingly, consider using resident council volunteers to help develop interview skills through mock interviews. </div> <div>Plan now for potential obstacles, such as access to appropriate interview locations, how interviews will be scheduled into daily routines, and language barriers between staff and residents. Remember, interpreters are required when they are needed.</div> <div> </div> <div>Beyond clinical resident assessments, the changeover to MDS 3.0 will have considerable impact on resident care planning, reimbursement, professional/general liability, public perception, and employee satisfaction. </div> <div>While health care professionals have been down this road before, the key question is: “Are we doomed to repeat past mistakes, or will we use past experiences to master this impending challenge?” The answer is that with proper planning and effective leadership, every facility has the opportunity to implement MDS 3.0 with confidence and assurance of success. </div> <div> </div> <div><em>Steven Littlehale, MS, GCNS-BC, is executive vice president and chief clinical officer, and Sheila Capitosti, RN-BC, NHA, MHSA, is senior health care specialist, at Lexington, Mass.-based PointRight, a company that provides information-based clinical management tools and services to providers, payers, regulators, suppliers, and consumers. For more information, call (781) 457-5900 or visit <a href="http://www.pointright.com/">www.pointright.com</a>. </em></div>Experts advise providers to consider organizational structure, processes, and outcomes as they transition from 2.0 to 3.0. 2010-08-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Management;ReimbursementColumn8

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Take Flight With Patient Safety In Nursing Facilitieshttps://www.providermagazine.com/Issues/2010/Pages/0910/Take-Flight-With-Patient-Safety-In-Nursing-Facilities.aspxTake Flight With Patient Safety In Nursing Facilities<p>​Medical errors have received increased scrutiny in recent years. In 1999, the Institute of Medicine (IOM) report, “To Err is Human,” found that medical errors were calculated to be the fifth-leading cause of death in the United States. Such errors are the cause of at least 98,000 deaths per year, according to IOM. But keep in mind that these numbers are estimates; no one knows how many errors go unrecognized or are simply not reported.</p> <p>John Nance, MD, author of “Why Hospitals Should Fly: The Ultimate Flight Plan To Patient Safety and Quality Care,” believes that the culture of health care is unsafe and incredibly dysfunctional. </p> <p>“Though the culture of each health care organization is unique, they all suffer many of the same disabilities that have so far effectively stymied progress, including an authoritarian structure that devalues many workers, a lack of a sense of personal accountability, autonomous functioning, and major barriers to effective communication,” Nance says in his book. </p> <h3 class="ms-rteElement-H3"><div><strong>Communication Emphasized</strong></div></h3> <div>The Joint Commission has deemed communication as the biggest root cause issue in patient safety. Health care operates in fragmented, silo-type facilities, which makes communication among a large team of caregivers complicated and bound to result in errors. </div> <div> </div> <div>Medical errors are driven by issues similar to those that used to plague aviation. When properly applied, an aviation error reduction concept known as Crew Resource Management (CRM) provides an excellent approach that has a direct impact on patient safety in long term and post-acute care settings.</div> <div> </div> <div>Much like aviation, medical care depends on a process being carried out by individuals with highly specialized expertise, each with distinct decision-making responsibility. Many accidents in these environments are not driven so much by errors made within any specific area of expertise, but rather breakdowns in communication or hand-offs that lead to a series of events resulting in extended hospital stays—or, worse yet, fatalities. </div> <div> </div> <div>CRM was originally developed to enhance the safety of air transport and has been adopted by air carriers worldwide. </div> <div> </div> <div>CRM began in 1979 during a National Aeronautics and Space Administration (NASA) workshop and is now a mandated requirement for most commercial pilots. NASA research found that the primary cause of most aviation accidents was human error and that many of the major problems were failures of interpersonal communication, leadership, and decision making in the cockpit.</div> <div> </div> <div>The track record of aviation safety, especially since the rigorous introduction of CRM, speaks for itself with regard to the success of this innovative methodology. </div> <h3 class="ms-rteElement-H3"><div><strong>Research Mounts</strong></div></h3> <div>Further evidence of CRM’s efficacy can be found in research results that show clinical error rates in hospitals were reduced from 30 percent to 4.4 percent (Marion, G., 2004) adverse outcomes were cut by 53 percent (Morey, J., 2002) and observed errors dropped 55 percent (“Beyond Blame: Solutions to America’s Other Drug Problem: [DVD], Solana Beach. Calif.: Bridge Medical; 1997).</div> <div> </div> <div>The Healthcare Excellence Institute puts it this way: “Imagine if the deaths due to medical errors were translated into aviation scenarios. The reported number of deaths due to medical errors in this country alone is at least 98,000 per year. In aviation terms, this rate would be equal to the fatal crashes of two fully loaded Boeing 737 airliners every day of the year. Certainly, that kind of safety record would trigger action on part of the traveling community, the aviation community, and lawmakers.”</div> <div> </div> <div>Aviation refuses to allow for such errors as this, yet health care error rates remain high. It is no wonder that regulatory bodies have incorporated the patient safety aspect as their No. 1 priority. </div> <div> </div> <div>CRM is part of a broader strategy of building stronger teams, clarifying roles, and empowering both leaders and team members to raise safety concerns. The goal is to prevent work overload situations that compromise awareness that could lead to errors. CRM includes clear guidelines for how to delegate, how to build strong and cohesive teams, and how to conduct a formal debriefing. </div> <div> </div> <div>The following strategies are utilized during the CRM process: standardized communications, team briefings, team debriefings,<a href="/Issues/2010/Pages/0910/Situational-Awareness.aspx"> situational awareness</a>, decision making, leadership strategies, effective teamwork, and critical language vocabulary and usage.</div> <div> </div> <div>CRM improves patient safety on three distinct levels: Error avoidance, error trapping, and error mitigation.</div> <h3 class="ms-rteElement-H3"><div><strong>Training Pinpoints Problems</strong></div></h3> <div>Training for CRM teaches participants to identify potentially dangerous patterns and then teaches behavior and communication patterns that address these situations in a nonconfrontational way. </div> <div> </div> <div>For example, participants are taught a required communication pattern that can be used in the case of “outranking,” which can sometimes jeopardize patient safety.</div> <div> </div> <div>An example of outranking in health care is the all-knowing surgeon who barks orders and nurses follow without question. Historically, outranking has been an issue in aviation, and currently it is a reality in many health care </div> <div>organizations. </div> <div> </div> <div>CRM is concerned not so much with the technical knowledge and skills required to operate equipment, but rather with the cognitive and interpersonal skills needed to effectively manage a team-based, high-risk activity. </div> <div>In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, solving problems, and making decisions. </div> <div> </div> <div>CRM fosters a climate or culture where the freedom to respectfully question authority is encouraged. It recognizes that a discrepancy between what is happening and what should be happening is often the first indicator that an error is occurring. </div> <h3 class="ms-rteElement-H3"><div><strong>Systemized Communication</strong></div></h3> <div>Questioning authority is a delicate subject for many organizations, especially ones with traditional hierarchies, so appropriate communication techniques must be taught to supervisors and their subordinates so that supervisors understand that the questioning of authority need not be threatening and subordinates understand the correct way to question orders. </div> <div> </div> <div>Such skills, while seeming like common sense, are difficult to master as they require a change in interpersonal dynamics and organizational culture of a company.</div> <div> </div> <div>Through a blended and systematized approach, including education, practical skill development, and interdisciplinary simulation, research has shown that CRM skills can be successfully embedded within a high-risk department or organization.</div> <h3 class="ms-rteElement-H3"><div><strong>A Practical Approach</strong></div></h3> <div>One key component of CRM is SBAR, or Situation Background Assessment Recommendation, an approach that provides health care facilities with a practical and easy-to-implement solution providers can use to streamline communication.</div> <div> </div> <div>Through a standardized approach to patient reporting during shift changes or patient transfers, such as when a resident is transferred from the nursing facility to the hospital, SBAR encourages concise, factual communication among clinicians, including nurse-to-nurse, doctor-to-doctor, or between nurse and doctor communications.</div> <div> </div> <div>As Nance says, health care organizations will truly fly when “this is the way we have always done it” is finally recognized as the way it should never be done again</div> <p> </p> <p><em>Kathleen Martin, RN, a licensed nursing home administrator and certified professional in health quality, is chief clinical executive with Philadelphia-based Hospicomm, New Jersey facilities, with a predominant role in patient safety initiatives. She is also a Malcolm Baldrige Health Care Quality board member and American Health Care Association/National Center for Assisted Living Gold Award examiner. She can be reached at <a href="mailto:martgatt@yahoo.com">martgatt@yahoo.com</a>.  </em> </p>A medical error-reduction concept borrowed from aviation is ripe for application in long term and post-acute care.2010-09-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/nurses_6.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;Quality;Quality ImprovementFocus on Caregiving9
Get Ready For MDS 3.0https://www.providermagazine.com/Issues/2010/Pages/0910/Get-Ready-For-MDS-3-0.aspxGet Ready For MDS 3.0<p>In order to maintain the financial resources necessary to provide ongoing quality care, it is essential for every facility to take action. </p> <h3 class="ms-rteElement-H3"><strong>Unprecedented Change </strong></h3> <div>Over the past decade, long term care facilities have demonstrated tremendous proficiency in dealing with change and adapting to new regulations. From PPS and MDS to all the other quality initiatives in between, it’s been a decade of constant change and tremendous progress. What’s unique about this transition is the reality that both MDS 3.0 and RUG-IV are being implemented at the same time. Although RUG-IV was officially delayed by Congress for one year (to Oct. 1, 2011), there is not enough time for CMS to act on it, so beginning Oct. 1, 2010, payments will be made using the RUG-IV system until such time as a Hybrid RUG-III (HR-III) can be developed. At that time, the Centers for Medicare & Medicaid Services (CMS) will determine a method for adjusting payments using the HR-III grouper.</div> <div> </div> <div>Together, these systems are the backbone of the long term care industry, with far-reaching implications from resident care to reimbursement. That said, it is important to invest the time and resources on the front end to anticipate and minimize potential transition problems. <br><br>RUG-IV and MDS 3.0 will introduce pervasive change for all providers of therapy services in skilled nursing facilities. Of primary significance, given its potential impact on reimbursement, is the provision of concurrent therapy. All things being equal, facilities that aggressively use a concurrent therapy model are likely to experience a negative impact on total reimbursement after transitioning to RUG-IV.</div> <div> </div> <div>Under RUG-III, a facility could realize two, three, or even four or more hours of revenue-generating treatment time for every one hour that a therapist physically treated a resident. However, this is no longer the case under RUG-IV, as CMS’ Staff Time and Resource Intensity Verification study determined that individual and concurrent therapy sessions are not equally resource intensive. To accommodate this change in reimbursement, MDS 3.0 will require the collection and reporting of individual therapy minutes separately from concurrent therapy and group minutes.</div> <h3 class="ms-rteElement-H3"><strong>Concurrent Versus Group Therapy</strong></h3> <p>As defined by CMS, concurrent therapy is the practice of one professional therapist treating multiple patients at the same time while the residents are performing different activities. After Oct.1, 2010, concurrent therapy will be limited to no more than two residents per therapist, and the RUG-IV category will be based on “adjusted” concurrent therapy minutes. </p> <div>In the skilled nursing facility Medicare Part A setting, concurrent therapy is distinct from group therapy, where one therapist provides the same or similar services to everyone in the group. </div> <div> </div> <div>Part A defines a group as two to four residents, regardless of payer source, who are performing the same activity for a therapist who is not supervising any other individuals. Group therapy is limited to 25 percent of total therapy hours.</div> <div> </div> <div>It is important to understand that while total individual, concurrent, and group therapy minutes will still be recorded on the MDS, those minutes will be adjusted before determining the applicable RUG-IV score for the resident. Providers do not need to burden themselves with the math in RUG-IV as the software will perform the calculation based on allowed minutes.</div> <div> </div> <div>Beyond the obvious challenges of maintaining adequate reimbursement and managing facility-wide resistance to change, this transition is likely to create logistical challenges as well. Assuming the same total minutes of therapy are still required after Oct. 1, 2010, meeting that demand will require more therapist hours and, possibly, more therapists. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0910/Renewed-Demand-For-Therapists.aspx">HERE </a>for more information about what providers should do to assess, and possibly beef up, their therapy staffing levels.</div> <div> </div> <div>Other changes related to therapy include the elimination of Section T, which allowed for the projection of therapy minutes. Under RUG-IV, only therapy minutes actually provided can be used to establish a RUG-level assignment. </div> <div> </div> <div>Also new is the addition of a Start of Therapy OMRA (Other Medicare Required Assessment), which allows for capture of a rehab RUG group on the first day of therapy. Under RUG-III, the facility would continue with the non-rehab RUG until the next scheduled assessment.</div> <div> </div> <div>Medicare Short Stay Assessments have been added to allow capture of a rehab RUG group for those residents with a length of stay of seven days or less, and changes were made in the assessment reference date for an End of Therapy OMRA. No longer will facilities wait eight to 10 days after therapy to set the Assessment Reference Date (ARD) of the OMRA. </div> <div> </div> <div>In MDS 3.0, the ARD of the End of Therapy OMRA must be set one to three days after all therapies are discontinued. This change results in a closer alignment of payment for services on dates received.</div> <h3 class="ms-rteElement-H3"><strong>Additional MDS Changes</strong></h3> <div>Under the current system, facilities are allowed to “look back” to the acute setting for data on probable acuity, like intravenous medications or fluids, to capture a higher-paying RUG score. With RUG-IV, this look-back provision is modified, except parenteral IV and tube feedings coded in Section K (with a look-back period of seven days). </div> <div> </div> <div>The modified look-back period for Special Treatments, Procedures, and Programs coded in Section O on the MDS 3.0 remains 14 days but limits the collection of data for items A through Z in column 1, “While NOT a Resident,” and column 2, “While a Resident.” </div> <div> </div> <div>Furthermore, intravenous medications and fluids will no longer function as qualifiers for extensive services. Instead, extensive service qualifiers will be limited to ventilator care, tracheotomy care, and infectious disease isolation.</div> <div> </div> <div>The overall goal of revisions to the RUG system is to place residents with like “resource utilization needs” into the same payment group. RUG-IV will be based on eight major classification categories and 66 different payment groups with redefined “inclusion” definitions. Grouping is based on provided therapy minutes and specific conditions or services further classified by splits for ADLs, indications of depression, and restorative nursing services. </div> <div> </div> <div>While the same four late-loss ADLs of mobility, transfer, eating, and toileting use are still measured, the point values are rebased (the base year was changed for the structure of costs), and a new code for eating support was added.</div> <div> </div> <div>Under RUG-III, the point index for ADLs ranged from four to 18, and the point system for RUG-IV will range from zero to 16, which increases the sensitivity of this tool. </div> <h3 class="ms-rteElement-H3"><strong>Learn The System</strong></h3> <div>To align for success, clinical reimbursement managers must learn the new RUG 66 system and understand the realignment of clinical criteria. </div> <div> </div> <div>From a leadership perspective, it is also important to formulate a prediction of future reimbursement under RUG-IV to act as a baseline from which to measure performance after Oct. 1, 2010. </div> <div> </div> <div>Predictions can be formulated by looking at key variables and how they will affect future reimbursement. </div> <div> </div> <div>This fast-approaching transition promises to deliver the greatest challenge ever faced by today’s long term care leadership. Given the magnitude of this change, success will depend on the unfailing support of every manager and every staff person. As such, it’s time to build unity by pulling interdisciplinary teams together, ensuring communication systems, and patching any cracks in the system.</div> <div> </div> <div>When Oct. 1, 2010, arrives, facilities that have implemented effective operational strategies, educated their staff accordingly, and empowered them to communicate openly with management will be rewarded for their efforts and foresight. </div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0910/Strategies-For-Success.aspx">HERE</a> for more strategies for a successful to MDS 3.0.</div> <div> </div> <div><em>Nancy Augustine, RN, MSN, NHA, Sheila Capitosti, RN-BC, NHA, MHSA, and Cheryl Field, RN, MSN, CRRN, are senior health care specialists at PointRight, based in Lexington, Mass., a company committed to improving the quality of care in long term and post-acute care settings by providing information-based clinical management tools and services to providers, payers, regulators, suppliers, and consumers. For more information, please call (781) 457-5900 or go to www.pointright.com.   </em></div>The new MDS and RUG-IV systems will have a dramatic impact on providers and reimbursement.2010-09-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Management;ReimbursementColumn9
Specialty Services In Nursing Homes: A Crucial Component Of Quality Carehttps://www.providermagazine.com/Issues/2010/Pages/0910/Nursing-Home-Specialty-Services-A-Crucial-Component-Of-Quality-Care.aspxSpecialty Services In Nursing Homes: A Crucial Component Of Quality Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>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. </p> <div><h3 class="ms-rteElement-H3"><strong>Seeking Help</strong></h3></div> <div>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.</div> <div> </div> <div>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.</div> <div>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.</div> <h3 class="ms-rteElement-H3"><div><strong>Finding A Dentist</strong></div></h3> <div>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.</div> <div> </div> <div>“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.</div> <div> </div> <div>But after nine teeth were pulled and the remaining teeth were cleaned, all of those mysterious health problems ceased, as did the behavioral symptoms. </div> <div> </div> <div>“If it hurts and you can’t tell them it hurts, you do act out,” says Knutson.<img width="252" height="781" class="ms-rtePosition-2 ms-rteImage-0" src="/Issues/2010/PublishingImages/0910/coverstory1.jpg" alt="" style="margin:15px;width:158px;height:237px;" /><br><br>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.</div> <div> </div> <div>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. </div> <div> </div> <div>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.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div><h3 class="ms-rteElement-H3"><strong>Specialty Services Critical</strong></h3></div> <div>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. </div> <div>Other medical specialty services, too, like podiatry, vision, and hearing services, can have a huge impact on residents’ health and quality of life. </div> <div> </div> <div>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.</div> <div> </div> <div>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.</div> <div> </div> <div>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.</div> <div> </div> <div>Click <a href="/Issues/2010/Pages/0910/Locating-Specialists.aspx">HERE</a> for information about finding location dental, optometry, or podiatry services.</div> <h3 class="ms-rteElement-H3"><div><strong>Hearing Services</strong></div></h3> <div>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 <a href="/Issues/2010/Pages/0910/Audiologists-Provide-More-Than-Just-Hearing-Aids.aspx">certified geriatric audiologist </a>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.</div> <div> </div> <div>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.</div> <div> </div> <div>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.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><div><strong>Optical Care</strong></div></h3> <div>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.</div> <div> </div> <div>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.</div> <div> </div> <div>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.”</div> <div> </div> <div>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.</div> <div> </div> <div>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.</div> <h3 class="ms-rteElement-H3"><div><strong>Foot Problems</strong></div></h3> <div>When Kirk Geter, chief of podiatry at Howard University’s College of Medicine in Washington, D.C., first started providing <a href="/Issues/2010/Pages/0910/Preventing-Foot-Problems.aspx">podiatry services at LTC facilities</a>, 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.</div> <div> </div> <div>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.</div> <div> </div> <div>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.</div> <h3 class="ms-rteElement-H3"><div><strong>Dental Care</strong></div></h3> <div>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.</div> <div> </div> <div><img width="338" height="453" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/0910/coverstory2.jpg" alt="" style="margin:10px 15px;width:253px;height:169px;" />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. </div> <div> </div> <div>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.</div> <div> </div> <div>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<a href="/Issues/2010/Pages/0910/Dental-Health-A-Priority-In-Kansas.aspx"> daily oral health care from certified nurse assistants </a>(CNAs), who spent an average of 16.2 seconds providing that care.</div> <div> </div> <div>“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.”</div> <h3 class="ms-rteElement-H3"><div><strong>The Apple Tree Experience</strong></div></h3> <div>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. </div> <div> </div> <div>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. </div> <div> </div> <div>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. </div> <div> </div> <div>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.</div> <div> </div> <div>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.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><div><strong>Specialty Care Underfunded</strong></div></h3> <div>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.”</div> <div> </div> <div>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.</div> <div> </div> <div>“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?</div> <div> </div> <div>“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.</div> <div> </div> <div>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. </div> <div> </div> <div>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.”</div> <div> </div> <div>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.</div> <h3 class="ms-rteElement-H3"><div><strong>Paying For The Service</strong></div></h3> <div>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. </div> <div> </div> <div>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.</div> <div> </div> <div>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.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div><h3 class="ms-rteElement-H3"><strong>A Success Story</strong></h3></div> <div>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.</div> <div>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.</div> <div> </div> <div>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.</div> <div>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.</div> <div> </div> <div>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. </div> <div>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.</div> <div> </div> <div>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.”</div> <h3 class="ms-rteElement-H3"><div><strong>Recruiting For Resources</strong></div></h3> <div>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.</div> <div> </div> <div>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. </div> <div> </div> <div>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.</div> <div> </div> <div>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.</div> <div> </div> <div>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.</div> <div> </div> <div>“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?’”</div> <h3 class="ms-rteElement-H3"><div><strong>Benefits Are Many</strong></div></h3> <div>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. </div> <div>“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.” </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Manassas, Va.</em>​ </div>Providers are starting to look at offering on-site specialty services.2010-09-01T04:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/0910/coverstory1.jpg" width="100" style="BORDER:0px solid;" />Caregiving;Clinical;Quality;Quality ImprovementColumn9
Resumes: Read Between The Lineshttps://www.providermagazine.com/Issues/2010/Pages/0910/Resumes-Read-Between-The-Lines-.aspxResumes: Read Between The Lines<p>​When it comes to resumes, applicants are typically judged by their cover. Why? A resume is a glance at someone’s track record, a window to one’s career and decision-making abilities, and, ultimately, it is the first impression made about an applicant’s entire professional life. </p><p>The implication of a bad resume is that if someone does not have an outstanding one, then what kind of employee will he or she be? This may not be fair, but perception is typically equated with reality. </p><p>For employers to compete effectively in the long term and post-acute care industries and provide the highest quality care to residents and patients, they need to hire the very best people. Knowing what to look for in a resume is essential to the hiring process. Consider the following fact: The average employer initially spends about 15 seconds reviewing a resume. <br></p> <div>Indeed, this is quite sobering, but it means that many employers miss out on hiring great candidates. Most employers evaluate a resume based on antiquated models or human resource guidelines without taking into consideration a number of factors based on a new generation of health care employees in an ever-changing landscape of the human dynamic. </div> <h3 class="ms-rteElement-H3"><div><strong>Duration Not Critical</strong></div></h3> <div>There has been a dramatic shift in the health care workforce in the 21st century, and suffice it to say that employers need to adjust how they review resumes and adapt to these changes if they want to hire the best applicants. </div> <div> </div> <div>Times have changed dramatically from the previous generation’s workforce regarding an employee’s length of stay. Gone are the days when someone stays at one company for an entire career. The Internet has changed everything. It is much easier now to find out about new job openings and to research companies. Depending on the position, in long term care the average length of employment at one job is less than two years—a staggering statistic. </div> <p>In fact, if someone has been at the same job for longer than 10 years, there is now the impression that this person might be considered “stale” for having had fewer career experiences and less exposure to new ideas, systems, and people. </p> <p>Moving forward, there must be a monumental shift in the conventional wisdom of how employers review and interpret resumes of prospective applicants in these settings. For health care employees, performance demands have never been more challenging. Regulations have become increasingly enforced, and there has been an enormous shift toward mergers and acquisitions. </p> <p>In many cases, employees accustomed to working in a smaller company need to adapt, change, and acquire new skills to work in larger settings. So during the first 15 seconds of reading an applicant’s resume, frequent job changes should not mean instant disqualification. </p> <div>Many jobs on a resume no longer automatically translate to instability and or lack of loyalty. In some cases, it may just mean the opposite. It could imply ambition, enthusiasm, creativity, or a yearning for growth. </div> <div>It is important to remember that the purpose of a resume is to win a job interview, not the job itself. </div> <h3 class="ms-rteElement-H3"><div><strong>Transferable Skills </strong></div></h3> <div>Does an applicant have the necessary skills or the transferable skills to do the job and be successful? Transferable skills can be extremely useful and could even create success in a way that the job had never intended to address, such as someone with hospitality experience who could bring a specific skill to assisted living or skilled nursing. </div> <div> </div> <div>For instance, a very progressive assisted living facility in Houston recently hired a new director of sales and marketing. The chosen candidate had a successful career working in sales at a local resort but lacked assisted living experience and had no health care experience at all. Fortunately, however, the hiring authority had the vision to look past this “obstacle” while examining the resume and imagined the possibilities that this person could bring to their organization.</div> <div> </div> <div>This person is now thriving and has taken the facility to full census capacity. This is becoming a very common example in the seniors housing industry.</div> <div> </div> <div>It is critical that a resume be assessed creatively and in its totality, as there may be some intangibles that do not appear on paper. One way to identify such intangibles is to simply phone an applicant and ask for clarification. </div> <div> </div> <div>A short telephone interview can be instrumental in learning more about an applicant and just might reveal an aspect that could be critical to the success of an operation. Ask situational questions to identify transferable skills.</div> <h3 class="ms-rteElement-H3"><div><strong>Talent Trumps All</strong></div></h3> <div>Another element to consider when reviewing a resume is talent. Skills can be taught, but talent is a gift. Most employers want to see quantifiable achievements on a resume, but there are times when achievement cannot be quantified. </div> <div> </div> <div>How does one measure talent such as a quick mind, leadership, or charisma? The truth is that sometimes they cannot be measured in a statistic or a number. Talent implies that someone has special know-how and a take-charge and get-the-job-done ability, a likeability factor that can inspire and empower an organization. </div> <div> </div> <div>Someone with talent may have created something special in a previous job that hadn’t existed before. </div> <div> </div> <div>For example, that director of sales and marketing referenced earlier is being considered for a sales specialist position to help train and assist other directors of sales in the organization’s other facilities. This position had not even existed before this candidate was hired. In essence, someone with talent has an aptitude to do certain things. </div> <div> </div> <div>Talent, in the sense of natural ability or giftedness, is not the same as skill, which is a learned process, and one that is enhanced or inhibited by an underlying talent. </div> <div> </div> <div>Finding talent on a resume means reviewing it with an open mind as if reading a mystery novel. Natural talent rarely shows up in conventional ways and sometimes can be detected by a phone interview.</div> <h3 class="ms-rteElement-H3"><div><strong>Education Comes In Many Forms</strong></div></h3> <div>No one can dispute the advantage of a superior education, but many applicants are eliminated because they do not fit a traditional educational model. </div> <div> </div> <div>Notwithstanding licensure and credentialing requirements such as registered nurses, nursing facility administrators, and the like, employers usually equate a traditional college degree with intelligence. However, some very successful people have high emotional and creative intelligence but didn’t graduate from college, such as: Bill Gates, co-founder of Microsoft; Michael Dell, founder of Dell Computers; Steve Jobs, Apple Computer co-founder; and Richard Branson, founder of Virgin Music and Virgin Airlines. </div> <div> </div> <div>What do all these people have in common? A certain intelligence that cannot be measured by test, degree, or certification. </div> <div> </div> <div>Nontraditional, “real-life” education or entrepreneurship warrants serious consideration. For example, caring for a loved one with Alzheimer’s disease is oftentimes a “call to action.” A caretaker often needs to self-educate, join associations, conduct research, and dedicate one’s life to provide the appropriate care necessary. </div> <div> </div> <div>A college degree in health care simply cannot replace the experience of providing for and living daily with a person who has Alzheimer’s. Having had this experience, it is not uncommon for someone without formal health care experience to pursue a career as a memory care coordinator or similar position in a skilled nursing or assisted living facility. </div> <div> </div> <div>Stuart Lindeman, senior vice president of Revera Health Systems, Middletown, Conn., says, “When I look at a resume I want to see career growth, performance, and results.” </div> <div> </div> <div>Employers such as Lindeman want to see a successive career background. On a resume, performance can be assessed by doing the job effectively, increasing efficiency, improving returns, and performing a job to satisfaction. Performance need not be limited to the workplace. Continuously investing in one’s professional development—training programs, professional associations, education, certifications, keeping up with professional literature, and the like—speaks volumes on a resume.</div> <h3 class="ms-rteElement-H3"><div><strong>Culture Counts</strong></div></h3> <div>Equally as important as successive career growth is the reputation or style of the organization where the applicant was previously employed. Knowing this offers insight into whether or not the candidate will be a good culture fit for the company. </div> <div> </div> <div>“When I look at a resume I want to know where the applicant has worked previously and the company’s reputation in the industry,” says Lindeman. “I’ve hired many of my best employees by knowing who my most successful competitors are in the industry and plucking from the very best.” </div> <div> </div> <div>Having the skills to do a job is one thing, but being able to fit in culturally is paramount to the success of a new employee and to the morale of the new hire’s co-workers. </div> <div> </div> <div>Budgie Amparo, executive vice president of Quality Services and Risk Management at Emeritus Senior Living, Seattle, contends that resumes rarely tell the whole story.</div> <div> </div> <div>“I think that it is important to speak with an applicant to learn if there will be a fit based on the personality with whom this person will be reporting to,” he says. “For example, can this applicant work with a strong manager?” </div> <div> </div> <div>The time has come for employers to re-examine the parameters by which resumes are evaluated and perhaps revisit resumes that may have been preliminarily eliminated from the interviewing process. A resume is only a starting point, but the intricacies of a person’s career are next to impossible to examine in a one- or two-page document. </div> <div> </div> <div>Employers must be creative as they assess new talent. Furthermore, the landscape of long term and post-acute care is constantly changing, and the employment world is constantly </div> <div>evolving. </div> <div> </div> <div><em>Bernie Reifkind is chief executive officer and founder of Premier Search, a health care executive search firm based in Los Angeles. Reifkind is nationally known as an expert in the recruitment and placement process in the long term and post-acute care industry. He can be reached at bernie@psihealth.com or (800) 801-1400. His company’s website is: www.psihealth.com.</em></div> <br><br>An expert offers five essentials a provider should take into consideration when reviewing a prospective employee’s resume. 2010-09-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/staff_2.jpg" style="BORDER:0px solid;" />Management;WorkforceHuman Resources9

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Dynamic Designs In Long Term Carehttps://www.providermagazine.com/Issues/2010/Pages/1010/Dynamic-Designs-In-Long-Term-Care.aspxDynamic Designs In Long Term Care<div>​The renovation or construction of a long term or post-acute care facility begins with a process that will engage administrators, finance officers, owners, operators, and the design team in a dialogue that will shape the facility and how it operates. How that dialogue unfolds will determine the success, or lack <img width="175" height="271" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/1010/Design-Feature-Photo-3.jpg" alt="" style="margin:15px;width:281px;height:210px;" />thereof, for years to come. </div> <div><div>Selecting a design team that understands the process is essential.</div> <h3 class="ms-rteElement-H3">Identify Mission, Ideals, Values</h3></div> <div>Discussions regarding new construction, expansion, or renovation of a nursing facility or assisted living residence must examine the mission and values of the provider. </div> <div> </div> <div>With a focused reflection and analysis of how the mission and vision should be reflected in the desired environment, these discussions can lead to projects that serve their residents particularly well. </div> <div> </div> <div>Engaging, passionate, and reflective conversations articulate a community’s ideals and values for quality of care and quality of life. This process maximizes the potential of design to create a long term care facility that enhances quality of care, while also meeting the provider’s critical business objectives.</div> <div> </div> <div>To facilitate a reflective conversation, begin with a clear, broad discussion of mission, vision, and ideals. Open-ended questions should be posed rather than statements that contain implied design solutions. To gain the broadest possible perspective, these sessions should involve the organization’s administrative leaders, financial officers, medical directors, nursing staff, support and facilities staff, and potentially residents and family members. </div> <div><img width="441" height="330" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/1010/Design-Feature-Photo-4.jpg" alt="" style="margin:15px;width:360px;height:269px;" />As the team grapples with mission and value questions, two other sets of drivers can be overlaid in the discussion: quality of life and price point. When the provider’s mission is viewed through the lens of quality and price, the design team can begin to create spatial images of the facility. </div> <div> </div> <div>This process, which is continual and repeated several times throughout the design process, allows a design to evolve that can be tested against the criteria of mission, quality, and price.</div> <h3 class="ms-rteElement-H3">A Day In The Life Of A Community</h3> <div>When design teams examine practices in long term and post-acute care, they should seek an appropriate understanding of the regional community—its values, its ideals, and its way of life. Participants should be encouraged to reflect on these issues during interactive conversations. </div> <div> </div> <div>This is the time to explore what participants or their community believe is appropriate or not, desirable or unwanted, relevant or unimportant. Participants should be probed about why they feel the way they do.</div> <div> </div> <div>Design teams gain insight when they ask participants to imagine and describe key events in a resident’s typical day, such as waking, bathing, dining, sleeping, socializing, receiving visitors, and participating in other activities. This type of probing enables the design team to envision the facility from the resident and employee point of view. </div> <div> </div> <div>Over time, the discussion leads to an in-depth understanding of the facility’s current approach, as well as desired areas of improvement. At this point, the design team is ready to develop a building program that will in turn be the basis for schematic design. </div> <div> Administrators and staff should be aware that when the design team presents an initial design, it was created by translating words into visual concepts. It will therefore represent a first level of understanding for which more interaction and discussion are necessary. </div> <div> </div> <div>Through the continued work of the project team, the design is refined; the design team will test its interpretation of the vision and<img width="211" height="246" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/1010/_Design-Feature-Photo-2.jpg" alt="" style="margin:15px;width:270px;height:189px;" /> adjust the design accordingly. When all participants fully contribute to this process, their input maximizes the possibilities. </div> <div> </div> <div>Beginning to unfold is a facility that reflects the community’s way of life, enhances quality of care for residents, and meets the provider’s financial objectives.</div> <h3 class="ms-rteElement-H3">A Win-Win For All</h3> <div>Utilizing a continual design approach and an exploratory process maximizes the design team’s potential to create a facility that improves quality of care for residents. </div> <div> </div> <div>In the most successful cases, administrators and staff share their passion and creativity in an open-minded approach. Beginning the conversation with a focus on the best care for residents and not solely how the facility can be constructed for less can yield unanticipated benefits. </div> <div> </div> <div>What’s more, identifying features that are highly desirable will inspire design innovations that can enhance staff recruitment, retention, and overall satisfaction. </div> <div> </div> <div><em>Christopher Ewald, AIA, NCARB, LEED AP, is a retired vice president at SSOE Group, an international engineering, procurement, and construction management firm. He can be reached at cewald@SSOE.com. Lynne Gochenour, IIDA, AAHID, LEED AP, senior interior designer and senior associate at SSOE Group, can be reached (419) 255-3830 or <a href="mailto:lgochenour@SSOE.com">lgochenour@SSOE.com</a>. Robert Siebenaller, AIA, NCARB, LEED AP BD+C, serves as a division manager, project manager, and senior associate at SSOE Group. He can be reached at (419) 255-3830 or rsiebenaller@SSOE.com.</em></div>Experts offer advice on seniors housing design that improves quality of life for residents and still meets the bottom line.2010-10-01T04:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/1010/Design-Feature-Photo-4.jpg" width="150" style="BORDER:0px solid;" />DesignColumn10
Leaders Neededhttps://www.providermagazine.com/Issues/2010/Pages/1010/Leaders-Needed.aspxLeaders Needed<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​Senior care professionals are accustomed to change, but it is one thing to meet the daily challenges of your calling when the road ahead is well marked and brightly lit. It is quite another to stay on track when conditions make that road less visible, or doubts creep in as to whether it is the right road at all. Some may have begun to wonder if they even have control of the steering wheel anymore. </p> <p>An anemic economy; battered federal and state budgets; record public debt levels; health care reform that is sweeping, conflicted, and confusing; political unrest and uncertainty—all these together (if not the Great Depression revisiting) can certainly lead to a feeling of depression, if not paralysis, in individuals and companies. </p> <div>Under such conditions, it is imperative for forward-thinking leaders to gain an understanding of the changing environment. It is equally important for them to retain control of what matters most—the basics that define what they do, why they do it, and what must be in place in order to survive and thrive under any conditions. In past recessions and periods of health care policy change, there were always new opportunities hidden inside the apparent threats. Successful leaders will assess both—and find ways to capitalize on those openings. </div> <h3 class="ms-rteElement-H3">Meeting new opportunities with a new value proposition.</h3> <div>In the world of Medicare and Medicaid, traditional top-down regulatory strategies and fee-for-service payment policies still prevail, but are in slow-but-sure retreat as the twin poles of quality and value are brought into closer alignment. Signs abound that Congress, state legislatures, and public agencies will continue to invoke nontraditional methods of assessing the performance of nursing facilities as part of a general policy evolution toward value-based purchasing and greater public transparency of price and quality information in the health care sector.</div> <div> </div> <div>Health care reform, even if altered by a new Congress, will only accelerate these trends, while bringing to the forefront two specific, related objectives: </div> <div> </div> <div>1. Avoidance of costly rehospitalizations; and</div> <div>2. Bundling of payments across provider settings with the potential of making money follow value in a way not possible under fee-for-service. </div> <div> </div> <div>Neither of these evolving trends is guaranteed to be effective, but point to a new game-changing status quo in the next few years.</div> <div> </div> <div>While new ways of measuring technical outcomes of care are receiving their proper attention, the fundamentals of a broader concept of a quality culture from the perspectives of residents, families, and caregiving staff now occupy a comparable level of consideration for both practice and policy.  </div> <h3 class="ms-rteElement-H3">Some states now require satisfaction surveys to be made public.</h3> <div>As noted in My InnerView’s November 2009 report, “Rewarding Quality Nursing Facility Care: State Quality Programs and Purchasing Models Point the Way,” several states are experimenting with “market-based” reforms, which commonly include offering more actionable information to consumers, together with steps to directly align Medicaid payment incentives with measurable quality outcomes and demonstrated improvement. </div> <div> </div> <div>Customer satisfaction is a measure of performance found in nearly all such programs, and employee satisfaction is or will be used in a majority of them. </div> <div> </div> <div>A small group of states, also likely to expand, have enacted legislation requiring or enabling nursing facilities to periodically obtain independent assessments of resident satisfaction and make the results public.</div> <div> </div> <div>While these trends were under way before the appearance of the current severe strains on public and private budgets, the new prospect of sector rationing has only focused attention more sharply on the desire to define and seek greater value within available resources. </div> <div> </div> <div>Long term care providers, no less than other health system participants, are caught up in a political and fiscal vortex that is unlikely to abate in the foreseeable future. Thus success, or even survival, of providers will require timely adaptation to the requirements of value-based and evidence-based practice. A key variable will be the ability to engage customers and staff in a common commitment to deliver services in a culture of excellence. </div> <h3 class="ms-rteElement-H3">Customer expectations will continue to grow.</h3> <div>In the world we live in today, the mantra is “doing more with less.” But what does that mean to the post-acute health care provider? Consumers’ expectations are high and will continue to grow. Today’s consumers are more knowledgeable and much more demanding, as they have lived their adult lives accustomed to having choices and information about a broad spectrum of the products and services they have purchased.</div> <div> </div> <div>As health care providers scramble to understand and prepare for health care reform and other changes, leading organizations will be rewarded for being customer-centric and maintaining a fully engaged and motivated workforce. In the new world of greater transparency, there will be no place to hide. The old ways of doing things will no longer work.</div> <div> </div> <div>Over the next five to 10 years, the senior care profession will see transformational change like never before. So, what should providers do that will allow them to lead the way in the care and services their customers want and expect?</div> <div> <span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"><div>Competitive advantage No. 1: You must be customer-centric.</div></h2> <h3 class="ms-rteElement-H3">Don’t manage your customer experience in a vacuum.</h3> <div>Before your organization can improve the customer’s experience and satisfaction, you must understand what you are currently offering to your customer and exactly where you might or might not be meeting their expectations. Forrester Research has found that the most significant obstacles to improving the customer experience/satisfaction are:</div> <div> </div> <div>1. Lack of a clear customer experience/satisfaction strategy.</div> <div> </div> <div>2. Lack of a customer experience/satisfaction management process.</div> <div> </div> <div>First, you can improve customer experiences only if you know and understand what those experiences are. The organizational culture and business processes that you have put in place translate into the service that your customer experiences. How often does the customer experience your intent to deliver get lost in the translation? </div> <div> </div> <div>Your care delivery processes have been mainly designed to support your organization internally and meet regulatory specifications; in many cases, they put up customer barriers, confuse your customer or, at best, make it difficult for them to effectively communicate with you.</div> <div> </div> <div>Second, not all of the customer experiences are created equal. The customer experience is not a static phenomenon. Jan Carlzon in his classic book, “Moments of Truth,” says that through the customer life cycle with your organization, there are many moments of truth where your customer experiences what it is like to do business with you. </div> <div> </div> <div>It is important for your organization to understand the weight each moment of truth plays in your design of systems and processes. </div> <div> </div> <div>Be sure that you communicate frequently with your customers throughout the customer life cycle. </div> <div>My InnerView has processed millions of resident and family surveys and has never had a single survey returned that said the nursing facility over-communicated with them.</div> <div> </div> <h3 class="ms-rteElement-H3">Know where you have service gaps, and fix them.</h3> <div>It is critical that your organization start measuring and managing the potential gaps in your customer’s experience. Through research conducted at My InnerView, we know that three major gaps can exist in any nursing facility: </div> <div> </div> <div>1. The gap created by the communication the customer receives (both verbal and written) prior to being admitted to your facility. The organization may overstate services to be provided or talk about “best case” rather than “more likely.” These types of communications raise customer expectations and can damage later customer perceptions. </div> <div> </div> <div>Leading organizations will continuously monitor and adjust the initial communication that their customers receive to make sure those expectations are set on a factual foundation.</div> <div> </div> <div>2. The gap that can exist between what customers expect and what management thinks they expect. </div> <div> </div> <div>Regularly surveying your customers using common as well as targeted instruments is an effective way to help narrow this gap, and can pick up changes in expectations based on actual experiences that occur during the customer’s stay. </div> <div> </div> <div>One can get a false sense that because you have worked in the profession for a number of years that you know exactly what the customer wants. Leading organizations will dialogue with their customers frequently in order to understand expectations and service requirements. </div> <div> </div> <div>3. The gap between processes put into place to deliver the customer experience and the actual experience that the customer receives. Be sure that systems and processes are actually delivering the desired experience for your customer. </div> <div> </div> <div>Many times what makes life easier for your organization can in fact make life more difficult for your customer. Leading organizations will redesign the resident-care processes to ensure a more positive, memorable, and powerful customer experience. </div> <h3 class="ms-rteElement-H3">Change your paradigm.</h3> <div>There are three key paradigm changes that leading service excellence organizations make:</div> <div> </div> <div>1. View each resident/patient first as an individual customer and then as a partner in service delivery. Leading organizations know that success can only be attained by recognizing customers as partners in conceiving, developing, and delivering care systems and processes. This is a difficult jump for many organizations to make, but once they do, improvement and satisfaction accelerate exponentially. </div> <div> </div> <div>The best way to ensure that your customers are happy with the care and service you deliver is to involve them in the design and delivery process. Who knows better than the customer how, when, and where they prefer to receive their care and your service.</div> <div> </div> <div>2. Move from viewing the focus on service excellence as a program or initiative to that of realizing it is a key strategy that should be embedded in the organizational culture. Service excellence is not a flavor of the month or “that latest program being pushed down from senior management.” Leading organizations know that service excellence must be a key pillar of the organizational culture and that every employee knows the strategy by heart.</div> <div> </div> <div>3. Move from “management is responsible for the experience the customer has and their overall satisfaction” to “everyone in the organization is responsible for the experience the customer has and their overall satisfaction.” Leading organizations are embedding responsibility for the customer experience into everyone’s job description—holding everyone accountable for the results.</div> <h2 class="ms-rteElement-H2">Competitive advantage No. 2: You must have an engaged workforce.</h2> <h3 class="ms-rteElement-H3">The power of an engaged workforce is invaluable.</h3> <div>Committed employees are loyal and not only drive their own performance but the performance of the organization as a whole. Every leader wants their workforce to be committed to who they work for and passionate about their work. </div> <div> </div> <div>Employees need to have a clear focus and understanding of the organization’s mission, vision, and values and how it relates to their own future. And they need to understand how their roles and efforts in the organization make a difference in achieving the overall organizational goals.</div> <div> </div> <div>As Jack Welch, retired CEO of General Electric, said, “No company, small or large, can win over the long run without energized employees who believe in the company’s mission and understand how to achieve it.” </div> <div> </div> <div>Employees who are engaged in their work and committed to their organization provide the critical competitive advantage in today’s marketplace through lower turnover and higher productivity. They also drive higher customer satisfaction.</div> <div> </div> <div>The overall employee engagement numbers in North America, according to Blessing White, are not as impressive as one would like. Less than one-third of employees are fully engaged, and 19 percent are actually disengaged. There is a clear correlation between engagement and retention in that 85 percent of engaged employees plan to stay with their employer through the next year.</div> <div> </div> <div>Employee engagement is a complex equation that reflects the unique and dynamic characteristics that each employee brings when he or she walks in the door each day. There is no silver bullet when it comes to employee engagement. A multi-faceted, ongoing approach to engagement is usually the most effective. Most managers will tell you that the best thing that they did was to do a lot of things.</div> <div> </div> <h1 class="ms-rteElement-H1B" style="font-size:15px;"><span style="font-size:15px;"><span style="font-size:15px;"><span style="font-size:15px;"></span></span></span></h1> <a href="/Issues/2010/Pages/1010/Leaders-Must-Set-The-Tone.aspx" target="_blank" style="text-decoration:underline;"><h1 class="ms-rteElement-H1B" style="font-size:15px;"><span style="font-size:15px;"><span style="font-size:15px;"><span style="font-size:15px;"><strong>Leader Must Set The Tone</strong></span></span></span></h1> </a><div> </div> <div><em>This article was written by Neil Gulsvig, President/</em><em>Founder, and Bruce Thevenot, Senior Vice President, </em><em>My InnerView, </em><a href="http://www.myinnerview.com/"><em>www.myinnerview.com</em></a><em>, (715) 848-</em><em>2713. My InnerView is an applied research company</em><em> that promotes evidence-based management practices in </em><em>U.S. senior care organizations.</em></div> <p> </p>Senior care professionals are accustomed to change, but it is one thing to meet the daily challenges of your calling when the road ahead is well marked and brightly lit. 2010-10-01T04:00:00Z<img alt="" src="/Issues/2010/PublishingImages/Web%20images/handshake_thumb.jpg" style="BORDER:0px solid;" />Management;Workforce;QualityColumn10
Beyond Hospital Referrals: Gaining Ground With Innovative Marketing Tools https://www.providermagazine.com/Issues/2010/Pages/1010/Matching-Patient-Needs-To-Provider-Services.aspxBeyond Hospital Referrals: Gaining Ground With Innovative Marketing Tools <div>The new world of long term care marketing has expanded the boundaries of where and from whom skilled nursing facilities (SNFs) and assisted living facilities (ALFs) seek referrals, from the old days of working only with discharge planners and social workers at hospitals to the 2010 version, where marketing targets practically anyone influencing seniors’ post-acute care decisions.</div> <div> </div> <div>The federal government says the goal of discharge planning is a “smooth move” to the next care setting, but making that happen oftentimes pivots on provider marketing. </div> <div> </div> <div>Matching the needs of an exiting hospital patient or senior looking to move from home with the care capabilities of a post-acute care provider involves many factors and has seen many new trends emerge in recent times. </div> <div> </div> <div>Marketing, both “inside” the industry and related settings of care and “outside” to the general public, can involve a slew of different strategies for providers to pursue, from physically having a representative working in a hospital with case managers and discharge planners, to tracking data on potential residents via electronic health record management systems, to working on advertising and other outreach campaigns for bolstering the brand and boosting occupancy.</div> <div> </div> <div>Everyone in the post-acute care business knows that hospitals need to move people out as quickly as is feasible, and long term care settings, in turn, need to gauge, sometimes quickly, how a discharged patient best fits into the continuum of care they provide.</div> <div> </div> <div>Caregivers and patients, along with the discharge planning staff at a hospital, all have ideas on what qualifies as a “smooth move.” And, for seniors looking to transition out of their homes and into an ALF, the decision relates as well to what their next residence will do for quality of life. </div> <div><h3 class="ms-rteElement-H3"><div><strong>Reaching All Points Of Access</strong></div></h3> <div>Seeking access to all sorts of influencers—the people who live with, provide services to, or simply know potential residents—is a growing trend in provider marketing, be it before or during the discharge planning cycle.</div> <div> </div> <div>In addition to senior centers, post-acute providers promote their services among themselves (home care, hospice, rehabilitation, SNF, ALF) and to those influencing seniors: estate planners, clergy, ophthalmologists, Meals on Wheels volunteers, pharmacists, paramedics, and many more stakeholders, says Rhoda Weiss, an international consultant, writer, and educator based in Santa Monica, Calif. “As the numbers of people needing post-acute care moves from seniors to younger generations suffering heart attacks, strokes, orthopedic issues, uncontrolled diabetes, asthma, trauma, and more, the SNFs, rehab facilities, home care, and other providers are expanding their marketing and rethinking strategies, tactics, and techniques,” she says, tapping into her experience as past national chair of the American Hospital Association Society for Healthcare Strategy & Market Development and ex-chief executive officer of the Public Relations Society of America.</div> <div> </div> <div>Weiss relates that her 93-year-old father, who volunteers weekly at a center offering programs for seniors, understands how important referrals are to SNFs. </div> <div> </div> <div>“He sees scores of SNF personnel stopping by with information and goodies in quest for recognition, positioning, and, hopefully, referrals to their facilities,” she says.</div> <div> </div> <div>Patricia Cokington, senior sales trainer for Sikeston, Mo.-based ALF provider Americare, agrees that the old days of SNFs simply making weekly visits to a hospital are over, and for ALFs the net is cast just as wide. “You are definitely seeing more referrals from different people,” she says. “You see lots of influencers in church. The clergy know when one of their elderly worshipers can no longer come to services. Overall, they are very receptive.” </div> <div> </div> <div>The main role clergy fulfill is, of course, is as spiritual guides, making any work they do as a conduit to a provider an informal task, says Father Kevin Walsh, pastor of Saint Anthony of Padua Catholic church in Falls Church, Va. </div> <div> </div> <div>While tending to the elderly in his parish, he occasionally recommends programs he sees that work well for his parishioners. “There is a hospice that has done very good work, so informally I recommend them,” he says.</div> <div> </div> <div>Besides an increase in the number of people receiving at least part-time home care, Walsh says in his 18 years as a priest, the main goal of families continues to be in trying to keep their loved ones with them, or in their own homes, as long as possible.</div> <div> </div> <div>The key for provider marketing and sales staff is to reach out into the community, especially in rural America, Cokington says, noting Americare does most of its business outside of metropolitan areas. While increasing the focus on nontraditional sources of referrals, the best place for provider marketing remains the hospital, be it by placing a representative within the hospital walls or a computer linkup for word on the latest prospective residents.</div></div> <div><h3 class="ms-rteElement-H3"><div><strong>Physicians Receive Attention</strong></div></h3> <div>Inside the hospitals, providers have tried more aggressive and straightforward approaches to let doctors treating their potential future clients know that their long term care facilities can offer patients a second professional home. </div> <div> </div> <div>Blaise Mercadante, chief development and marketing officer for Miami Jewish Health Systems, says doctors are tops on their list. “We talk to physicians, and we talk to case managers and discharge planners. Part of our sales force meets with physicians and holds these events in their offices,” he says.</div> <div> </div> <div>The goal is to make the doctor a partner in the future care of their existing patients and others. </div> <div>“We really want them to feel comfortable,” Mercadante says. “The key message is that their patients will be cared for. We respect the role of doctors, and we will provide the service they feel comfortable with. If they want calls at 3:00 in the morning about their patients, we will do that.” </div> <div> </div> <div>The next level is to work with case managers “to smooth discharges,” which also includes automated links with the nearby Aventura Hospital and Medical Center, he adds.</div> <div> </div> <div>Kindred Healthcare, which has instituted a new marketing campaign under its Continue the Care program (<a href="http://www.continuethecare.com/">www.continuethecare.com</a>) in Cleveland and Indianapolis (with more target cities coming soon), says amongst all of its varied efforts, the communication with physicians is one of its chief marketing priorities.</div> <div> </div> <div>“We really tell them that they can build a practice [at our facilities]. We make the economic case to the doctors by making the physician aware of the quality outcomes we provide and that we care for them,” says Kindred’s Benjamin Breier, executive vice president and president of the hospital division, as well as the incoming chief operating officer (COO) for the company.</div></div> <div><h3 class="ms-rteElement-H3"><strong>No ‘Bounce-backs’</strong></h3> <div>Dan Benson, COO of Indianapolis-based American Senior Communities (ASC), says his company has personnel right in the hospital “helping to be part of the solution” for discharge planners and hospital administrators, because assessing where to place patients is not as easy as looking up the nearest long term care facility and getting the elderly person there.</div> <div> </div> <div>He says that especially today providers must be savvy in finding appropriate care for discharged patents, to prevent “bounce-backs” from the long term care setting to hospital. “Information gathering about patients really helps to prevent bounce-backs, a negative for reimbursement purposes as well as for patient care,” Benson says. “It is much better to coordinate care with the hospital, to cover the patient’s drug regime and all aspects of their care.”</div> <div> </div> <div>ASC hires nurse liaisons to work at nursing stations to best gauge where potential residents stand in terms of needs, even working on transportation issues. “We go into a marketplace and find the sharpest discharge planners and case managers and have them become employees of ours,” Benson says.</div> <div> </div> <div>Once a possible match for an ASC facility is discovered, the team works back to the facility level to make sure the care can actually be satisfied, he says.</div> <div> </div> <div>“We ask if we can care for this person, are we able to meet this person’s needs,” Benson says, including physical layout of the SNF or appropriate machinery such as ventilators. </div> <div> </div> <div>“It is the folks at the building level that have to be able to focus and see if we can make a good decision.” </div> <div> </div> <div>In the old days, he notes, the decision by families to place a loved one in an SNF might take a day or two to sort out, but today it is usually accomplished in a few hours, with the policy emphasis on moving patients along the care continuum and competition for space.</div> <div> </div> <div>Families can get a jump on research by looking at the Internet, but also viewing marketing materials, like virtual tours, provided by the long term care provider. </div> <h3 class="ms-rteElement-H3"><strong>Critical To The Care Process</strong></h3> <div>Weiss says as hospitals face higher costs, lower reimbursement, shorter stays, and growing post-acute community resources, discharge planning has become even more of a top priority. This importance translates into more collaboration and partnership with case management and utilization review programs.</div> <div> </div> <div>“The role of discharge planning is growing in importance and respect as a critical part of the hospital’s medical and financial future and its ability to safely and effectively discharge patients to the appropriate post-acute provider, reduce re-admissions, increase patient and family satisfaction, and help lead the critical work of comprehensive continuity of care in their communities,” Weiss says.</div> <div> </div> <div>During the past decade, Weiss says she and others have witnessed an explosion in best practice medicine that involves physicians leading teams of clinicians and support staff who compile, share, and implement best practice plans for scores of medical conditions. </div> <div> </div> <div>“During the last few years, we are seeing more of these best practice care plans integrating discharge planning and discharge planners into the best practice plans,” she says.  </div></div> <div><h3 class="ms-rteElement-H3"><strong>Technology In Play</strong></h3> <div>In years past, discharge planners would spend hours upon hours playing phone tag with multiple referral sources to place patients with the most appropriate after-hospital provider that had the time, space, and staff to accommodate the patient. Now, <a href="/Issues/2010/Pages/1010/Technology-Helps-Referral-Process.aspx">referrals </a>are increasingly made electronically, securely, safely, and more efficiently, thanks to electronic referral management.</div> <div> </div> <div>This benefits the hospital that can match patient needs to the capabilities, availability, and services of the referral source as well as safely and electronically share secured patient information with the after-hospital provider. </div> <div> </div> <div>One of the main players in the electronic health records (EHRs) business is PointClickCare (<a href="http://www.pointclickcare.com/">www.pointclickcare.com</a>), which bills itself as the market leader in long term care software-as-a-service (SaaS). At the start of this year, some 5,000 long term care centers in Canada and the United States used the company’s software for tracking demographics; managing current, historical, and waiting list clients; and maintaining a physician registry for all care professionals such as attending physicians, dentists, therapists, and consultants.</div> <div> </div> <div>Mike Wessinger, PointClickCare president, says the EHR helps track bed availability and <a href="/Issues/2010/Pages/1010/Pre-Booking-For-Elective-Surgeries.aspx">pre-booking </a>assessments in a real-time fashion for often quickly developing discharge scenarios. </div> <div> </div> <div>PointClickCare’s software does this by allowing hospitals to capture critical information on the abilities, capabilities, and resources available from post-acute providers.</div> <div> </div> <div> “It benefits after-hospital providers with easier and quicker access to patient information, which speeds referrals and patient transfers,” Wessinger says.</div></div> <div> </div><strong>The Kindred Campaign</strong><div> <div>At Kindred, the Continue the Care campaign has boosted business in the Indianapolis and Cleveland markets where the program has first been rolled out, Breier says.</div> <div> </div> <div>Besides marketing to hospitals and doctors inside the hospital, he says the two pilot markets have seen an initial round of saturation advertising through print ads, direct mail, aggressive social media, and other outlets to first raise recognition.</div> <div> </div> <div>“The content of the campaign is to build the brand,” Breier says. It seems to be working, as he points to double-digit growth in the pilot markets as a result of the marketing campaigns in what is a “pretty tough market out there.”</div> <div> </div> <div>Kindred plans to expand the Continue the Care strategy to 20 markets in total, gradually rolling out to more cities in 2011. Breier said the company did its homework before embarking on the campaign and stresses that it is important to remember that pre-planning is critical.</div> <div> </div> <div>“The lessons are you can’t be all things to everyone at once. Be careful on what and where you spend the dollars. I mean, we didn’t decide to roll out to 40 states,” he says.</div> <div> </div> <div>At <a href="http://www.continuethecare.com/">www.continuethecare.com</a>, the public can access information about Kindred facilities across the country, covering long term and acute care, skilled nursing, assisted living, inpatient rehab, home health care, outpatient rehab, and hospice. </div> <div> </div> <div>There are also click-throughs to refer patients, receive a newsletter, and even find employment, with one of the provider’s goals being to attract new and skilled talent through the marketing program, Breier says.</div></div> <div><h3 class="ms-rteElement-H3"><strong>Remember The ‘Smooth’ Goal</strong></h3> <div>Through all of the various ways providers seek to manage their end of the discharge planning process, it is important to remember the factors in play and sometimes in conflict. </div> <div> </div> <div>Discharge planning demands a continual balance between the needs of patients and their families and pressures of managed care and health plans for timely discharge from a hospital—often causing conflicts among nurses, social workers, and professionals who are part of the utilization review and discharge planning process; physicians responsible for each patient’s care; health plans; employers; and post-acute care providers.</div> <div> </div> <div>Medicare defines discharge planning as “a process used to decide what a patient needs for a smooth move from one level of care to another.” But, Weiss notes, discharge planning is not an isolated event—it starts prior to hospitalization once the patient is referred to and/or admitted to the hospital or at admission for unplanned medical events. </div> <div> </div> <div>“The goal is to ensure patients can function appropriately and safely following a hospital stay,” Weiss says. The objectives are to conduct a patient-centered, comprehensive assessment with the most complete data, resulting in the best possible decision making for patient placement. Whether the decision is to send the patient back home or to post-acute care, appropriate and safe reductions in lengths of stay and quick transfers are imperative.</div></div> <div><h3 class="ms-rteElement-H3"><strong>It's A Team Event</strong></h3> <div>Providers note that <a href="/Issues/2010/Pages/1010/What-Patients-Are-Being-Told.aspx">discharge </a>planning demands close working relationships among all members of the health care team, from both the hospital and post-acute provider. </div> <div> </div></div> <div>“Discharge planning is a comprehensive activity involving not only medical and physical needs, but psychological; spiritual; financial; and practical and family needs, capabilities, and available resources,” she says. </div> <div> </div> <div>The process is data- and labor-intensive and requires comprehensive knowledge by the discharge planning team of available community resources that best match patient needs and knowledge of how to make the best connections for patients and loved ones.</div> <div> </div> <div>Discharge planners often know as much as primary care physicians about patients as they are typically involved in that care prior to or at hospitalization through hospital discharge to a post-acute provider and follow up, Weiss adds.</div> <div> </div> <div>The challenge for discharge planners, and why providers seek to help in the process or are connected to the process via electronic means, are many, from the hospital and its maze of clinicians, support and back office staff, primary and secondary physicians, and the many parts of a puzzle that comprise such a facility.</div> <div> </div> <div>Weiss says these challenges also have been exacerbated greatly by higher hospital costs, inadequate reimbursement from government payers and health plans that often are lower than the cost of care provided, and enormous pressures from health plans and payers for short stays and early discharges. </div> <div> </div> <div>“Another challenge is identifying an appropriate post-acute provider that matches the patient’s continuing health care needs, requirements for medical equipment, single or multiple diagnoses, the patient’s insurance plan, ability to pay, family budget and availability and age of caregivers, along with their capabilities to care for a loved one at home,” Weiss says. “The emotional distress of the family as well as their ability to accept different levels of post-acute care also play a key role.” </div> The new world of long term care marketing has expanded the boundaries of where and from whom SNFs and ALFs seek referrals, from the old days of working only with discharge planners and social workers at hospitals to the 2010 version, where marketing targets practically anyone influencing seniors’ post-acute care decisions. 2010-10-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_woman_thinking.jpg" style="BORDER:0px solid;" />ManagementColumn10
Preemptive Measures Boost Wellness For Long Term Care Residentshttps://www.providermagazine.com/Issues/2010/Pages/1010/Preemptive-Measures-Boost-Wellness-For-Long-Term-Care-Residents.aspxPreemptive Measures Boost Wellness For Long Term Care Residents<div>According to the National Center for Injury Prevention and Control, fall-related injuries are the leading cause of injury deaths and disabilities among older adults. Hip fractures are considered the most serious fall injury, with less than half of all older adults hospitalized for hip fractures regaining their former level of function. </div> <div> </div> <div>Hip fractures are also expensive. Using existing data as a guideline and taking inflation into account, a 1990 study in the Journal of the American Medical Association estimates the total annual cost of hip fractures in the United States could reach $82 billion to $240 billion by the year 2040.</div> <div> </div> <div>These statistics and more spurred Charlotte, N.C.-based Senior Living Communities (SLC), a continuing care provider that utilizes wellness programs throughout each of its care settings, to create a program that would help its members stay mobile and independent longer by reducing their risk of injury. </div> <div> </div> <div>SLC’s lower-body exercise program known as CLIMB—an acronym for Confidence, Longevity, Independence, Mobility, and Balance—was born after two research studies on a pilot program found very encouraging results. In fact, the two studies, conducted by SLC’s research partner Wake Forest University, were so positive that the company is implementing <img width="233" height="156" class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/1010/Caregiving-Photo-ONE.jpg" alt="" style="margin:10px 15px;width:286px;height:191px;" />CLIMB throughout all of its 11 communities. </div> <div><h3 class="ms-rteElement-H3">Preliminary Research Positive</h3> <div>The first study was conducted with members from all 11 SLC communities, while the second utilized members from Homestead Hills, SLC’s Winston-Salem, N.C., community. Both found a majority of residents had deficits in lower-body strength and were responsive to exercise interventions lasting as little as six weeks.</div> <div> </div> <div>Twenty-nine Homestead Hills members were selected to participate in the follow-up study and were randomized into two groups: a control group whose members maintained their normal daily routine and a progressive resistance exercise group that met for about 30 minutes, three times per week, for six weeks. </div> <div> </div> <div>To develop a baseline, all 29 adults were evaluated at the beginning and end of the six-week intervention. Their lower-body strength and physical function were measured by a one-repetition strength test using leg extensions and leg curls, a timed 400-meter walk test, and the Short Physical Performance Battery that tests walking speed, balance, and lower-limb strength.</div> <div> </div> <div>The progressive resistance exercise group completed a variety of exercises designed to increase leg strength. Residents wore weighted vests for resistance while performing toe raises and step-ups on an aerobic step and used strength-training equipment for leg extension and flexion exercises.</div></div> <div><h3 class="ms-rteElement-H3">Strength Improves Confidence</h3> <div>Preliminary results showed that adults who participated in the lower-body strength training exercises had an average increase in leg extension strength of 51 percent and an average increase in leg curl strength of 31 percent, while the strength of those in the control group did not change. </div> <div> </div> <div>Members in the control group were encouraged by their peers’ results and requested the introduction of a lower-body-specific exercise program into their daily wellness offerings at Homestead Hills.</div> <div> </div> <div>Easy and affordable to implement, CLIMB will span 16 weeks and include a variety of exercises hand-picked from other wellness classes. Residents who participate in the program will focus on improving their mobility to reduce their dependence on spouses, children, or other informal caregivers.</div> <div> </div> <div>Research suggests that the strength-training exercises will also help members improve their balance, reducing the likelihood that they will suffer a catastrophic event like a fall, which may lead to disability, hospitalization, or other negative complications.</div></div> <div><h3 class="ms-rteElement-H3">Residents Praise Program</h3> <div>Ruth Kessler, a member of the progressive resistance exercise group, is all too familiar with the side effects of a catastrophic fall. The Homestead Hills member fractured her left femur two years ago, and the recovery has been long and difficult. </div> <div> </div> <div>“At the beginning of the six-week period, it was extremely difficult for me to get up from a seated position,” Kessler says. “After I finished the sessions, I progressed from lifting 40 pounds to lifting 70 pounds with my leg curls, and I can do five chair-stands now when I couldn’t even do one before.”</div> <div> </div> <div>Roburta Trexler, a retired physical therapist, also reports increased confidence in her walking ability. “I feel like I’m definitely making some improvements,” Trexler says, while resting in between exercises inside Homestead Hills’ wellness center. </div> <div> </div> <div>“I exercise regularly on my own, but I was losing my balance at times,” she says. “The CLIMB program has definitely made a difference. I plan to continue with the exercises because I would like to walk with a feeling of confidence, improve my posture, and stand up without hurting.”</div> <div> </div> <div>During the implementation process, wellness coordinators at each of SLC’s communities evaluate residents to establish a baseline for that individual’s lower-body strength. <br></div></div> <div>Coordinators collect data on each resident’s progress throughout the 16-week period, and problem areas are targeted for improvement. </div> <div> </div> <div><div>Although numeric data will be collected to accurately measure each resident’s progress, quality-of-life indicators such as the ability to walk further distances or go up and down stairs will also be considered signs of success. </div> <div><img width="214" height="145" class="ms-rtePosition-2" src="/Issues/2010/PublishingImages/1010/Caregiving%20Photo%20TWO.jpg" alt="" style="margin:15px;width:305px;height:179px;" /></div> <h3 class="ms-rteElement-H3">Prevention Is Key</h3></div> <div><div>Preventive health programs such as CLIMB will no doubt enjoy greater popularity as the baby boomer population ages. Medicare reimbursement continues to shrink, and providers will be required to implement affordable rehabilitative solutions that produce quick results. </div> <div> </div> <div>Simultaneously, many older adults and their children will find the cost of long term care prohibitive. This trend is already showcased by an increase in the number of home health agencies and geriatric care managers offering services that allow seniors to remain in their own homes as they age. </div> <div> </div> <div>With data collected from each community, residents will likely spread the word to their friends and neighbors about the relationship between exercise, strength training, and future independence.</div> <div> </div> <div>Homestead Hills member Sally Bost agrees that preventive wellness programs like CLIMB are beneficial for seniors and thinks the amount of effort people put into the program is directly related to the benefits they will receive. “It’s too easy to say, ‘Oh, you’re getting older, this is what you should expect,’” Bost says. “But I say, no way, you can’t quit just because you’re older!”</div> <div> </div> <div><em>Kelly Stranburg, M.Ed., is vice president of member services for Senior Living Communities, based in Charlotte, N.C. She can be reached at </em><a href="mailto:kstranburg@senior-living-communities.com"><em>kstranburg@senior-living-communities.com</em></a><em> or (704) 815-7334.</em><br></div></div>A provider’s wellness program champions lower-body strength as one way to prevent injury and boost independence.2010-10-01T04:00:00Z<img alt="" height="150" src="/Issues/2010/PublishingImages/1010/Caregiving-Photo-ONE.jpg" width="150" style="BORDER:0px solid;" />Caregiving;Clinical;Quality ImprovementColumn10
Providers Mine For Qualityhttps://www.providermagazine.com/Issues/2010/Pages/1010/Providers-Mine-For-Quality.aspxProviders Mine For Quality<p>​When challenged to document their commitment to quality, this year’s winners of the American Health Care Association/National Center for Assisted Living National Quality Awards answered the call by digging into their quality practices; tracking their progress; and identifying activities, programs, systems, and processes that make their facilities extraordinary and enable them to thrive and grow. </p> <div><div>The 505 recipients this year were selected in three categories—Bronze, Silver, and Gold (previously Step I, Step II, and Step III, respectively). </div> <h3 class="ms-rteElement-H3">Going For The Gold</h3></div> <div>Celebrating this year as the sole Gold recipient, and the first independently owned organization to receive the distinguished award, was Manchester Manor Health Care Center in Hartford, Conn. Administrator Mary Ellen Gaudette says, “I’ve been a nursing home administrator for 25 years, and this is the most exciting, rewarding honor I’ve ever received.” She adds, “Families, residents, and staff alike are so proud. One family member said that she can’t stop talking about it and bragging that her mother is at this home!”</div> <div> </div> <div>Going for the Gold was Gaudette’s goal from the start. Her facility received the Bronze and Silver awards after only one try. It took Manchester two years to obtain the Gold, but it was well worth the effort. “We wanted to do this to advance the profession and to show the evidence of our organization’s dedication to quality,” she says. “The award shows that you stretch and improve constantly and never stop pursuing improvement, even after you achieve goals.” </div> <div> </div> <div>How does a facility get from Bronze to Gold? “You go about it in small steps,” says Gaudette, adding, “As you get into the process and learn about the Baldrige criteria and how they work, the process becomes easier.”</div> <div>Writing the Gold application was a huge task, she says, but she says that she had a slight edge. She served as a senior examiner, reviewing Silver applications, which allowed her to gain insight into the process, how it works, and what constitutes a successful </div> <div>application. </div> <h3 class="ms-rteElement-H3">Telling The Facility’s Story</h3> <div>Gaudette, as well as other award recipients, stresses the importance of the application having a single voice. However, she says that this doesn’t mean that one person alone is involved in ensuring a successful application. “You must have the support from other people in the building. I had help with the writing, and I had help from others who enabled me to leave the building on occasion to focus on my writing.”</div> <div> </div> <div>Whoever writes the application, Gaudette says, “you have to write it as a story—the story of your facility and the great things you do, as well as those for which you are striving. You start the story with the Bronze, then go into greater depth and involve more data collection in the Silver. With the Gold, you are pulling together all of your systems and the great things you’ve worked on, tying everything together and showing comparisons with others in the state and nation.”</div> <div> </div> <div>Along the way, the facility enjoys many partnerships that make it successful, including relationships with other providers, vendors, staff, and volunteers. Staff involvement, in particular, is key. As Gaudette says, “As a facility, we honestly don’t make any decisions—including working on activities such as these Quality Awards—without staff input.” </div> <div> </div> <div>However, the lack of one partnership has enhanced Manchester’s success—nursing staff agencies. “We have a summer incentive program designed to encourage staff to keep shifts covered. Staff can earn points for picking up extra hours. They then can cash these points in at summer’s end for gift certificates.”</div> <div>The facility also has a winter incentive program in which staff with excellent attendance are eligibl'e for a drawing for a trip to Aruba or Disney World. </div> <div> </div> <div>While winning facilities were proud of their work, many didn’t realize just how far they had come until they saw it </div> <div>in black and white on their application. Many also appreciate the validation they received regarding the effectiveness of the processes and systems they have employed.</div> <div> </div> <div>“Through the application process, we learned that the system we used to grade ourselves on our efforts to improve quality and safety works. We practice ‘plan, do, check, and act,’ and our quality assurance system has earned us distinction from our peers because of our consistently positive outcomes,” says Judy Dunman, administrator at St. Elizabeth’s Place in Jonesboro, Ark., 2010 Silver recipient.</div> <h3 class="ms-rteElement-H3">Successful Facilities Share Qualities</h3> <div>Clearly, successful facilities share a passion for quality care. However, they also have other characteristic in common. For example, they all expressed a commitment to strategic planning. </div> <div> </div> <div>“When I read the application criteria, I thought that it correlated with what we do every year—our strategic action plan that aims at providing exceptional care, developing our people, focusing on our customers, and achieving operational excellence,” says Troy Guntulis, executive director of Windsor Rehabilitation and Healthcare Center-Kindred in Connecticut, 2010 Silver recipient. “Every year, we develop 16 strategic plans in several core areas.” He adds, “This fits right into the application. The strategic planning fosters independent thinking, empowers people, and enables everyone to see themselves in the organization’s future.”</div><div><br></div> <div>Facilities’ commitment to strategic planning often made the application process easier. As Brian Scheri, administrator at Mitchell-Hollingsworth Nursing and Rehabilitation Center, Florence, Ala., 2010 Silver recipient, says, “Without a plan, we wouldn’t even have been able to start. </div> <div> </div> <div>“At our meetings, we had dry erase boards and just blurted out ideas. Then we looked at everything in terms of what fit into the spirit of the award. They made writing assignments and set a schedule for completion.” </div> <div>The team started with a 40-page draft that they had to trim down to 18 pages. “We couldn’t have done that without planning, organization, and discipline,” Scheri adds.</div> <div> </div> <div>Dunman adds, “Before you begin the application process, you have to know your strengths and weaknesses. You have to evaluate your systems, set expectations, and then raise your expectations.”</div> <div> </div> <div>Facilities also share a knack for measuring outcomes and comparing results with other facilities statewide and nationwide. This isn’t always easy. As Renee Looker, executive director at Forestview Nursing Home of Wareham, in Massachusetts, 2010 Silver recipient, notes, her facility wanted to spotlight its Mind-Body-Spirit Program that offers free services such as aromatherapy, massage, Reiki, and music therapy. </div> <div> </div> <div>“It was challenging to measure outcomes and compare results, because no one else was doing the same thing. So we approached it in terms of measurable issues such as [quality indicators] on pain and medication use,” she says.Facilities receiving Gold and Silver awards share the honor with staff, residents, and family members alike. At Gaudette’s facility, they built a special trophy case for the Silver Award with a light “that shines on it all the time. It’s there for everyone to see, and we point it out to visitors.” She adds, “We’ll go beyond this with the Gold Award.” </div> <div> </div> <div>Brentwood Rehabilitation and Nursing Center in Yarmouth, Maine, celebrated “with a big barbeque for staff, residents, and families. We decorated with silver balloons—of course,” says Executive Director Dan Burns. </div> <div> </div> <div>Lori Cooper, administrator at Silver recipient Stonebrook Healthcare Center in Concord, Calif., says, “This means a lot to the whole state, because we were the only facility in California to obtain the Silver Award. We’ll make up T-shirts for staff and highlight it on our Web site. We’ll have a big celebration in October. </div> <div>“This is huge for us.”</div> <div> </div> <div>Many award recipients said that residents and families were as proud as staff. As Looker says, “They take ownership. We won this for quality, and that means a lot to them.” Residents are proud to live in a home where their needs, concerns, health, and safety are paramount, and families feel good that their loved one is recieving the best possible care.</div> <div> </div> <div>Most Silver and Bronze recipients are planning to pursue the next level. They are driven by pride and satisfaction. As Burns says, “The application validated the quality improvement process we have. It makes you look at the big picture, and we were able to document our successes. We discovered that we gave better customer service, which in turn made transitions of care easier. The opportunity to see how far we’ve come is priceless.”</div>When challenged to document their commitment to quality, this year’s winners of the American Health Care Association/National Center for Assisted Living National Quality Awards answered the call by digging into their quality practices; tracking their progress; and identifying activities, programs, systems, and processes that make their facilities extraordinary and enable them to thrive and grow. 2010-10-01T04:00:00Z<img alt="" height="740" src="/PublishingImages/default-article-image.png" width="740" style="BORDER:0px solid;" />Quality;Quality AwardsNational AHCA/NCAL Quality Awards10
Social Media: Know The Lawhttps://www.providermagazine.com/Issues/2010/Pages/1010/Social-Media-Know-The-Law.aspxSocial Media: Know The Law<p>​The use of Facebook, Twitter, and MySpace in the workplace is escalating, and employers should know the risks that come with it. </p> <p>Consider this hypothetical: An administrator in charge of hiring at her skilled nursing facility needs to find one new staff member and has five resumes, all of which appear adequate. What’s the first thing she does? That’s right, she Googles them.</p> <p>She scans through links to their high school class reunions, perhaps some noteworthy events that made the local papers, maybe even something they have written. Finally, she comes to a juicy link—a Facebook page. Aha! Now here’s the good stuff. </p> <p>But thinking before clicking is the best advice in this situation. Why? The legalities surrounding the ability to view an applicant’s Facebook page are not clear cut. Yes, employers are entitled to look at an applicant’s Facebook page, provided they meet certain requirements. And yes, employers are entitled to use what they find there, provided they do not use it in an inappropriate way. </p> <h3 class="ms-rteElement-H3">Avoid The Pitfalls</h3> <div>So how does one avoid the pitfalls of a potential lawsuit and still get to check out what the applicant has been </div> <div>Tweeting? </div> <div> </div> <div>First, the person in search of the information must access the page herself. Hiring a third party to do it, perhaps in conjunction with a criminal or credit background check, could be considered an act under the jurisdiction of the Fair Credit Reporting Act, which has notice and disclosure requirements that could render such an act illegal.</div> <div> </div> <div>Second, don’t be sneaky. Many applicants will have their Facebook or MySpace blocked. If it’s blocked, it’s blocked. Some of the more creative types may try to think of ways to access this information. Creating an alias account or trying to guess the passwords are “no nos.” The information needs to be publicly available. </div> <div> </div> <div>Using any sort of subterfuge to access an applicant’s information puts an employer at risk of a privacy lawsuit.</div> <div>The other way to generate a Facebook lawsuit is to use information the wrong way. This angle is a little stickier. The first thing to remember is that employers cannot discriminate against someone. This is as true in cyberspace as it is in person, which means that using any information discovered in a discriminatory manner cannot be used. </div> <div> </div> <div>Translation: Using Facebook to screen out applicants based on discriminatory criteria such as race, gender, religion, or disability is completely illegal. If caught doing it, employers will be sued. </div> <div> </div> <div>Enter the Genetic Information Nondiscrimination Act, or GINA. It has a cute name, but it’s a real problem for any employer that wants to check an applicant’s social media site. Under GINA, an employer is not permitted to acquire genetic information about employees or potential employees. </div> <div> </div> <div>Notice it says “acquire,” not “use.” There are exceptions to this law, but because it is relatively new, the courts have not given employers much guidance on where the lines are. The way the law is written now, if an employer checking an applicant’s Facebook page discovers that the applicant participated in a multiple sclerosis fund raiser on behalf of her father, that employer has just violated GINA. </div> <div> </div> <div>The employer has acquired genetic information, which triggers the violation even if it’s not used for any purpose. This is one area of the law to monitor as it develops.</div> <h3 class="ms-rteElement-H3">Protect Employee Rights</h3> <div>One hopes, by now, most employers know about the importance of social media policies (see Provider’s cover story, March 2010). With this in mind, it’s important to remember that employees have rights, the government has laws, and a policy can’t infringe on either.</div> <div> </div> <div>The National Labor Relations Act (NLRA) gives employees the right to engage in what’s called “concerted activity.” Generally, it protects employees’ rights to talk openly with one another and their employer about the terms and conditions of their employment. These protections apply regardless of whether the employees are unionized or not. </div> <div> </div> <div>The risk as an employer is that its policy may be overly broad and infringe on employees’ NLRA rights. There are a number of things that employers can and should restrict in their social media policies:</div> <ul><li>Confidential or proprietary information of the company and its clients, patients, and vendors;  </li> <li>Embargoed information such as launch dates of new upcoming services or products, release dates, and pending reorganizations;</li> <li>A company’s intellectual property, such as new ideas and innovations; </li> <li>Explicit sexual references;</li> <li>References to illegal drug use;</li> <li>Use of obscenity or profanity; and</li> <li>Disparagement or harassment of anyone on the grounds of race, religion, gender, sexual orientation, disability, or national origin.</li></ul> <div>There is one more thing that many employers would probably like to have, but must be careful about including in social media policies: restricting employees from disparaging the company or competitors’ products, services, executive leadership, employees, strategies, and business products.</div> <div> </div> <div>Disparaging comments can be very damaging to a company, but restricting them does come close to infringing on employee rights to comment on their employment conditions under the NLRA. There is some legal authority out there suggesting such restrictions are permissible, but it’s still a risky proposition.</div> <h3 class="ms-rteElement-H3">Watch Those Testimonials</h3> <div>The National Labor Relations Board (NLRB), the entity charged with enforcing the NLRA, recently underwent a seismic shift in its makeup, and many observers expect it to take a much harder line against employers allegedly in violation of the act.</div> <div> </div> <div>As much as employers may want to include this in their social media policy, the prudent course of action for now is not to. If the law changes or even gets clarified, having this restriction could put an employer at the wrong end of an Unfair Labor Practice Charge before the NLRB.  Better to wait until the issue has been settled.</div> <h3 class="ms-rteElement-H3">FTC Weighs In</h3> <div>The NLRA is not the only federal regulation creating new risks for employers and social media. The Federal Trade Commission (FTC) has promulgated a rule that requires people providing endorsements or testimonials about a company’s products to disclose any material connections they may have to the company that produces the product or service. Huh?</div> <div> </div> <div>In non-legalese, this means that if a company develops a brand new widget, its employees cannot go around anonymously posting on blogs and social media sites this new widget is the best ever. The key word in that sentence is anonymously. Employees are certainly free to provide endorsements or testimonials about the widget, but FTC guidelines require that they identify themselves as employees of the company.</div> <div> </div> <div>The rationale behind this is that consumers are entitled to consider this material interest in assigning credibility to the testimonial. </div> <h3 class="ms-rteElement-H3">Devise Social Media Policies</h3> <div>There’s a lot more to say about the risks of social media, but all articles must come to an end. A good parting thought to keep in mind is that while social media policies are a necessity, they are not a panacea. They must be drafted well and enforced appropriately. Whether using social media to learn more about potential new employees or attempting to implement a social media policy to protect the company, the path is fraught with risks and liability. </div> <div> </div> <div>The Internet owes its vibrancy in large part to the veil of anonymity people feel when they use it. As law and technology start to catch up, employers can no longer simply assume that what happens on the Web, stays on the Web. They need to create meaningful policies, follow them, and stay vigilant. </div> <div> </div> <div>John Cruickshank is an attorney at Alaniz and Schraeder, a national labor and employment firm based in Houston. He is an experienced trial attorney and a former assistant district attorney for Fort Bend County, Texas. Cruickshank can be contacted at (281) 833-2200 or jcruick<a href="mailto:shank@alaniz-schraeder.com">shank@alaniz-schraeder.com</a>. </div>It may now be easier to find information about prospects on the Internet, but being able to use it is another story. 2010-10-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/socialmedia.jpg" style="BORDER:0px solid;" />Legal;TechnologyTechnology in Health Care10
Web Tools Speed Claims Processinghttps://www.providermagazine.com/Issues/2010/Pages/1010/Web-Tools-Speed-Claims-Processing.aspxWeb Tools Speed Claims Processing<p>​Today, the pressure to reduce health care costs is everywhere. And nowhere is that more evident than within the Medicare system. With approximately 36 percent of national health care expenditures generated by the Centers for Medicare & Medicaid Services, the federal government is actively pursuing initiatives to reduce its program costs. </p> <p>Long term and post-acute care organizations are particularly affected by these changes, and Medicare often represents a significant portion of their revenue. Initiatives that reduce expenses and assert more control over their Medicare revenue cycles are therefore of primary importance to providers. </p> <p>It doesn’t take a huge investment to utilize readily available technologies to realize big gains in productivity and revenue cycle management, as the following four testimonies illustrate. </p> <h3 class="ms-rteElement-H3">Shorten Revenue Cycle</h3> <div>GentleCare Home Health in Dallas offers a good example for how long term care providers can improve Medicare cash flow using technology. Faced with a growing senior citizen population whose Medicare coverage generates the majority of its revenue, Henry Fofang, GentleCare’s administrator, needed a new strategy to accommodate increased Medicare volume without adding administrative staff.</div> <div> </div> <div>After analyzing the organization’s cash flow and the time it took to submit each Medicare claim, Fofang decided to send his claims directly to Medicare, instead of outsourcing to a billing company. By doing so, he estimated a resulting cost savings of 50 percent, while shortening his revenue cycle by three days.</div> <div> </div> <div>Fofang was able to implement this strategy by leveraging GentleCare’s existing Internet connection to access the entire Medicare workflow electronically—from claims submission to payment. By working with an approved third party that provided GentleCare with secure, direct access to Medicare’s systems, the home health company was able to improve the speed and accuracy of its billing cycle.</div> <div> </div> <div>GentleCare Home Health also has implemented batch claims processing software. Rather than submitting Medicare claims one at a time, Fofang’s staff can now submit a group of claims at once. This allows his team to focus on a certain task for a period of time instead of switching back and forth between tasks, claim by claim.</div> <div> </div> <div>His team can also use the batch function to check Medicare claim status. GentleCare uploads a group of outstanding claims to Medicare’s online claims status request function and receives a batch of claims status response files, in return.</div> <div> </div> <div>By doing so, GentleCare is able to identify and address claim issues quickly to speed up payment. This also makes it easier for the organization to spot opportunities to improve its claims submission process, such as identifying diagnostic codes that may be used incorrectly, facilitating lower denial rates and a shorter revenue cycle.</div> <div> </div> <div>According to Fofang, “I wanted to bring our billing in-house to reduce expenses and gain more control over my cash flow. I now know when our Medicare claims go out, what their status is, and when they get paid. It’s made the entire billing process much easier.”</div> <h3 class="ms-rteElement-H3">Accelerate Cash Deposits</h3> <div>Beyond electronic claims submission and batch processing, GentleCare and other providers are taking advantage of Electronic Remittance Advice (ERA), which is an electronic version of the Standard Paper Remittance (SPR). ERA allows a provider to receive all of the information contained on an SPR in an easy-to-read-and-store electronic format.</div> <div> </div> <div>ERA can be used to automatically post claims payment information into an accounts receivable system, and any provider with an active submitter identification number may apply to receive ERA files or have the ERA forwarded to another party, such as a billing agency, vendor, or clearinghouse that submits claims on behalf of the provider.</div> <div> </div> <div>A major benefit of an ERA is that it provides the electronic equivalent of the Explanation of Payment several days sooner than the paper posting. While providers can use a claim status request function to determine the corrective action needed to move a claim through the approval process, an ERA enables a provider to uncover trends in claims that are paid, partially paid, or denied.</div> <div> </div> <div>Neetra Barclay, director of financial services at Glastonbury Health Care Center in Connecticut, currently uses both claims status requests and ERA. Before, it would take days after she submitted claims to find out if they had been accepted by Medicare, and she received all her remittance advice via paper.</div> <div> </div> <div>By accessing the Medicare workflow electronically, Barclay says, “It increases productivity and makes my job much easier because I have access to all the information that I need immediately.”</div> <div> </div> <div>For those whose practice management systems are configured to accept ERA, the payment information can also be automatically posted to each patient account. This makes it much simpler to track patient balances and conduct follow-up steps, such as submitting claims to other insurers for secondary payment.</div> <div> </div> <div>Electronic Funds Transfer (EFT) is a useful companion to ERA. Already widely used in most industries, EFT allows Medicare to deposit payments directly into a provider’s account. In addition to saving time and reducing the amount of paper in an office, providers also gain faster access to funds because banks often credit direct deposits faster than paper checks. </div> <div> </div> <div>Providers also receive an addenda record in addition to the EFT, so they are able to reassociate the dollars in the EFT to their outstanding claims and close the loop on their Medicare billing cycle.</div> <h3 class="ms-rteElement-H3">Speed Up Eligibility Verification</h3> <div>Perhaps one of the most important tools for managing the Medicare revenue cycle is electronic Medicare eligibility verification. It helps prevent billing issues from the beginning by giving providers information about a patient’s eligibility for services before care is provided.</div> <div> </div> <div>Jacob Perlow Hospice, located in New York City, regularly uses Medicare eligibility verification in its day-to-day operations. The hospice is a large facility that generates 86 percent of its revenue from Medicare. </div> <div>Allison Maughn, chief operating officer, explains that she needed to update the hospice’s Medicare billing process to meet its increasing Medicare volume. When Jacob Perlow switched from dial-up to broadband for submitting its claims directly to Medicare, the facility also took advantage of the ability to check patient Medicare eligibility electronically.</div> <div> </div> <div>Jacob Perlow is able to determine the Medicare program benefits available to its patients by accessing eligibility data within just a few seconds, directly from Medicare’s systems.</div> <div> </div> <div>By combining electronic eligibility checks with direct claims submission to Medicare via broadband technology, the hospice was able to eliminate time-consuming eligibility verification via phone, significantly reduce its claims denial rate, and process more than 600 Medicare claims each month with just two employees. </div> <h3 class="ms-rteElement-H3">Upgrade To Broadband</h3> <div>Providers do not need to add staff or make large technology investments to enjoy the benefits of these tools for managing Medicare billing in-house. In fact, because these technologies eliminate manual processes, reduce data entry, and speed up the payment process, providers are able to handle a growing claims volume with the same team or reallocate staff to other functions where they are needed.</div> <div> </div> <div>For example, Hospice Family Care, Mesa, Ariz., was already billing directly to Medicare but was using a dial-up connection. Six people processed claims: three full-time billers and three back-up staff members.</div> <div> </div> <div>By upgrading from dial-up to broadband and implementing electronic eligibility verification, the hospice was able to handle a growing volume of Medicare business and free up all three back-up staff to focus on their primary responsibilities.</div> <div> </div> <div>“The employee time is our biggest benefit, as we now have less people doing more,” says Enrique Ramirez, Hospice Family Care’s regional information systems director. “Before it would take a full day to process Medicare claims, and now it’s just a few hours of work.”</div> <div> </div> <div>With the baby boomer generation near retirement, experts predict a significant uptick in Medicare volume. Fortunately, by making better use of technology that is readily accessible and does not require additional staff to manage, health care providers can institute more control over cash flow now and prepare for an increased work load in the future.</div> <div> </div> <div><em>Clare DeNicola is president and chief executive officer of IVANS, a strategic consulting company that provides fully managed network, electronic data interchange, and agency-company interface solutions to help solve complex business issues. DeNicola can be reached at (203) 698-7209 or clare.denicola@ivans.com.</em></div>It doesn’t take a huge investment to utilize readily available technologies to realize big gains in productivity and revenue cycle management, as the following four testimonies illustrate.2010-10-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/tech_2.jpg" style="BORDER:0px solid;" />Column10

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Family Engagement In Nursing Care Bolsters Qualityhttps://www.providermagazine.com/Issues/2010/Pages/1110/Family-Engagement-In-Nursing-Care-Bolsters-Quality.aspxFamily Engagement In Nursing Care Bolsters Quality<div>Family members are a crucial part of a team approach to resident and patient care. This is especially so when a family member is serving in a health care proxy role. The intensely busy schedules of staff in long term and post-acute care facilities make it even more important to work collaboratively with family members. </div> <div> </div> <div>A systems approach to family collaboration is one in which the organization as a whole—in this case the facility—and each of its components, such as admissions, nursing, activities, housekeeping, and therapy, take an interdependent approach to caregiving. </div> <div> </div> <div>A facility that implements a systems approach to family collaboration examines the overall structures, patterns, and cycles in systems, rather than seeing only specific events in the system. </div> <div> </div> <div>Focusing on the entire system can help facility leaders identify solutions that address as many problems as possible in the system. </div> <div><h3 class="ms-rteElement-H3">The Family’s Viewpoint</h3> <div>Family members see only the care provided during the part of the day they are present. While this may seem obvious, caregivers working eight or more hours a day sometimes fail to appreciate that a <a title="Formalizing Family Involvement" href="/Issues/2010/Pages/1110/Formalizing-Family-Involvement.aspx">family member’s impression</a> may be based on the observations of only a few moments of care. </div> <div> </div> <div>Viewing this from a systems perspective, what a person sees today at 1:00 p.m. is all he or she can know about the organization as a whole. This makes every moment important, but it also helps staff understand why it is sometimes hard for family members to believe their mother or father was cheerful all week, when what they see today does not support that claim.</div> <div> </div> <div>A systems approach means that facility staff would first listen to families’ concerns and then provide them with information about what has taken place when they were not present. If the family members generally visit in the afternoon, invite them for an evening or a breakfast visit. Share specific anecdotes about times when they are not there. This can be very reassuring for families, especially when they feel their views have also been heard.</div> <div> </div> <div>It is also helpful to understand that many family members are going through their own struggles. Adjusting to the move of a mother, father, husband, wife, child, or other loved one into long term care is a major life transition.</div> <div> </div> <div>In meeting the challenge of appreciating a family member’s viewpoint, it is helpful to understand that the individual who visits the facility is usually someone who cares a great deal. Developing a connection with him or her will help to support the resident’s care.</div></div> <div><h3 class="ms-rteElement-H3">Think Holistically</h3> <div>In addition to seeing only moments of the full range of care, it is important to understand that family members who visit do not usually think separately about the different care venues.</div> <div> </div> <div>For example, nursing, activities, and rehabilitation are seen as part of the whole organization, and the actions of one staff member in one area will affect the family member’s perception of the entire facility. </div> <div> </div> <div>Thinking of the whole organization as part and parcel of the solution is key to successful collaboration with family members. </div> <div> </div> <div>In an example from one facility, a family member was sitting with her loved one at a meal when one of the assistants shouted at a resident and pulled her by the arm for trying to get something from the refrigerator.</div> <div> </div> <div>How the other assistants or nurses respond to situations of this nature is critical. If no one addresses the action in any way, a family member witnessing this can only assume this is normal.</div> <div> </div> <div>In another example, a family member saw that her loved one, sitting in a wheelchair, was locked in place, literally facing the corner of the room. In shock, she asked an assistant what was going on. The assistant immediately apologized, went to the nurse, and expressed concern that this had happened. Thus, the family member considered this to be an anomaly as opposed to a normal event.</div></div> <div><h3 class="ms-rteElement-H3">Mission Should Reflect Culture</h3> <div>Does the organization have a stated vision or mission for responding to family members? Does everyone in the organization know about and share this vision? If not, developing a statement that clarifies expectations of staff toward family members is very helpful.</div> <div> </div> <div>If there is a stated mission or vision, is this the actual culture of the organization? That is, while one organization may say they intend to welcome family members, the daily reality may be quite different. It is important for facility leaders to determine what the actual daily response is to family members. </div> <div> </div> <div>In one facility, when family members walk into the living area, assistants look away and whisper with each other, ignoring the family member. In another, the assistants greet the families warmly and ask how they are doing.</div> <div> </div> <div>All members of the facility impact the family members’ experience. For example, in the elevator, when the building supervisor or grounds crew say hello, it makes the family member feel positive about the facility. </div></div> <div><h3 class="ms-rteElement-H3">Create Feedback Loops </h3> <div>Develop a specific protocol for staff and family to give suggestions and new ideas. Openness to <a title="Technology Keeps Families Informed" href="/Issues/2010/Pages/1110/Technology-Keeps-Families-Informed.aspx">new ideas</a> allows for continual development. While most administrators tend to agree with these concepts, it takes real commitment to be willing to consider ideas that are different or unexpected. </div> <div> </div> <div>Offer a variety of venues for staff, family, and residents to provide suggestions. At the same time, management should be given opportunities to discuss new ideas and get back to families, staff, and residents about those ideas. </div> <div> </div> <div>It is also important to respond in a timely way. Calls from family members should be returned within 24 hours. If an employee doesn’t know the answer to a question, she should say so and give a time when she will respond. </div> <div> </div> <div>Follow through on all promises. In one facility, the family member, having followed clothing directions carefully and asked repeatedly about their whereabouts, found her parent’s clothes strewn about the floor in an unmarked basement storage area. In another facility, all the resident’s clothes are carefully washed, organized, and placed back in their own personal locked closet.</div> <div> </div> <div>Do not underestimate the importance of how personal effects are managed or treated. It can be perceived as an extension of the perception of the quality of care.</div></div> <div><h3 class="ms-rteElement-H3">Listen</h3> <div>It is critically important to listen and to do so with the least amount of contention as is possible. Listen to the whole story, the whole concern, the whole issue, before venturing suggestions. </div> <div> </div> <div>A family member may have helpful ideas. Family members cannot know or understand an organization’s expectations, rules, or way of doing things unless they are informed of them.</div> <div> </div> <div>Are assistants encouraged to talk with family? Are a family’s questions encouraged and appreciated? Is it very different depending on whose shift it is? These are all cultural aspects that administrators should be able to answer. Attending to vision, goals, culture, follow-up, and commitments can make the entire difference in people’s lives as residents. </div> <div> </div> <div>It can also make the difference for those family members who are involved. </div> <div> </div> <div>A systems perspective suggests that supporting a culture that is <a title="Educating Family Members" href="/Issues/2010/Pages/1110/Educating-Family-Members.aspx">inclusive</a>, engaged, communicative, and upbeat will be most likely to support the best patient care and the best community for all involved. </div> <div><em></em> </div></div> <div><em>Jeannette Gerzon, EdD, SPHR, based in Belmont, Mass., is an organization </em><em>development consultant, trainer, and licensed psychologist. She can be reached at </em><a title="email Jeannette" href="mailto:jgerzon1@verizon.net"><em>jgerzon1@verizon.net</em></a><em>.</em>​</div>Family members are a crucial part of a team approach to resident and patient care. This is especially so when a family member is serving in a health care proxy role.2010-11-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_family_1.jpg" style="BORDER:0px solid;" />Caregiving;Management;Quality ImprovementColumn11
GPS Use Raises Legal Concernshttps://www.providermagazine.com/Issues/2010/Pages/1110/GPS-Use-Raises-Legal-Concerns.aspxGPS Use Raises Legal Concerns <p>​<span lang="EN">The use of global positioning systems (GPS), sometimes referred to as real-time location systems (RTLS), to track the movement of individuals is being introduced to the care of the elderly and individuals with disabilities. In recent years, GPS has been used for military and law enforcement purposes and to keep track of vehicles, equipment, pets, and even children.</span></p> <p><span lang="EN"></span><span lang="EN">These systems are raising new challenges to the privacy protections that Americans have come to expect over the past 50 years. Some caution that the use of monitoring devices could usher in a dystopian, Big Brother era. Others are more optimistic about the ability of human beings to use this technology for the greater good. </span></p><div>With people living longer and suffering alarmingly high rates of Alzheimers disease and similar cognitive disorders, GPS has been introduced to help prevent people from wandering away or wandering into unsafe situations. </div> <h3 class="ms-rteElement-H3">The Privacy Concern</h3> <div>On one hand, use of GPS could enhance freedom for these vulnerable groups by allowing them to venture farther from protected environments and to live in the community rather than in facilities. </div> <div>It may also be possible to achieve efficiencies that lower the cost of care in some circumstances, an important consideration as the wave of baby boomers threatens to crush the economy with the sheer enormity of its health care needs.</div> <div> </div> <div>In the wrong hands, however, GPS could be used to monitor and control vulnerable populations in a way that unnecessarily curtails individual freedom. It is not only elderly people with Alzheimers who are at risk, but people with mental illness and mental disabilities as well.</div> <div> </div> <div>GPS receivers can be hidden in shoes, cell phones, watches, and handbags, raising the question of whether it is ever acceptable public policy to monitor certain people secretly for their own good. </div> <div>The use of GPS has been analyzed by the courts under the fourth amendment of the Constitution, which protects citizens from unreasonable searches and seizures. </div> <div> </div> <div>The protection of the fourth amendment turns on the question of whether an individual has a reasonable expectation of privacy. In private homes, for example, people have a high expectation of privacy, but courts have found the expectation of privacy is reduced when curtains are left open or a person steps out to a balcony where he can be observed by the naked eye or videotaped without specialized equipment. </div> <div> </div> <div>In the law enforcement context, courts are divided about whether GPS monitoring violates the fourth amendment if it is conducted without probable cause and a court order. One court found that use of GPS attached to a vehicle did not violate the fourth amendment because there is no reasonable expectation of privacy on a public road. </div> <div> </div> <div>In another more recent case, however, the surreptitious placement of a GPS device under the carriage of a van and the monitoring of the vans movements over a period of months were found to violate the fourth amendment.</div> <h3 class="ms-rteElement-H3">Weighing The Benefits</h3> <div>An individual with dementia or mental disabilities is generally entitled to the same privacy protections as the general population, subject to measures that may be necessary to protect the individual from injuring herself or others. Licensed nursing facilities are required under the Medicare conditions of participation to refrain from unnecessarily restraining residents and to promote self-determination and dignity. </div> <div> </div> <div>Various governing bodies, including the United Nations, have issued declarations concerning the rights of individuals with mental disabilities to be accorded, to the maximum degree of feasibility, the same rights as other human beings.</div> <div> </div> <div>An important principle in the care of people diagnosed with Alzheimers disease is that they should be treated like adults, not children. </div> <div> </div> <div>A person who has an infirmity or mental disability does not lose the right to be afforded the same privacy rights generally afforded to adults in society. In light of these generally accepted principles, the best practice would be to obtain consent from individuals before implementing GPS monitoring. When consent is not practicable but protection is necessary, the severity of the potential harm should be weighed against the benefit of protection afforded by the invasion of privacy. </div> <div> </div> <div>GPS devices can be useful in facilities for managing wandering residents and residents at risk for resident-on-resident abuse. Such RTLS devices can be individually programmed to trigger an alarm if a resident gets too close to a particular elevator, door, or another resident.</div> <h3 class="ms-rteElement-H3">Monitoring Independent Living</h3> <div>GPS can also be used in the home or assisted living setting, with alarms that alert caregivers if an individual at risk for wandering tries to leave the house or enter an area of a residence that is unsafe, such as the kitchen. Individuals with milder dementias can be monitored with GPS when they are out of the house in the community, and such individuals can use the devices for help in navigating their way home if they are prone to becoming disoriented.</div> <div> </div> <div>Although expectations of privacy are generally lower in the public domain, they are not absent. Monitoring of vulnerable individuals should be kept to the absolute minimum necessary, as many people consider their activities in the community to be personal and private.</div> <div> </div> <div>In facilities that specialize in care of people with Alzheimers disease or mental disabilities, it may be possible to make the use of GPS a condition of admission, but providers should check with their legal counsel for advice about their particular states law in this area. </div> <h3 class="ms-rteElement-H3">No Substitute For Face-To-Face Care</h3> <div>Whether use is mandatory or voluntary, GPS should not be used as a substitute for face-to-face interactions. Implementation of the devices would require staff education and monitoring to ensure that the devices are used as an adjunct to visual checks rather than supplanting them. A potential downside of GPS technology is that it is easy to imagine staff relying on the computer screen to track residents when the better practice would be to make rounds and check in with residents personally.</div> <div> </div> <div>In fact, residents are at risk of becoming more isolated while being monitored electronically, to the detriment of their overall quality of life. </div> <div> </div> <div>In addition to privacy and quality-of-care concerns, providers may be concerned about whether GPS data can be used on them. Could a government investigator or a plaintiffs attorney turn the tables and monitor the facility? </div> <div> </div> <div>To the extent GPS data are collected and saved, they would likely be subject to audit and discovery. It probably is not feasible to limit the amount of time the data are retained because electronic data can always be recovered from hard drives, even if they have been deleted. </div> <div> </div> <div>On balance, GPS data probably have as much potential to help a facility establish that appropriate care was given as to hurt a facility where there was a departure from the standard of care, and is probably no more damaging than written documentation or the lack thereof. </div> <div> </div> <div>If GPS is implemented, it is important to ensure its proper use. For example, there should be a system in place to ensure that the devices cannot be removed by a resident. If a resident at risk of wandering could remove the device, leave it on his bed, and wander to an unsafe location and if staff were not also using visual checks to verify the residents location, the improper reliance on the device could form the basis for a claim of negligence or substandard care. </div> <h3 class="ms-rteElement-H3">Review Service Agreements</h3> <div>Finally, if use of GPS becomes a standard of care in the future, those facilities that do not adopt the technology could risk liability for incidents that could have been prevented by GPS use. The industry is not there yet, however. </div> <div> </div> <div>Providers that decide to purchase GPS tracking systems should be aware when presented with a vendors contract. As with any software or electronic systems, service agreements should be reviewed thoughtfully to ensure that the vendor is responsible for maintaining the system, providing training and support, and upgrading if necessary to achieve regulatory compliance. </div> <div> </div> <div>Providers are better protected by contracts that specify the maximum amount of downtime, hours and levels of support services, and after-hours support. Gag rules, which can prevent a user from telling other providers about problems with a system, and sunset clauses, which allow a vendor to discontinue older versions of a system, should be avoided. </div> <div> </div> <i><div>Kathleen Carver Cheney, partner with Duane Morris, represents a range of health care providers with a focus on long term care and post-acute care. Cheney has a clinical background as a nurse leader, combined with 15 years of health care transactional and regulatory experience. She can be reached at: kccheney@duanemorris.com or (212) 692-1097. </div></i><p></p> A legal expert examines the benefits and potential pitfalls of utilizing global positioning systems to monitor residents.2010-11-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/legal_1.jpg" style="BORDER:0px solid;" />Legal;Management;WorkforceHuman Resources11
Lawyers Baiting The Hook With Nursing Hourshttps://www.providermagazine.com/Issues/2010/Pages/1110/Lawyers-Baiting-The-With-Nursing-Hours.aspxLawyers Baiting The Hook With Nursing Hours<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000"></a><span>a</span><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><span></span></div> <div>No reasonable person could have anticipated the stunning $677 million jury award levied against Skilled Healthcare Group last July for a case in which the plaintiffs did not allege any harm had occurred to any patient, says Mark Reagan, managing partner of Hooper, Lundy, and Bookman out of their San Francisco office. Reagan and partner Scott Kiepen were regulatory counsels for the Skilled Healthcare case.</div> <div> </div> <div>Rather, the plaintiffs’ charge was that Skilled Healthcare’s 22 California facilities had failed to meet a purported regulatory requirement to provide an average of 3.2 hours of nursing care per patient per day, a charge the company still maintains is false.</div> <div> </div> <div><h3 class="ms-rteElement-H3">Unexpected Results</h3> <div>In fact, attorneys involved in the case fully expected it would be dismissed. In 2007, the California Supreme Court in Alvarado vs. Selma Convalescent Hospital upheld a superior court’s dismissal of a similar class action case, holding that “calculating staffing pursuant to 1276.5 [a California Health and Safety Code that was also used in the Skilled Healthcare case] was better left to the administrative agency charged with regulatory oversight rather than trial courts,” says Kippy Wroten, lead trial counsel for the Skilled Healthcare case. </div> <div> </div> <div>“For that reason it was felt that this judge would follow the wisdom of the Alvarado court, but obviously he did not.” Instead, not only did Judge Bruce Watson of Superior Court in Humboldt County, Calif., take the case, he exhibited behavior and made numerous rulings that caused defense attorneys to seriously question his impartiality.</div></div> <div> </div> <div><h3 class="ms-rteElement-H3">Patient Harm Not The Issue</h3> <div>The case is disturbing on many levels, observers note, but perhaps the most disturbing aspect is that a case with no allegation of patient harm led to such a massive award. The plaintiffs’ primary allegation—that the company had violated a vague staffing statute—had no regulations as required by the statute, nor any legal precedents to back it up and help a court determine whether and in what way the purported staffing requirement should be enforced, defense attorneys say.</div> <div> </div> <div>“Without legislative and regulatory change, you can expect to see more of the same type of <a href="/Issues/2010/Pages/1110/A-Voice-Of-Calm.aspx">lawsuit </a>in the future against other health care providers,” says Wroten.</div> <div> </div> <div>“It’s a strange, sordid tale,” says Reagan. “I don’t think anyone, whether it was us or anybody else involved in this case, could have reasonably expected any outcome that was so aberrant and so outrageous given the facts here, by virtue of … the combination of a judge misunderstanding and misinterpreting the law and a jury taking [his] instructions and applying the maximum amount of damages,” he says. “It really turned existing law on its head.” </div> <div> </div> <div>Long term care defense attorneys report that staffing regulations used as a foot in the door to sue providers is occurring with greater frequency, and it’s a trend that alarms them. </div></div> <div><h3 class="ms-rteElement-H3">Attorneys See Disturbing Trends</h3> <div>Both in California and across the nation, Reagan says he has seen “an increased collapsing of the regulatory system in the civil liability system.” </div> <div> </div> <div>This happened several years ago in Florida, he says, when an increase in <a href="/Issues/2010/Pages/1110/Case-Studies-Tell-The-Story.aspx">patients’ rights litigation </a>resulted in so many lawsuits that insurers were forced to raise their liability rates to unprecedentedly high levels. The state saw an exodus of multifacility operators because they simply could not afford the dramatically increased liability insurance costs. </div> <div> </div> <div>Although Reagan and Kiepen are hopeful that cases in other parts of the country will receive a more rigorous review of the law and face a more impartial judge than Skilled Healthcare confronted, Darren McKinney of the American Tort Reform Association expresses alarm. “It is and ought to be seen as a big warning horn. The storm is rising, it’s over the horizon, and if you don’t batten down the hatches” you might just get swept overboard, he says. The Skilled Healthcare case’s outcome “speaks volumes about where long term care litigation could go if policy makers don’t soon get a handle on it.”</div> <div> </div> <div>“Very generally speaking, the plaintiffs’ bar has increasingly, for the last several years, begun to target long term care companies,” says McKinney. Personal injury lawyers are working at both the state and federal level, with legislators who are “bought and paid for,” says McKinney, to have legislation passed that would make it easier to bring lawsuits and to increase providers’ liability, “and so you’ve got not only legislative efforts under way, but the frequency of actual lawsuits against long term care providers has been steadily increasing.”</div> <div> </div> <div>And staffing levels are increasingly being used to show that a long term care company was willfully negligent in its care for patients.</div></div> <div><h3 class="ms-rteElement-H3">Staffing Levels Under Fire</h3> <div>Priscilla Shoemaker, legal counsel for the American Health Care Association (AHCA), is concerned that the litigation situation is returning to something like what it was in the late 1990s, when cases went all the way through litigation rather than being settled early on. The result was high jury verdicts with additional punitive damage awards that, in turn, drove liability costs so high in some states, such as Florida, Arkansas, and Texas, that some providers were forced to close their doors or divest themselves of facilities in those states. </div> <div> </div> <div>“We’re seeing a new explosion of tort litigation resulting in jury verdicts for excessiveley high amounts,” Shoemaker says. And a key complaint being used to attack long term care companies in these cases, she says, is inadequate staffing levels.</div> <div> </div> <div>The Skilled Healthcare decision is different from many recent cases in that there was no claim of any patient harm. But the focus on staffing is the same. In the more typical case today, harm is alleged and then blamed on understaffing, says Shoemaker. “There always seems to be this inference that staffing is not up to par,” she says.</div> <div> </div> <div>The other trend that Shoemaker is seeing is that parent companies are being held liable along with their targeted facilities. </div> <div> </div> <div>In July 2010, a Sacramento, Calif., court ruled there was “…overwhelming evidence of the corporate defendants [Horizon West] running their business based, time and again, predominantly on a concern for the bottom line on the financial reports instead of any focus on compassionate patient care.” No surprise, understaffing was alleged in this case, too, and the plaintiffs’ award was approximately $29 million, with $28 million of it in punitive damages.</div></div> <div><h3 class="ms-rteElement-H3">Going After The Corporation</h3> <div>Perhaps the focus on staffing is precisely to take the case to the parent corporation, whose pockets are deeper, observers note. “Staffing is being argued as a fundamental corporate responsibility,” says Shoemaker. The corporation is supposed to know whether staffing is adequate. If it’s not, “that may be willful and intentional disregard for patient safety, which under some states’ statutes and regulations triggers the additional assessment of punitive damages,” she says. </div> <div> </div> <div>In Pennsylvania, “we’re seeing staffing levels as a predominant theme” in lawsuits being brought against long term care facilities or companies, says Stuart O’Neal, a member of the Pennsylvania Health Care Association’s Tort Liability Committee and a private attorney defending medical malpractice and long term care cases throughout the state. </div> <div> </div> <div>Pennsylvania is an attractive venue for some personal injury lawyers because it hasn’t had tort reform and has no caps on awards, says O’Neal.</div> <div> </div> <div>“The baseline allegation,” he says, is that long term care organizations are putting profits over people—that “a facility will understaff intentionally, knowing that the quality of care will suffer,” he says. Regardless of the kind of case it is—be it wound care, failure to thrive, or slips and falls—“it’s the same kind of complaint over and over again where they focus on staffing levels,” he says.</div></div> <div><h3 class="ms-rteElement-H3">Steps To Take</h3> <div>Long term care providers can protect themselves from these major jury awards in four main ways: providing quality care and meeting regulatory requirements, creating a system that ensures thorough and accurate documentation of every aspect of care and staffing, being prepared for possible testimony by ex-employees, and providing new residents the opportunity to sign carefully crafted alternative dispute resolution agreements, experts say.</div> <div> </div> <div>1. First, do no harm.</div> <div>It’s self-evident that the most important thing providers can do to keep from losing a lawsuit alleging negligence or abuse is to make sure that they are providing quality care and complying with all regulations. Because staffing levels are receiving so much attention, it’s important to make sure a facility is staffed appropriately for the facility’s acuity level, say attorneys, and that it always at the very least meets the state’s minimum requirements.</div> <div> </div> <div>“Every provider needs to incorporate staffing requirements as part of its compliance program,” says Kiepen. </div> <div> </div> <div>“One thing providers need to know is that any cracks in your regulatory compliance are potentially exploitable by trial lawyers; that is, trial lawyers are going to be looking for regulatory noncompliance just as regulators are,” says Reagan. </div> <div> </div> <div>And to prove that compliance, accurate and thorough documentation is essential.</div></div> <div> </div> <div>2. Documentation can win a lawsuit.<br>A good defense in the event of a lawsuit will require supporting documentation to prove that the facility did, in fact, comply with regulations, says Reagan. “There is a very high premium placed on maintaining accurate and supportable documentation.” </div> <div> </div> <div>Providers would also be wise to evaluate the documentation systems they maintain and consider eliminating or augmenting certain documents to be sure plaintiffs’ lawyers cannot later misconstrue their purpose and use the documents against them.</div> <div> </div> <div>For example, take a company that has internal documents, some of which are designed to provide operators with a general snapshot of a facility’s daily compliance and others of which are prepared later and take into account various operational issues so providers can track trends and confirm actual compliance. If they’re sued, the documents designed to merely provide a general snapshot of compliance can actually work against them.</div> <div> </div> <div>Plaintiffs’ lawyers argue to jurors, who are unfamiliar with the intricacies of systems for tracking employee hours and patient census, for example, that the snapshot documentation is inaccurate—and providers find themselves arguing against their own documentation to defend themselves, trying to explain that the documentation was not designed to be used in the manner plaintiffs allege.</div> <div><h3 class="ms-rteElement-H3">Teach Documentation Skills</h3> <div>Providers need to conduct frequent in-services on documentation, says O’Neal, so that details about things like when a resident received a bath, or when the resident left the facility to go to a hospital, for example, are written down and kept in such a way to make them easily accessible, even four or six years later. </div> <div> </div> <div>If the documentation is “not filled out properly—doesn’t have the date or the time, or consists of very short and abbreviated entries, or doesn’t track pain appropriately, those are all easy targets for plaintiffs to latch onto and show injury,” O’Neal says. </div> <div> </div> <div>If a resident has a fall, is transferred to a hospital, has a severe change in condition, or the family or physician is notified of an event or situation regarding a resident—all of that needs to be neatly, accurately, and thoroughly documented, along with staff schedules, with the census calculated to make sure that the staffing level is in accordance with state laws, so that allegations can be rebutted with proof, he says. </div> <div> </div> <div>When a facility has that kind of proof, “those claims are more defensible,” says O’Neal. </div> <div> </div> <div>3. Protect the facility from testimony by ex-employees.</div> <div>Another element that often crops up in litigation involving long term care organizations is testimony from ex-employees, says O’Neal. “Disgruntled ex-employees will testify that the facility was understaffed, and that the facility knew about the understaffing and didn’t do anything about it, and put the residents at an increased risk of harm.” Even unsubstantiated testimony by ex-employees will be taken as evidence in court, he says. “Ex-employees would say that ‘we were understaffed because I felt that we were understaffed’ without providing any documentation to prove the assertion,” and that may well be taken as evidence of actual understaffing, he says.</div></div> <div><h3 class="ms-rteElement-H3">Value Of Exit Interviews</h3> <div>Providers can take steps to protect themselves, says O’Neal. The most important thing they can do, aside from keeping accurate and thorough documentation, is conduct detailed exit interviews. </div> <div> </div> <div>These interviews, which should be thoroughly documented, are aimed at determining why an individual is leaving and give them a chance to tell the provider their side of the story. Then, if the provider sees that person in court giving false testimony, the provider has documentation to show that the real reason the person left was something other than what they’re testifying to, or to prove that they did have a chance to air their grievances. Exit interviews are “aimed at deflating the testimony of someone who may have an axe to grind,” says O’Neal.</div></div> <div> </div> <div>4. Use alternative dispute resolution agreements.</div> <div> Another thing that providers can do to protect themselves from excessive jury awards is have an alternative dispute resolution (ADR) agreement. The two main forms of ADR are arbitration and mediation. The main difference between the two is that the parties in a dispute aren’t bound by what a mediator agrees, whereas with an arbitrator they are.</div> <div> </div> <div>Increasingly, companies are looking at using both forms—first mediation and then arbitration, says Chris Puri, a partner of Bradley Arant Boult Cummings in Nashville, Tenn., and vice chair of AHCA’s Legal Committee.</div> <div> </div> <div>Arbitration, the most common form of ADR, benefits both the resident and the provider in the event of a dispute, according to Aon Global Risk Consulting based in Columbia, Md. It benefits the resident because it’s a much faster process and the resident receives financial compensation much more quickly, which may be of critical importance to a resident in his or her twilight years. Another benefit is it greatly reduces transaction costs, which may enable residents and their families to keep more of the settlement than they would have with a lawsuit.</div> <div> </div> <div>Arbitration agreements benefit providers because the total cost of an arbitrated settlement tends to be about 37 percent lower than a litigated award, according to a 2009 report by Aon Global Risk Consulting.<img class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/1210/CS_Provider%20expense.jpg" width="324" height="179" alt="" style="margin:15px;width:427px;height:206px;" /></div> <div><h3 class="ms-rteElement-H3">Make Agreements Fair</h3> <div>The most important thing when drawing up an arbitration agreement is to be fair to both the resident and the provider, says Puri. If it’s not balanced, it won’t be upheld if challenged in court. </div> <div> </div> <div>Second, keep state law in mind when putting it together. For example, an arbitration agreement that caps any settlement at a certain dollar amount won’t be seen favorably in court if the state doesn’t have the same cap on awards, says Puri.</div> <div> </div> <div>And make sure the agreement is written in plain language, not legalese. The agreement should be very readable and understandable. For example, “courts have found that the agreement should make it very clear that [the resident] is waiving the right to a jury trial,” says Puri.</div> <div> </div> <div>Agreements should provide the resident with a period of time after signing it, called a rescission period, that they can change their minds and have the agreement shredded—at least 15 days, but more commonly 30 days.</div> <div> </div> <div>Finally, the agreement should state that it is under the Federal Arbitration Act (FAA), rather than a state arbitration act, says Puri. “Essentially, the FAA says that states and state courts have to treat arbitration agreements the same way they would any other contract in terms of enforcing it,” Puri explains. </div> <div> </div> <div>“The reason the FAA was actually passed at all was the notion that state courts had a long-standing hostility toward the use of arbitration,” he says. If the agreement is under the FAA, “the only basis on which you cannot enforce a contract for arbitration would be the same as for any other contract—for example, fraud,” Puri says.</div> <div> </div> <div>“Those are all things that help [get the provider] to the ultimate goal, and that is to have the agreement be enforceable,” says Puri.</div></div> <div><h3 class="ms-rteElement-H3">Ensure Agreements Are Enforceable</h3> <div>It’s important that any ADR agreement be enforceable, because according to the Aon study on arbitration, about 12 percent of claims with ADR agreements do not hold up in court, and when that happens the settlement has a much higher total cost. In fact, “the average indemnity amount [awarded] for claims where ADR was challenged and found unenforceable was more than double any other category,” including claims where the case went to trial, the study says. </div> <div> </div> <div>The most common challenge to an ADR agreement involves the authority and capacity of the person who signed it, so determining whether a resident is truly capable of making that decision is key.</div></div> <div><h3 class="ms-rteElement-H3">Leave Agent Spot Open</h3> <div>One other thing that Puri personally thinks is a good idea is to leave open who is going to arbitrate the agreement. This would allow the parties to agree on an appropriate arbiter when a dispute arises, perhaps through mediation, with a default course of action identified in case the two are unable to agree, such as having a court appoint an arbiter. The reason for this is that the person or entity that is named in the original agreement may not be arbitrating contracts anymore, or may be inappropriate given the context.</div> <div> </div> <div>And remember: An arbitration agreement is “only as good as the people in the facility who present it to the patient and/or their family,” says Puri. </div> <div> </div> <div>“There have been plenty of cases where they’re not signed by the right person, or not explained or not explained right. So with my clients I suggest they have a training program that goes along with the actual piece of paper to make sure it gets presented correctly,” he says.</div> <div> </div> <div>“The whole purpose is to design a mechanism where if you have a dispute you can resolve it in a way that reduces the conflict as much as possible. As a facility, you ought to want to be able to explain why you think arbitration has advantages for the resident.” The training program should make sure that the people who will be explaining the contract really understand what’s in the contract and what everything means. “A lot of times they don’t,” he says. “It’s just another piece of paper in a big stack.”</div></div> <div><h3 class="ms-rteElement-H3">Don’t Panic, But Be Aware</h3> <div>While Reagan and Kiepen don’t think the Skilled Healthcare verdict should cause providers to panic—most of the staffing-level-based cases Hooper, Lundy, and Bookman has handled have either been settled out of court or have been dismissed by a court not willing to get into “this kind of fight”—the firm is seeing a number of copycat lawsuits springing up.</div> <div> </div> <div>“For any state that has a mathematical nursing ratio, there will be attempts to essentially replicate, under whatever the state’s platform for civil liability might be, the equivalent” of the Skilled Healthcare case, says Reagan.</div> <div> </div> <div>All a plaintiff’s attorney has to do is go through public health records of nursing facilities for technical violations of state regulations and attempt to plead the case as a class-action lawsuit. </div> <div> </div> <div>“But the sheer size and proportion of the Skilled Healthcare verdict are an aberrance, rather than a huge, enormous comparable risk that everybody is faced with at this point,” says Reagan. </div></div> <div><em></em> </div> <div><em>Kathleen Lourde is a freelance writer based in Manassas, Va.</em></div>Thorough documentation, arbitration agreements can help to stem the tide.2010-11-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/supreme_court.jpg" style="BORDER:0px solid;" />Legal;ManagementColumn11
Nursing, Rehab Therapy Under MDS 3.0https://www.providermagazine.com/Issues/2010/Pages/1110/Nursing-Rehab-Therapy-Under-MDS-3-0.aspxNursing, Rehab Therapy Under MDS 3.0<span lang="EN"><div>The implementation date for the new minimum data set (MDS) 3.0 has come and gone, but the confusion surrounding how it will impact reimbursement under the new Resource Utilization Group (RUG) IV levels remains. Providers that wish to avoid drastic reimbursement cuts and realize potential revenue gains under the new therapy rules should review the comparisons presented in this article and conduct a thorough review of individual, group, and concurrent therapy provided in their facilities. </div> <h3 class="ms-rteElement-H3">Extensive Changes</h3> <div>Why is this so important? Under RUG-IV, concurrent therapy minutes will be allocated among the patients instead of being counted as one-on-one therapy minutes. Concurrent therapy is defined as treating no more than two patients in differing therapies regardless of payer source, both of whom must be in the line of sight of the treating therapist. </div> <div> </div> <div>Group therapy, which is unchanged in RUG-IV, consists of two to four patients who are performing the same or similar activities and are supervised by a therapist who is not supervising other individuals. Group therapy is capped at 25 percent of total therapy hours.</div> <div> </div> <div>The Centers for Medicare & Medicaid Services (CMS) redesigned the MDS so that it collects and reports individual therapy minutes separately from concurrent therapy and group minutes. </div> <div> </div> <div>Along with the newly designed MDS, new RUG categories were created to coincide with the release of the MDS 3.0. According to the CMS final rule on the topic, overall payments under RUG-IV will be at the same level as they would be under RUG-III. </div> <div> </div> <div>The difference with RUG-IV is that the distribution of payments will change, meaning that the payment rates for the complex groupsextensive care, special care, and clinically complex carewill increase significantly.</div> <div> </div> <div>The new RUG-IV categories are: Rehab Plus Extensive Services, split into Ultra High, Very High, High, Medium, and Low; Rehab, split into Ultra High, Very High, High, Medium, and Low; Extensive Services; Special Care High; Special Care Low; Clinically Complex; Behavioral Symptoms and Cognitive Performance; and Reduced Physical Function. </div> <h3 class="ms-rteElement-H3">Impact On Reimbursement</h3> <div>To illustrate how the changes in concurrent therapy will impact reimbursement under RUG-IV, this article presents a simulation (<em>see Box 1, below)</em> of therapy and payment scenarios under the new RUG 66 grouper, with varying levels of concurrent therapy, the current RUG 53 levels, and also under the hybrid 53 levels, expected to be ready in the next several months. (CMS is currently paying on the RUG-IV system, which is not scheduled for implementation until Oct. 1, 2011, and then recalculating the rate in February 2011 or thereabouts under the hybrid 53 grouper.)</div> <div> </div> <div><img class="ms-rtePosition-1" src="/Issues/2010/PublishingImages/1110/MDS-box1.gif" width="348" height="1041" alt="" style="margin:10px 15px;height:426px;" />The simulation applies 2009/2010 year-to-date Medicare Part A data from multiple skilled nursing </div> <div>facilities.</div> <div> </div> <div>This comparison assumes that CMS will estimate its hybrid grouper 53 by using the RUG 66 therapy rules and RUG 53 nursing services rules. For the RUG-IV side of the comparison, therapy minutes for concurrent therapy were reduced across all RUG levels.</div> <div> </div> <div>It is notable that the RUG 66 source code provided by CMS and used to create the RUG-IV was used to generate the RUG 66 model. This source code is available to any and all who ask for it. Here, the RUG 66 code is applied to calculate the hybrid RUG 53 therapy days and the RUG 53 current code to generate the nursing levels and days that may fall below skilled levels of care as defined by Medicare policy. </div> <h3 class="ms-rteElement-H3">Decision Time</h3> <div>These scenarios place long term and post-acute care executives in a challenging decision mode. </div> <div><br></div><div>The options are to ignore the forecast and pray for luck or to evaluate the forecast, learn from the model, and evaluate how to act today to improve the future. </div> <div> </div> <div>Based on this simulation, providers that do not lower the application of concurrent therapy in the model will see a significant reduction in Medicare payment for services. </div> <div> </div> <div>Illustrating how therapy levels will change under RUG-IV is another table (<em>Box 2, below</em>) that takes therapy minutes as they were under RUG-III and MDS 2.0 and allocates them under RUG-IV with a 30 percent concurrent therapy utilization to show how levels will likely shift to lower payment categories.</div><div><br></div> <div><img src="/Issues/2010/PublishingImages/1110/MDS-box2.jpg" width="1680" height="591" alt="" style="margin:15px 10px;width:768px;height:270px;" /><br></div> <h3 class="ms-rteElement-H3">Prepare For CMS Recoupment</h3> <div>Providers should use the lesson of these tables to establish a reserve for potential CMS payment recoup for services as the agency begins to apply the hybrid 53 grouper to the payments made under RUG-IV. </div> <div> </div> <div>The potential recoupment under RUG-IV can be determined by the difference between the RUG-IV and hybrid 53 reimbursements. Hence, it is important to evaluate and manage resources for the best implementation of care for Medicare beneficiaries.</div> <div> </div> <div>Under the hybrid 53 grouper, CMS will pay according to the RUG-IV, re-evaluate that payment, and then adjust facility payments. </div> <div> </div> <div>The requirement imposed by the Patient Protection and Affordable Care Act to delay the RUG-IV implementation until Oct. 1, 2011, imposed on CMS is daunting. </div> <div> </div> <div>CMS must eliminate the RUG 53 hospital look-back service capture, eliminate estimated therapy, and discount payment for concurrent therapy, all items captured in the MDS 3.0, but with an MDS 2.0 payment structure. </div> <div> </div> <div>As a result, providers must reserve funds for the possibility that some will need to be paid back to CMS. </div> <div>For FY 2011, providers will need to improve their utilization of therapy resources to increase group therapy and one-on-one therapy and reduce the use of concurrent therapy. Even a 1 percent concurrent therapy level will reduce Medicare payment. However, it is unrealistic to eliminate concurrent therapy altogether. </div> <div> </div> <div>The big challenge for leadership will be to manage a balance and, by managing a balance, achieve budget neutrality. </div> <div>Next month, Provider will examine how RUG-IV and MDS 3.0 will impact staffing needs for rehabilitation therapy. </div> <i><div> </div> <div>John Sheridan, president of eHealth Data Solutions, a health care information company based in Cleveland, Ohio, has more than 30 years of experience in the health care industry as a strategic advisor, analyst, and entrepreneur serving the pharmaceutical, hospital, physician, and long term care professions. He can be reached at (937) 767-1885. </div></i></span>​An expert explains how and why RUG-IV will have a significant impact on therapy reimbursement. 2010-11-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Management;ReimbursementManagement11

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Choices And Teamwork Improve End-of-Life Carehttps://www.providermagazine.com/Issues/2010/Pages/1210/Choices-And-Teamwork-Improve-End-of-Life-Care.aspxChoices And Teamwork Improve End-of-Life Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div>What makes end of life so important to long term care providers is the fact that of the around 2.5 million people who die each year in the United States, some 83 percent are Medicare beneficiaries, and a good number of those pass away in a facility setting. The American Association of Homes and Services for the Aging’s Institute for the Future of Aging Services says as many as 25 percent of all deaths occur in nursing facilities. </div> <h3 class="ms-rteElement-H3">Hospice Need Growing</h3> <div>For providers, the intersection of hospice and palliative care and their own nursing facility services has grown in importance over the past decade as more and more residents receive hospice care, due to a number of factors that will be explored here. Outside of specific hospice care, research shows 20 to 25 percent of nursing facilities have end-of-life programs with staff trained to administer these efforts. </div> <div> </div> <div>As with the day-to-day operations of nursing facilities, the way buildings look, the way administrators communicate with families, and the way care is tracked and given, there are major culture change issues happening with end-of-life care. </div> <div> </div> <div>“Honoring the goal of patients rather than doing what a cookbook might say” is how James Avery, MD, senior vice president and chief medical officer for Golden Living and chairman of the American Health Care Association’s Quality Improvement Committee, describes the trend. He speaks of the “cookbook” as the purely medical options in caring for the dying, which may or may not be useful. </div> <div> </div> <div>Experts see even more change coming as baby boomers age. The same transformation the boomer generation has prompted in other areas of the consumer economy will alter the way care for the dying is undertaken, with the sentiment of “we want what we want when we want it” taking hold. </div> <h3 class="ms-rteElement-H3">The Trigger</h3> <div>Once a physician declares a resident of a nursing facility, or anyone for that matter, has a life expectancy of six months or less, then a referral to a hospice agency can occur, says Patti Scholten, RN, manager of home health and hospice for the Evangelical Lutheran Good Samaritan Society, a not-for-profit long term care provider with hospices in Minnesota, Iowa, and Arizona, among its other services.</div> <div> </div> <div>From that point, and if the resident wants hospice, the long term care provider and hospice work together on a care plan. This coordination is vital to ensuring the wishes of each person receiving such care and ties into advance directives on how care is to be directed in the final months of life. </div> <div> </div> <div>Most <a href="/Issues/2010/Pages/1210/Hospice-Care-Shifts-To-Facilities.aspx">hospice care </a>is accomplished in the home, Scholten says, but wherever the care occurs, it is in a complementary role to the caregivers at home or in a nursing facility. </div> <p>“Hospice supports caregivers,” she notes, adding that residents are getting quality care from a facility, but that a hospice team can focus on end-of-life issues while the day-to-day care continues. When hospice arrives in a facility, it is usually in the form a nurse assigned to tend to physical needs, a social worker, and possibly volunteers for aiding the basic needs of the resident when family cannot be there. </p> <p><span id="__publishingReusableFragment"></span> </p> <p>Social workers take on many roles, all depending on what an individual requires, be it emotional support, funeral and financial planning, or finalizing unfinished business on a personal level. </p> <p>“It is all up to the individual,” Scholten says. </p> <p>Avery recounts the time a woman sought peace with her dying father at one of his nursing facilities. <br>The man suffered from Alzheimer’s and caused no problems for staff; he was actually thought to be gentle and kind. The daughter, however, sought out the help of facility clergy to confront her anger toward a man she knew had been abusive to her and her brother when they were children. </p> <p>The clergy had her direct this anger not at the man, but at an empty chair in a quiet room, representing the father. Eventually, the daughter worked out her anger and in the process confronted her own abusive ways with her own children. “But it got to the point of forgiveness, and she became nicer to him after this,” Avery says. </p> <h3 class="ms-rteElement-H3">The ‘Good’ Death </h3> <div>Defining the best way to die is not an easy task, or even one most Americans want to ponder for more than a moment or two without getting depressed or distracted by the inevitability of it all. </div> <div> </div> <div>Despite this aversion to looking at death and dying as the natural part of a lifespan, much thought has been given to the subject by caregivers, the medical community, providers, researchers, philosophers, and spiritual leaders into the way people ought to look at the issue. The results can be useful for providers to know when reviewing care plans for their own residents and designing programs for their staff and administration.</div> <div> </div> <div>Judith Peres, a clinical social worker and independent consultant in hospice, nursing facility, and palliative end-of-life care policy, uses the “wave” theory to explain where society as a whole stands on the subject of dying. There is change going on out there now with how Americans treat death—the start of a beginning of a new era where more attention is being paid to the wishes of those dying, Peres says. This is being directed by law in some cases and by cultural practices in others, she notes. </div> <div> </div> <div>An Institute of Medicine report from the late 1990s put the terms “<a title="Planning For A Good Death" href="/Issues/2010/Pages/1210/Planning-For-A-Good-Death.aspx">good death</a>” and “bad death” into the health care lexicon. A good death was one free from avoidable distress and suffering for patients, families, and caregivers in accordance with patients’ and families’ wishes and consistent with clinical, cultural, and ethical standards. </div> <div> </div> <div>The flip side, a bad death, is one that includes needless suffering, disregard for patient or family wishes or values, and a sense among participants that norms of decency have been offended. </div> <div> </div> <div>Avery, who has a decades-long background in hospice, relates the story from a report in a medical journal that described the way one patient in an acute care hospital setting spent his final days. </div> <div> </div> <div>“There was a case of an older man who ended up in a hospital for 50 days straight, nothing to eat or drink [because of medical concerns], who died delirious, in pain, tied to a bed,” he said, recounting how terrible this ordeal must have been for the man and his family. </div> <div> </div> <div>Indignant at the plight of this unnamed man in the report, Avery says the medical model is a great thing to treat people and make them better, but when people end up in a skilled nursing-hospice situation, “the medical model doesn’t work.” </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Hospice And Palliative</h3> <div>It is important to look at the difference between hospice and palliative care, experts say. Hospice is a philosophy of care that accepts death as the final stage of life. The goal of hospice is to enable patients to continue an alert, pain-free life and to manage other symptoms so that their last days may be spent with dignity and quality, surrounded by their loved ones. </div> <div> </div> <div>Hospice affirms life and does not hasten or postpone death. Hospice care treats the person rather than the disease; it focuses on quality rather than length of life. Hospice care can be given in the patient’s home, a hospital, nursing facility, or private facility. </div> <p>Palliative care, on the other hand, is not limited to hospice since hospice care is meant specifically for those approaching the last stages of life, while palliative care is appropriate for any stage of a serious illness.</p> <p>The goal of palliative care is to relieve the pain, symptoms, and stress of serious illness—whatever the prognosis. It is appropriate for people of any age and at any point in an illness, and it can be delivered along with treatments that are meant to cure, according to getpalliativecare.org. </p> <p>For long term care providers, the goals of palliative care are to maintain hope, preserve dignity, and answer the question of healing versus cure. Peres notes there is a growing focus on how much medicine is enough medicine. </p> <p>Many hospice care programs added palliative care to their names to reflect the range of care and services they provide, as hospice care and palliative care share the same core values and philosophies, according to the National Hospice and Palliative Care Organization (NHPCO). <br>Defined by the World Health Organization in 1990, palliative care seeks to address not only physical pain, but also emotional, social, and spiritual pain to achieve the best possible quality of life for patients and their families. </p> <p>To better serve individuals who have advanced or terminal illnesses and their families, many hospice programs encourage access to care earlier in the illness or disease process. Health care professionals who specialize in hospice and palliative care work closely with staff and volunteers to address all the symptoms of illness, with the aim of promoting comfort and dignity. </p> <h3 class="ms-rteElement-H3">When And Why Hospice Care</h3> <div>The relationship between skilled nursing facilities (SNFs) and hospice providers, even when part of the same provider’s long term care offerings, has not always been an easy one. The situation has improved markedly in recent years, say providers, and part of the reason—beyond the common sense of collaboration for meeting the needs of residents—was a policy decision. </div> <div> </div> <div>“Part of it was regulatorily driven when CMS [the Centers for Medicare & Medicaid Services] came up with new Conditions of Participation in 2008, which mandated collaboration,” Scholten says. </div> <div> </div> <div>“CMS wanted to look at the types of patients in the long term care setting who were receiving hospice to make sure there was collaboration and ensure that hospice and nursing homes were not functioning in silos,” she says. </div> <div> </div> <div>Some of the unease nursing facilities may feel toward hospice comes from the heavy regulations on every aspect of what nursing care does, making attention to detail vital. “There are some barriers hospices may not understand, like the survey process and scrutiny that long term care goes through,” Avery says, noting as an example that some medications put in use by a hospice nurse may cause “alerts to ring” in a state survey. </div> <div> </div> <div>Nursing facility staff are also accustomed to being in control, making it hard for some to adapt to the presence of hospice personnel, he adds. </div> <div> </div> <div>For J. Donald Schumacher, NHPCO president and chief executive officer, much has changed since he started in the business in 1978. Then there were very few programs and people involved in hospice (the association added the “palliative” part of its name in 2000), leading to the time the hospice benefit was added to Medicare in 1982, he says. </div> <div> </div> <div>“There has been a dramatic increase in the last five years, which mirrors population growth,” Schumacher says.  </div> <h3 class="ms-rteElement-H3">People Seek Comfort</h3> <div>Decades ago, nearly all hospice patients were cancer patients; now that number is less than 40 percent, with a “whole wide range of diseases recognizing the need for hospice care,” he adds. “People do want comfort, a pain-free existence. This trend has been steadily building over the years. You don’t have to die in extreme pain.” </div> <div> </div> <div>Schumacher is excited by one part of the health care reform law that will see the Medicare program begin a 15-site demonstration project in 2012 to provide both hospice care and life-sustaining treatments to Medicare beneficiaries. The law establishes a three-year-long demonstration program during which Medicare will experiment with concurrent coverage. Medicare currently will cover the cost of hospice care only after a physician diagnoses a patient as having less than six months to live, and after the patient stops receiving any life-sustaining treatments. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Does Hospice Work? </h3> <div>Researchers at the University of California-Los Angeles found that the use of hospice care by terminal prostate cancer patients jumped from 30 percent in 1992 to 60 percent in 2005. These hospice patients were 20 percent less likely to receive costly, high-intensity care and were also less likely to undergo imaging tests. Researchers believe this is evidence that increased use of hospice care, especially for cancer patients, can cut health care costs. The report findings were published in the Archives of Internal Medicine. </div> <div> </div> <div>On the other side, a study of terminal heart failure patients did not indicate any cost savings from increased hospice services. Duke University School of Medicine researchers analyzed the records of 230,000 Medicare heart failure patients who died between 2000 and 2007. The study, which also appeared in the Archives of Internal Medicine, found that although the rate of hospice care climbed from 19 percent in 2000 to 40 percent in 2007, the rate of costly hospitalizations remained around 80 percent. Health care costs for this group during the last six months of life rose from $28,000 per patient to $36,000 per patient. </div> <h3 class="ms-rteElement-H3"><span class="ms-reusableTextView ms-rtestate-read s4-wpActive"></span>Minding The Gaps</h3> <div>Avery notes that Golden Living obviously thinks a lot about the importance of end of life since it hired him as medical director. Before Golden Living, he was the senior medical director for Visiting Nurse Service Hospice Care of New York, the largest hospice in New York City. </div> <div> </div> <div>Now ensconced at Golden Living, which has a hospice arm called Asera Care Hospice, he preaches the mantra of minding GAPS, which Avery explains as G—Goals of Care, A—Advanced Care Directives, P—Pain and Symptom Management, and S—Spiritual and Social Care. The elements contained in GAPS are many, from making sure advanced care directives travel to the emergency room, to working off a unified pain scale with hospices and other caregivers, including special provisions for patients with dementia who cannot communicate. This can include clenching of teeth or hands to indicate the level of pain. </div> <div> </div> <div>For spiritual matters, Avery says top Golden Living executives learned a lot on this subject when they took a pilgrimage to the Duke Institute of Care at the End of Life, understanding the importance of getting every aspect of a resident’s end of life tailored to his or her specific needs. </div> <div> </div> <div>NHPCO, in collaboration with Duke and Project Compassion, has created a nondenominational guide intended to help hospices and coalitions reach out across traditional religious and cultural lines. </div> <div> </div> <div>Separately, a survey of professional clergy and lay leaders by Duke indicates that many faith community leaders do not have the knowledge, resources, and support they need to care for people during the end of life. Though 90 percent of clergy report visiting with people at end of life, only 60 percent describe themselves as “very comfortable” making these visits; fewer than 40 percent of leaders surveyed feel comfortable training lay people to offer support for others; and fewer than 20 percent of respondents offer any education related to serious illness, caregiving, end of life, or grief. </div> <h3 class="ms-rteElement-H3">Advance Directives</h3> <div>Amidst the discussion on end-of-life care is the growing emphasis on advance directives, resulting in part from the 1990 Patient Self-Determination Act. This law requires all health care facilities receiving Medicare or Medicaid funding to inform patients of their rights to refuse medical treatment and to sign advance directives. These directives can be formal, legally endorsed documents like living wills and health care power of attorney. </div> <div> </div> <div>Advance directives are not the same as DNR (do-not-resuscitate) orders; instead, these orders are signed by a medical doctor and put into a patient’s medical record acting as a complement to the advance directive. The DNR order is part of an overall paradigm, called the Physician Orders for Life-Sustaining Treatment (POLST). </div> <div> </div> <div>A POLST Paradigm form is a brightly colored medical order form used to write orders indicating life-sustaining treatment wishes for patients with serious illnesses. The form accomplishes two major purposes: It turns treatment wishes of an individual into actionable medical orders, and it is portable. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">POLST Goes A Step Further </h3> <div>POLST was developed initially in response to patients receiving medical treatments that were not consistent with their wishes. The goal of a POLST Paradigm Program is to honor patients’ end-of-life treatment preferences either to have or to limit treatment, even when transferred from one care setting to another. </div> <div> </div> <div>The POLST form complements the advance directive and is not intended to replace it. An advance directive is necessary to appoint a legal health care representative and provide instructions for future life-sustaining treatments. The advance directive is recommended for all adults, regardless of their health status. A POLST form should accompany an advance directive when appropriate. </div> <div> </div> <div>A health care professional (usually a physician, nurse practitioner, physician assistant, or social worker) completes the form after understanding the patient’s values and goals of care. A POLST Paradigm form is a medical order and is not completed by the patient. The form must be signed by a physician to be in force. </div> <div> </div> <div>Many states also require the patient’s or chosen decision-maker’s signature. </div> <div> </div> <div>Family members may be able to speak on behalf of a loved one. A health care professional can complete the POLST Paradigm form based on family members’ understanding of their loved one’s wishes. </div> <h3 class="ms-rteElement-H3">Medicare Problems</h3> <div>Miller’s report says there are major shortcomings in the Medicare hospice benefit that appear to influence the timing of referral (resulting in very short and very long stays), and these may limit further increases in access for nursing facility residents. </div> <div> </div> <div>First, the need for a physician-certified, six-month terminal prognosis creates substantial barriers for persons with non-cancer chronic terminal illnesses for whom a six-month prognosis is difficult to predict. Although this barrier affects persons dying in SNFs and others settings (72 percent of persons with non-dementia chronic terminal illnesses die in non-SNF settings), the barrier is particularly important given the high proportion of SNF residents with chronic terminal illnesses. </div> <div> </div> <div>Another major barrier arising from the Medicare hospice benefit is the requirement that beneficiaries enrolling in hospice must forgo other Medicare Part A care when such care is related to the terminal illness. For beneficiaries in the community or in SNFs, this means that hospital care and curative treatment must be abandoned, but it also often means abandonment of expensive treatments such as blood transfusions or palliative radiation (when hospices lack financial resources to support such care). </div> <div> </div> <div>The Medicare Payment Advisory Commission has recommended changing the Medicare payment system so that the per diem rate for hospice routine home care better reflects the intensity of hospice service provision. </div> <div> </div> <div>Because research has shown hospice visits to be more frequent closer to the beginning and end of hospice episodes, it is reasonable to have higher payment rates around the time of hospice admission and around the time a patient is dying, Miller says. </div> <h3 class="ms-rteElement-H3">Spreading The Word</h3> <div>In total, the care for a resident is becoming more and more person-centered. And, as this attention to the individual is applied at end of life, the questions asked of the dying are the most important part of ensuring a “good” death. </div> <div> </div> <div>Peres uses a slide, from The One Slide Project (<a title="Engage With Grace" href="http://www.engagewithgrace.org/">www.engagewithgrace.org</a>), to spread the gospel of care for the dying. The point is to engage death with the same purpose as life was engaged. The slide asks: “Can you and your loved ones answer these questions? </div> <ol><li>On a scale of 1 to 5, where do you fall on this continuum? “Let me die in my own bed, without medical intervention” is 1 on the scale, and “Don’t give up on me no matter what, try any proven and any unproven intervention possible” is 5. </li> <li>If there were a choice, would you prefer to die at home or in a hospital? </li> <li>Could a loved one correctly describe how you’d like to be treated in the case of a terminal illness? </li> <li>Is there someone you trust whom you’ve appointed to advocate on your behalf when the time is near?</li> <li>Have you completed any of the following: written a living will, appointed a health care power of attorney, or completed an advance directive?</li></ol> <div>The point is to see the passing into death as part of life and to make the process embraceable and as easy on the dying as possible. It is inevitable.  </div>Death is unavoidable, but how it happens is becoming a top priority for the long term care community.2010-12-01T05:00:00Z<img alt="" src="/Issues/2010/PublishingImages/Web%20images/hands_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;Quality ImprovementColumn12
Dementia: Spotlight On Abilities-based Care Modelhttps://www.providermagazine.com/Issues/2010/Pages/1210/Dementia-Spotlight-On-Abilities-based-Care-Model.aspxDementia: Spotlight On Abilities-based Care Model<div>According to the Alzheimer’s Association, 5.3 million Americans have Alzheimer’s disease, and those numbers are increasing as the population ages. As individuals with Alzheimer’s disease and related dementias (ADRD) become more numerous in long term care environments, a workforce capable of specialized dementia care will become a vital part of the health care system. Traditional care, which focused on keeping dementia patients clean and safe, is now seen as an outmoded form of institutionalized care. </div> <div> </div> <div>Fortunately, a paradigm shift is occurring within dementia care as experts discover new models that improve outcomes and quality of life for persons with dementia. An individualized, abilities-based care approach is giving the entire interdisciplinary team, including occupational, physical, and speech therapists; nurses; and activities and other direct care staff, the tools they need to ease their job burden and enable those with ADRD to thrive.</div> <div> </div> <div>This person-centered care model incorporates essential life-story information while also prioritizing the discovery and facilitation of the person’s best ability to function at every dementia stage. It also facilitates higher levels of independence and quality of life.</div> <div> </div> <div>An individualized, person-centered care approach helps the person with dementia to feel a greater sense of purpose and security as the resident remains connected to his or her <br>individuality. </div> <h3 class="ms-rteElement-H3">Facilitating Abilities</h3> <div><div>Using past memories in daily care plays to the strengths of the resident with dementia, which is long-term memory. The use of familiar products and the integration of familiar activities and routines primes the cognitive reserves, and with the correct care approach the person’s remaining cognitive abilities are facilitated, yielding the highest potential level of independence in daily activity.</div> <div> </div> <div>In addition to meaningful therapeutic and recreational activities for persons with dementia, the new models extend this approach to activities such as grooming, bathing, dining, and mobility.</div> <div> </div> <div>Residents may be resistant to bathing and showering, for example, and lash out at the nurse assistant or therapist verbally or physically, or exhibit signs of obvious fear or embarrassment. Rather than forcing both resident and care partner to endure a bad experience, triggers can be identified and steps taken to bring about a satisfying outcome. </div> <div> </div> <div>If the person feels cold, for instance, the care partner can keep the person warm by keeping him or her wrapped in a blanket or warm towels as much as possible and by maintaining a comfortable temperature in both the room and the water. </div> <div> </div> <div>If pain is a trigger, a gentle touch and comfortable position are in order, as well as a possible change in pain medication frequency. </div> <div> </div> <div>The new care model also urges team members to offer a choice whenever possible to maintain the resident’s sense of control. Instead of telling him or her, “It’s time for your shower,” the care partner might ask permission to take the resident to be bathed, or offer a choice of shower or bath. If the person isn’t able to communicate clearly, life-story characteristics can help to develop an understanding of the resident’s preferences ahead of time.</div> <h3 class="ms-rteElement-H3">Respectful Reactions Improve Outcomes</h3> <div>Perhaps one of the most important steps to person-centered, abilities-based care is a retraining of staff reactions to residents, which can make a world of difference in that resident’s behavior, as well as in future interactions.</div> <div> </div> <div>When a resident is scolded or belittled, his or her attempts at communication or independence are undermined, leaving the resident with a sense of failure. For instance, when a resident is demanding of a care partner’s time, the care partner might brush the resident off with a sharp, “Not now!” reaction. But with a kind, person-centered reaction, such as, “Hi Martha, what a pretty necklace you’re wearing; would you like to help me finish putting these clothes away?” that same resident can be reassured, comforted, and encouraged to open up. </div> <div> </div> <div>Reactions that show respect and provide a sense of purpose will help gain the trust and agreement of the resident and can, and should, be of primary importance in every person-centered dementia care environment. </div> <div> </div> <div>Since many individuals with ADRD live with occupational and emotional deprivation, a quality staff training program designed to mitigate the impact of ADRD is essential. Training must begin with an exploration of staff beliefs and perspectives about those with dementia. This activity often reveals the negative paradigms that facilitate negative outcomes. </div> <div> </div> <div>For example, someone may describe a person who can walk, explore his environment, and use hands to pick up objects as a “confused rummager who wanders.” This perspective suppresses and masks the person’s preserved abilities, which then leads to helplessness.</div></div> <div><h3 class="ms-rteElement-H3">Stage Assessment Essential</h3> <div>Another critical component of a quality dementia training program is the identification of common dementia stage characteristics and the key care approaches to facilitate the best ability to function at every stage of dementia.</div> <div> </div> <div>When working with someone with dementia, the best approach to help her adjust to an activity is to consider how the caregiver is handling the situation and to adjust the activity or the environment. In addition, training must teach staff to be better “dementia-capable communicators” and to understand the common triggers behind many negative behaviors. </div> <div> </div> <div>Much is being researched and written regarding the increased costs to care for persons with ADRD, some of which is related to the health complications that often occur and lead to hospitalization. Other costs are related to the increase in functional dependency. </div> <div> </div> <div>However, research has shown that the identification of a person’s dementia stage is an essential piece to the package of services to enable a person with dementia to attain and maintain the highest practicable level of function and health possible.</div> <div> </div> <div>The dementia stage can be broadly identified with a very quick tool, such as the Global Deterioration </div> <div>Scale (GDS) or <a title="Functional Assessment Staging Tool" href="/Issues/2010/Pages/1210/Functional-Assessment-Staging-Tool-(FAST)-.aspx">Functional Assessment Staging Tool </a>(FAST), that is administered by a nurse or social worker. </div> <div> </div> <div>An occupational therapist with specialized dementia therapy training should then go on to further evaluate the individual through the use of a more in-depth assessment such as the <a title="Allen Cognitive Level Screen" href="/Issues/2010/Pages/1210/Allen-Cognitive-Level-Screen-(ACLS)0620-1607.aspx">Allen Battery assessments</a> from the Cognitive Disabilities Model (CDM). These assessments and the understanding of the CDM help to truly discover the person’s dementia stage, their highest possible level of function, and the techniques to facilitate and maintain this best ability.</div> <div> </div> <div>Medicare regulations state that a therapist may evaluate and create a maintenance program to enable a person with a chronic, progressive disease such as Alzheimer’s “to maximize function” and “to prevent or minimize deterioration associated with a disease.” Without this additional specialized evaluation from therapy, the caregiver may never determine the individual’s true potential or how best to facilitate this potential.</div></div> <div><h3 class="ms-rteElement-H3">Benefits Are Many</h3> <div>Among the benefits of identifying and facilitating the highest degree of independence at each dementia stage is a reduction in the likelihood of a health complication arising, such as a fall, infection, or dehydration, which are frequent precipitating factors for emergency room visits and hospitalizations. In addition, such identification can lead to less care time and, therefore, costs associated with daily care of a person with greater care needs.</div> <div> </div> <div>The argument is growing louder for management of revenue through reduction in costs for persons with dementia. If every therapist were capable of identifying a resident’s Allen Cognitive Level, then care plans would be designed to help identify high risks and corresponding prevention and intervention plans and to maximize the level of independence possible in order to reduce care time and costs. </div> <div> </div> <div>Most importantly, the person-centered model adds meaning and fullness to the lives of residents and their families. Rather than sequestering persons with dementia away in an impersonal, one-size-fits-all setting, person-centered care offers them an opportunity to share their life stories and embrace their past, present, and future in an environment where they feel safe, productive, and appreciated. </div> <div> </div> <div><em>Kim Warchol, OTR/L, is the founder and president of Dementia Care Specialists, Hillsborough, N.C., a dementia training and consulting company that provides state-of-the-art dementia products, training, and program consultation. She can be reached at (919) 245-3447. </em></div></div> A new abilities-based care model optimizes the strengths of individuals with Alzheimer’s disease and related dementias.2010-12-01T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_man_thinking_1.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;Quality ImprovementColumn12
Don’t Forget The Exclusion Listshttps://www.providermagazine.com/Issues/2010/Pages/1210/Don’t-Forget-The-Exclusion-Lists.aspxDon’t Forget The Exclusion Lists<div>The enforcement of penalties for employing or contracting with individuals or businesses that are excluded from federal health care programs or federal contracts is on an upswing at both the federal and state levels. Reports of significant violations of the rules still occur, so the renewed interest in enforcement is paying off at a time when governments need additional sources of revenue.</div> <div> </div> <div>The likelihood of enforcement activity on this issue subsiding soon is pretty low, and all health care providers should implement systems that are designed to prevent exposure to excluded parties.</div> <div><h3 class="ms-rteElement-H3">OIG Authority</h3> <div>Generally, excluded parties in the health care context are persons or businesses that have either been excluded from participation in federal health care programs or excluded from participation in federal contracts. The U.S. Department of Health and Human Services Office of Inspector General (OIG) has the authority to <a href="/Issues/2010/Pages/1210/Steering-Clear.aspx">exclude individuals </a>and entities from Medicare, Medicaid, and any other program funded directly or indirectly by the federal government.</div> <div> </div> <div>Medicare and Medicaid providers found to be contracting with excluded parties can be subject to significant penalties and recovery of funds. If an item or service is provided at the medical direction or on the prescription of a physician or other authorized individual who is excluded from participation in federal health care program, that item or service is not reimbursable if the provider acting upon the excluded individual physician’s direction or prescription knew or had reason to know of the exclusion. </div></div> <div><h3 class="ms-rteElement-H3">Civil Money Penalties Apply</h3> <div>In addition to denying payment and recovering funds, the federal civil money penalties (CMP) law imposes fines on providers that seek reimbursement for health care services or items provided at a time during which the health care provider was on the<a href="/Issues/2010/Pages/1210/Checking-The-Lists.aspx"> exclusion list</a>. Up to $10,000 in monetary penalties, plus an amount of up to three times the amount claimed for each item or service, are allowed under the CMP law. What’s more, officers and managing employees of an excluded provider that submit claims for reimbursement are subject to the same monetary penalties, as are individuals and entities with a direct or indirect ownership or control interest in the excluded provider, if such individuals or entities knew or had reason to know of the action constituting the basis for the exclusion. </div> <div> </div> <div>All long term and post-acute care providers must ensure that all of their employees and every individual or entity that the provider contracts with in order to provide services or supplies is not excluded from participation in Medicare or Medicaid. </div></div> <div><h3 class="ms-rteElement-H3">Fines Can Multiply</h3> <div>It is worth noting that an individual or <a href="/Issues/2010/Pages/1210/Who’s-Covered.aspx">entity </a>submitting claims for items or services by or at the discretion on an excluded individual or entity can be found liable for monetary penalties up to $10,000 per item or service claimed or “caused to be” claimed, plus treble damages and be subject to possible exclusion. </div> <div> </div> <div>In addition, there is also the possibility of liability under the Federal False Claims Act, either through the claims of a whistleblower or other provision of the law. </div> <div> </div> <div>The Centers for Medicare & Medicaid Services (CMS) generally has the authority to deny or revoke Medicare enrollment or billing privileges for individuals or entities that are doing business with individuals or entities that are listed on the List of Excluded Individuals and Entities or the Excluded Parties List System as debarred, suspended, or otherwise excluded from federal programs. </div> <div> </div> <div>CMS can revoke Medicare certification or billing privileges of providers if owners, managing employees, authorized or delegated officials, medical directors, supervising physicians, or health care personnel furnishing Medicare reimbursable services are excluded, debarred, or suspended from a federal health care program.</div></div> <div class="ms-rteThemeForeColor-2-0"> </div> <div class="ms-rteThemeForeColor-2-0"><em>Ari Markenson is of counsel with Benesch, Friedlander, Coplan, & Aronoff in its White Plains, N.Y., office. He can be reached at (914) 682-6822 or amarken </em><a href="mailto:son@beneschlaw.com"><em>son@beneschlaw.com</em></a><em>. Sara Bunke Evans is an associate with Benesch, Friedlander, Coplan, & Aronoff in Columbus, Ohio. She can be reached at (614) 223-9349 or </em><a href="mailto:sevans@beneschlaw.com"><em>sevans@beneschlaw.com</em></a><em>.</em></div> Stay on top of the list of excluded individuals and health care entities as OIG and others intensify enforcement activities. 2010-12-01T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/capitol_blue_skies_2.jpg" style="BORDER:0px solid;" />LegalColumn12
Engage Every Customerhttps://www.providermagazine.com/Issues/2010/Pages/1210/Engage-Every-Customer.aspxEngage Every Customer <div>Engaging customers is not rocket science. With all of the articles, books, blogs, and conferences that are available, it can seem that creating an engaging service experience requires a lifetime worth of training. Not true. Improving customer service begins with the idea of “touchpoints.”</div> <div> </div> <div>A <a href="/Issues/2010/Pages/1210/Touchpoints-At-Work.aspx">touchpoint </a>is any moment of interaction between two parties. If an employee passes a resident in the hallway of an assisted living facility, that’s a touchpoint; when the receptionist answers the phone, that’s a touchpoint; when a door is opened for someone, that’s a touchpoint.</div> <div> </div> <div>There are literally hundreds of touchpoints in a typical workday. Now here’s the interesting part: Every touchpoint has either a deposit or a withdrawal. If a nurse at nursing facility XYZ walks past two customers in the hallway without acknowleding them, that’s a withdrawal. If a rehab therapist gives eye contact and smile, that’s a deposit. Better yet, if that therapist gives eye contact, smiles, offers a greeting, and provides assistance, it’s an even bigger deposit. </div> <div><h3 class="ms-rteElement-H3">Deposits And Withdrawals</h3> <div>So how does one identify touchpoints? The fastest way may be for the administrator to sit in her office and brainstorm alone. Unfortunately, she would be missing a tremendous opportunity to involve her staff in matters that directly affect them. If the goal of identifying touchpoints is to engage customers, then one must first engage those that serve the customers.</div> <div> </div> <div>Get the team’s input on deposits and withdrawals for each touchpoint as well. The administrator will earn the staff’s respect and simultaneously make a big deposit to the team. Deposits equal more engagement, and withdrawals equal less engagement. </div> <div> </div> <div>Not too long ago, a perfect example of a touchpoint withdrawal took place on board a transatlantic flight from Europe to Washington, D.C. Since these flights are at least six hours long, airlines tend to offer beverage service at multiple times, especially for those of who fly coach. When the flight attendants were on their third cycle of beverage service, one passenger asked a flight attendant about what drinks were available. The attendant looked at the passenger and said, “The same drinks we had 2,000 miles ago!” </div> <div> </div> <div>If there was ever a candidate for the “king of all withdrawals,” this was it. </div> <div> </div> <div>The sad part is that anyone who was within four or five rows of that passenger could hear the flight attendant clearly. That means the attendant’s statement was a withdrawal for everyone else on the flight that could hear him. The key business point here is that most passengers will not remember the attendant who made the withdrawal, but they will remember the airline. </div> <div> </div> <div>All it takes is one employee, one touchpoint, and one withdrawal to lose a customer. On the other hand, one employee, one touchpoint, and one deposit can create an engaged customer. </div></div> <div><h3 class="ms-rteElement-H3">Purpose Driven</h3> <div>At a recent hotel stay, a guest barely missed the breakfast buffet by a few minutes. As the buffet attendant was cleaning up, she saw the disappointed look on his face when he approached. She told him that she would be happy to get him something from the back. So he asked for cereal with skim milk. The attendant returned with two boxes of cereal, skim milk, and a big smile. </div> <div> </div> <div>She then asked if there was anything more she can do, and when the guest said no, she wished him a pleasant day. He did not feel like he was an interruption of her job, but rather the purpose of it. </div> <div>As this touchpoint is examined, there were multiple deposits made: an offer to get breakfast, two types of cereal presented, an offer of additional assistance, and a wish to the guest for a pleasant day. </div> <div> </div> <div>The beautiful part is that the entire transaction took less than five minutes. </div> <div> </div> <div>Multiple deposits encourage free word-of-mouth advertising. In the same touchpoint, multiple withdrawals could have easily been made. The buffet attendant could have pretended not to see the guest. She could have fled to the back when she saw him coming, or she could have told him that the buffet was closed and there was nothing she could do about it</div> <div> </div> <div>Those examples merely illustrate that enhancing each touchpoint does not have to be expensive, or cost any money, for that matter. </div> <div> </div> <div>All it requires is a team of employees who consistently “work like they own it.” </div></div> <div><h3 class="ms-rteElement-H3">Creating World-Class Service</h3> <div>Chances are that the vast majority of everyone reading this has heard the term, “world class” before. Businesses make promises to provide world-class service to their customers. Restaurants boast of having world-class chefs, and even long term and post-acute care providers claim to provide world-class care.</div> <div> </div> <div>What does it really mean? A quick look in the dictionary and an online search says that world-class means “to be ranked or considered among the world’s best.” Makes sense, but how does one get there? </div> <div> </div> <div>Before answering that question, here is a recent service experience that will illustrate the point about world-class service. A colleague called a nursing facility, and the phone rang five times before the operator answered, “How can I provide world-class service today?” The colleague’s curiosity was peaked; he was eagerly anticipating the world-class experience. Unfortunately, what followed was anything but world class. The operator cut him off mid-sentence at least three times and then transferred him without saying she would do so. </div> <div> </div> <div>Even if that particular operator provided outstanding service, that would not be world class. World class is primarily about one word—consistency. Being excellent is not enough—one has to be consistently excellent. Being memorable is not enough—one has to be consistently memorable. Being engaging is not enough—one has to be consistently engaging. </div> <div> </div> <div>World class means that service providers are “on” every day, regardless of their personal or professional circumstances. Being a service professional means that everyone does what they are supposed to do, when they are supposed to do it, whether they feel like it or not. </div> <div> </div> <div>It is probably clear by now that this world-class thing requires lots of hard work—it does. It’s not easy, otherwise everybody would be world class. It requires consistent effort, and that effort is what separates good from great and great from world class.</div> <div> </div> <div>By making a commitment to engage facility teams in a discussion about touchpoints, administrators and department heads can identify the key touchpoints in their departments </div> <div>and brainstorm ways to enhance each one. </div> <div> </div> <div>Serving others is a privilege, and residents deserve the very best that facility staff have to offer. A legion of engaged customers will follow. </div></div> <div><em></em> </div> <div><em>Bryan K. Williams, DM, is chief service officer of B. Williams Enterprise (</em><a href="http://www.bwenterprise.net/"><em>www.bwenterprise.net</em></a><em>), a customer service consulting, training, and auditing company that focuses on service excellence. The goal is to assist organizations in various industries to enhance their service to world-class levels. He can be reached at </em><a href="mailto:bwilliams@bwenterprises.net"><em>bwilliams@bwenterprises.net</em></a><em>.</em></div>Improving customer service today begins with the idea of "touchpoints." There are literally hundred of touchpoints in a typical workday.2010-12-01T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_woman_nurse_2.jpg" style="BORDER:0px solid;" />Workforce;ManagementHuman Resources12