Design for Senior Livinghttps://www.providermagazine.com/Issues/2011/Pages/0111/Design-For-Living.aspxDesign for Senior Living<div class="ms-rteThemeFontFace-2">Interior design renovations are key investments senior living community operators must make to ensure long-term success. Design updates can increase a facility’s value, boost marketing potential, and build loyalty among current residents as they see operators investing in their homes. As a critical ingredient in the recipe for what makes residents feel at home within a community, interior design can be a determining factor in residents’ decisions to move into a community. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">First impressions are certainly lasting impressions when it comes to selecting a community. A facility may provide top-quality service and care, but if the first impression the community generates is that its décor and design look dated, potential residents and their family members may choose to look elsewhere before ever learning about the facility’s outstanding services. </div> <div class="ms-rteThemeFontFace-2"> <img width="493" height="327" class="ms-rtePosition-1" alt="Attractive lounge areas give residents a place to meet and form clubs or to socialize in a pleasant setting." src="/Issues/2011/PublishingImages/0111/Brentwood-lounge.jpg" style="margin:10px;width:413px;height:244px;" /><br><strong>Stay Current</strong></div> <div class="ms-rteThemeFontFace-2"><div>Maintaining a fashionable, fresh look within the property is critical to creating that great first impression. </div></div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Keeping up with current style trends is essential to this visual appeal. This is particularly important to family members who naturally want their loved ones to live in an attractive, well-maintained community that has fashionable furnishings and design features.</div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">What this may mean, for example, is that a facility’s carpeting may show no signs of excessive wear and tear but still may need to be replaced because its style is outdated. Solid-colored carpeting in a low-cut style and color, such as mauve, often creates an institutional look and is generally considered outdated. Today, residential-style patterned carpeting is more appealing in senior living communities. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Color choices should complement the overall design scheme, and carpeting should be able to withstand everyday use and high traffic. In addition, vinyl composite tile, or VCT, hard flooring is a more appealing choice than wooden laminate or vinyl flooring.</div> <div class="ms-rteThemeFontFace-2"><br>Attractive color, fabric, and furnishing choices will vary depending on whether the facility is designed with a traditional or contemporary feel. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">The selection of finishes and surfaces will be determined by the market niche in which the facility is competing. For instance, facilities positioned in the high-end luxury market are more apt to use granite counter tops rather than Formica. Style preferences will also differ by region, and it is important to research what is considered attractive in each facility’s market. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">On the west coast of Florida, for example, many facilities are designed with bright paint colors and fabric selections. In contrast, the Atlanta area tends to favor a more traditional style using color choices such as burgundy and green. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2"><div><h3 class="ms-rteElement-H3"><strong>Design And Efficiency Can Coexist</strong></h3></div> <div>While style is important, there are several other design factors that operators should not ignore, as they can significantly improve residents’ standard of living and promote operational efficiency. </div> <div> </div> <div>One common mistake operators make is overlooking the importance of blending décor with operations. It is critical that management work together wi<img width="346" height="294" class="ms-rtePosition-2" alt="Cafes offer a convenient place for residents to enjoy snacks and refreshments." src="/Issues/2011/PublishingImages/0111/Brentwood-cafe.jpg" style="margin:10px;height:240px;" />th architects to create a visually appealing design plan that meets operational requirements. </div></div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">It is a balancing act operators must perform to please prospective and current residents and their family members, while keeping the facility operationally friendly. </div> <div class="ms-rteThemeFontFace-2"> <br>Market research will help management determine how best to maintain that balance by looking at design through the eyes of all target audiences—including staff—to create a workable interior design plan that satisfies all groups. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Staff input is extremely important, as incorporating their ideas will give them a sense of ownership and result in a much happier environment.</div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2"><h3 class="ms-rteElement-H3"><div><strong>Senior-Friendly Technology</strong></div></h3> <div>Another critical element of design in today’s senior living community is technology, which can include safety features important to operations and technology residents can use for their enjoyment. Of particular interest is the growing trend for facilities to make computers accessible and easy for seniors to use, which may include senior-friendly touch-screen computers. </div></div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Computer-based programs that help residents stay active through cognitive stimulation are also becoming popular. Many facilities have included Nintendo Wii game consoles to introduce technology while promoting fitness and entertainment. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Leading senior living providers incorporate technological features in a strategic way to prevent the facility from seeming overly high-tech or institutional. The focus, instead, should be on comfort, while positioning the technology as another component of a homelike environment. </div> <div class="ms-rteThemeFontFace-2"> <img width="356" height="278" class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/0111/Brentwood-billiards-room.jpg" alt="" style="margin:10px;height:198px;" /><br>For example, rather than setting up the Wii in an activity room, many operators place the Wii in a living room to promote comfort and encourage use. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Senior-friendly features can do a lot to differentiate facilities while enhancing residents’ standard of living. These features may range from upgraded television systems for easier listening and viewing to planning more attractive outdoor living spaces with gazebos, shaded areas, and raised planters that can accommodate resident gardening. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Bathrooms should provide senior-friendly counter heights and seating, while hallways should include comfortable seating areas for residents to rest as they walk through the community. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Another facet is that of providing a continuum of independence and socialization through design by ensuring that amenities are user-friendly and common areas have enough seating to allow residents to share the space and socialize. Providing plenty of common space for informal meetings can encourage residents to form their own clubs or groups. Shared space may include television lounges; rooms for games, billiards, and arts and crafts; and a private dining room for residents to use when family and friends visit. </div> <div class="ms-rteThemeFontFace-2"><strong></strong> </div> <div class="ms-rteThemeFontFace-2"><strong>Bring In The Outside </strong></div> <div class="ms-rteThemeFontFace-2"><div>A café is another attractive amenity, offering a convenient way to provide daily snacks and refreshments. Rather than using carts and trays to serve snacks at scheduled times, a café can be accessible to residents all day, providing choice as well as a more homelike way for residents to enjoy snacks on their own time. Installing a café may cost between $5,000 and $25,000, depending on the size of the area, décor selections, level of detail, and extent that design choices reflect an old-fashioned café. </div></div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Another unique feature gaining design attention is a Main Street-themed area that resembles a town center, allowing residents to feel they are going out, but without actually leaving the community. This may feature a walkway that looks like a cobblestone or brick road, lined with storefronts with awnings and decorated with lampposts, benches, and trees. </div> <div class="ms-rteThemeFontFace-2"> <img width="431" height="326" class="ms-rtePosition-1" alt="Attractive outdoor spaces bring residents together and offer a place for families to visit and have a meal together." src="/Issues/2011/PublishingImages/0111/Brentwood-courtyard.jpg" style="margin:10px;width:378px;height:252px;" /><br>This design option is an effective way to create a warmer, friendlier setting for amenities like a doctor’s office, barbershop, beauty salon, and wellness center. In addition, the former medication room can be replaced with the look of a neighborhood pharmacy. </div> <div class="ms-rteThemeFontFace-2"><br>Residents’ level of comfort within a community can also depend on how at home they feel within their own apartments. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">While many communities allow residents to “age in place” within the facility, few facilities have created design plans to minimize the need to relocate residents from the apartments where they feel at home to another unit in order to provide the care they require as their acuity levels change. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Basic design and furnishings can play an important role in this process, as each room should be designed for residents who will ultimately need the highest level of care. When residents begin to need a higher level of care than is provided in an entry-level assisted living unit, the services they need are brought to them, rather than moving them to another part of the facility that is specialized for the level of care they require. </div> <div class="ms-rteThemeFontFace-2"><h3 class="ms-rteElement-H3"><strong>Looking Ahead</strong></h3> <div>As the seniors housing industry moves forward, senior-friendly furniture, design options, and technology will become more prevalent. More manufacturers are tapping into the senior market, creating variations of products designed specifically for seniors.</div> <div> </div></div> <div class="ms-rteThemeFontFace-2">Technology is also being designed with seniors in mind, such as television remote controls with larger buttons that are easier to see and push and touch-screen computers with a larger keyboard and a trackball mouse that is easier for seniors to maneuver. <br><img width="146" height="498" class="ms-rtePosition-2 ms-rteImage-0" alt="An accessible space for residents to utilize a computer encourages social media interaction and communication." src="/Issues/2011/PublishingImages/0111/Brentwood--Resident-Computer.jpg" style="margin:10px;width:238px;height:158px;" /><br>Communities that strive to be perceived as the most desirable will incorporate the best and most current thinking in design and furnishings. This need not be as comprehensive as a total overhaul—it may well be that a design “facelift” with new colors and upholstery will serve the need, while in other cases a more complete refurbishment or structural change may be needed to keep the community competitive. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">In the long run, investing in a community through design can significantly increase a facility’s value and marketing potential, while creating a comfortable home for seniors with the amenities they desire and the features they need to age in place. Each renovation allows operators to update a community with the newest design features, thereby improving the residents’ standard of living and enhancing the visual appeal that is so important to their family members and caregivers.<br></div>Interior design renovations are key investments senior living community operators must make to ensure long-term success.2011-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0111/design_thumb.jpg" style="BORDER:0px solid;" />Management;DesignColumn1
Industry Perception Needs Rehabhttps://www.providermagazine.com/Issues/2011/Pages/0111/Industry-Perception-Needs-Rehab.aspxIndustry Perception Needs Rehab<p>It’s not easy being a public relations professional for the nursing facility industry these days. Plagued by intense media scrutiny and longstanding negative perceptions that could rival the tobacco industry’s worst days, long term and post-acute care providers are getting a bum rap, according to Bob Van Dyk, chair of the American Health Care Association (AHCA).  </p> <p><img class="ms-rtePosition-2" alt="Bob Van Dyk" src="/Issues/2011/PublishingImages/0111/VanDyk.jpg" style="margin:20px;width:150px;height:150px;" /></p> <p>“We need to change that,” he told attendees during an impassioned speech at AHCA’s recent annual meeting. “It’s time to shake things up.” Van Dyk’s declarations reflect his devotion to a profession that he grew up with. His father owned and operated two nursing facilities for many years before Van Dyk took over and grew the company into a continuum of services that include seniors housing; assisted living; and rehab, home, and nursing care. </p> <p>“Because the pubic doesn’t understand the important work we do, they don’t value us, nor do they fully appreciate the quality care we provide,” he says, noting that providers understand their residents like none other—“not hospitals, not academes, not politicians in Washington.” </p> <p>This belief has fueled Van Dyk’s efforts to launch an image campaign aimed at “changing deeply rooted perceptions about the long term and post-acute care industry.” If approved, the endeavor will mark a first for the organization.  “We’ve never approached something like this on such a large scale,” says Van Dyk. </p> <p>The timing for such an undertaking is certainly ripe. With many provisions of the health care reform law not yet implemented, AHCA hopes to get a seat at the table with the Centers for Medicare & Medicaid Services as they draft rules and regulations that guide how components of the new law are put into practice.</p> <p>Greg Crist, AHCA vice president of public affairs, concurs with Van Dyk’s suggestion that the public doesn’t understand what providers do every day. He says that if a campaign gets a green light, it will certainly include an education campaign that “raises awareness of what caregivers do every day.” </p> <p>But altering public perception will not happen immediately, he stresses. “When you look back at successful image and branding campaigns through the years, from milk to pork and diamonds to medicines, they all shared certain commonalities,” he says.  “Chief among them was the fact they were multi-year efforts with considerable resources dedicated, recognizing that perceptions would not change overnight.”</p> <p>Van Dyk believes that providers are not going to be successful in areas of reimbursement, survey, or regulatory reform until the image of the profession is changed. “We’re no longer the nursing homes of the ‘50s," he says. "We’re providers of excellent care that help people get better and get home. And we need to have our story told.”</p> <p>He contends that long term and post-acute care providers are the most efficient and effective health care providers in the continuum. “We have devoted our lives to understanding the needs of an aging population and the care they need and deserve,” Van Dyk says. </p> <p>An image campaign is not simply about spending dollars to convince the public that the industry is good, Van Dyk adds. “You have to be good, and you have to be deserving of that image.” ​</p>AHCA Chair advocates for an image campaign2011-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0111/VanDyk.jpg" style="BORDER:0px solid;" />ManagementColumn1
Learning From Adverse Eventshttps://www.providermagazine.com/Issues/2011/Pages/0111/Learning-From-Adverse-Events.aspxLearning From Adverse Events<p>Scenario: A resident falls and sustains a fracture. The resident has a recent history of falls. The certified nurse assistant reports the tab alarm was not in place, as was required by the care plan. </p> <div>Incidents should not happen; deficient practices should not happen; but they do. Preventing the occurrence of adverse events is ideal.  Once an event occurs, the facility staff have the ability to react rapidly using a sound performance improvement (PI) framework. </div> <div> </div> <div>Such a response demonstrates the facility’s ability to self-identify problems and self-correct a flawed system. </div> <h3 class="ms-rteElement-H3"><strong>Legal Ramifications</strong></h3> <div>There are regulatory implications associated with adverse events. The intent of the Quality Assurance and Assessment F-Tag is to require the facility to self-identify and self-correct breakdown in systems that have resulted in actual or potential for poor quality of care. </div> <div> </div> <div>In addition, many serious events also meet the criteria for “self-reporting” to the state regulatory agency. Based on these state-specific guidelines, the center reports an incident; the state investigates, agrees there was an incident, and then fines the center.</div> <div> </div> <div>These same types of events can result in a community complaint to the state agency, which in turn can result in citations and/or civil money penalties for the center.  </div> <div> </div> <div>An appropriate response will reduce the risk of adverse outcomes for other residents and may help mitigate the regulatory and financial impact. The facility can embrace a serious event as an opportunity to evaluate systems and correct practices as indicated.</div> <div> </div> <div>The purpose of this article is to provide a practical framework to guide a facility response to a serious issue.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Improving Performance</strong></h3> <p>The following events are likely to lead to an actual harm citation or a potential for high severity and scope: sentinel events, such as dehydration, fecal impaction, development of a pressure ulcer in a low-risk individual, and serious incidents, such as abuse, fall with injury, serious medication error, lack of identification or response to a change of condition, and avoidable pressure ulcers.</p> <p>What defines an appropriate and prompt response to a serious event? Too often, there is a “hit or miss” approach to addressing the issue at hand. The Centers for Medicare & Medicaid Services has provided a framework to direct the facility in using a systematic performance improvement approach. Known as the traditional Plan of Correction (POC), it provides a step-by-step framework for the center’s action plan. </p> <div>After determining root cause(s) for the adverse event, the facility then implements the four steps of the POC:  corrective actions, identification of others at risk from same deficient practice, systemic changes, and monitoring.</div> <div> </div> <div><img width="502" height="540" src="/Issues/2011/PublishingImages/0111/0111%20Caregiving_Table%201.jpg" alt="" style="margin:5px;width:640px;height:688px;" /><br><br> </div> <div>Performing a<a href="/Issues/2011/Pages/0111/Explanation-Of-Root-Cause-Analysis.aspx"> root-cause analysis </a>and addressing the cause or causes with the four-step action plan is, in essence, a dynamic application of PI. It is recommended that the facility’s quality assurance committee promptly review the root-cause analysis and four-step action plan.</div> <div> </div> <div>This element provides evidence and validation that the facility is self-identifying and self-correcting under the PI process.</div> <div> </div> <div>In addition, the facility’s medical director should review any new action plans. Medical director involvement is particularly important if the facility has any concerns the issue may represent a substandard quality-of-care situation. Facility leadership needs to remain aware of the status of current action plans and ensure that trends are identified through ongoing monitoring.</div> <div> </div> <div>This process requires disciplined focus and leadership to mobilize a team to execute the root-cause analysis and the four-step action plan. The facility should maintain an organized tracking and documentation process as evidence for completing the course of action. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Evidence Of Effectiveness</strong></h3> <div>An informal retrospective review of the results of standard, self-reported, and complaint surveys for 58 facilities over a one-year period found that in at least 15 instances, surveyors cited the facility at a lower severity and scope or chose not to cite at all after review of a facility’s four-step action plan response. </div> <div> </div> <div>In a number of these situations, the surveyors commented about how impressed they were with the facility’s organized and thorough effort. There was also a significant correlation between high severity and scope citations in situations where the facility responded to an event with an inadequate root-cause analysis or an incomplete four-step action plan.</div> <div> </div> <div>Traditionally, nursing facilities employ the elements of a POC only in response to formal survey findings. But facilities will benefit by reacting rapidly to a serious situation as if they were already cited. Proactively embracing the discipline of a four-step action plan when a serious event occurs is good clinical practice. This approach assists the facility in identifying a system breakdown, correcting it, and preventing other residents from being harmed by a similar practice.</div> <div> </div> <div>The added benefit of the four-step action plan is the potential reduction in severity and scope or avoiding a citation altogether. </div> <div> </div> <div><em>Kathy Owens, RN, MSN, is vice president clinical operations and Donna Kelsey, NHA, MS, is senior vice president for the West Region, Health Services Division of Kindred Healthcare, in South Jordan, Utah. </em><span lang="EN"><em>Owens can be reached at (801) 302-0058 or <a href="mailto:Kathy.owens@kindredhealthcare.com">Kathy.owens@kindredhealthcare.com</a></em></span><span lang="EN"><em>. Kelsey can be reached at (801) 302-0061 or <a href="mailto:Donna.kelsey@kindredhealthcare.com">Donna.kelsey@kindredhealthcare.com</a>.</em></span></div> <div><span lang="EN"><em></em></span> </div>Root-cause analysis and a four-step action plan can improve performance and quality of care following a serious patient incident.2011-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0111/bandaid_rollup.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;Quality ImprovementColumn1
MDS 3.0: News From The Frontlineshttps://www.providermagazine.com/Issues/2011/Pages/0111/MDS-3_0-News-From-The-Frontlines.aspxMDS 3.0: News From The Frontlines<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p><span class="ms-rteThemeForeColor-2-0">While the minimum data set (MDS) 3.0 mandate requirements were clear—new policies, new procedures, and new paperwork for all nursing facilities—the ultimate benefits could only be implied: positive organizational culture change and improved resident care planning. </span><br class="ms-rteThemeForeColor-2-0"><span class="ms-rteThemeForeColor-2-0"></span></p> <p><span class="ms-rteThemeForeColor-2-0">Specifically, the goal of MDS 3.0 is to introduce advances in assessment measures, increase relevance of items, improve accuracy of the tool, and include the resident’s voice through new interviews. </span><span class="ms-rteThemeForeColor-2-0">To meet this goal, every department in a nursing facility now faces multiple challenges and responsibilities. The questions remain: How are facilities meeting these challenges since the mandate went into effect Oct. 1, 2010? How do providers assess their progress to date? And what are their concerns and expectations going forward? </span> </p> <h3 class="ms-rteElement-H3"><div><span><strong>Managing The Mandate</strong></span></div></h3> <div><span class="ms-rteThemeForeColor-2-0">Elizabeth Beeson is MDS coordinator for Foss Home and Village, a 24-hour skilled nursing, long term, and dementia care facility with 211 beds in Seattle. In her view, the resident interviews have been the “best part of the whole MDS 3.0 process,” thanks to some training and preparation. “We had expert help in developing an effective transition plan and comprehensive on-site training,” she says. </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">To conduct resident interviews and gather the increased amount of information required with MDS 3.0, the facility takes an interdisciplinary approach, according to Beeson. Social workers do mood assessments, activities workers do customary routines, and nursing staff do cognition and pain assessments. </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">In fact, MDS 3.0 not only requires more interaction with residents, but also more interaction with other staff members to compile multiple assessments as determined by various schedules and resident status and condition, she says.</span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0"></span><span class="ms-rteThemeForeColor-2-0">Care plans are also handled by different staff, depending on resident status. “For custodial care or long term care residents, the whole team is involved in interviews, and we’ll do the care plan on an annual basis,” Beeson says. “For our short-term clients or for quarterly assessments, the nurse will write the care plan.”</span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">Nurses involved with short-term care—or the Medicare unit—are the most time-challenged. “We had what were called nurse managers, or resident care managers, that had numerous responsibilities, including staffing, oversight of their unit, admitting and discharging people, and dealing with families,” says Beeson. “Those nurses now are more focused on completing the MDS, so part of the work they were doing is now being passed down to medication nurses.”</span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">There are no plans now to add staff, she adds. “We’re in the process, like many facilities, of downsizing rather than hiring, so the workflow just gets stretched further and further.”</span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">Beeson is concerned about the overwhelming work load for staff—and the possible impact on assessment accuracy. “I see people talking about the fact that if you have a five-day Medicare assessment that’s done and a discharge three days later, we have to do two assessments only three days apart and collect the same information with a different end point. We basically have to redo the same assessment but look at everything differently,” she says. </span> <span class="ms-rteThemeForeColor-2-0">“And the expectation from the Centers for Medicare & Medicaid Services [CMS] is that you would again do the interview even though it’s three days later.”</span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><div><span></span><span><strong>New Benefits To Staff And Residents</strong></span></div></h3> <div><span class="ms-rteThemeForeColor-2-0">As staff face new challenges, are they seeing new benefits? “Absolutely,” says Beeson. “They have verbalized to me that they see the benefit in the interaction they have with the residents. Everybody is hoping that there will be some changes down the road in some of the requirements to make it more realistic in getting the work completed. But the interview process, giving the residents voice, including them in decisions about their care, their preferences—everybody has been very optimistic about that.” </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">In fact, staff have been very surprised with how many residents can actively participate in the interviews and with their level of appreciation. “The bottom line is that it’s been a very positive thing,” Beeson says. “Giving residents voice is right in line with the whole concept of achieving culture change.” </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">Pamela Powell, director of nursing at Elness Convalescent, a 99-bed skilled nursing facility run by Mark One Corp., Central Valley, Calif., experienced a rocky start during the MDS 3.0 transition, with computer problems at the state level and the lack of return validation for data transmittals from the facility. </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">The staff transition is going much smoother, Powell admits. “It’s just been a change. I had to go in and change all our assessment forms for our different departments that do input on the MDS, and that made it easier for them. </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">“And I’ve added another [MDS] person to help out because [the original coordinator] is just overwhelmed,” says Powell. </span><span class="ms-rteThemeForeColor-2-0">“The MDS takes longer right now, and we can’t run behind.” </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <h3 class="ms-rteElement-H3"><span><strong>From Our Care To ‘I Care’</strong></span></h3> <div><span class="ms-rteThemeForeColor-2-0">Elness also takes an interdisciplinary approach to conducting resident interviews, which meets one goal of the MDS 3.0 transition: increasing resident voice. “Yes, it gets your resident much more involved in your care planning process. In our training, we learned about doing new ‘I Care’ plans as opposed to the care plans we’d normally done in the past,” says Powell. </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0"></span><span class="ms-rteThemeForeColor-2-0">“Now we can write it as if we were the resident talking, and it makes much more sense when you read it. It’s the resident’s goals, not our goals. </span><span class="ms-rteThemeForeColor-2-0">We invite residents to the care plan meetings, so every time we do an MDS we also have a care plan meeting where the whole team gets together with the resident or the resident’s responsible party, or both, and we all sit down and talk about what’s gone on with the resident and what the care plan goals should be.” </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">Powell believes MDS 3.0 will help with state surveys as well. “You should be doing better on surveys in the future, because you will know your resident better than you have in the past,” she says. “And better surveys can help change your [CMS] Five-Star rating. That’s a good thing for your facility and your business.”</span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">Powell speaks for many in the long term care industry when she says, “You have to be able to adapt to change.” </span></div> <div><span class="ms-rteThemeForeColor-2-0">Though facilities are now coping with workflow and work load issues, internal and external computer issues, delays in the availability of quality indicators, and other challenges, some providers are seeing improved resident care planning and positive organizational culture change. </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">The biggest factor in determining if MDS 3.0 presents a success or crisis for the facility is the proper preparation of staff—and systems—through on- site training combined with effective, market-tested system solutions. </span></div> <div><span class="ms-rteThemeForeColor-2-0"></span> </div> <div><span class="ms-rteThemeForeColor-2-0">Click<a href="/Issues/2011/Pages/0111/Implementation-And-Impact.aspx"> <strong>HERE</strong> </a>for some preparation tips and information about how MDS 3.0 impacts each and every department within the nursing facility.</span></div> <div> </div> <div><span class="ms-rteThemeForeColor-2-0"><em>Ladd Nichols is vice president of marketing for Gulf South Medical Supply, a leading supplier of products and services for long term care, assisted living, and home care. Gulf South provides MDS 3.0 training programs in conjucnction with Pathway Health Services and PointClickCare.</em></span></div>A look at how providers are faring during the transition process.2011-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/nurse_thumb.jpg" style="BORDER:0px solid;" />Policy;Management;ReimbursementColumn1
New House Member Has Long Term Care Rootshttps://www.providermagazine.com/Issues/2011/Pages/0111/New-House-Member-Has-Long-Term-Care-Roots.aspxNew House Member Has Long Term Care Roots<font class="ms-rteThemeFontFace-2" face="Cambria"><div>With Jim Renacci’s election to Congress, long term care providers have one of their own in office, considering the new representative from Ohio’s 16th district used to own and operate nursing facilities throughout the state as part of his LTC Management Services company.<br><img class="ms-rtePosition-2" alt="Jim Renacci" src="/Issues/2011/PublishingImages/0111/Renacci.jpg" style="margin:20px;" /><br>Renacci will be one of more than four dozen new Republican members taking office this month in the House of Representatives, helping to sweep Democrats out of power and setting the stage for a divided government, with the White House and Senate remaining in the hands of Democrats. <br><br>Health care is a top priority for Renacci, 52, a Pennsylvania-born businessman turned politician who defeated freshman lawmaker John Boccieri by a wide margin in November. He spoke to <em>Provider </em>magazine recently and is the first lawmaker to be profiled in what will be a regular series in this space. <br></div> <div>Renacci is deeply concerned about protecting the safety net—Medicare and Medicaid—that exists for caring for the elderly but at the same time is coming to Washington to promote policies for growing the economy, reining in spending, and correcting what he views as a flawed health care reform law.<br><br>“I campaigned on ‘repeal and replace,’” he says of the reform law, noting the changes in the law addressed coverage issues but ignored costs, which vastly overemphasizes the lesser of the two major problems in the system. <br></div> <div>There were some positive measures in the law, like protecting coverage for preexisting conditions, but it fell way too short of being a good law, he says. “All of these good points could be molded into a new bill as long as you take care of costs. We need to replace that bill and take care of some of the safety net issues. Bringing competition to health care is a main priority,” Renacci says.</div> <div><br>From his time in the nursing facility business, Renacci identifies with providers who see a need to change the survey process and the Five-Star rating system. He calls it inconsistent and without real logic. <br><br>“One of the problems with it is that some of the best homes can be rated low, and some of those that don’t operate as highly rate higher. You can walk into any nursing home and find issues if you want to, but it depends on the day and the survey team. It is not consistent and not standard,” he says.<br><br>Over-regulation of the long term care industry is a major problem, and there needs to be a determination of which rules are necessary and which are not, Renacci says. “Long term care is an essential part of the economy, and it is a necessity to take care of the safety net for the elderly,” he says. </div> <div> </div> <div>Renacci will be undertaking a major move in coming to the nation’s capital. He has lived in the 16th district for 27 years, calling Wadsworth, Ohio, home, and raising three now college-age and older children with his wife, Tina. He grew up in a working-class home outside of Pittsburgh, graduating from Indiana University of Pennsylvania. Shortly after graduation, he moved to Wadsworth where he initially worked as a certified public accountant. In 1985, Renacci formed LTC Management Services, owning and operating nursing facilities throughout Ohio.<br></div> <div>The road to Washington began in local government. Renacci served on the Board of Zoning Appeals from 1993-1994, from 1999-2002 as president of the City Council, and then as mayor from 2004-2008, where he balanced Wadsworth’s $80 million budget without raising taxes. <br><br>Beyond all of the specific issues that will come before him as a lawmaker, Renacci says the focus should be on how policies affect the country’s citizens moving forward. “In every decision we make, we need to make sure we are considering our children and grandchildren. This is what I learned from talking to the people during the campaign,” Renacci says.</div></font>With Jim Renacci’s election to Congress, long term care providers have one of their own in office, considering the new representative from Ohio’s 16th district2011-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0111/Renacci.jpg" style="BORDER:0px solid;" />PolicyColumn1
Providers Tackle Preventable Hospitalizationshttps://www.providermagazine.com/Issues/2011/Pages/0111/Ramping-Up-For-Higher-Acuity.aspxProviders Tackle Preventable Hospitalizations<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>​</div> <div>Registered nurses (RNs) are taking center stage lately in some providers’ efforts to combat avoidable hospitalizations. Genesis HealthCare is one example. The Kennett Square, Pa.-based company has had laudable success in this area by employing more RNs, as well as nurse practitioners and doctors, in its nursing facilities.</div> <div> </div> <div>“We have really moved to an RN model of care,” says Mike Reitz, chief operating officer. He describes the company’s nursing centers as “med-surg units” where physicians and nurse practitioners are employed in “as many of our centers as possible. We still work under the mantle of long term care, but half of the people we’re admitting today are discharged within 25 days,” he says. “We need to staff with a much more medically intensive model.” </div> <div> </div> <div>Genesis’ initiative, which began in 2004, has led to an 11 percent decline in unplanned hospitalizations. </div> <div> </div> <div>Aiding in this effort is a requirement by the company that each facility must generate a performance scorecard that allows management to monitor, manage, and set expectations, says Reitz. And one of the clinical metrics on the scorecard is unplanned hospital readmissions. According to Genesis’ calculations, about 25 percent of hospitalizations are avoidable.</div> <h3 class="ms-rteElement-H3"><strong>Tracking The Variables</strong></h3> <div>In an effort to reduce this figure, 60 percent of Genesis facilities now have a “transitional care unit,” in which an RN-intensive staff team cares for residents who have been in the hospital within the past 25 days. In addition, these units are required to have a nurse practitioner or physician on staff every day.</div> <div> </div> <div>All of the facilities’ RNs are intravenous (IV)-certified, says Reitz, and the nurse practitioner’s role is to provide not only direct care but to act as a clinical mentor for RNs to further develop their skills. “We want all new admits seen by an RN at a maximum of two hours after admission,” says Reitz. The physician or nurse practitioner is expected to see all new admissions within 12 hours of admission, if not sooner. </div> <div> </div> <div>Having recently hospitalized residents all in one place—in the transitional care units—makes tracking what causes rehospitalizations much easier and gives facilities a better coordination of care, especially in the hand-off from facility to hospital, or vice versa. It becomes possible for Genesis to track a wide array of variables and identify patterns and potential triggers that may have caused an unplanned hospitalization, as well as what happens to residents at the hospital, including the number of days post-discharge that they’re readmitted, what the diagnosis was, any inquiries from the hospital, and the name of the discharging physician at the hospital. </div> <div> </div> <div>Discharge information is important because “those folks that are going back [to the hospital] within three days of admission…in all probability, there were issues related to the hand-off” that caused the rehospitalization, says Reitz. “Once it gets beyond three days, we generally feel the issues related to rehospitalization are controllable within our setting.” </div> <div> </div> <div>If something happened during the hand-off that may have caused the rehospitalization, Genesis staff discuss the situation with hospital staff. “The attention that we are now getting on this topic from acute care [facilities] has gone up exponentially in the last six months,” says Reitz. That’s because outlying hospitals will face reimbursement penalties for unnecessary rehospitalizations starting in 2012, says Reitz. “They’re as interested as we are” in bringing avoidable rehospitalizations under control, he says. </div> <div> </div> <div>Genesis isn’t stopping there, however. The company is rolling out respiratory therapy as a way to “manage down” the pulmonary conditions that trigger many hospitalizations, says Reitz. That, he says, is producing results.</div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>Why Hospitalize?</strong></h3> <div>There are a variety of reasons why some nursing facilities choose to hospitalize residents rather than manage lower-acuity situations in-house. To begin with, there is a “culture of hospitalization” not only on the part of nursing facilities but emanating from physicians and families as well. Health providers worry about being sued, and families become anxious and assume that the resident will be better served in a hospital. </div> <div> </div> <div>According to one in a series of reports from the Henry J. Kaiser Family Foundation, residents are hospitalized so routinely that it tends to happen with little active decision making among facility staff. Nurses are especially likely to hospitalize a resident when the resident has fallen, has an infection, or is disruptive or violent. But other reasons simply involve the capabilities of the nursing facility.</div> <div> </div> <div> Its nurses may not be trained to care for sicker residents or in identifying changes of condition early, before they require a hospital. Or nurses may not think facility staff have time for all of the extra duties that may be required—collecting specimens and starting and monitoring IVs, for example. </div> <div> </div> <div>What’s more, they may not have the skills to communicate a physical assessment and history to an off-site, on-call physician. Sometimes, of course, a resident is so sick that the hospital is necessary no matter how well prepared and equipped nursing staff are, depending on what the resident’s advance directive says. Further, staff may not feel comfortable or competent to talk with families about on-site palliative care.</div> <div> </div> <div>A study by Joseph Ouslander, MD, project director of INTERACT, a systematic program designed to reduce avoidable hospitalizations, looked at medical records of 20 Georgia nursing facilities. The results showed that hospitalizations occurred for the following reasons: not having an on-site primary care clinician, not being able to get lab tests quickly, and difficulties with identifying a change of condition. </div> <div> </div> <div>Click<strong> </strong><a href="/Issues/2011/Pages/0111/Interact-The-Prevalent-Underlying-System-For-Reducing-Hospitalizations.aspx"><strong>HERE </strong></a>to learn more about the INTERACT program. </div> <div> </div> <div>But licensing limitations won’t allow some nursing facilities to do lab work on-site, and other diagnostic tools like X-rays and EKGs may not be readily accessible. Another reason for hospitalizations may be a lack of advance care planning, so that in the event of a critical illness, even in a terminal patient, what to do is open to question, and everyone prefers to err on the side of caution, providers say. </div> <div><h3 class="ms-rteElement-H3"><strong>Medicare’s Role In The Issue</strong></h3></div> <div>Further, one of the Kaiser studies’ authors found that Medicare contractors that adjudicate doctors’ claims appear more likely to question daily visits to a long term care facility than those to a hospital.</div> <div> </div> <div>What’s ironic is that nursing facilities technically have further disincentives to reduce unplanned hospitalizations because patients who go to the hospital can requalify for Medicare if they’re in the hospital for three days. But long term care providers unanimously said that this didn’t play into their strategizing. “We basically ignore that,” says Genesis’ Reitz. “We want to provide good care.” </div> <div> </div> <div>However, facilities will realize that if they get really good at preventing hospitalizations, their Medicare numbers may go down because fewer patients will get that qualifying three-day stay. One could say there’s a financial disincentive to preventing rehospitalizations, according to several providers interviewed.</div> <div> <img class="ms-rtePosition-1" alt="Barbara Baylis" src="/Issues/2011/PublishingImages/0111/Baylis.jpg" style="margin:15px 10px;" /><br></div> <div>In addition, facilities good at preventing hospitalizations will have higher ancillary costs, some of which they won’t be able to bill for, says Barbara Baylis, senior vice president, clinical and residential services, for Kindred Healthcare, Louisville, Ky. “But in the long run, [preventing unplanned hospital visits] is the right thing to do,” she says.</div> <div> </div> <div>“Clearly, it’s the right thing to do for the patient,” says Keith Krein, MD, chief medical officer of Kindred’s nursing center division.</div> <div> <img class="ms-rtePosition-2" alt="Keith Krien, MD" src="/Issues/2011/PublishingImages/0111/Krein.jpg" style="margin:15px 20px;width:150px;height:150px;" /><br><br></div> <div>But Reitz is convinced that decreasing unplanned hospitalizations in the emerging new world order of health care will result in more business. “It is good clinical care that drives market share,” he says. “Our mission is to manage this metric [of unplanned hospitalizations] down as low as we possibly can, and as hospitals are seeing that we’re having better clinical outcomes, that’ll drive market share.” </div> <div> <br><span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Charting Patient Wellness</strong></h3> <div>Genesis RNs are specially trained to watch out for at-risk patients—those who come to the facility with a history of noncompliance, have severe depression, or experience an acute change of mental status. “Generically, those are three that are immediate flags even prior to doing the initial assessment,” says Reitz. </div> <div> </div> <div>Three common reasons for hospitalizing a resident are because of pneumonia, kidney or urinary tract infection, or congestive heart failure—these three categories make up nearly 25 percent of hospitalizations. In the past, a change of condition would send a resident to the hospital, says Baylis. </div> <div> </div> <div>Today, treatment is initiated “sooner and more appropriately, and as long as the patient is responding to the treatment they’ll stay in the facility. When we’ve exhausted what we’re able to do and the patient is not responding, then the decision is made to transfer the resident to the hospital.”</div> <div> </div> <div>Baylis and Krein were involved in the development several years ago of the American Medical Directors Association’s industry-recognized guidelines on identifying changes of condition and, thereby, avoiding unnecessary hospitalizations. “It has to be a collaborative effort of the entire interdisciplinary care team,” says Krein, whether that’s a certified nurse assistant (CNA), a therapist, or housekeeping or maintenance staff. “The key is that if anyone notices something different about a resident that could be the early onset of a change in medical condition, it needs to be reported to the right personnel. It’s a team effort.”</div> <div> </div> <div>“You would be surprised at the number of housekeeping staff and maintenance staff that will bring up things at the morning meeting,” says Baylis. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Symptoms May Be Subtle</strong></h3> <div>The reason why identifying changes of condition is so important, says Krein, is that “the geriatric population doesn’t react in the same way that a normal, healthy person would react to, say, an infection. Early onset might manifest itself as simply a little bit of confusion, some slight mental status change that someone might not be as alert to as they were before. Oftentimes, it’s just subtle changes in the demeanor and mental status and such that need to be observed and reported so a more thorough assessment can be done by the nursing personnel.”</div> <div> </div> <div>Reitz agrees that early identification of changes in condition is crucial. “We believe the best solution to managing down hospital readmissions is for the RN to be very competent at physical assessment and change of condition,” says Reitz. “We see when we don’t do a good job of reacting to change of condition, that is a key factor” in patients being readmitted to a hospital. </div> <div> </div> <div>Making an impact on rehospitalization rates means the skill-sets and competencies of nursing staff need to be enhanced, as does the follow-up and backup support by the physician, says Krein. In addition, equipment will likely need to be purchased and communication protocols will need to be overhauled. </div> <div> </div> <div>Whether residents can receive IVs, how long it takes for staff to get lab results, whether the facility has a portable X-ray machine, and how long it takes for the pharmacy to deliver a new medication all must be assessed, says Krein. </div> <div> </div> <div>Other things might not seem obvious at first blush. For example, it’s not enough to have good communication in place with attending physicians, says Krein; you must have good communication with on-call physicians as well, so that when a resident’s doctor is on vacation that on-call physician doesn’t just order the resident to the hospital as a knee-jerk reaction. </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><div><strong>Kindred’s Story</strong></div></h3> <div>Not all facilities may be geared to handling higher-acuity patients. Figuring out what facilities were best suited to provide transitional care with reduced hospitalizations was a process of years, says Baylis. The first step was recognizing that rehospitalizations were a problem. </div> <div> </div> <div>Then they collected retrospective data on those hospitalizations to figure out who was returning to the hospital and what factors were involved in making the hospitalization necessary, identifying what equipment would have helped and what kinds of assessments would have helped, and what to measure to determine the effectiveness of interventions. </div> <div> </div> <div>Kindred started working on preventing unplanned hospitalizations several years ago by piloting INTERACT tools, and it continues to refine its approach. Fifty percent of Kindred’s patients go home within 33 days, 90 percent go home within 90 days, and the company has started hiring respiratory therapists to help staff manage bronchitis, pneumonia, and congestive heart failure. </div> <div> </div> <div>But not all nursing facilities have the capabilities to adequately care for residents with more acute conditions.</div> <div> </div> <div>“The crux of this is what kind of nursing facility it is,” says Krein. “This notion that if you’ve seen one nursing home you’ve seen all nursing homes, that might have been true maybe even a decade ago, but what has happened in the last decade is we have a tremendous variety of skill-sets across the spectrum” of long term care, he says. </div> <div> </div> <div>He compares two facilities in Kindred’s own portfolio: One cares solely for residents who have dementia but are otherwise medically stable and may live at the facility for years. That facility is, therefore, appropriately staffed with a lot of nurse assistants and restorative aides, but not a lot of therapists or RNs. Another facility of the same size has high resident turnover, admitting 160 patients a month and sending 100 home. It is heavily staffed with RNs and has a host of diagnostic capabilities and two full-time physicians making rounds in the center each day. </div> <div> </div> <div>The two facilities represent “very different situations,” says Krein, and very different capabilities when it comes to being able to prevent unplanned hospitalizations.</div> <h3 class="ms-rteElement-H3"><strong>Hospitals Act As Gatekeepers</strong></h3> <div>“Hospitals are under great scrutiny of inappropriately admitting folks,” says Reitz. It’s getting harder to admit someone to the hospital, which means residents transferred to the hospital may spend hours on a gurney in the emergency room and then are sent right back to the facility.</div> <div> </div> <div>“Many hospitals are ... certainly gate-keeping at the emergency department more than ever before,” says Krein. “You’re not just going to show up at the ER and say you want to be hospitalized. If [a resident’s] condition is such that they don’t need to get into the hospital, they may get all kinds of tests done in the ER and lie on a stretcher for eight hours and get stuck several times by the lab, and the end result may be that they’re going to be sent back to the nursing center.” </div> <div> </div> <div>Letting people leave the hospital “quicker and sicker” has been a hospital trend for many years, observer says. “The sooner they can get them out of the hospital, the more profitable the hospital is,” says Krein. Reimbursement is based on diagnosis, with an expected length of stay. So, if the hospital can get the patient out of the hospital sooner than expected, it makes money; if the patient stays longer, the hospital loses money. Under a clause in the health care reform act, in 2012 hospitals will face financial consequences for certain readmissions that have yet to be determined.</div> <div> </div> <div>Because there is concern that hospitals are discharging people to nursing facilities before they’re fully stabilized, the government “has been proposing bundling—one payment for the hospital stay as well as the first 30 days after the hospital stay,” says Krein. </div> <div> </div> <div>It will force hospitals and nursing facilities to work collaboratively to both ensure the resident isn’t discharged too soon and that the nursing facility receives more complete information “so the receiving facilities can be more prepared with equipment and such to care for the patient,” Krein says.</div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>Implementing Solutions</strong></h3> <div>A study by Ouslander and others, published in the <em>Journal of the American Medical Directors Association</em>, took stock of the INTERACT program. The six-month study of three volunteer facilities with high rates of hospitalization was conducted by the Georgia Medical Care Foundation, the Medicare quality improvement organization for Georgia. Participating nursing facilities received, in addition to the INTERACT materials, on-site and telephonic support from an advance practice nurse. </div> <div> </div> <div>The study found that none of the facilities fully implemented the INTERACT tools and that the degree to which the materials had been adopted varied among the facilities. Despite the degree to which the program was not implemented, participating facilities saw, on average, a 50 percent reduction in the overall hospitalization rate. The percentage of hospitalizations later deemed to have been potentially avoidable also dropped by 30 percent.</div> <div> </div> <div>A study participant, SavaSeniorCare, Atlanta, found that those facilities that really took to the program and made it a part of their culture did see noticeable reductions in their hospitalization rates.</div> <div> </div> <div>Most nursing facilities need “more infrastructure and resources in order to make a big dent in avoidable hospitalizations,” says Ouslander. It’s not enough to just up the number of nursing staff, says Ouslander; their training needs to be enhanced as well. And more primary care clinicians—doctors, nurse practitioners, physician assistants—need to be more available to long term care facilities. </div> <div> </div> <div>On top of that, facilities need the capability to “administer intravenous fluid and have rapid access to diagnostic tests and pharmacy services,” he says. “However, there are some things that most nursing homes have the capability to do that aren’t being done now as well as they could be,” he says. </div> <div> </div> <div>The first and, arguably, most important of these things is to become more skilled at identifying changes in condition early and intervening so they don’t become so severe as to require hospitalization. </div> <div> </div> <div>Nursing facilities need to become better at identifying certain conditions that can be managed without transferring the resident to a hospital, such as a “lower respiratory infection, where the resident is not critically ill, or a urinary tract infection or an exacerbation of congestive heart failure,” says Ouslander. “Lots of nursing home residents get sick with those conditions and need to go to the hospital, but some are only mildly ill, and the <a href="/Issues/2011/Pages/0111/The-Risks-Of-Hospitalization.aspx">risks </a>of complications in the hospital outweigh the benefits” of transferring them.</div> <div> </div> <div>“The INTERACT tool addresses both of these” areas in which most nursing facilities could impact their rehospitalization rates without a dramatic change in their infrastructure, he says.</div> <h3 class="ms-rteElement-H3"><strong>Set Facility Goals</strong></h3> <div>INTERACT recommends that facilities begin implementation by identifying a hospitalization reduction goal to strive for and measure progress with a quality improvement tool. The program promotes the enlistment of key personnel to act as an implementation team. These people would oversee and monitor the progress, involve the attending physicians and the medical director, and educate everybody—residents, families, and staff—on what the facility is working toward.</div> <div> </div> <div>In the INTERACT study, implementation teams were composed of the director or assistant director of nursing, a member of the social worker staff, and a licensed nurse. One member was designated as the project champion, acting as the key contact and promoting the use of the tools. Every two to three weeks, the champion met with the project coordinator to systematically review hospital transfers. </div> <div> </div> <div>A critical component of successfully implementing a program to reduce unplanned hospitalizations is “working with [the] entire staff to understand that this is a No. 1 priority for the facility, and for the care of the resident and success of the business,” says Reitz. “The No. 1 thing that an administrator needs to do is help the entire staff embrace the program and understand it.”</div> <div> </div> <div>“I would begin with as few beds as possible” when starting the effort to reduce unplanned hospitalizations, says Reitz. “We chose to do it on a unit basis.” </div> <div> </div> <div>Second, well-trained staff are key. “Clearly you have to staff those units very differently than traditional units,” he says. Intensify the involvement of RNs in the admission process, he says, so that residents are thoroughly assessed upon admission and any change in condition can be identified. “To the extent that you can employ nurse practitioners on those units, all the better,” he says. </div> <div> </div> <div>Limit the number of physicians seeing patients in the facility, Reitz recommends. While it might not be feasible for a smaller, independent nursing facility to have a physician on staff, “clearly, limiting the number of physicians who are attending at your center will help” make managing the incidence of rehospitalizations more doable, says Reitz. </div> <div> </div> <div>In the past, a nursing facility might see 30 different physicians coming into the facility to care for various patients. “You can’t do that in this environment,” he says. Staff need to build good communication with each attending physician so that in the event of a change of condition, the physician and nursing facility staff can communicate quickly and clearly about the resident’s situation, and the physician can have confidence in the nursing facility staff’s ability to handle it.</div> <div> </div> <div>Finally, consider hiring a respiratory therapist to limit the number of discharges due to pulmonary problems. This, says Reitz, “is going to be absolutely essential for the long term care provider to manage down the readmits.”</div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Change Is Coming</strong></h3> <div>Medicare is planning to use pay for performance, bundled payments, and other strategies to provide financial incentives to reduce avoidable hospitalizations. </div> <div> </div> <div>“The world is beginning to change in terms of this whole effort of looking at rehospitalization rates,” says Krein. He believes that the “perverse incentives” to send long term care residents back to the hospital repeatedly will be eliminated. </div> <div> </div> <div>In the new world, hospitals will “keep the patients in the hospital as long as they need to be there” and then expect long term care providers to do an adequate job of “meeting the needs of the patient and not sending them back to the hospital,” he says. </div> <div> </div> <div>“What health care reform is looking at is coordination and integration, and we know health care reform is putting us in a position” where improved coordination with hospitals and physicians will be a must, says Donna Hendrickson, senior vice president, clinical services, for Sava. </div> <div> </div> <div>“Sava is trying to be very progressive and look ahead,” says Hendrickson. “First, it’s important that we’re providing the highest quality of care,” including being able to prevent avoidable hospitalizations. This is a focus for our health care industry as well as for the regulators, focusing on, ‘Are the individuals paying for health care getting what they deserve and are paying for?’” says Hendrickson.</div> <div> </div> <div><strong>Paradoxical Results</strong></div> <div>“There may be diminishing returns” with a hospital reduction program, says Krein. “If these trends continue” with hospitals increasingly sending their more complex patients to a facility that’s proven to do a good job with medically intensive patients, “it may be harder and harder to lower [hospitalization] rates.” </div> <div> </div> <div>Krein tells a story about a Tufts teaching nursing facility where the prevalence of pressure ulcers was way too high at 15 percent. Tufts worked hard to improve its wound care, and three years later, after the involvement of wound care experts and surgeons, its prevalence rate was 40 percent—because it had become known as being an outstanding provider of care for people with pressure ulcers, so all the hospitals sent their patients with complex pressure ulcers to Tufts.</div> <div> </div> <div>“What we really need is a more robust risk adjustment strategy,” says Krein. “My concern is if, for example, the government starts comparing [rehospitalization] rates without doing adequate risk adjustments” to allow for the acuity level of a facility’s patients. </div> <div> </div> <div>“Like everything else, this rehospitalization rate is going to need to be put in some type of context,” he says. </div> <div> </div> <div>“We know we have to impact this outcome, first and foremost, for those residents that we care for,” says Hendrickson. </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Manassas, Va.</em></div> <div> </div>Registered nurses (RNs) are taking center stage lately in some providers’ efforts to combat avoidable hospitalizations. Genesis HealthCare is one example.2011-01-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0811/hospital_rollup.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;Quality;Quality ImprovementColumn1




West Virginia Lawmaker Makes Long Term Care Issues A Priorityhttps://www.providermagazine.com/Issues/2011/Pages/0211/West-Virginia-Lawmaker-Makes-Long-Term-Care-Issues-A-Priority.aspxWest Virginia Lawmaker Makes Long Term Care Issues A Priority<div>Rep. Shelley Moore Capito  (R-W.Va.) is a leader in Congress on long term care matters, working as the co-chair of the Long Term Care Caucus, a forum for lawmakers to discuss legislative proposals and important issues affecting the elderly across the country.</div> <div><img class="ms-rtePosition-1" alt="Shelley Moore Capito" src="/Issues/2011/PublishingImages/0211/Capito.jpg" style="margin:15px;" /><br></div> <div>Capito, 57, who won re-election to a sixth term in the House of Representatives this past November, says her interest in long term care is both personal and professional.</div> <div><br></div> <div>“We all either have a relative or friend who in some way has to deal with a long-term illness or condition,” she says. “Our family is currently facing these challenges. I don’t think people truly appreciate the importance of long term care until they go through it with a loved one.</div> <div><br></div> <div>“The more we can educate people about the role long term care plays in health care, the better we can prepare future generations. My state of West Virginia has an aging population, so having effective and compassionate long term care facilities and providers is critical,” she says.</div> <div><br></div> <div>Capito is the daughter of former West Virginia Gov. Arch Moore and is considered a leading candidate to run for the Senate in 2012 against incumbent Sen. Joe Manchin.  She turned down a chance this past July to run against Manchin in a special election for the open seat created with the passing of legendary West Virginia lawmaker Robert Byrd. The focus now for Capito is certainly on the 112th Congress, which began work last month. While long term care issues will remain a priority, </div> <div><br></div> <div>Capito notes there is a much more fundamental need for lawmakers to pay attention to what the people want.  </div> <div><br></div> <div>“The Congress must start listening to the American people. I think that was blatantly clear in the midterm elections,” she says.</div> <div><br></div> <div>To start down that road, Congress has to address the national debt, both on a year-to-year basis and the much larger overall debt, she stresses.</div> <div><br></div> <div>“Countless families have sat down at their dinner tables and made tough choices to pay off their debts and do without certain expenses; the Congress needs to do the same,” Capito says.  </div> <div><br></div> <div>To make her point, she notes that last summer House Republicans began the YouCut program, which is an opportunity for the public to vote on an area of the federal budget to cut.   </div> <div><br></div> <div>“There has been tremendous participation from the American people, and this program will continue in the new Congress,” Capito says.  </div> <div><br></div> <div>As for the health care reform law, she sees a need for major change. “The health care law should be repealed and replaced with measures that have strong bipartisan support. I think many supporters of this new law were shocked at the public’s rejection of the president’s health care law. You simply cannot overhaul that large of a component of our economy in a partisan manner. There were areas of bipartisan agreement such as reducing the burden on those with a pre-existing condition and those who cannot afford insurance because of life-time or annual caps,” she says.   </div> <div><br></div> <div>To make reform actually work, the Glen Dale, W. Va., native and mother of three and grandmother of one says medical liability reform must be made part of the solution.</div> <div><br></div> <div>“My home state of West Virginia was facing a crisis from 2001 to 2003, and the state legislature was able to come together and pass medical liability reform. It has worked well in West Virginia, but we need a national law,” she says.   </div> <div><br></div> <div>The new Congress has made a major committee assignment change for Capito, who will now chair the House Financial Services subcommittee on Financial Institutions and Consumer Credit.</div> <div><br></div> <div>As for the Long Term Care Caucus, Capito says the group needs new blood to help replace departed co-chair Earl Pomeroy, who lost his re-election bid in North Dakota.</div>Educating others about long term care is the key to preparation, says Capito.2011-01-01T05:00:00Z<img alt="Shelley Moore Capito" src="/Issues/2011/PublishingImages/0211/Capito.jpg" style="BORDER:0px solid;" />PolicyColumn2
Unique Dementia Care Activities Boost Quality Of Lifehttps://www.providermagazine.com/Issues/2011/Pages/0211/Activities-On-The-Move.aspxUnique Dementia Care Activities Boost Quality Of Life<div>​The early design of most Alzheimer’s and dementia communities focused primarily on safety, with secured doors and other devices to protect residents. In this type of setting, staff often spent their days redirecting residents, creating an environment of “sorry you can’t go there or do that.” But today’s leading providers strive for more of a “yes, you can” approach. </div> <div> </div> <div>According to the Alzheimer’s Association, the planning of activities for individuals with Alzheimer’s should be focused on the person, activity, approach, and place. Activities should be well-planned and customized to each person based on individual interests. </div> <div> </div> <div><strong>Staff Role Vital</strong></div> <div>The approach that staff take is also important. Staff can help create a sense of purpose for residents through activities, as long as they are encouraging and create a comfortable and supportive environment. </div> <div> </div> <div>A sound activity program reduces the stress and frustrations that residents may experience each day, helping to eliminate behavioral challenges such as anger, agitation, depression, and wandering. Examples include the establishment of a daily routine and consistent daily living activities such as bathing, dressing, and eating. </div> <div> </div> <div>These can be augmented by activities that are fun, educational, and reminiscent of residents’ earlier days with their families or relate to their past occupation or hobbies—all designed to encourage and support physical and mental well-being and socialization, reducing anxiety, depression, and isolation. These can include light exercise, crafts, games, field trips, listening to music, pet therapy, computer classes, yoga, and spa treatments. </div> <div> </div> <div>Sometimes, it’s the simple things that provide the greatest value. Trivia games, discussing events in history, and sharing family photo albums can stimulate precious memories and discussions of days gone by. Some communities will simulate the planning of a wedding, baby shower, or other events to stimulate residents’ memories and help them reconnect with their loved ones. Planning and talking about the event can be very enjoyable for the residents.</div> <div> </div> <div><strong>Engage The Familiar</strong></div> <div>Activities that promote cognitive skills can be helpful, but tasks should not be too difficult. And, although creating a consistent plan for all residents that includes typical activities of daily living is important, residents can respond differently based on their stage of Alzheimer’s or dementia. </div> <div> </div> <div>As a result, flexibility and experimentation are important as staff strive to create the most effective program for each individual. According to a Johns Hopkins University white paper, reminiscence is an activity that can be particularly beneficial to the resident with dementia while also strengthening family bonds, by using objects, art, music, or other items with personal meaning to connect to the past. </div> <div> </div> <div>“Sorting old photos or making a scrapbook may trigger shared memories from your loved one’s youth or early adulthood, which can add to a family’s sense of history,” the paper says. “An emotion-linked aroma like that of freshly baked cookies may encourage the individual to talk about his or her childhood.” </div> <div> </div> <div>Families are an important source of information in program planning and can be invaluable in suggesting activities that will help their loves ones reconnect with their memories. Asking residents’ families to complete a biographical questionnaire or participate in an interview with facility staff can be extremely helpful. </div> <div> </div> <div>Interviewing residents can be even more valuable. These discussions should focus primarily on their past, as that is what they will most easily remember. It’s important to ask residents about their families, occupations, hobbies, and important events in their life.</div> <div> </div> <div>The key is not to press for answers but to let the discussions develop naturally. When an interview is conducted correctly, staff may be surprised by the touching stories residents tell them. </div> <div> </div> <div>After successful interviews with residents and family members, staff members are better prepared to customize activity programs to residents’ interests. For example, if a resident has always loved painting, then staff could start a painting class or provide the resident with art supplies and a place to paint. </div> <div> </div> <div>In addition, family members should be encouraged to take part in activities and events (<em>See </em>Provider<em>, <a href="/archives/archives-2010/Pages/1110/Family-Engagement-In-Nursing-Care-Bolsters-Quality.aspx">November 2010 </a>for more information about family involvement</em>). This can be therapeutic not just for the residents but for the family members as well. However, staff should caution the family to have realistic expectations about their loved ones’ abilities and encourage participation without being critical.</div> <div> </div> <div>The most important aspect is focusing on the enjoyment of the activity, not the specific achievement.</div> <div> </div> <div><strong>Staff Training </strong></div> <div>Specialized training will be of great value in helping staff encourage residents to become more involved with activities. Training should include an understanding of the aging process, proper Alzheimer’s and dementia care, and the behavioral and social needs of the residents. </div> <div> </div> <div>To avoid agitation among residents, staff should avoid correcting them if they answer questions incorrectly. For example, some facilities’ activity programs have a morning activity that starts with, “Today is Monday, July 26, 2010,” followed by a discussion of current events and events in history. </div> <div> </div> <div>If a resident insists that the date is Tuesday, July 26, 1965, staff should move on without correcting the person. The key is for staff to be trained to live in the residents’ worlds and not frustrate them by insisting that they are wrong. </div> <div> </div> <div>The design and features of memory care communities are constantly evolving. As management and staff listen and observe the needs of their residents and the expectations of their caregivers, they can adjust their programs and features accordingly. </div> <div> </div> <div><strong>The Physical Setup</strong></div> <div>An interior design scheme that creates the perception of a barrier-free environment, for example, offers operators and activities professionals a place for residents to wander. A purposeful design that enables residents to feel like they can explore freely without barriers, while still maintaining a safe, secure community, can have a positive impact on residents. </div> <div> </div> <div>Hallways may be designed in a complete circle or square so residents feel they can go where they please and never run into a dead end. </div> <div> </div> <div><a href="/Issues/2011/Pages/0211/‘Life-Skills’-Bring-Solace-And-Purpose.aspx">Life skills “stations” </a>are a more recent development in memory care programs. These enable residents to find comfort in practicing daily routines and life skills that were previously part of their everyday lives, such as folding laundry, hobby work, or gardening.</div> <div> </div> <div>In addition, some facilities have added computer-based, memory-stimulating programs such as Dakim Brain Fitness, which shows evidence of helping residents with Alzheimer’s and dementia remain more active through cognitive stimulation. As new generations of tech-savvy seniors enter senior living communities, even more technological advances will be required to meet their needs and expectations.</div> <div> </div> <div><strong>Day Care Programs </strong></div> <div>Other new approaches support family caregivers trying to juggle multiple responsibilities as well as seniors who are not quite ready for full-time residency.</div> <div> </div> <div>Senior day programs make it possible for non-resident seniors to spend four, eight, or 12 hours at the community to enjoy social opportunities, games, and a wide range of activities, while avoiding the loneliness and isolation created when the primary caregiver is at work. </div> <div> </div> <div>Similarly, some communities have begun to provide professional overnight care to offer a respite for weary caregivers. A “dusk-to-dawn” program offers overnight accommodations, normally from 7:00 p.m. to 7:00 a.m., including holidays, for seniors with sleep disturbances, confusion, Alzheimer’s, or wandering habits. </div> <div> </div> <div>For those residents who have difficulty sleeping, staff members provide therapeutic activities to help them relax and eventually fall asleep. </div> <div> </div> <div>No matter what innovations in memory care programming and technology may be on the horizon, the best providers will continue to create an environment that allows residents to explore and enjoy life. Creating a true home where residents with Alzheimer’s and dementia can walk, explore, and enjoy their time in a comfortable, barrier-free environment sets certain communities apart. </div> <div> </div> <div>Click <a href="/Issues/2011/Pages/0211/Provider-Programs-Enhance-Offerings.aspx">HERE</a> for more information about what other providers are doing to enhance activities for residents with Alzheimer's and related dementias.</div> <div> </div> <div><em>John Moschner is director of operations for Senior Management Advisors, <a href="http://www.seniormanagementadvisors.com/">www.seniormanagementadvisors.com</a>, an operator of full-service independent living, assisted living, and Alzheimer’s care residential communities in Florida and Georgia. Contact Moschner at j<a href="mailto:moschner@smaservices.net">moschner@smaservices.net</a>. Marki Greer is memory care program director for The Cottage at Plantation South Dunwoody, a senior living and Alzheimer’s care residential community in Dunwoody, Ga.</em></div> <div><em></em> </div>A refresher on providing meaningful activities for people with Alzheimer’s and related dementias can validate the resident’s experience.2011-02-01T05:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/0211/Caregiving-photo-vanity-Life-skill-Station.jpg" width="150" style="BORDER:0px solid;" />Caregiving;Quality Improvement;QualityColumn2
Long Term Care Providers Tackle Disaster Preparedness In A Post-Katrina Worldhttps://www.providermagazine.com/Issues/2011/Pages/0211/Disaster-Preparedness-In-A-Post-Katrina-World.aspxLong Term Care Providers Tackle Disaster Preparedness In A Post-Katrina World<div> </div> <div>Tragedies like Hurricane Katrina in 2005 have shaped a new era of disaster preparedness for skilled nursing and assisted living facilities across the country, with more providers taking proactive steps to become part of governmental emergency planning to keep residents as safe as possible before, during, and after any manner of threat. </div> <div> </div> <div>Providers are also advocating for legislative and regulatory changes to upgrade the status of long term and post acute care facilities in the eyes of first responders and emergency planners at all levels of government. Once often treated like a retail outlet in the pecking order for emergency utility restoration, some locales now recognize long term care providers for their vital role in providing health care services and have made nursing facility utility restoration a priority. </div> <div> </div> <div>Threats to the normal operation of a long term care facility come in many forms, be they from fire or power outages or seasonal weather events, such as hurricanes, tornados, and floods. Disaster planning also comes into play when incidents of food-borne illness, flu, or community-based alerts created by terrorism, a train derailment, or police action occur, for example. <br><img width="359" height="384" class="ms-rtePosition-2" alt="First responders must be made aware of a long term care facility's needs." src="/Issues/2011/PublishingImages/0211/FEATURE-Exempla-Drill-10.jpg" style="margin:20px 10px;width:276px;height:184px;" /><br>Experts say the threats seem to be growing, notably in the area of natural disasters, but as they increase so does the assistance being made available for implementing effective disaster plans. “The reality is that we have a pretty awesome responsibility. The people in our facilities are fragile and not resilient, and the need for preparedness has been ever-increasing over time for skilled nursing facilities and assisted living,” says Jocelyn Montgomery, director of clinical affairs for the California Association of Health Facilities (CAHF).</div> <div> </div> <div><strong>Challenges Abound</strong></div> <div>Preparing for emergencies has become even more trying because skilled nursing beds are now occupied by residents with much higher acuity levels than seen only 10 to 15 years ago, she notes. “Anything that disrupts service poses a health and safety threat. We all have the sense that it is not going to happen to us, but you need to have back-up systems in place,” Montgomery says.</div> <div> </div> <div>One look at the Federal Emergency Management Agency website shows the plethora of potential disasters the federal government sees as worthy of special mention. These include dam failures, tornados, volcanoes, wildfires, winter storms, terrorism, hurricanes, landslides, heat, floods, hazardous materials, earthquakes, chemical events, nuclear power plants, and tsunamis. </div> <div> </div> <div>Where a facility is located dictates which unique threats are most important, says Montgomery. She notes that California has earthquakes to contend with, as well as wildfires and landslides. </div> <div> </div> <div>“In Iowa the most frequent hazard is tornados,” says Patricia Giorgio, president of Evergreen Estates, a family-owned residential living provider in Cedar Rapids. So, her staff conduct an annual tornado drill to stay prepared for such an occurrence.</div> <div> </div> <div>It was actually floods that caused the most recent emergency on a wide scale in the area in June 2008, she notes, when<img width="326" height="347" class="ms-rtePosition-1" alt="Transportation is a vital component of any long term care facility's emergency plan." src="/Issues/2011/PublishingImages/0211/FEATURE-Exempla-Drill-20.jpg" style="margin:15px 10px;width:290px;height:194px;" /> the Cedar River crested beyond a 500-year floodplain, wreaking havoc and forcing local hospitals to transfer patients to long term care facilities out of the way of the water, Giorgio says.</div> <div> <br>In Vermont, precautions are taken for nuclear power, says Deb Choma, administrator of residential care home Shard Villa in Salisbury, Vt. The Vermont Yankee plant in Vernon creates considerations for how to evacuate residents if there were ever a major problem, Choma notes.</div> <div> </div> <div>But it was a recent train derailment with the potential for a chemical leak that sent her back to ensure her facility was ready. “All of us were in Montpelier [at a meeting] when cell phones went off and all had to go back to our facilities to prepare for a potential problem,” Choma says.</div> <div> </div> <div><strong>Getting A Seat At The Table</strong></div> <div>While being ready for an emergency has always been a priority for providers, it was made more so over the past decade. Sometimes it takes a dramatic event, even ones as tragic as Katrina or the Sept. 11 terror attacks in 2001, to shock the system and change the way things are done. Learning from mistakes and taking into account real-life lessons have given providers new tools for ensuring that quality care extends to residents even in the most trying of times. </div> <div> </div> <div>“We’ve learned a lot over the past six years,” says LuMarie Polivka-West, senior director of policy for the Florida Health Care Association (FHCA) and a member of the American Health Care Association’s (AHCA’s) Disaster Planning Committee, referring to the time span from the especially trying hurricane seasons of 2004 and 2005 to present day.  </div> <div> </div> <div>She has been a major mover in the evaluation of what went wrong during the 2004-2005 hurricane seasons and worked with a number of long term care leaders in the first Gulf Coast Hurricane Summits in February 2006 and then in 2007 to assess what could be done to better protect long term care residents during emergencies.  </div> <div> <br>The summits, supported by a grant to FHCA from the John A. Hartford Foundation in response to the events of Hurricanes Katrina, Rita, and Wilma, noted that long term care was an afterthought in existing emergency response systems and plans. “We learned we did not have a seat at the table,” Polivka-West says. </div> <div> </div> <div>Or, as Amy Berman, senior program officer at the Hartford Foundation in New York City, says, “Long term care was at the same level as a 7-Eleven for utility restoration.”</div> <div> </div> <div>Vulnerable medically frail elderly and disabled patients and residents were largely dependent on the limited capability of each individual provider and their individual disaster plan, which was not coordinated with governmental emergency efforts, Polivka-West says. </div> <div> </div> <div>The summits recommended that the then National Response Plan incorporate long term care facilities in its unified, all-discipline, all-hazards approach to disaster planning, response, and recovery, she says.</div> <div> </div> <div><strong>Tragedy Spurs Action</strong></div> <div>The obvious reason for the prioritization of disaster preparedness for the long term care community was the direct result of the awful deaths brought about by Katrina. “When Katrina, Rita, and Wilma struck in 2005, older adults were disproportionately affected. Two-thirds of deaths in New Orleans were age 65 or older. Many of the deaths, including the tragedy at St. Rita’s, occurred after the hurricanes had passed,” says Berman.</div> <div> </div> <div>St. Rita’s was a nursing facility in the St. Bernard section of New Orleans where 34 residents died after the building flooded as a result of Katrina. Seventy-eight nursing facility residents in New Orleans in total lost their lives during Katrina, and 23 long term care residents were killed in a bus accident in Texas during evacuations caused by Hurricane Rita.</div> <div> </div> <div>Following those tragedies, the Hartford Foundation funded a three-year, $361,556 grant titled “Hurricane and Disaster Preparedness for Long-Term Care Facilities,” administer<img width="330" height="294" class="ms-rtePosition-2" alt="Transportation is a vital component of any long term care facility's emergency plan." src="/Issues/2011/PublishingImages/0211/FEATURE-Exampla-Drill-9.jpg" style="margin:10px 15px;width:416px;height:277px;" />ed by FHCA. As a result of the grant, nursing facilities in Alabama, Florida, Louisiana, Mississippi, and Texas are now classified as health care providers, giving them priority for utility restoration. FHCA in turn has spearheaded the creation of the Emergency Management Guide for Nursing Homes, with AHCA.</div> <div> </div> <div>To Berman, frail, older adults in nursing facilities were at risk because the facilities were (and are) excluded from the National Response Plan. “That meant that, unlike hospitals, nursing homes were not prioritized for restoration of electrical power and telephone service,” she says. “Restoration of utilities could be a matter of life and death for a nursing home resident. Without air conditioning or refrigeration for medication, older adults would perish.”</div> <div> </div> <div>There was also a lack of guidance for evacuation versus sheltering in place. “Sheltering in place is generally preferred given that high-acuity patients could be harmed in an evacuation. But there needed to be an ethical informed process to determine whether to evacuate or shelter-in-place,” Berman says. “Nursing home contracts for transportation and other supports during the crisis were worthless. Buses and other needed resources were commandeered. When nursing homes weren’t integrated into disaster planning efforts, their own plans became worthless.”</div> <div> </div> <div>As a result of the changes in local and state policy, nursing facilities now have more access to resources for recovery, and the medical needs of the elderly are now recognized, including refrigeration for medications, air conditioning to avoid heat-related illnesses, and washing machines to keep elders’ linens and clothes clean, Berman says.</div> <div> </div> <div>She points out that these changes bore fruit when in 2008, Hurricanes Gustav and Ike threatened Louisiana and Texas. Unlike in 2005, emergency officials routinely reported the numbers of nursing facility evacuations and acknowledged residents’ needs.</div> <div> </div> <div>There are now explicit guidelines for decision making about evacuating the residents of long term care facilities. Several states, including Alabama, Mississippi, and Utah, have used state Department of Homeland Security funding to purchase satellite phones to bolster communications systems.</div> <div> </div> <div>Resident tracking and case management have also been made a priority, she says. Sheltering in place is preferred, but in the case of evacuation, steps have been taken to keep track of long-term residents in a more effective manner. </div> <div> </div> <div>Berman says Gulf Coast states have developed databases that track facility status and bed availability during disasters, but there remains an unmet goal to develop a universal patient identification system since privacy and dignity rules prevent nursing facilities from maintaining identification labeling, such as a Medicare identification number, on individual patients.  </div> <div> </div> <div><strong>Florida Sees Success, Even In Face Of Storms</strong></div> <div>FHCA is on the frontlines of disaster planning because of the threats posed by frequent hurricanes. When Hurricane Charley hit on Aug. 13, 2004, Polivka-West says the state’s long term care facilities had to grapple with evacuating more than 10,000 residents from the path of the storm from Tampa to Orlando. </div> <div> </div> <div>“By pulling together we had no deaths in the 2004-2005 hurricane seasons,” she says, noting this good fortune came despite the physical damage to buildings, including one facility losing its roof to Charley.</div> <div> <img width="340" height="246" class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/0211/Katrina-043.jpg" alt="" style="margin:10px;height:255px;" /><br>Long term care providers are now part of the Emergency Operations Center in Florida and are active in communicating with first responders on the unique needs of the frail and elderly in facilities across the spectrum of long term care, Polivka-West adds.  </div> <div> </div> <div>Berman says Florida has long been a model state for long term care providers. “Florida was an exception, a model state. Even in 2005, Florida was a model state. Florida has never lost a nursing home resident in an emergency because the needs of nursing homes are and were integrated into the state’s response,” Berman says.</div> <div> </div> <div>In working with FHCA over the past five years, the Hartford Foundation-funded effort has produced the first national decision-making guidelines for evacuation in disasters. </div> <div> </div> <div>A disaster planning software and guide now assists nursing facility administrators and staff prepare for future emergencies and create a plan specific to their facility in accordance with the federal “all-hazards” approach. And tabletop exercises help nursing facility staff practice the implementation of the plan.</div> <div> </div> <div>“But perhaps the most impressive gains are on the state and federal levels. Needs of the nursing homes and the residents they care for are on the national agenda. Unfortunately, the National Response Plan still has not formalized this integration of nursing homes,” Berman says.</div> <div> </div> <div>The nuts and bolts of preparing for a disaster are many. Steps include physically preparing by hardening a facility for inclement weather, purchasing extra supplies, and arranging evacuations if needed. What others have learned from past emergencies is vital to prepare for the next disaster, Polivka-West says.</div> <h3 class="ms-rteElement-H3"><strong>How To Get Ready</strong></h3> <div>Perhaps one of the most important first steps, beyond creating a plan, is to reach out to the local community and let them know what a long term care facility is, and is not, says Montgomery. “Work with the local community and don’t meet for the first time at a disaster. Every 9-11 anniversary is a good time to open your doors and offer refreshments to first responders and the like and build that rapport before an event happens,” Montgomery says.</div> <div> </div> <div>Many long term care facilities are not called “nursing homes” or “nursing facilities” in their titles, confusing the uneducated in the community on what a “rehab center” is, for instance. </div> <div> </div> <div>Montgomery says beyond letting the community know of your existence there are concrete steps to follow in disaster planning. “The first thing we talk to providers about is to do an evaluation of the hazards you are most likely to face. Know what your hazards are. There are lots of tools out there to do a hazard-vulnerability analysis. And go beyond what you see and talk to local response experts,” she says.</div> <div> </div> <div>“Second, every long term care facility has to be ready for a disruption of infrastructure—water, fire, and power come to mind. This depends a lot on the geography. In California, there is a high risk of earthquake, and in certain parts of the state there is the threat of catastrophic quakes.”</div> <div> </div> <div>She recalls that CAHF’s Disaster Preparedness Program (DPP) was helping facilities in Alaska where volcanoes are a danger, but discovered it wasn’t the obvious threat from an eruption or lava flow that worried people the most, but instead the ash that would cause respiratory issues for residents.</div> <div> </div> <div>“There are the four Cs of an all-hazards analysis,” she says. These start with command and control. “You need good leadership and a good incident command system.”</div> <div> </div> <div>The other Cs include obtaining critical resources, supplies and transportation, communications, and collaboration. “One of the top things identified in after-action reports is we could have done better in communications,” Montgomery says.  </div> <div> </div> <div>Collaboration is when facilities put off their rivalries in order to help each other out. “You have to stop your competition long enough to discuss who can do what for each other. All of us want these vulnerable people to be safe,” she says. Her last point is that an active training program is necessary to put every staff member on the same page for disaster. “You are not done until everyone is able to do the plan. An emergency no doubt will happen at 3 a.m. on a Sunday, and you may not be able to get there. The night shift, the charge nurse, everybody has to be ready to perform their role. They must know how to hold down the fort, save lives, know how to communicate,” Montgomery says.</div> <div> <img width="447" height="349" class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/0211/FEATURE-Exampla-Drill-11.jpg" alt="" style="margin:20px 10px;height:299px;" /><br>CAHF, like FHCA in Florida, is a leader in the field of long term care disaster preparedness. In September 2006, CAHF received funding through the California Department of Health Services to support the integration of long term care into the disaster planning and response efforts in California.</div> <div> </div> <div>CAHF’s DPP provides services to all long term care facilities in the state, including and beyond its own membership. The DPP takes an all-hazards approach, and its work has several aspects, including education, coordination, and development of resources and tools. </div> <div> </div> <div>A key project for DPP in 2006-2007 was the Pandemic Workbook for Long-Term Care and in July 2009, the Model Respiratory Protection Program, both being the first of their kind to be written specifically for long term care. Both also have worksheets and targeted tools and recommendations that providers can put into practice immediately. <br></div> <div><strong>Shelter In Place Or Evacuate?</strong></div> <div>The National Criteria for Evacuation Decision-Making in Nursing Homes by the Hartford Foundation, University of South Florida, and FHCA details the process in deciding whether to evacuate a facility. Within the report is the description of Homeland Security Presidential Directive 5, which called for a single, comprehensive system to enhance the ability of the United States to manage domestic incidents. </div> <div> </div> <div>The National Incident Management System (NIMS) was rolled out in 2004 by the Department of Homeland Security, providing a template enabling all levels of government, the private sector, and nongovernmental organizations to work together during an incident. A key component of NIMS is the Incident Command System (ICS). The ICS is a standardized, all-hazard incident management concept, allowing its users to adopt an integrated organizational structure. ICS is structured to support five major functional areas: command, finance, logistics, operations, and planning.</div> <div> </div> <div>When deciding whether to evacuate, a provider has to consider internal factors as well as outside forces. The criterion notes that resident acuity is a vital part of the evacuation equation. Residents with complex medical conditions, like radiation therapy or dialysis, may need to be evacuated to a hospital. Others may have special care needs, like respiratory treatment or pressure ulcers, that may be manageable in the nursing facility if their condition is stable.</div> <div> </div> <div>The physical structure of the facility also plays a role in whether to abandon the property, the report said. Questions must be answered on whether the facility is hardened for an approaching storm, what hazards are immediately around the facility, like trees that can fall and destroy parts of buildings, as well as emergency power capacity and security.</div> <div> </div> <div>Transportation is of course vital to an evacuation plan. Poor planning by the facility, incorrect assumptions regarding vehicle sources and availability, vehicles destroyed in the disaster, and the lack of properly sized vehicles are all factors that may prevent an evacuation. </div> <div> </div> <div>Even when a provider decides to evacuate, there may be no place to evacuate to, the report said. Staff must also be in place for an evacuation, which may be difficult if roads are impassable or staff have their own families to tend to.</div> <div> </div> <div>A decision to shelter in place requires the ability of a facility to be self-sufficient. There must be adequate supplies to do so. States vary on what supplies, and how much, are needed for sheltering in place, but for example, Florida law requires a one-week supply of nonperishable food and supplies, three gallons of water per resident per day during and after a disaster (defined as 72 hours), and one gallon per staff member per day, along with 72 hours worth of essential supplies. The Hartford report notes that it recommends seven to 10 days of supplies, well beyond the Florida law.</div> <div> </div> <div><strong>Location Matters</strong></div> <div>As for external factors, the report says a provider has to assess the nature of the emergency when deciding to evacuate. The time and scope of the event are important, but sometimes, like during a fire or gas leak, there is no time to assess such matters.</div> <div> </div> <div>The location of a facility, whether it is in a prescribed zone, like a hurricane evacuation zone, will play a big role in deciding to stay or go, the report said. In the end, the report recommends precautions at every turn when planning for an evacuation or sheltering-in-place episode. </div> <div> </div> <div>“Redundancy in disaster planning is strongly encouraged as it is certain that resources will be stretched thin by constantly changing conditions. Facilities are encouraged to implement a three-deep philosophy, entering into contracts with multiple vendors for the provision of food, water, emergency power, transportations, and emergency destinations,” the report said. “Most importantly, a facility’s ICS must be prepared to consider and act on a facility’s evacuation decision-making criteria,” it noted.</div> <div> </div> <div>Polivka-West has noted that Hurricane Charley is a prime example of the conundrum of whether to evacuate or not. When the storm made landfall, it was not expected to turn into Port Charlotte, Fla., as a strong, Category 4 storm with winds up to 180 miles per hour. Roofs were being blown away from hospitals and long term care facilities across southwest Florida, up through Orlando, and northeast to Jacksonville. </div> <div> </div> <div>The expanse of the storm left nursing facility and assisted living facility planners at a loss since emergency transport had collapsed as ambulances were being used by hospitals for evacuations. “Thousands of nursing home and assisted living facility residents were properly and effectively evacuated from the St. Petersburg and Tampa areas into central Florida around Orlando. Unfortunately, that is precisely the direction Hurricane Charley followed, damaging the facilities that had accepted the evacuees from Tampa and St. Petersburg,” she says.</div> <div> </div> <div>The lesson learned was the importance of hardening physical plants even more to withstand the force of Charley’s winds because of the gaps in evacuation transportation. </div> <div> </div> <div>Researchers from Brown University and the University of South Florida, with funding from the National Institute on Aging, found that because of the difficulty in evacuating nursing facility residents, it may be wiser to stay in buildings that will not be flooded, Polivka-West notes.</div> <div> </div> <div><strong>Other Lessons</strong></div> <div>The cause of disasters may differ, but a facility’s ability to handle disruptions comes down to the same issues: Is the power on, are the toilets working, is there enough food and shelter, and can residents be safely cared for as during a routine day?</div> <div> </div> <div>Polivka-West says Florida providers have learned that cooperation is key. Even competitors give up food, beds, and supplies for residents in need of shelter during emergencies. </div> <div> </div> <div>They also learned the importance of securing transportation for an evacuation and to gauge the need to do so in a careful manner. “The category of storm matters—3 to 4 you have to evacuate, 2 to 3 maybe not,” she says.</div> <div>Other issues to track are making sure to update staff on training since “new staff have to be trained because they did not live through 2005.” There also has to be enough fuel to top off generators, seven days of food and water, and the sewage aspect.</div> <div> </div> <div>Providers have learned how to capture sewage by using black garbage bags to secure and remove refuse when there is no service, which can be for a duration of two to three weeks if past experience is any measure.</div> <div>Giorgio notes the importance of practice drills and to keep such drilling as simple as possible. “Drill and plan but keep it simple,” she says.</div> <div> </div> <div>Other ideas she shares are to make sure to have an evacuation folder with basic information on each resident within, along with a recent photo and medical summary.</div> <div> </div> <div>Where to evacuate is also something to make note of, Giorgio says. She worked with her local Lynn County officials to change the relocation spot for her residents from an elementary school to a high school, given the small size of the toilets at the lower school.</div> <div> </div> <div>She also says working with insurance providers will help immensely by having representatives sit in on disaster planning meetings so everyone can understand the plan and possibly open the process to new ideas. </div> <div>“Consider your insurance company as a partner—that is very important,” Giorgio says. </div> <div> </div> <div><strong>Call For More Reforms</strong></div> <div>AHCA and the National Center for Assisted Living have pushed for Congress to close the loop on a number of issues that prevent long term care facilities from receiving proper treatment in the wake of disasters. Even with the positive steps occurring at the state and local level, it says there needs to be action in Washington for ensuring equal treatment for long term care reforms:</div> <ul><li>The National Disaster Medical System should be reconfigured to support the evacuation and care of nursing facility patients/residents, assisted living residents, and people residing in residential care facilities for the elderly and developmentally disabled. </li> <li>Electronic health records must be implemented. The lack of an interoperable electronic health information infrastructure that houses and allows access to personal health and medical information left evacuees of Katrina and Rita without sufficient records to allow caregivers to make appropriate and safe decisions about immediate care.</li> <li>The Stafford Act excludes for-profit nursing facilities that provide care to the publicly funded Medicare and Medicaid residents from receiving federal financial assistance during and after disasters. As a result, less than one third of all U.S. nursing facilities are eligible for critical and necessary federal assistance, with the one third representing the not-for-profit sector.</li> <li>Emergency communications must be improved. Weaknesses in the communications system may mean that local health care providers and facilities, as well as police, ambulance services, and others involved in search and rescue, will require satellite phone capacity, or broadband satellite Internet capacity, powered by generators.</li> <li>Federal government agencies need to work together in identifying requirements for long term care facilities in all-hazard approaches to disaster preparedness. An example of the lack of cohesion on this subject was the planning for the H1N1 Influenza A pandemic, when nursing facilities received conflicting guidance on the transmission dynamics of the flu.</li> <li>Finally, new protocols are necessary to improve communications and coordination between all providers and the local, state, and federal governments, with the National Response Framework as the guide for plan development at all levels. </li></ul>As acuity rises in long term care, planning and coordination become more critical than ever. 2011-02-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0211/katrina_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn2
Elevator Safety Crucial For Seniors Housing Providershttps://www.providermagazine.com/Issues/2011/Pages/0211/Going-Up-A-Look-At-Elevator-Safety-.aspxElevator Safety Crucial For Seniors Housing Providers<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>Senior residents depend on their facility management to provide a safe home, and management wants nothing less. Elevators are necessary for residents to avoid stairs with all the difficulties and dangers they pose, but elevators can also pose a danger to the elderly and infirm. </p> <div>What many facility operators do not realize is that there are options to configure elevators to be friendlier to residents and to serve them more safely. Elevator maintenance companies are the best source for learning about these options, but they will not tell facility operators about safety options unless they are asked. </div> <div> </div> <div><strong>S</strong><strong>afety Trumps Speed </strong></div> <div>Most residents are willing to take the extra time to be safe, and elevators can be adjusted to respect this need. There are a number of specific things facility administrators can do to respond appropriately to this need. </div> <div> </div> <div>Faster elevator operation at each floor means the elevator car can leave sooner and reach another floor sooner where other people are waiting. While this regimen is desirable for high-rise office buildings, it has no place in senior living facilities. </div> <div> </div> <div><img width="241" height="616" class="ms-rtePosition-1 ms-rteImage-2" alt="Most elevator injuries among elderly users are due to slips, trips, or falls." src="/Issues/2011/PublishingImages/0211/resident-exits-elevator.jpg" style="margin:10px;width:208px;height:277px;" />Ninety-five percent of the problems encountered by residents are while entering and exiting the elevator, a quantity that divides into 20 and 80 percent segments. Twenty percent of these are due to mis-leveling, meaning the elevator is not level with the floor when the doors open. The remaining 80 percent of the entry/exit problems revolve around the operation of the doors. Elevator doors are controlled by electronics that control how long the opened doors remain open, how slowly or how fast (and therefore forcefully) the doors close, how friendly the doors are when they find an obstruction in their closing path, and how well the doors sense or “see” the person trying to enter or exit.</div> <div> </div> <div>The average elevator doors are set to begin closing three to six seconds after opening. What is the hurry? The Americans with Disabilities Act (ADA) actually requires that elevators doors remain fully opened for at least 20 seconds or more after opening. </div> <div> </div> <div>Once in the car, an impatient resident can always press the Door Close button to get going sooner. However, most residents will be more comfortable with the service set this way, and fewer injuries and lawsuits will result. </div> <div> </div> <div>Ask the elevator maintenance company to set the time to at least to 20 seconds, in order to comply with ADA requirements.</div> <div> </div> <div>Physical contact with any user is undesirable, but it is unacceptable around seniors.</div> <div> </div> <div>The national code for safe operation of elevators, published by the American Society of Mechanical Engineering, allows speeds of up to one foot per second and forces as great as 30 pounds, but half the speed and one-tenth the force would be much better. Again, the elevator maintenance company can reduce the door speed and force it to a much slower pace. Because of other requirements in the Elevator Safety Code, one-third the “normal” speed and force should be immediately obtainable.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div><strong>Impatient Elevators </strong></div> <div>When a building is on fire, special rules apply. Doors need to close so that firefighters can use the elevator for access and rescue. To provide for this, the doors go into “nudging mode” and move slowly but inexorably to close. </div> <div> </div> <div>“Nudging mode” works this way: After a period of time, when the doors have not closed for whatever reason, they close at a reduced speed and force without regard for anything in the way. However, “nudging mode” is an option during normal operation that is often left enabled simply by chance. Nudging is fundamentally wrong for senior living facilities as the doors will close on residents and poses a high risk for injury and liability. </div> <div> </div> <div>Besides knocking people down, doors in nudging mode have been known to squeeze and trap people with disabilities. This happened once to a wheelchair-bound man in Michigan. Nudging has been outlawed in the state for many years.</div> <div> </div> <div>Until more states follow Michigan’s lead, the nudging can be turned off by the elevator maintenance company.</div> <div><strong></strong> </div> <div><strong>Sensors Replace Humans</strong></div> <div>Fifty years ago, human operators ran elevators. Then, in the 1950s, elevators began to operate automatically. Today, the eyes, ears, common sense, and compassion of a human being have been replaced with electromechanical devices that decide if, when, and how to close the doors. Sensors detect obstructions and attempt to reopen closing doors as needed.</div> <div> </div> <div>The first such device was a mechanical bar on the leading edge of the moving door that touched the obstruction to detect it. This concept of a mechanical object touching passengers to detect their presence should not be allowed in senior care facilities. Unfortunately, many elevators in two- and three-story facilities are still equipped with this mechanical bar, making them inherently dangerous and in violation of the ADA. Imagine something as inappropriate as pushing on frail people before backing off. </div> <div> </div> <div>For 30 years, various configurations of light beams have been arranged to detect objects in the direct path of the car doors. For the past 10 years, camera systems have been available that look out into the hallway to detect people giving them even more time to safely enter and exit. </div> <div> </div> <div>The cost of this very best, state-of-the-art protection is around $2,000 or less per elevator. This small, one-time capital expenditure is well worth the protection it provides from both injuries and lawsuits.</div> <div> </div> <div><strong>Ask For Help</strong></div> <div>A physical therapist, Susan Parys, at an East Coast senior living facility, became concerned with the speed and force of the elevator doors and began searching for solutions. Taking charge, she found the telephone number for the elevator maintenance company. </div> <div> </div> <div>The first words from the young mechanic when he arrived were, “There is nothing wrong with these elevators.” By elevator industry standards, he was absolutely correct, but their dialog was complicated by differences in their knowledge and backgrounds.</div> <div> </div> <div>She explained the need, he responded with a simple screwdriver adjustment, and the time the doors remained opened was greatly increased. The residents now have several facility elevators that are set appropriately for their needs. Asking really can make a difference.</div> <div> </div> <div>The speed and force with which doors close and the way they sense people in the way are critical requirements for safe elevators in senior facilities. </div> <div> </div> <div>It is important to remember that  owners must ask their elevator maintenance company to tell them about options and inform them about safer alternatives.</div> <div> </div> <div>Click <a href="/Issues/2011/Pages/0211/Elevator-Study-Urges-Consistent-Monitoring.aspx">HERE</a> for information about the causes of elevator injuries among older adults.</div> <p> </p> <p><em>C. Stephen Carr, PhD, an engineer with Technology Litigation Corp., specializes in elevator and escalator safety and accident investigation. Carr, who has analyzed more than 230 accident cases in 37 states over the past decade, can be reached at (800) 656-8876, ext. 102, or at C.Stephen</em><a href="mailto:.Carr@gmail.com"><em>.Carr@gmail.com</em></a><em>  </em></p> <p><em></em> </p>Thousands of injuries occur on elevators each year, but proper maintenance and monitoring can ensure the safety of elderly users.2011-02-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0211/elevator_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn2
MDS 3.0 Documentation And RUG-IVhttps://www.providermagazine.com/Issues/2011/Pages/0211/MDS-3-0-Documentation-And-RUG-IV.aspxMDS 3.0 Documentation And RUG-IV<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>The minimum data set (MDS) 3.0 and the new skilled nursing facility payment system resource utilization group IV (RUG-IV) ushered in a new era of change for providers of long term and post-acute care. For many facilities, the implementation of these new systems had been preceded by months and months of planning and analysis. </p> <p>For others, the planning was cut short and limited due to available resources. In either case, now is the time for every provider to circle back and assess the internal processes that were put in place to manage under these new systems. This post-implementation step is essential to ensure the accuracy of da<img width="800" height="533" class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/Clip%20art%20images%20Nurse%20at%20computer.jpg" alt="" style="margin:10px 15px;width:263px;height:175px;" />ta captured for optimal resident care, favorable survey results, and appropriate reimbursement. </p> <h3 class="ms-rteElement-H3"><strong>Focus On ADLs</strong></h3> <p>Under MDS 3.0 and RUG-IV, the categories of Late Loss Activities of Daily Living (ADLs) that affect reimbursement are unchanged. They include bed mobility, transfer, eating, and toilet use. Accurate capture of these ADLs is still essential, as they influence each of the 66 RUG-IV categories, just like they did for the groupings under RUG-III. </p> <div>What has changed is the methodology for scoring on the ADL index. As a result of this change in methodology, many residents are expected to generate a lower ADL score under RUG-IV as compared with the previous RUGIII reimbursement system. </div> <div> </div> <div>For example, under RUG-III, the Reduced Physical Functioning category was the only group that broke the ADL index into five different “end-splits” that were reflected as A through E in the score. Under RUG-IV, there are now four such categories with five ADL end-splits. The new additions to end-splits include Special Care High, Special Care Low, and Clinically Complex. </div> <div> </div> <div>From an operational perspective, this change in methodology introduces 15 new opportunities for a one-point documentation error that could cause a resident to drop into a lower end-split. This means that it is much more likely that a missed ADL designation will cause a facility to be reimbursed at a lower rate than is appropriate. </div> <div> </div> <div>To illustrate, under RUG-III, missing one ADL end-split meant losing, on average, approximately $20 per day. </div> <div> </div> <div>In contrast, under RUG-IV that average jumps to more than $34 per day. That’s more than a 50 percent increase in the value of one missed ADL point. Extrapolate that calculation across the entire resident population, and it is easy to see how some facilities could face thousands of dollars in lost reimbursement. </div> <div> </div> <div>In addition, over time, miscoded assessments could also lead to residents receiving care plans that are inadequate for their needs. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div><strong>New ADL End-Splits </strong></div> <div>In conjunction with adding more ADL end-splits, RUG-IV also increased the number of categories that are unattainable with low ADL scores. The RUG-III ADL index range was four through 18, while the RUG-IV range is zero through 16. </div> <div> </div> <div>Eight RUG-IV categories will not be attainable with an ADL score of less than two (most notably, the higher  nursing categories). For example, under RUG-III, residents who were otherwise qualified for Extensive Services would fall to the Special Care categories if their ADL score was below the threshold. </div> <div> </div> <div>Under RUG-IV, these same residents, each having the exact same resource demands, will bypass the Special Care categories and fall into the lower reimbursement group of Clinically Complex. </div> <div> </div> <div>This serves as another and more severe penalty for missing an ADL score. For more information about how to reduce coding errors under RUG-IV, click <a href="/Issues/2011/Pages/0211/Reduce-Coding-Errors.aspx">HERE</a>.</div> <div> </div> <div><strong>Beyond ADLs </strong></div> <div>In RUG-IV, 26 RUG groups are affected by depression indicators. This compares with only six RUG groups under RUG-III (Clinically Complex). At the same time, the average value for missing a depression indicator end-split has increased. </div> <div> </div> <div>More specifically, under RUG-III rates, missing a depression end-split cost, on average, about $15 per day in lost reimbursement. Under RUG-IV, missing a depression end-split will cost on average more than $45 per day, an increase of more than $30 per day. </div> <div> </div> <div>Pre-admission documentation is another area that providers should monitor. A key change that stems from MDS 3.0 is the elimination of a look-back period, which means that facilities can no longer “look back” for most services delivered outside of the skilled nursing facility to establish acuity and appropriate reimbursement. </div> <div> </div> <div>This reinforces the importance of immediately capturing services delivered inside the walls of the facility, especially services such as ADLs and mood and behavior, which have historically been under-coded. Effective processes and accurate coding are essential for success under RUG-IV and MDS 3.0. Accordingly, it is important to provide adequate employee education, coupled with incentives and opportunities for employees to demonstrate their coding comprehension. </div> <div> </div> <div><strong>Leverage Technology </strong></div> <div>It is also important to leverage available technology like electronic documentation systems, which offer a host of benefits, including protection from copied documentation and tools that alert the appropriate staff when documentation is not complete. </div> <div> </div> <div>Electronic systems offer many benefits that allow facilities to capture more accurate and timely ADL data. </div> <div> </div> <div>Since the MDS focuses on activities that happen three or more times at a given level over the course of seven days, it is helpful to use an electronic system where information can be added multiple times throughout a shift. </div> <div> </div> <div>Electronic data capture also gives providers a tool to monitor data on a more timely basis. This ability helps identify significant changes in resident status within the 14-day window as required by the </div> <div>resident assessment instrument manual. </div> <div> </div> <div>Ultimately, a rapid detection of any decline in resident status also helps improve overall resident care. </div> <div> </div> <div>Along with changes in reimbursement comes increased federal scrutiny and oversight. The most notable example is the introduction of Recovery Audit Contractors. These contractors have, over the past few years, increased the quantity of claims being reviewed for accuracy by an outside entity. The increased scrutiny affects the survey and certification process and can lead to deficiency findings and survey tags related to inaccurate documentation. </div> <div> </div> <div>Having an electronic documentation system allows providers to identify and correct incomplete or inaccurate data. This process increases confidence in the documentation and minimizes exposure for penalties and citations. </div> <div> </div> <div>While the transition to MDS 3.0 and RUG-IV may represent the greatest challenge since the prospective payment system was implemented, it can be done successfully. Just stay positive, and focus on capturing resident data accurately and in a timely manner by educating employees and leveraging technological advancements. ​</div> <p> </p> <p><em>Steve Herron is director of business development for Resource Systems, a company that provides innovative solutions designed to help organizations care for residents. For more information, visit www.resource</em><em>systems.net. DaviD rokeS, rn, is chief operating officer for Post Acute Consulting, a company that helps clients ensure maximized reimbursement by monitoring compliance, containing costs, implementing s</em><em>ystems, and providing ongoing education. For more information, visit www.postacute consulting.com. </em></p>Accuracy under new RUGs leads to better care, appropriate payment. 2011-02-01T05:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/Clip%20art%20images%20Nurse%20at%20computer.jpg" width="150" style="BORDER:0px solid;" />Management;ReimbursementColumn2
The QIS Experthttps://www.providermagazine.com/Issues/2011/Pages/0211/The-QIS-Expert.aspxThe QIS Expert<h3 class="ms-rteElement-H3">Q. How does the QIS methodology compare with customer satisfaction surveys?</h3> <p class="ms-rteElement-H3"> </p> <div><strong>A. </strong> As the importance of resident-centered care has become more widely acknowledged across the entire range of long term care stakeholders, so has the importance of being able to measure its quality. The QIS, resident assessment instruments (such as MDS 3.0), and satisfaction survey instruments have all increased coverage of resident-centered care. </div> <div> </div> <div>In the process, domains of long term care have often been segmented into two groups, quality of care (QOC) and quality of life (QOL). Methods for measuring QOC have long been thought of as “objective” or, more specifically, measured in terms of outcome, procedure, and staff performance. </div> <div> </div> <div>On the other hand, measurements of QOL have traditionally been through more “subjective” methods that solicit respondents’ opinions about QOL areas. QIS has introduced measurement methods of QOL areas for both state surveyors and providers that are constructed in the more objective model of what has been done in the past for QOC. </div> <div> </div> <div>There are similarities between the QIS and customer satisfaction survey methodologies. Both are statistical and both require testing for reliability, accuracy, and validity. However, the language and grammar must be designed very carefully to ensure that the intended target of the question is actually measured. Both typically allow comments to be entered while measurements are conducted so they can be reported in various formats. </div> <div> </div> <div>One main difference between QIS and customer satisfaction survey methodology is in the construct of the items. For satisfaction surveys, a 4-point or 5-point scale is often used to indicate respondents’ level of agreement with a statement or their rating of the item. In QIS, the constructs are almost all dichotomous items that have either a yes or no response or otherwise require respondents to choose one of two responses. </div> <div> </div> <div>In this way, QIS respondents are indicating the existence, or not, of the service associated with the QOL area, as opposed to rating or evaluating their satisfaction with it. </div> <div> </div> <div>Another main difference is that satisfaction surveys typically contain substantially fewer items than the QIS. This facilitates shorter satisfaction surveys that improve response rates, but doesn’t provide the direct tie to regulation and replication of the state survey process that conducting QIS protocols affords. Surveys are conducted for facility staff to provide very important insight into drivers of workforce satisfaction, which QIS does not cover.</div> <div> </div> <div>Both QIS methodologies and satisfaction surveys provide valuable tools for providers to assess and improve the operation of their organizations in the eyes of all stakeholders.</div>As the importance of resident-centered care has become more widely acknowledged across the entire range of long term care stakeholders, so has the importance of being able to measure its quality. The QIS, resident assessment instruments (such as MDS 3.0), and satisfaction survey instruments have all increased coverage of resident-centered care. 2011-02-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/AKramer_rollup.jpg" style="BORDER:0px solid;" />Management;Survey and CertificationColumn2




Ramping Up Energy Performance In LTChttps://www.providermagazine.com/Issues/2011/Pages/0311/An-Eye-On-Energy-Performance.aspxRamping Up Energy Performance In LTC<p>​Imagine two buildings: One is brand new with all the latest energy-efficient windows, lighting, and insulation. The second building plods along using older technologies installed 20 years ago. Which one is more energy efficient? Surprisingly, older buildings can often win the race of delivering better energy performance than new ones. As impossible as it sounds, this happens time and again among buildings of every size. </p> <p><strong>Energy Consumption Monitored</strong></p> <p>The Environmental Protection Agency’s ENERGY STAR rating system, which was recently expanded to long term and post-acute care communities, gives a miles-per-gallon equivalent for buildings using a 100-point scale. A 50 is defined as a property that consumes an amount of energy equivalent to the industry average. Buildings that score higher are more energy efficient and use less energy. </p> <p><img width="193" height="225" class="ms-rtePosition-1 ms-rteImage-4" src="/Issues/2011/PublishingImages/0311/ENE_chng_v_c.jpg" alt="" style="margin:10px 15px;width:169px;" />New building owners that install modern equipment should, in principle, receive higher scores. Some do, but the interesting story is why many don’t. While many building components today are 30 percent more energy efficient than 20 years ago, improvements don’t necessarily mean a better-performing building overall. </p> <p>In a population of similar buildings, the energy intensity (the amount of energy used per square foot) varies by 200 to 400 percent, regardless of the technologies used, so a building built today may not automatically outperform one built 20 years ago. </p> <p>There are many reasons why buildings might experience poor energy performance. Improper sizing of equipment, incorrect application of technology, underfunded operations departments, and insufficient training can all play a role in degrading expected energy performance. </p> <p>Sometimes facility management lacks technical expertise or staff to perform diagnostic tests and repair problems. Whatever the cause, failing to maximize energy performance of existing systems can be costly. <br></p> <p>ENERGY STAR scores will help determine if a property is operating efficiently. </p> <p><strong>Consider Recommissioning</strong></p> <p>If properties score below 50, and standard energy management procedures fail to improve performance, consider recommissioning. Recommissioning, or retrocommissioning, refers to the process of verifying that everything in a new building is installed correctly. Over time, as new equipment is installed to replace the old, incorrect installations can sometimes occur. </p> <p>Recommissioning helps identify improper equipment performance and low-cost operational strategies for improving existing heating, ventilation, air conditioning (HVAC), controls, lighting, and electrical systems. It will require spending funds up front, but the payoff can be enormous. Energy savings range from 5 to 15 percent, according to a study on more than 40 tune-up projects. </p> <p>Texas A&M University reports that nearly 80 percent of savings from recommissioning comes from optimizing building controls, while better operations and maintenance accounts for the remaining 20 percent.</p> <p><em>Clark Reed is director of Healthcare Facilities Division for ENERGY STAR at the U.S. Environmental Protection Agency. He can be reached at reed.clark@epa.gov or (202) 343-9146.</em></p>Proper installation of new equipment and diagnostic testing of existing systems can achieve surprising levels of energy efficiency, even in older buildings.2011-03-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/Energystar_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn3
Rep. Courtney Keeps Keen Eye On LTC Challengeshttps://www.providermagazine.com/Issues/2011/Pages/0311/March-2011-Congressional-Profile.aspxRep. Courtney Keeps Keen Eye On LTC Challenges<p>​Rep. Joe Courtney (D) is now in his third term representing Connecticut’s second district, the eastern half of the state bordered to the south by the Long Island Sound and the states of Massachusetts and Rhode Island to the north and east, respectively.<br><img width="197" height="338" class="ms-rtePosition-1" alt="Joe Courtney" src="/Issues/2011/PublishingImages/0311/Courtney_Joe.jpg" style="margin:15px 10px;width:130px;height:195px;" /><br><strong>A Background In Medicaid</strong><br>Before he came to Washington, Courtney worked as a state legislator in Hartford, specializing in health care issues. He notably led efforts to reform the state’s Medicaid budget policies in the 1990s, putting in what he describes as “countless hours” on an issue that will not go away as a growing state and national concern.<br></p> <p>“The system we put in place is still in use in Connecticut, so it gives me a pretty good taste of the scope of this issue,” he says. Medicaid shortfalls are making headlines on a daily basis these days as most states grapple with huge budget deficits and look to programs such as care for low-income seniors for cutting.<br></p> <p>The actual and proposed cuts are made even more acute because funds contained in the economic stimulus law will run out mid-year, taking away the partial Band-Aid that was helping to prop up state budgets during the worst of the recession.<br></p> <p>Courtney sees all of this from his front-row seat as a lawmaker in Congress, and he will be watching closely to see what the new leaders in the House of Representatives do with the federal budget moving forward. He does not expect any extension to the stimulus money, but says a major discussion of what to do about public health care dollars must occur.<br></p> <p>“The immediate challenges are demographic, with an aging country. The weight of this issue will force Congress and future presidents [as well as the current one] to confront it,” Courtney says. Even the revamp he undertook 20 years ago in his own state needs a fresh scrub, he says. “We need a soup to nuts review of sorts.”<br><br><strong>Impact Of Long Term Care</strong><br>As for long term care’s role in the health care spectrum, Courtney says he is amazed at the advances made in both skilled and assisted living care, from the way buildings look to the type of care being provided these days. </p> <p>“Nursing care is truly an untold story. It is one of the biggest job creators in our state. The upgrades to plants and facilities show the results of the grassroots effort to drive new approaches to improving the quality of life of seniors, and it is all being done in such a challenging environment,” Courtney says.</p> <p>In addition to health care, Courtney’s main focus is on his committee assignments on the armed services and agriculture panels. It is from these posts that he will work for the interests of his district’s Groton Naval Base, shipbuilding concerns, and farming communities. He is especially concerned about Groton, which has faced what he calls “harrowing times” in the face of federal cuts to military outposts. </p> <p>With the Republican takeover in the House after this past fall’s election, Courtney lost his assignment on the House Education and Labor Committee. He had been the first lawmaker from his district to sit on the committee since the World War II era.</p> <p>Before serving in the House, Courtney represented Vernon in the Connecticut General Assembly from 1987 to 1994. Courtney was recognized in a legislative poll in 1994 by Connecticut Magazine for his bipartisan efforts and was named the “Most Conscientious” and the “Democrat Most Admired by Republicans.”</p> <p>On a personal note, Courtney graduated from Tufts University in Boston and later earned a law degree from the University of Connecticut School of Law. He resides in Vernon with his wife, Audrey, and their two children, Robert and Elizabeth.</p>Connecticut Rep. Joe Courtney Keeps Keen Eye On LTC Challenges2011-03-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0311/Courtney_thumb.jpg" style="BORDER:0px solid;" />PolicyColumn3
Music Therapy Hums In SNFs & Assisted Livinghttps://www.providermagazine.com/Issues/2011/Pages/0311/Music-To-Their-Ears.aspxMusic Therapy Hums In SNFs & Assisted Living<div>​The idea of music as a healing influence that could affect health and behavior is as least as old as the writings of Aristotle and Plato, according to the American Music Therapy Association. </div> <div> </div> <div>As described on the organization’s website, www.musictherapy.org, the modern version of music therapy began after World Wars I and II when amateur and professional community musicians visited veterans’ hospitals around the country to play for the thousands of patients who had suffered both physical and emotional trauma from the wars. After seeing notable physical and emotional responses to music, the hospitals began hiring musicians to play for patients. Click <a href="/Issues/2011/Pages/0311/What-Is-Music-Therapy.aspx">HERE</a> for an explanation of music therapy.</div> <div> </div> <div>Fast forward to the 21st century, and people of all ages are benefiting from music therapy. Long term care providers have recognized the soothing and therapeutic benefits of music and adopted programs as part of their wellness, activity, or caregiving programs. </div> <div> </div> <div>According to the Institute for Music and Neurologic Therapy (IMNT), the majority of research over the past 40 years has focused on music perception and performance, while basic science today continues to produce promising new information about the neuro-scientific effects of music. </div> <div> <img width="296" height="258" class="ms-rtePosition-1" alt="Musical experience is not a prerequisite." src="/Issues/2011/PublishingImages/0311/Duncaster-Photo-1.jpg" style="margin:10px;width:345px;height:259px;" /><br>In addition, numerous universities and clinical sites in the United States and Canada are currently involved in music and brain function research. Researchers and clinicians maintain that if specific responses to music can be mapped and then linked to what is needed by patients to accelerate their healing, they will find new ways to apply music prescriptively to hasten recovery. IMNT believes that such research has enormous possibilities for millions of people with impairments throughout the world.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>A Therapy Tool</strong></h3> <div>A continuing care retirement community in Bloomfield, Conn., has taken music therapy to a new level by using it as both a wellness and therapy tool. Duncaster Retirement Community’s innovative program was made possible through a $10,000 grant from a local foundation. </div> <div> </div> <div>In the dedication ceremony for the Music Enrichment Program, guest speaker Emily Pellegrino, a board-certified music therapist and co-director of Connecticut Music Therapy Services, explained that music therapy can have wide-ranging benefits for older adults, including stress reduction, pain management, and building social intimacy and community. People don’t need to have any musical ability to benefit from this type of therapy, according to Pellegrino. </div> <div> </div> <div>One of the most powerful things music does is to bring up memories, and music will trigger memory recall. People don’t even have to sing along for that to happen. They will just listen and a piece of music will evoke memories and reminiscences. </div> <div> </div> <div>In a recent music therapy session, Pellegrino played the old classic, “You Are My Sunshine,” triggering a variety of memories from those in the program, which ranged from: “That’s what we sang around the campfire” and “I remember my father singing to my mother” to “That reminds me of my first date with my husband.” </div> <div> </div> <div>Residents ended up discussing what they felt in ways that they might not have been comfortable sharing had the music not brought them together like that. Music becomes a bridge; a commonality that allows people to open up to each other.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Guitars, Drums, And Shakers</strong></h3> <div>The people involved in Duncaster’s innovative music program also marvel at how music reconnects older people to their whole lives, not just their current ages. </div> <div> </div> <div>Many noticed that a song can take residents back to that place where they were when they heard it; it connects residents to their whole self, their whole life. </div> <div> </div> <div>The program has also brought residents closer together by promoting a sense of emotional well-being, especially if people participate with it on some level. </div> <div> <img width="407" height="338" class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/0311/Duncaster-Photo-2.jpg" alt="" style="margin:15px;width:335px;height:251px;" /><br>A significant portion of the residents’ association budget is allocated for music-related programs, including orchestras, pianists, big band, swing, and a cappella groups. At Caleb Hitchcock, Duncaster’s long term care facility, four to six music programs are offered each week, including music education, sing-a-longs, and music trivia. </div> <div> </div> <div>One of Duncaster’s music therapists will start a session off with a guitar and then encourage people in the program to jump in with drums or shakers. They may come into that session without knowing the other people in the group, but by the end they will have a connection. This musical experience becomes the common element that brings them together, even if they didn’t start out knowing each other when they walked into the room. </div> <div> </div> <div>The program will allow for greater frequency and more diverse hands-on and listening music experiences and will soon include a hand-chime choir, drum circle, and harp therapy. It is anticipated that 20 to 24 residents will take part in the hand chime choir, eventually performing for residents, family, and staff. Participation in both the choir and the drum circles will be open to anyone regardless of knowledge or ability. </div> <div> </div> <div>Many of the drums are hand-held or can be placed on the floor in front of participants for ease of use. Participatory drumming has been shown to have positive benefits, including increased socialization, an increase in circulation, and stress relief. In addition, Duncaster will host appearances by a musical ensemble from the Hartford Symphony Orchestra.</div> <div> </div> <div>Duncaster’s Music Enrichment Program is the only one of its kind in the area and expands on the retirement community’s long history of music programming.</div> <div> </div> <div>Click <a href="/Issues/2011/Pages/0311/Music-Therapy-Resources.aspx">HERE </a>to find more resources on starting a music therapy program.</div> <div> </div> <div>Click <a href="/Issues/2011/Pages/0311/An-iPod-And-A-Mission.aspx">HERE </a>for information about one person's mission to get iPods into every facility.</div> <div> </div> <div><em>Heather Clinger, MPH, is Duncaster's director of wellness. Andrea Obston is president of Andrea Obston Marketing Communications. She can be reached at </em><a href="mailto:aobston@aomc.com"><em>aobston@aomc.com</em></a><em>. </em></div> <div> </div>Music therapy for long term care residents is gaining ground, and it has been proven to be beneficial for residents in nursing facilities and assisted living.2011-03-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0311/caregiving_rollup.jpg" style="BORDER:0px solid;" />Caregiving;Quality Improvement;Culture ChangeColumn3
Providers Make Sense Of The Datahttps://www.providermagazine.com/Issues/2011/Pages/0311/Making-Sense-Of-All-That-Data.aspxProviders Make Sense Of The Data<div id="__publishingReusableFragmentIdSection"><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>As health information technology (HIT) has become more prevalent in long term care settings across the country, administrators and clinicians have access to more information than ever before. However, they now face the challenge of sorting through the vast volumes of data available to them and determining how to use them to enhance quality. </div> <div> </div> <div>As Sarah Crane, MD, medical director at a Mayo Clinic facility, says, “There is so much data that it’s challenging to make it customer-specific. It’s like trying to swallow an elephant. We need to figure out how to make the elephant smaller and easier to digest.” </div> <div><strong></strong> </div> <div><strong>From Collection To Analysis</strong></div> <div>Many senior and long term care communities have evolved from data collection to full-fledged data analysis. They are targeting specific information to collect and analyze, and they are using it to identify trends, track outcomes, implement quality improvement initiatives, and recognize and celebrate successes.  </div> <div> </div> <div>When the first Presidential Order to establish person-centric integrated electronic health records (EHRs) came out in 2004, health care facilities started thinking about how they would access, pay for, implement, and use this technology. Over the subsequent years, various government officials have urged health care facilities across settings to embrace technology, and various programs began establishing financial incentives for HIT and EHR adoption. The Office of the National Coordinator for Health Information Technology estimated that the health care system will save $140 billion annually if HIT is adopted on a widespread basis.</div> <div> </div> <div>Facilities that have embraced technology and used it to track and manage quality have powerful stories to share, and none would go back to the days before technology was part of their daily lives and their efforts to maximize outcomes. “We have come a long way,” says Carol Carder, manager of medical records at Levindale Hebrew Geriatric Center and Hospital in Baltimore. “We started out with electronic medical records. Now everyone does their portion of the MDS [minimum data set] on computer. We try to keep everything electronic and not print the chart out and hand-enter data.”</div> <div> </div> <div>The move to electronic data makes it easier for organizations to track quality. Mary Norman, MD, regional medical director for Erickson Living in Dallas, says, “It’s an incredible way to care for patients.” The physician notes are custom made for senior patients and trigger questions relating to outcomes. For example, patients are asked about falls. If the person reports experiencing a fall recently, the notes trigger additional questions about home environment evaluations, blood pressure, medications associated with falls, physical therapy history, use of assistive devices, and so on.</div> <div> </div> <div>“The physician notes move you through a checklist and encourage you to think of everything you can do to reduce patient risk,” she says. The notes are particularly designed for the senior outpatient population and used when patients come in for each visit. It includes prompts for the physician that address conditions and issues common for seniors, and the information becomes part of the patient record. Norman says, “Each time the patient comes in, the physician can view the notes from the individual’s last visit.” </div> <div> </div> <div>She loves the system. “At the touch of a button, I can graph weight and blood pressure for the last few months or years. I can show the patients right there how—for example—their blood pressure came down as they lost weight. It’s a great teaching tool and a way to empower patients.” </div> <div> </div> <div>Norman and her medical group use these data to track outcomes. “Every year, we target issues for improvement in the coming year—important quality markers for Medicare,” she says. “To date, our ‘quality scoreboard’ has looked at issues such as influenza and bone health.” This year, the group is focusing on memory and dementia. To this end, Erickson Living will track and analyze data related to functional status, cognitive levels, and depression. “Part of the record template is designed to pull these data,” says Norman. </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Getting Results In Real Time</strong></h3> <div>In addition to tracking quality issues over time, the electronic system enables Norman and her team to address quality at the drop of a hat. For example, she says, “If I have a patient who says she wants to stop taking calcium, in two minutes I can pull up her profile and see the results of bone-density testing, what medications she is taking, and whether she is at risk for falling. As a result, I can help the patient in the moment with this decision.” </div> <div> </div> <div>The amount of data available through the electronic record can be daunting, so Norman suggests “choosing your issues and goals carefully. Really focus on something and measure it. You need to narrow down where you set quality goals and how you will invest your time. Once we meet goals, we rotate onto other issues.” The system is working for Norman, her team, and their patients. “We’ve seen dramatic improvements in areas such as ER [emergency room] visits and hospital stays,” she adds.</div> <div> </div> <div>Determining what reports to pull for quality purposes is key, Crane agrees. For example, she was involved in a project focusing on managing heart failure. By electronically flagging the charts of heart failure patients, Crane can check weights and other information at will in real time. “Before, we were depending on other people to determine what information they should communicate to us. The electronic system removes the middle person. Now we can identify problems and correct them quickly,” she says.</div> <div> </div> <div>The ability to identify issues and problems quickly is key to quality improvement. As Gary Kelso, president of Mission Health Services in Huntsville, Utah, says, “You have things happening every day that affect the quality of your elders’ lives, but you don’t know what you don’t know. With HIT, you can stay on top of what is taking place. I can see issues every day and can jump on them. I get knowledge instantaneously.” As a result, he adds, “All of our surveys have improved dramatically. We have created an environment where surveys are easy.”</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Quality Data Increase Buy-In</strong></h3> <div>As organizations increasingly see the link between data analysis and quality, more clinicians are embracing HIT. “There’s a book that talks about the difference between ‘digital natives’ and ‘digital immigrants;’ that is, those who grew up with technology and those who had to learn it later in life. Many digital immigrants didn’t want to change, and we saw some older physicians retire rather that adopt technology,” says Norman. “Those that stayed are starting to see the benefits and are embracing it. They like getting information instantly and being able to look up something on the spot. It’s easier to provide better care.”</div> <div> </div> <div>Kelso notes that even clinicians who initially oppose HIT come to embrace it. “There were a couple of times I got frustrated and said to our clinical directors, ‘If we can’t do this right, we’ll go back to paper.’ And they were adamant that they didn’t want that. They realize that technology is 100 times better than paper, and they don’t want to go back to the old ways,” he says. When organizations get past the cost and hassle of introducing technology, Kelso says, they see what it can do to improve quality. He concludes, “For me, it’s a no brainer.”</div> <div> </div> <div><strong>HIT And Care Transitions</strong></div> <div>An obvious quality improvement role for HIT involves improving care transitions. For example, Cynthia Morton, executive director of the Virginia-based National Association for the Support of Long Term Care, observes that HIT can help prevent hospitalizations due to medication errors. “When providers have EHRs for residents, they can view the medication list and see all the meds prescribed by different physicians. The paper record doesn’t follow patients as readily,” she says. “With technology, you can set up a sophisticated pharmaceutical review to prevent problems from happening. You can work with the consultant pharmacist to run these reports and identify various medications or issues you want to track.” </div> <div> </div> <div>Organizations such as the Center for Medicare Innovations are ramping up the idea of increasing quality by reducing hospitalizations and transfers. As Morton says, “Providers that have not taken steps to use technology and be interoperative will have to catch up on the learning curve. They will hear more and more that this is a national priority designed to reduce costs, improve quality, and maximize efficiencies by reducing hospitalizations and improving communication between care settings. Consumers will demand this, too.”</div> <div> </div> <div>Technologies to improve transitions are promising, but Morton notes that there still are some issues to address. “Hospitals and nursing facilities have to accept and agree to the same standards so that information can easily flow back and forth. The two settings have to work on interoperability,” she says. </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>The Power Of Portals</strong></h3> <div>One way to enable users to focus on specific data is to create portals. These are websites or computer-based entry points that offer various services and resources, such as e-mail, bulletin boards, and information and education. For example, Mayo created portals for physicians and providers. Crane explains, “The physician can log on and see a patient’s record and only that patient’s record. A provider portal enables a broader snapshot of what is happening in the facility—beyond individual patient information. The goal is to get the information people need when they need it.”</div> <div> </div> <div>Norman talks about her organization’s patient portal. “Patients can access portions of their charts—allergies, meds, diagnoses, advance directives. They can view this information and then print it out. At the same time, family members across the country can have a password and access data from anywhere. </div> <div> </div> <div>So, for instance, a daughter in California can review the lab results for her mother on the East Coast.” The patient portal also enables seniors to set appointments and communicate with their physicians. “This is the way of the future,” says Norman.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Data Analysis As Marketing Tool</strong></h3> <div>“People know they are providing good care, and they want to do what is best for their patients but they find themselves short on reimbursement,” Kelso says. “They may not realize what they are leaving on the table. As we got more into HIT, our case-mix scores started to improve. By capturing our acuity, our Medicare rates went up substantially. And if you get paid for what you do, the odds are that you can provide better quality,” he says. </div> <div> </div> <div>Kelso utilizes a program in Utah designed to give providers incentive to invest in technology and quality. The program identifies those who embrace culture change and those who invest in HIT systems that create change and provides them with financial incentives. “By doing this, we encourage people to embrace technology. It doesn’t pay for everything, but it helps.”</div> <div> </div> <div>Norman and her team are compensated based on quality goals and are paid according to their performance on various quality markers (such as immunization rates). Each year, the community sets a different theme. This year the focus is on falls, so the markers are things such as asking about falls, discussing physical therapy for patients with gait problems, and bone-density testing. “We advertise this to patients and celebrate reaching milestones during town hall meetings,” Norman says. “We educate patients about what we’re doing and what our quality standards are. We’re all in this together.”</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Studies Say…</strong></h3> <div>While there currently is a dearth of research about the impact of HIT on long term care quality, there likely will be more in the years ahead. And these are likely to show a significant relationship between quality improvement and the use of EHRs and other technology in nursing facilities and other long term care settings. </div> <div> </div> <div>To date, studies are validating anecdotal knowledge. For example, one study of small- and medium-sized physician practices, reported by A.S. O’Malley et al. in the Dec. 29, 2009, issue of the<em> Journal of General Internal Medicine</em>, found that electronic medical records (EMRs) systems can help coordinate patient care. However, the authors said, interoperability issues make it difficult to share information between settings.</div> <div> </div> <div>“We are advocating for interoperability standards so that the information that populates personal health records [EMRs] can be shared to populate EHRs, especially when patients are being transferred between settings,” says Morton. Interoperability likely will continue to be a priority for the health care HIT industry, and this is an issue that purchasers of EHR systems should address with their vendors, she says.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Paper-Driven Data Still Have Power</strong></h3> <div>While technology makes data tracking and analysis for quality purposes easier, even those facilities without EHRs or other HIT can use data to make a difference. As Norman says, “I came from a system that didn’t have EHRs but was very interested in quality. We had a flow sheet that included a wide variety of data and information. And we were able to use this to track issues and improve quality.</div> <div> </div> <div>“The basic thing is that what is measured gets improved. You have to have a system and processes in place to measure outcomes so that you can improve them. If we don’t measure something on our quality dashboard, it probably isn’t going to change.” </div> <div> </div> <div>The dashboard—what many call their monthly reports—is key for any facility but is especially useful when HIT is used, says Kelso. Norman agrees. She says, “You can’t run a car without the information on the dashboard—speed, mileage, temperature gauge, etc. And you need your facility’s dashboard to help you gauge what is happening with individual patients and the facility as a whole.” Kelso says his dashboard provides all the key indicators—everything from a labor report to case mix and MDS scores. “It’s a one-stop shop of data where I can find anything I need. For example, I can review quality survey reports in preparation for a federal survey.”</div> <div> </div> <div>The dashboard gives staff trending information for a community and lets them track specific issues such as falls. “We have 600 reports built into the system. For me, a successful HIT system allows you access to this kind of information,” Kelso says. These reports include data regarding missed medications, risk assessments, activities of daily living, falls, fractures, wound care, bowel and bladder, and much more. Kelso admits that his is a very robust system, and others might not have such extensive capabilities. </div> <div> </div> <div>How does Kelso decide what reports to access? He starts with information from director of nursing reports that identify issues or problems. For instance, if a pharmacy was late in its delivery of medications, he can drill down to find out exactly what happened and what impact it had on medication administration. He is automatically notified about common issues of global importance such as falls. </div> <div> </div> <div>The beauty of the system, he says, is its flexibility. He is able to view information as broadly or narrowly as necessary. He can see what is happening in the entire facility, view broad data on a subset of patients—such as those with diabetes or those who have had a recent fall—look at what is happening in one area such as incidents or medication errors, or examine data for a single patient.</div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Keep It Person-Centered</strong></h3> <div>Nonetheless, combining high-tech and high-touch also can have a positive impact. As Kelso says, “You can embrace technology that seems to be high-tech and embrace quality care that is low-tech in a way that builds relationships and becomes relationship-centered.</div> <div> </div> <div>He adds, “We are totally paperless right now. We have created technology that allows us to implement innovations such as not having a nurses’ station. We are eliminating these and creating congregation centers instead. Nurses are working on laptops or kiosks in the hallway. They can collect data in the same amount of time that it took them before—and less in some cases.” </div> <div> </div> <div>While the high-tech approach to data management increases efficiency, eliminating the nurses’ stations creates a more person-centered environment.</div> <div> </div> <div>While data analysis without technology is possible, Kelso stresses the value of technology in quality improvement. </div> <div> </div> <div>“With HIT, you can run trending reports on issues such as medication errors or weight loss. It’s very important to be able to see if falls have increased or decreased 10 percent and be able to identify the reasons,” he says. “We are approaching care more holistically, and these HIT tools give us the capacity to do this.” </div> <div> </div> The abundance of data can be overwhelming, but providers are learning how to harness it in very useful ways.2011-04-01T04:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/Clip%20art%20photo%20mag%20glass%20eye%20web.jpg" width="150" style="BORDER:0px solid;" />Technology;Quality;Quality Improvement;ManagementColumn3
New Look At Meds Distributionhttps://www.providermagazine.com/Issues/2011/Pages/0311/New-Look-At-Meds-Distribution.aspxNew Look At Meds Distribution<div>​Like other skilled nursing facilities across the United States, the Crawford County Care Center, Saegertown, Pa., takes life quality and resident safety very seriously. Medication administration has an enormous impact on residents’ health and happiness, and that is why the center, in conjunction with its pharmacy partner, decided to change the way they administered medications. </div> <div> </div> <div>Crawford’s traditional model, which is the current industry standard, required that much of the nurses’ attention be spent on the medication dispensing process. </div> <div> </div> <div>It is a time-intensive process of preparing and distributing the right medications, in the right doses, to the right residents at the right time. </div> <div> <img class="ms-rtePosition-2" alt="Remote dispensing" src="/Issues/2011/PublishingImages/0311/Tech-photo-1.jpg" width="242" height="819" style="margin:5px;width:178px;height:249px;" /></div> <div>However, since medication preparation and distribution can take up to five hours, many of the center’s nurses wished they could spend less time on this task and more time with their residents.  </div> <h3 class="ms-rteElement-H3"><strong>An Evolving Process</strong></h3> <div>The time that nurses spent counting and organizing medications wasn’t the only downside to the center’s former medication distribution model. The nature of the center’s business means that residents are in flux—prescriptions change or they transfer to different facilities.</div> <div> </div> <div>In addition, given that many residents arrive at the center during their last life stage, the older medication distribution model created a significant amount of medication waste given that each prescription was delivered in a 30-day dose. </div> <div> </div> <div>Any time a resident no longer requires a particular medication, it becomes waste. While no one likes producing waste, it can be harmful to the environment and costly. It was par for the course—an unfortunate residual effect of the model. </div> <div> </div> <div>Now, however, health information technology (HIT) developments have given new medication distribution options to long term care and post-acute care pharmacies and their partners. </div> <div> </div> <div>Crawford’s pharmacy, Vantage Care Apothecary, had been searching for a better approach to serving its residents. The pharmacy adopted a remote-dispensing model, which makes medication passes quicker and safer, while nurses get to put their energy into what they like best—residents.  </div> <h3 class="ms-rteElement-H3"><strong>Advantages To Change</strong></h3> <div>Residents were impressed with the new system—most had never witnessed anything like it in their lifetime and were intrigued about the ways in which it worked and would benefit them and their caregivers. The machine that makes remote dispensing possible is a medication-dispensing unit, about the size of a large refrigerator or large copy machine, which is housed at the facility in a secure location. </div> <div> </div> <div>The pharmacy owns and manages the inventory in the systems and remotely monitors the dispensing of medications. The unit allows for 24-hours-a-day, seven-days-a-week access to medications by nurses. Its down-to-the-dose accountability for every single pill is a unique feature of the unit. Because the process is automated, the machine also virtually eliminates medication waste—nothing is distributed unless it is needed directly before a medication pass.  </div> <h3 class="ms-rteElement-H3"><strong>How It Works</strong></h3> <div>Medications, including controlled substances, are delivered in bulk by the pharmacies and packaged in canisters that are placed inside of the unit. The machine and its inventory are then monitored remotely by the pharmacy. When medications are needed by residents, the technology automatically dispenses labeled, patient-specific, multi-dose packets immediately prior to administration. </div> <div> <img class="ms-rtePosition-1" alt="Remote dispensing is capable of delivering multi-dose packets on the spot." src="/Issues/2011/PublishingImages/0311/Tech-photo-2.jpg" width="196" height="257" style="margin:5px;width:193px;" /><br>For Crawford, on-demand medication dispensing means stat orders are dispensed in real time straight from the machine, and any residents who arrive after hours or require first doses will have prescriptions approved off-site by pharmacists and dispensed on location. </div> <div> </div> <div>This functionality has dramatically reduced the time frame it takes for residents to receive their medication. </div> <div>The system guarantees that medications are available to nursing staff around the clock—and they are automatically tracked, dispensed, and accounted for. </div> <div> </div> <div>This means that nurses no longer need to spend time at the beginning or end of their shifts doing narcotic counts. Nor do they need to spend valuable time on cumbersome pill counting. </div> <div> </div> <div>While medication distribution is part of every nurse’s job, it doesn’t have to define it. Crawford has found a balance for its residents through the implementation of innovations like remote dispensing.</div> <div> </div> <div><em>Noreen Lee, RN-BC, NHA, is administrator at Crawford County Care Center, Saegertown, Pa.</em></div> <div> </div>Medication administration has an enormous impact on residents’ health and happiness, and that is why the center, in conjunction with its pharmacy partner, decided to change the way they administered medications. <img alt="" src="/Articles/PublishingImages/740%20x%20740/medications_1.jpg" style="BORDER:0px solid;" />Column3




Rehab Goes High Tech With The Basicshttps://www.providermagazine.com/Issues/2011/Pages/0411/Back-To-The-Future.aspxRehab Goes High Tech With The Basics<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>Rehabilitation after surgery, stroke, or injury is most effective when the patient is a highly motivated participant. However, many physical therapists concede that engaging a patient is often a tough sell. </div> <div> </div> <div>“Many medical procedures and treatments are done to a patient by a health care provider, and the patient’s role in the treatment is small,” said Karen Lohmann Siegel, a physical therapist at the National Institute of Health Clinical Center, in a recent institute newsletter. “That is not the case in rehabilitation. In rehab, the patients do a lot of the work themselves to get better.”</div> <div> </div> <div>Indeed, studies have shown that poor patient participation in physical and occupational therapy has clinical implications that could lead to reduced functional improvement and longer lengths of stay.  The good news is that a great deal of new and emerging technologies now hold the potential to motivate and keep patients engaged in their recovery. </div> <div> </div> <div>Among these exciting developments are devices that utilize a range of technological advances, such as gaming, virtual reality, anti-gravity, robotics, and aquatics. Coinciding with these discoveries is the recent ramp-up of post-acute care services in skilled nursing facilities. Over the last decade, long term care providers have expanded their range of services to include post-acute rehabilitation care, spurred on by the opportunity to bridge the gap from facility to home.</div> <div> </div> <div>Also driving the shift is the need to complement ever-shrinking and abysmal Medicaid payments. Between 2001 and 2010 the provision of physical, speech-language, and occupational therapy climbed for nursing facility residents by more than 10 percent, according to an analysis conducted by the American Health Care Association/National Center for Assisted Living. As of 2010, the number of skilled nursing facility residents receiving specialty rehab had reached 24.6 percent, the research showed.</div> <h3 class="ms-rteElement-H3"><strong>Building A Better Rehab Unit</strong></h3> <div>As providers have taken on this role, their need for tools of the trade has become more critical than ever. One tool that is sure to to induce the “wow” factor is a true space-age device known as the AlterG Anti-Gravity Treadmill. Derived from NASA technology, the AlterG helps users walk in a weightless or near-weightless environment. </div> <div> </div> <div>According to Gabriel Griego, vice president of marketing for AlterG, the genesis of the engineering came from NASA scientists who developed gravity control technology so astronauts could train during space exploration. “AlterG harnesses the technology to deliver anti-gravity on earth,” he says.</div> <div> <img width="293" height="381" class="ms-rtePosition-2 ms-rteImage-2" alt="The AlterG treadmill is FDA--cleared for rehabilitative use to older patients." src="/Issues/2011/PublishingImages/0411/Alter-G-Photo-3.jpg" style="margin:10px;width:190px;height:235px;" /><br>First developed by a Stanford University engineer as a sports medicine application for training and conditioning, AlterG launched its first product in 2007. </div> <div> </div> <div>Last year, the company released its M300 model, built with skilled nursing rehabilitation patients in mind. Today, nearly 30 of them are in use in skilled nursing facility rehab units across the country. Among its therapeutic benefits is its ability to improve endurance and strengthen muscles, increase muscle tissue mass and decrease age-related muscle atrophy, advance range of motion, and improve balance, says Griego. </div> <h3 class="ms-rteElement-H3"><strong>System Advantages</strong></h3> <div>AlterG’s unweighting technology “reduces impact and stress on the body…proportional to the amount of unweighting selected, while simultaneously natural gait mechanics and muscle-firing patterns are preserved,” the company’s literature says.</div> <div> </div> <div>Peoplefirst Rehabilitation, a therapy staffing company owned by Kindred Healthcare, is piloting the AlterG in several facilities, as has Life Care Centers of America. Patients use the device by stepping into what looks like a pair of pants that are attached to the treadmill. Once on the treadmill, it appears that the patient is inside an inflated, air-filled chamber that envelopes the user from the waist down.  </div> <div> </div> <div>Megan Harper, outpatient rehab manager at Life Care Center of Littleton, Colo., has used AlterG for more than one year. She finds the technology to have many benefits for patients and therapists alike. </div> <div> </div> <div>“Patients feel very supported in the device,” she says. “They feel like they can do things they couldn’t if they were standing on the floor.” Although the device looks like it could be a little difficult to get patients into, Harper says she’s been able to get everyone to use it. </div> <div> </div> <div>Patients of all types—short-term rehab, outpatient, and even long term care—have utilized the AlterG at Harper’s facility, including a 100-year-old woman who had not been ambulatory for a long time. Compared with a harness-assisted treadmill system—in which a patient is suspended by a harness while walking on a treadmill—the AlterG appears to be a superior technology.</div> <h3 class="ms-rteElement-H3"><strong>Robotics Rule</strong></h3> <div>According to a 2010 review of advances in neurorehabilitation, published in the journal Stroke, several technological advances are ripe for clinical application. Among them is the use of robotics. According to the review’s authors, some studies suggest that robot-assisted therapy can be effective for stroke rehab patients when compared with standard rehab therapy. </div> <div> </div> <div>Andrew Butler, a neuroscience researcher and physical therapist in the School of Medicine at Emory University in Atlanta, specializes in upper body, post-stroke rehabilitation. Much of his research entails the use of a robotic device that improves hand movement in stroke survivors. The technology is available in two products—the Hand Mentor and the Foot Mentor—both created by Kinetic Muscles (KMI), in Tempe, Ariz.</div> <div> </div> <div>According to Grant Farrell, KMI’s chief executive officer, the devices help users “maximize their potential for intensive neuro-rehab by using a robotic device combined with telemedicine.” </div> <div> </div> <div>The product is used in nursing facilities, but was designed principally for use by patients undergoing rehabilitation in their own homes. The Hand Mentor includes an interactive training program that encourages patients to improve their hand functions.</div> <div> </div> <div>Listed with the U.S. Food and Drug Administration (FDA) as a Class One medical device, the Hand Mentor’s technology was shown in clinical trials to be “an effective alternative or adjunct to the delivery of intensive task practice interventions to enhance hand function recovery in patients with stroke.”</div> <div> </div> <div>Farrell notes that the Hand Mentor actively involves patients in their own rehabilitation by encouraging self-powered motion of the wrist and fingers and assisting movement when necessary.</div> <h3 class="ms-rteElement-H3"><strong>How It Works</strong></h3> <div>The devices themselves provide instructions and assistance by encouraging and challenging patients to achieve, surpass, and increase their goals using three types of visual feedback: force, position, and electrical activity of the muscle.  </div> <div> <img width="174" height="424" class="ms-rtePosition-2" alt="The Foot Mentor is designed to repetitively train foot and ankle control." src="/Issues/2011/PublishingImages/0411/Foot-Mentor-PHOTO.jpg" style="margin:10px;height:190px;" /><br>One of the most common impairments following stroke is the inability to extend the wrist and fingers. The Hand Mentor works by helping people with movement limitations relearn how to extend their wrist and fingers. It works like this: An “air muscle” pulls the linkage mechanism, assisting the patient with desired movement when the patient is not able to move her wrist or fingers on her own. An air muscle is a soft and springy air-driven actuator that pulls a linkage system that raises the hand and wrist in a fluid motion.</div> <div> </div> <div>According to KMI’s website, the soft springy muscle-like properties of the “air muscle” make it safer than a motor- and gear-driven apparatus.</div> <div> </div> <div>Stroke and other brain-injury patients of varying degrees of ability can benefit from stroke devices aimed at restoring wrist and finger movement. Patients with high tone or spasticity can increase their passive range of motion using one of KMI’s spasticity reduction programs. Patients with some movement capabilities can improve active range of motion with the motor control and active recruitment programs.</div> <div> </div> <div>Butler, who has conducted research on the Hand Mentor for the past five years and continues to use the robotic mechanism in his current research, says he is testing a modality that combines a guided visual imagery treatment with the robotic device in an effort to help patients visualize the movement before they actually begin the work. </div> <div> </div> <div>“For example, Tiger Woods visualizes his actions before he swings the golf club,” says Butler. “There’s evidence that a post-stroke patient who visualizes moving his hand before actually doing it improves the outcome and speeds up the process by increasing the number of repetitions a person performs without becoming fatigued.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div><strong></strong> </div> <div><strong>Evolution Of Virtual Reality</strong></div> <div>The Stroke review also examined the use of virtual reality and gaming. In a randomized, single-blinded clinical trial using the Nintendo Wii system versus recreational therapy, such as playing cards, bingo, or Jenga, the nine users of virtual reality “significantly improved in mean motor function,” researchers said, concluding that “virtual reality using the Nintendo Wii is a potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke.”</div> <div> </div> <div>Another study in the journal Physical Therapy revealed that the use of virtual reality by patients resulted in a “powerful effect” on the progress of cardiac rehabilitation. The study’s authors suggested that “incorporating virtual reality into rehabilitation programs will accelerate the maximum recovery of a patient’s cardiovascular fitness.”</div> <div> <img width="378" height="248" class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/0411/Hand-Mentor-Patient-PHOTO-1.jpg" alt="" style="margin:15px 10px;width:277px;height:185px;" /><br>Although many rehab units deploy the Nintendo Wii system, it is not the only virtual reality game in town for use in rehab treatment. Accelerated Care Plus (ACP), a Reno, Nev.-based company that provides education and equipment to skilled nursing facilities, recently launched a virtual reality product geared specifically to rehabilitation. </div> <div> </div> <div>Mark Richards, a physical therapist and ACP’s vice president of clinical education, says the new OmniVR system “automatically captures a patient’s image and creates a three-dimensional avatar of the patient.”</div> <div> </div> <div>The patient views a large flat-screen color monitor and performs therapy-specific exercises and activities without the use of a controller. “The technology enables even very low-functioning patients to participate,” Richards says, noting that patients become quickly engrossed in the virtual world and therefore conduct a higher volume of exercise at a more intensive level. </div> <div> </div> <div>While the Wii systems are widely used in rehabilitation, they are game-based, more focused on entertainment, and not always appropriate for lower-functioning elderly patients, says Richards. “They’re typically rapidly paced, visually intense, and intimidating to many patients.” </div> <div> </div> <div>The OmniVR has multiple exercises, and each contains adjustable parameters to match the level of difficulty to each patient’s functional level. “This customization allows therapists to treat patients more effectively and better demonstrates the skills involved with virtual-reality-based therapy services.”</div> <div> </div> <div>Richards views the OmniVR as an adjunct to traditional therapy. “Research demonstrates that therapy augmented with virtual reality may achieve better clinical outcomes.” What’s more, he says, studies have demonstrated that skills acquired in a virtual world transfer to real-world activity. The system is more costly than a Nintendo Wii, but Richards believes the OmniVR is superior because it is customized to the rehab world and in the near future will contain extensive standardized outcome measures such as gait, balance, and range of motion. </div> <h3 class="ms-rteElement-H3"><strong>Charting Results</strong></h3> <div>At Marquis Care at Mt. Tabor in Portland, Ore., the new technology is already earning high marks. </div> <div>The systems being tested offer six different rehabilitation programs appropriate for a spectrum of aging adults from very frail to independent. </div> <div> </div> <div>“As a way to prepare Marquis for the future, our management team has been working together to explore the ways health care might evolve over the next 20 years. Our guess is that technologies like the OmniVR will be at the forefront of that evolution,” said Phil Fogg Jr., Marquis Companies’ chief executive officer, in a statement. </div> <div> </div> <div>In testing the OmniVR, the rehabilitation staff at Mt. Tabor worked with a patient who found it difficult to sit up on the side of the bed to get dressed, but once she immersed herself in a game on the OmniVR system that required her to lean side to side, staff members saw that the patient was able to balance on the edge of her bed, and her skills improved so much that she was able to put on a shirt without help. </div> <div> </div> <div>According to ACP, in another game, a stroke patient used the upper part of his body to catch objects from side to side on the screen. Mt. Tabor staff were able to identify a significant deficit in the patient’s visual field and focus further therapeutic attentions to improving that deficit.</div> <div> </div> <div>“We have already had several breakthrough moments with residents who were afraid to move, side step, or walk backwards, getting so caught up in the virtual games that they were moving in all directions without fear and with a large smile on their faces,” says Allison Dehaan, Mt. Tabor’s rehab director. “The most exciting piece is that these skills are transferred into their daily activities.” </div> <h3 class="ms-rteElement-H3"><strong>Hydrotherapy Advancements</strong></h3> <div>The use of water in rehab therapy is not new, but combining a treadmill with a moveable floor that is immersed in a pool is an innovative concept that is gaining ground in a wide variety of rehab treatment programs.  </div> <div> </div> <div>HydroWorx International, Middletown, Pa., produces hydrotherapy devices that combine treadmill training and the weightlessness of a pool. HydroWorx’s technology eliminates 20 percent to 100 percent of a person’s body weight, according to the company’s website. As a result, patients who are unable to exercise on land can achieve immediate rehabilitative results while carrying as little as 0 percent of their body weight under water. </div> <div> </div> <div>In addition, hydrostatic pressure, water temperature, and resistance combine to enhance cardiovascular stamina, muscle strength, and flexibility and drive early range-of-motion gains during rehab. </div> <div> </div> <div>Its key feature is gait training in a low-impact environment, which allows for “earlier replication of proper ambulatory biomechanics and reduces the accumulated damage of land exercise,” the website says.</div> <div> </div> <div>HydroWorx’s most recent product line is the HydroWorx 2000 Series, which includes a moveable floor, an eight-foot by 12-foot underwater treadmill, resistance jet technology, and computer and camera systems. A Texas A&M study found that the results were significant and that the study participants improved their overall health and fitness in the HydroWorx pool without the joint trauma and “wear and tear” that one normally experiences working out on land.</div> <div> </div> <div>Hydrotherapy research experiments at the University of Idaho also found that the HydroWorx pool can create “a metabolic and cardiovascular environment as stressful as traditional land-based treadmills but with reduced joint stress—a hallmark feature of aquatic therapy.”</div> <div> </div> <div>In follow-up studies, positive results were also verified with factors such as maximal oxygen consumption, heart rate, ventilation, blood lactate, leg-stride rate and length, and perception of effort. According to HydroWorx, each study confirmed the effectiveness and equivalent responses with aquatic therapy versus land-based treadmills.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>A Balancing Act</strong></h3> <div>For Mary Van de Kamp, senior vice president of clinical operations for Peoplefirst, staying on top of advancements in technology and engineering is a key component of an effective rehab therapy program.</div> <div>And given the variety of Medicare patients treated in rehab units today, it can be a tricky thing. </div> <div> </div> <div>“When you have patients who are so medically complex, managing their care can be a balance between providing modalities they are most comfortable with and still are effective,” she says. “Younger patients, for example, are more comfortable with more high-tech devices that are used in rehab treatment, while older patients may not feel at ease with it.</div> <div> </div> <div>“The balance is difficult because the technology also changes in a short amount of time.” </div> <div> </div> <div>This can mean a higher cost for the facility as it scrambles to purchase the best, state-of-the-art equipment. </div> <div>Nonetheless, the company stays abreast of the latest technology and engineering marvels that promise to send rehab residents home sooner.</div> <h3 class="ms-rteElement-H3"><strong>Basics Work Best</strong></h3> <div>Butler, the researcher, concedes that all the technological advances out there cannot replace the tried-and-true basics of movement and repetition. Physical exercise and hard work is a “magic pill” for successful physical rehabilitation, he says. </div> <div> </div> <div>If so, then why bother with research? “I am focused on increasing the recovery curve,” says Butler. </div> <div> </div> <div>“If we can develop therapies that reduce a patient’s stay in the hospital (or rehabilitation unit) from 20 days to seven days, and return them back to more activities of daily living,” all parties win, he notes. At the end of the day, the best rehabilitation therapy is not technology or engineering that will make stroke survivors better, says Butler. It’s people. </div> <div> </div> <div>“If you can get the best people, the best doctors, nurses, and therapists who are the most qualified, and who have a passion and commitment to helping people,” that’s half the battle, he says. </div> <div> </div> <div>To view additional state-of-the-art products and devices that aid rehabilitation therapy, click on a link below:<br><br>AlterG <br><a href="http://www.alter-g.com/senior-rehabilitation">http://www.alter-g.com/senior-rehabilitation</a>    <br> <br>Myomo<br>http://www.myomo.com/myomo_product_stroke_rehab_how_it_works.asp    <br><br>Hand Mentor and Foot Mentor<br><a href="http://www.kineticmuscles.com/recovering-from-a-stroke-videos.html">http://www.kineticmuscles.com/recovering-from-a-stroke-videos.html</a>  <br><br>ZeroG<br><a href="http://www.nrhrehab.org/About+NRH/News+Archive/1045.aspx">http://www.nrhrehab.org/About+NRH/News+Archive/1045.aspx</a>   <br><br>Hydroworx<br><a href="http://www.hydroworx.com/videolibrary/details.aspx?id=72&categoryId=21">http://www.hydroworx.com/videolibrary/details.aspx?id=72&categoryId=21</a>  <br><br>Accelerated Care Plus<br><a href="http://www.acplus.com/products.php">http://www.acplus.com/products.php</a>  <br><br>Northwestern University’s Balance and Falls Laboratory is conducting research<br>on how stroke and brain injury survivors recover and relearn to walk with the help<br>of experimental “co-bots”—intelligent robots that collaborate with physical therapists and patients.<br><a href="http://www.youtube.com/watch?v=Dgtt3zxgQwk">http://www.youtube.com/watch?v=Dgtt3zxgQwk</a>  <br></div>New advancements in rehab technology and engineering are aimed at motivating patients to engage in their own therapy and promoting a basic tenet of nearly all physical therapy rehab programs—movement and repetition.2011-04-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0411/coverstory_rollup.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;TechnologyColumn4
Culture Change Ideas That Workhttps://www.providermagazine.com/Issues/2011/Pages/0411/Culture-Change-Ideas-That-Work.aspxCulture Change Ideas That Work<div>​“The Long-Term Care Improvement Guide,” published by Planetree in partnership with Picker Institute, is a first-of-its-kind compendium of innovations and approaches created with the aim of propelling organizations in their culture change efforts. </div> <div> </div> <div>Grounded in the voice of residents, leaders, and frontline staff and spanning all models and settings, this unique resource complements and adds fresh insights and information to the existing body of literature about culture change. </div> <div> </div> <div>By spotlighting practices and tools from the field that have proven to be effective in meeting the full range of resident and staff needs and preferences, the guide aims to encourage communities to take action and serves as a road map for the process of engaging all stakeholders in a sustainable culture change journey.</div> <div><img width="172" height="224" class="ms-rtePosition-1 ms-rteImage-2" alt="Planetree's "Long-Term Care Improvement Guide" is geared toward a variety of settings." src="/Issues/2011/PublishingImages/0411/Caregiving-photo2.jpg" style="margin:10px;width:149px;" /><br>The aim was to develop content driven by the resident, family, and staff voices within—and across—the full spectrum of settings that comprise long term care. </div> <div> </div> <div>Commonalities that emerged during the focus group analysis and leadership dialogues provided the opportunity to examine person-centered practices that will likely work well across the continuum of care, with special attention placed on the nuances of different settings and how such practices can be adapted to meet the needs of specific populations. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>What The Guide Offers</strong></h3> <div>The <a href="http://www.residentcenteredcare.org/">online version </a>of the guide contains a chapter-by-chapter feature that allows users to pinpoint specific information. The entire guide may also be downloaded in its entirety as a PDF document. </div> <div> </div> <div>Users can also access a variety of practical tools such as sample policies, job descriptions, and evaluation methods utilized by long term care providers that are effectively implementing culture change. At the beginning of the guide is a Self-Assessment Tool, developed to support users by helping them to navigate to content that is most pertinent to the user’s organization. Completion of the tool is a good starting point for identifying and prioritizing opportunities for improvement and enhancement. </div> <div> </div> <div>The findings can be used to inform a site-specific implementation plan and to guide the trajectory of the change effort. Involving all stakeholder groups in completing the tool, and broadly sharing the findings, positions the company for any subsequent actions for greater success by establishing the change efforts as community-driven.</div> <div> </div> <div>For communities in the early stages of the change process, creating a sense of urgency for why business as usual will no longer suffice is essential. Section One, Making the Case for Change, uses outcomes data to demonstrate that improving the long term care experience for those who live and work in these communities is not merely a moral imperative, but increasingly a financial one. The data presented may be useful in creating a platform from which to launch improvement efforts. This section also tackles 20 of the most persistent myths that have long curtailed change efforts and demonstrates why they need not stand in the way of improvement. </div> <div> <a title="Download the guide" href="http://www.residentcenteredcare.org/" target="_blank"><img width="239" height="598" class="ms-rtePosition-2 ms-rteImage-2" alt="Download the guide" src="/Issues/2011/PublishingImages/0411/CoverDesignRev.jpg" style="margin:10px;height:309px;" /></a><br>Section Two, Building Community, explores a defined process for engaging all stakeholders in creating, implementing, and anchoring a comprehensive vision for change. Consistent with the aim of the guide to transcend specific models, the change process defined here is not specific to any one philosophy. </div> <div> </div> <div>The description of the change process is complemented with specific tools providers have used related to the different steps.</div> <div> </div> <div>Section Three, Practical Approaches for Building a Resident-Centered Culture, is organized around aspects of life in long term care communities identified as priorities by residents and staff. Topics covered include systems for getting to know residents, approaches to resident-centered staffing, the move-in process, grief and loss, spirituality, managing risk, culinary engagement, experiences that promote well-being, and transitions of care. This section presents resident-centered practices in place within a diverse set of culturally transforming long term care communities. Many of the strategies featured are relatively simple changes that can be implemented quickly and at little cost to the organization. The sequencing of the sections within the guide, though, is very intentional. </div> <div> </div> <div>The intended audience for the guide is not limited to those organizations yet to embark on a journey of transformation. It is equally relevant to those long guided by a person-centered philosophy who may be feeling stalled or who may be exploring what more can be done to cement and strengthen an already established culture.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Care Transitions</strong></h3> <div>In the Transitions of Care section, long term care leaders imparted their experiences with implementing, measuring, and sustaining resident-centered care. They also shared their insights into how culture change principles take on even greater relevance in this changing health care landscape, where person-centeredness and care coordination are emphasized as fundamental components of provider strategies to improve safety, quality of care, and health outcomes while at the same time avoiding significant costs and reducing inappropriate readmissions. </div> <div> </div> <div>With the move toward bundled payments, the quality-of-care transitions will soon have profound repercussions not only on individual patient and resident experience but also on providers’ bottom lines.</div> <div> </div> <div>Work to apply person-centered concepts to the transitions of care, therefore, is an important extension of any long term care community’s work to become more resident-directed and relationship-centered. Evidence has demonstrated definitively that quality transitions of care depend upon resident engagement, effective communication, family involvement, and care coordination. </div> <div> </div> <div>The project partners hospitals with local nursing facilities to improve care transitions through implementation of a validated Web-based patient self-assessment tool and a coordinated, cross-setting care partner program. </div> <div> </div> <div><em>Heidi Gil is senior director of continuing care at Plantree, Derby, Conn. She can be reached at (203) 732-1365 or </em><a href="mailto:hgil@planetree.org"><em>hgil@planetree.org</em></a><em>. </em></div>A new guide goes into the trenches to find what works and what doesn’t as providers aim their sights at resident-centered care.2011-04-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0411/caregiving_rollup.jpg" style="BORDER:0px solid;" />Caregiving;Quality;Culture ChangeColumn4
On The Road: Taking Stock Of Long Term Care’s Impact On The Economyhttps://www.providermagazine.com/Issues/2011/Pages/0411/On-The-Road-Taking-Stock-Of-Long-Term-Care’s-Impact-On-The-Economy.aspxOn The Road: Taking Stock Of Long Term Care’s Impact On The Economy<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p class="ms-rteElement-P">​<img width="239" height="184" class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/0411/Provider_on_the_road_logo_PRPR.png" alt="" style="margin:5px;width:154px;height:153px;" /><em>Provider's new feature, the On The Road series, which will give gives readers a snapshot of the <br><br>impact long term care providers and related manufacturers and vendors are having on the U.S. economy. In many regions of the country, skilled nursing and assisted living facilities have emerged as a stabilizing economic force for local economies. Even as long term care jobs become more of a mainstay, there are debates under way in state capitals and in Congress to sharply cut funding for senior programs, namely by reducing Medicaid expenditures at a time when the number of people joining the rolls grows exponentially.</em></p> <div>The Midwestern states of Illinois, Indiana, and Ohio were the first On The Road stops. Driving across the highways and byways connecting Ohio to Illinois via Indiana, there is no debating the obvious signs of tough economic times heavy industry has recently gone through. It is all visible from a car window or a bench at a train depot, with the number of boarded-up or emptied factories speaking volumes.</div> <div> <img width="750" height="643" class="ms-rtePosition-1 ms-rteImage-2" alt="Mundelein Park District's Diamond Lake Sports Complex, Mundelein, Ill." src="/Issues/2011/PublishingImages/0411/MPRD5-Diamond-Lake-Sports-Complex.jpg" style="margin:10px;width:368px;height:246px;" />In talking to long term care providers in Ohio, Indiana, and Illinois it is also obvious, but not as well-known, that area nursing facilities of all types have become a much more integral part of the local economies in which they provide care. And, importantly, a number of manufacturing centers serving the long term care sector have experienced strong growth to service such needs. </div> <div> </div> <div>The ripple-in-the-pond effect, with nursing care at the center, offers hope for not only families in need of care for their elderly, frail, and/or rehabilitative members, but for job seekers and business owners who want to establish themselves in these states. </div> <div> </div> <div>Nursing facilities are job creators, from the nurses on call to the vendors cutting the grass or maintaining the heating systems, to such an extent that a recent study by the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) showed long term care as the 10th largest employer in the country.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Ohio SNFs Making It Work</strong></h3> <div>Jason Napierala, administrator for Golden LivingCenters’ 96-bed Northcrest skilled nursing facility in Napoleon, Ohio, has seen firsthand the economic shifts in his northwestern Ohio city and its impact on the way people pay for long term care. “At one point in time it was 100 percent private pay” at the 45-year-old facility, he says. Now, the numbers show about 60 percent of residents on Medicaid, with 15 percent or so on Medicare/managed care, and roughly another 15 percent slice private pay.</div> <div> </div> <div>“It has been horrible,” Napierala says of the economic downturn in the region. “We are very close to Detroit and took a real hit with the auto industry.”</div> <div> </div> <div>Napoleon has just fewer than 10,000 residents and is the county seat for Henry County, positioned on the Maumee River around an hour’s drive from Toledo, which lies to the north and east. As the city has witnessed the decline in businesses tied to automakers, there has come the realization that Northcrest is a stable source of long-term employment and work for not just the 96 employees at the facility, but the scores of ancillary workers contracted out to make the nursing center a successful enterprise.</div> <div> </div> <div>“Absolutely, we are one of the biggest employers in town now,” Napierala says, running down the list of work he provides for other businesses, from the oxygen supply company, to the local electrician, to the snow plow operators, to the landscaping crews. “We give a lot back to the community by adding another 25-30 jobs” for vendors and contract workers, he notes.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>‘We Have Met The Enemy, And They Are Ours’</strong></h3> <div>If you follow the Maumee’s winding path north you will run into Perrysburg, close enough to Toledo to be called a suburb of the largest city in this part of Ohio. The “we have met the enemy” quote is from the city’s namesake, Commodore Oliver Hazard Perry, who won fame following a major victory over a superior British fleet on Sept. 10, 1813, in the Battle of Lake Erie. </div> <div> </div> <div>In Perrysburg, you will also find the Perrysburg Care and Rehabilitation Center just off Interstate 75, where Ken Zielinski is the administrator. The facility offers skilled nursing and short-term rehabilitation therapy for up to 95 patients and residents.</div> <div><img width="324" height="208" class="ms-rtePosition-2 ms-rteImage-2" alt="The Perrysburg Care and Rehabilitation Center features a patient care therapy gym." src="/Issues/2011/PublishingImages/0411/100_0261.jpg" style="margin:10px;width:277px;" /><br>The care center has served the Perrysburg community since 1984 and starting in 2007 has been operated by Belmont Nursing Center Corp., an affiliate of SunBridge Healthcare. The center employs around 100 individuals in the areas of nursing, dietary, social services, activities, housekeeping, and facility maintenance, Zielinski says. </div> <div> </div> <div>He notes his facility strives to be one of the employers of choice within the community. “With Perrysburg’s relatively small population of approximately 17,000, a loss of any one of those positions could profoundly impact a household. We all collectively benefit—our residents, the medical community that relies on us to provide follow-through care, in addition to the community as a whole—by offering positions that require specific licensing and certification such as RN, LNA, and STNA positions. The facility provides an invaluable contribution to the talent pool within Perrysburg,” Zielinski says.</div> <div> </div> <div>To meet changing demands, around two years ago services were expanded to include an 18-bed Rehabilitation Recovery Suites unit, specifically geared for short-stay patients. The success his facility has had in providing care, and jobs, to Perrysburg would be made extremely difficult to continue if proposed cuts in Medicaid in Ohio become reality. Residents will continue to get the care they need and deserve, but the cuts would impact the business and its workers, who have become a key to the local economy.</div> <div> </div> <div>“The proposed 5 percent reduction simply means jobs. The proposed Medicaid cut, which is scheduled to be announced next Wednesday [the time this article went to press], is a substantial loss of Medicaid revenue for my center annually,” Zielinski says.</div> <div> </div> <div>Around 70 percent of the average nursing facility expenses are salary- related, with the other 30 percent of expenses either fixed or already reduced to the extent possible without impacting care, he says. </div> <div> </div> <div>“Cutbacks would also prevent the center from providing the cost-of-living raises that our staff deserve. This could result in staff turnover, which could also impact consistency of care for our residents. We need our frontline caregivers and support personnel to know our residents,” Zielinski says. </div> <div> </div> <div>“Caregivers who love what they do are often forced to take positions in other industries because the amount we can pay, based on the rates we receive from Medicaid, do not allow us to pay them a living wage. This proposed Medicaid reimbursement reduction simply makes it worse,” he says. </div> <div> </div> <div>The recently released Eljay report for AHCA/NCAL showed that the state underpays more than $13 per patient per day for every Medicaid patient. “For us that equates to an estimated $780 per day, or $284,700 annually, based on our daily average of 60 Medicaid patients,” Zielinski says. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Nursing Care On Lake Erie</strong></h3> <div>In the past year, Edgewood Manor Nursing Center in Port Clinton, Ohio, on Lake Erie, has added 10 employees, to bring its total to 74, says Lori Opfer, executive director of the Covenant Care-owned operation.</div> <div> <img width="286" height="412" class="ms-rtePosition-1 ms-rteImage-2" alt="Marie Sehlmeyer, Edgewood Manor annual rehab olympics" src="/Issues/2011/PublishingImages/0411/RehabOlympicsMarie2.jpg" style="margin:10px 5px;height:215px;" /><br>Long-term stays for employees are not uncommon here, with the director of nursing recently celebrating a 33rd anniversary. Opfer says a third of the workers have been on the job at Edgewood for more than 10 years, and just over a quarter more have at least five years’ experience. “They are really committed to the residents” she says. </div> <div> </div> <div>A major emphasis at Edgewood is the Homeward Bound program to return residents to their homes once they receive the attention they need. Last year, 78 residents were returned home, up from 53 in 2009, Opfer says.</div> <div> </div> <div>She has 99 licensed beds, but this year is looking to sell 20 beds because Ottawa County, where Edgewood sits, is an “overbedded county.” There are currently 82 residents, many of whom are enjoying remodeled private rooms, reflecting a national trend in nursing care to give residents solo status accommodations.</div> <div> </div> <div>Opfer works to get elected officials in the facility, to educate them on what nursing care is all about, in the hopes that when votes come up on Medicaid and other issues, they will recall the important work being done at Edgewood.<img width="248" height="225" class="ms-rtePosition-2 ms-rteImage-2" src="/Issues/2011/PublishingImages/0411/LucilleKukayPic.jpg" alt="" style="margin:15px;height:186px;" /><br></div> <div>She writes letters to her lawmakers and notes the positive responses she has received from the district’s representative in Congress, Rep. Marcy Kaptur (D-Ohio). </div> <div> </div> <div>“The thing I would tell lawmakers is that while most of them have money, the average American cannot afford 24-hour care. If there are Medicaid cuts it would definitely make it more difficult to provide care,” she says. </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Dipping Into Indiana</strong></h3> <div>Well south of the northern tier of Ohio is the city of Richmond, Ind., close to the extreme eastern border of the state and an hour and change east of Indianapolis on Interstate 70. </div> <div> </div> <div>In Richmond, CarDon and Associates operates its Arbor Trace senior living community, an 86-bed health care facility and 30 one- and two-bedroom assisted living apartments. The community opened in the spring of 2007 and was fully occupied within seven months, says Susan Bonner, CarDon director of marketing.</div> <div>More than 140 people work at Arbor Trace.</div> <div> </div> <div>The community typically operates at 40 percent Medicaid census, 35 percent Medicare, and 15 percent private pay. The assisted living apartments operate at full capacity. The community is currently undergoing an expansion to add 19 private rehabilitation suites and expanding the therapy gym, she notes. </div> <div> </div> <div>The expectation, given the current economic climate, is that further cuts to Medicaid reimbursement are coming, says Jeff Huffman, director of external affairs and ancillary operations for CarDon.</div> <div> </div> <div>“These reductions will not affect our continued efforts to offer the highest quality of care to our residents, no matter what the reimbursement type. These cuts will have to be absorbed in the bottom line and will lead to the freezing of wages and benefits and less expenditure on improving physical plants and equipment,” he says. </div> <div> </div> <div>CarDon sees many of its 13 communities as one of the largest employers in a given area, making the continued education of lawmakers extremely important. “As for-profit organizations, it’s also important for elected officials to understand the amount of tax revenue generated by long term care in our state,” Huffman adds.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Medline’s Manufacturing Growth</strong></h3> <div>It makes sense that with all the economic activity being generated at long term care facilities across the Midwest and the nation as a whole, there would be demand for the manufactured products essential to senior care. A leader in doing just that for the long term care industry, and hospital and health care sectors in general, is Medline.</div> <div> </div> <div>Based in Mundelein, Ill., an hour’s drive north of Chicago, Medline is bringing its customers cost-saving solutions in a market under immense pressure to be as efficient as possible.</div> <div> <img width="426" height="172" class="ms-rtePosition-1 ms-rteImage-2" alt="Medicine cups manufactured by Medline" src="/Issues/2011/PublishingImages/0411/IMG_4181.jpg" style="margin:10px;width:353px;height:235px;" /><br>At some point when you get near Medline headquarters, the water tower bearing the company’s name comes into view. The water tower; the train tracks that run right into the manufacturing facility for supplying round-the-clock operations; and large machines pumping out any number of gloves, textiles, incontinence products, suction tubing catheters, and medicine cups, among its scores of offerings, attest to a bustling business.</div> <div> </div> <div>With more than 2,250 workers at the Mundelein facility and around 7,500 for the company as a whole, there is abundant activity in meeting customer needs, says Medline Chief Operating Officer Jim Abrams, part of the family-run executive team in charge of the privately held company. Cousins Andy Mills and Charlie Mills are president and chief executive officer, respectively.</div> <div> </div> <div>Abrams says Medline is focused on improving outcomes for patients and residents in the health care system and makes every effort to integrate the concerns and ideas of clinicians and providers who see daily how best to use the company’s products to prevent falls, eliminate infections, and cut down on all sorts of deficiencies.</div> <div> </div> <div>Medline is active in any number of programs, both training efforts inside its buildings and in the grassroots arena at the state and federal levels, with ties to associations and allied groups, in order to improve the caregiver’s capabilities at every level. For example, Medline helps organize and conduct seminars with state associations on the Quality Indicator Survey. Its Compass programs are practical, hands-on resources to help clinicians meet standards of practice, improve care outcomes, and reduce regulatory risk.</div> <div> <img width="247" height="537" class="ms-rtePosition-2 ms-rteImage-2" alt="Medline employs more than 2,200 workers in the Mundelein area." src="/Issues/2011/PublishingImages/0411/IMG_4198.jpg" style="margin:10px;width:182px;height:272px;" /></div> <div>Medline is seeking to bring value to customers, and in turn, help to reduce costs throughout the health care system. The new health care reform law will make it even more imperative that value, not just volume, be apparent in care models and reimbursement, Abrams says. “We’re seeing how we can help reduce readmission rates, working with nursing homes and all ends of the spectrum,” Abrams says. </div> <div> </div> <div>He is concerned that the nursing industry, dominated by family-run businesses, is in danger of having its “muscle, not fat” cut by further reductions. </div> <div> </div> <div>For Medline, Abrams emphazises that keeping costs low and striving for efficiencies is a way of life, and as the nursing care business evolves, its ability to grow jobs depends on it.</div> <div> </div> <div>Rep. Robert Dold (R-Ill.) represents the 10th district in Illinois, adjacent to Mundelein. He sees long term care as a vital issue for Congress to address now and into the future. “Long term care is very important as we look at an aging population, with seniors living longer,” he says. The challenge is balancing the obvious need to care for seniors with budgeting pressures. “There is no question the amount of spending by the federal government is unsustainable,” Dold says, stressing the need for public-private partnerships to stretch dollars as far as possible. </div>Provider-related Jobs A Mainstay In Midwestern States2011-04-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/POTR_logo_rollup.jpg" style="BORDER:0px solid;" />Reimbursement;Management;PolicyColumn4
The QIS Experthttps://www.providermagazine.com/Issues/2011/Pages/0411/QIS-Expert.aspxThe QIS Expert<h3 class="ms-rteElement-H3">​<strong></strong></h3> <h3 class="ms-rteElement-H3"><strong>Q.  If the QIS is supposed to be more consistent, why do we observe such a wide variation in The number of deficiencies?</strong></h3> <div><strong>A.</strong>  The answer has to do with what is meant by a “more consistent” survey process. More consistent in this regard has two meanings. First, with QIS we would expect that what surveyors actually do when they are on site in the survey will be the same across states, districts, and surveyors. Important details such as how they sample residents, how they conduct interviews with residents and families, and how they make observations of residents are more consistent in QIS.</div> <div> </div> <div>For example, the Stage 1 samples are larger and randomly selected so they are not based on prior survey results. This ensures that resident samples are selected in the same way by all surveyors and without a focus on preconceived concerns about quality that surveyors may have based on prior surveys.</div> <div> </div> <div>Each annual survey is an independent event, so if a facility has changed appreciably since the last survey—either by improving or declining in quality—then the surveyors are not biased by previous survey results. Stage 2 investigations also follow a more sequential and structured process, leading to a more systematic investigation process. </div> <div> </div> <div>The second meaning of more consistent relates to survey outcomes. Consistency in this regard means that if two different teams from different districts or states conducted a survey of the same building at the same time, then they would get the same result. The more consistent QIS process clearly helps to ensure that this occurs, but it also requires consistent decision making. Greater consistency is addressed by the rigorous surveyor training and review during training, as well as monitoring by the state agency using the QIS data in a procedure.</div> <div> </div> <div>What consistency in the survey does not mean is that surveys in all states, or districts, or buildings, will get the same number of deficiencies. For this to happen, it would mean that all the nursing facilities have the exact same level of quality—which is not the case. A different quality standard was in place over an extended period of time because the traditional survey was not consistent across teams, districts, and states. Providers naturally adapted to each local standard. </div> <div> </div> <div>So replacing this inconsistent standard with a consistent standard should result in a wide variation in the number of deficiencies across states, districts, and facilities. </div> <div> </div> <div>Many facilities that formerly had good or moderate survey results have worse results with the more comprehensive QIS. A fair number of homes have better results on QIS, particularly if they are very oriented to quality of life.</div>Andy Kramer, MD, explains how the Quality Indicator Survey is more consistent despite observations of wide variation in the number of deficiencies? 2011-04-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/AKramer_rollup.jpg" style="BORDER:0px solid;" />Management;Survey and CertificationColumn4




Boosting Quality In Nursing & Assisted Living Carehttps://www.providermagazine.com/Issues/2011/Pages/0511/Boosting-Quality-In-Nursing.aspxBoosting Quality In Nursing & Assisted Living Care​<div>​Planetree, a nonprofit organization founded in 1978 on the principle of “personalizing, humanizing, and demystifying the health care experience for patients and their families,” offers a model of care that could be beneficial to long term care providers. </div> <div> </div> <div>Planetree’s model is a patient-centered, holistic approach to health care aimed at promoting mental, emotional, spiritual, social, and physical healing.</div> <div> </div> <div>The organization’s designation program for providers interested in achieving person-centered care, and possible subsequent designation as a Planetree community, is based on 30 years of experience with patient-centered care in acute care settings. </div> <div> </div> <div>For Diane Judson, director of nursing for Bethel Health & Rehabilitation Center and The Cascades Assisted Living, a long term care campus in Bethel, Conn., the distinction between Planetree designation and other quality measures is resident involvement. “The patients and residents own it,” says Judson. “They’re in the driver’s seat.” </div> <h3 class="ms-rteElement-H3"><strong>A Fundamental Shift</strong></h3> <div>The Planetree designation program is structured around how residents, family members, frontline staff, and leadership define person-centered care. A set of 63 experience-based criteria derived from focus group work with various stakeholder groups comprises the framework of the program. Collectively, these criteria raise the bar for what consumers and staff can expect from a person-centered provider, including resident-direction in their care and in the operations of the community as a whole, empowerment of staff who work most closely with residents, and prioritization of relationship-building over tasks. </div> <div> </div> <div>For many long term care communities, actualization of these concepts requires a shift not merely in operations, but fundamentally in their culture. The designation program provides a road map for that work. This is achieved by translating high-level concepts into actionable, attainable, and sustainable practices.</div> <div> </div> <div>This is the key to enduring change, says Bethel Health Care Assistant Administrator Maggie Butler. “It is such a huge undertaking to effect change on all of these levels, so [designation] helps you realize that it’s an evolving process and you don’t have to do it all at once. It helps keep you focused.” </div> <div> </div> <div>For the Bethel community, this year’s priorities are implementing trayless dining, re-engineering its orientation process to incorporate the resident experience, developing a mentoring program, and working with residents on room renovations.  </div> <h3 class="ms-rteElement-H3"><strong>From Conceptual To Operational</strong></h3> <div>Azura of Lakewood is a short-term rehabilitation center in Colorado also working to achieve designation. For principal and founder Tim Heronimus, the opportunity to connect with others similarly committed to transforming the culture of long term care was a large part of the appeal of the process. </div> <div> </div> <div>“We don’t want to provide care the same way it has been provided in nursing homes for the past 60 years,” he says. “To do that, we need to look at best practices and work with others who are working to transform the culture of care.” </div> <div> </div> <div>Dialogue with providers about their most impactful changes and most pressing challenges has informed the program, most recently through the addition of criteria related to improved transitions of care. </div> <div>In addition, successful innovations culled from long term care communities across the country have been woven into the criteria. </div> <div> </div> <div>For instance, Bethel Health Care’s resident interview teams were the inspiration for the criterion that residents play a role in the hiring and evaluation of staff. As with all the criteria, the specifics of how the criterion is satisfied are left to the determination of individual sites based on their unique culture and structure. </div> <div> </div> <div>Others need not employ Bethel’s strategy of empaneling a resident interview team; however, the existence of established practices such as this can serve as inspiration for others.  </div> <h3 class="ms-rteElement-H3"><div><strong>Evidenced-Based Criteria</strong></div></h3> <div>The designation program is aligned not only with the experiences of residents, families, and staff, but also with the empirical evidence upholding person-centered care. </div> <div> </div> <div>This past year, with the support of the Commonwealth Fund, a collaborative of organizations, including My InnerView, the IDEAS Institute, the Brown University Center for Gerontology  and Health Care Research, and Planetree, refined the program’s criteria and measurement tools. The experience-based criteria consistently conformed to current literature on person-centered approaches. </div> <div> </div> <div>The review process also led to the identification of gaps, resulting in the addition of criteria related to leadership engagement, the dining experience, and gentleness in the provision of daily care. </div> <h3 class="ms-rteElement-H3"><strong>How The Pilot Works</strong></h3> <div>Now, the true test of the designation program begins. Fourteen continuing care communities spanning the continuum of long term care are serving as living laboratories where designation is being field tested. Their feedback will guide the refinement of the program to ensure that the criteria are indeed achievable within the parameters of the environmental, budgetary, and regulatory constraints that are operational realities in long term care.</div> <div> </div> <div>For these communities, selection as designation pilot sites affords the opportunity to benchmark their progress with other like-minded organizations, to be exposed to evidence-based, person-centered practices, and to celebrate their successes as a community. </div> <div> </div> <div>The team at Loch Lomond Villa in New Brunswick, Canada, is confident that participation in the designation pilot will help maintain momentum for their person-centered care initiatives, even in the face of competing priorities. </div> <div> </div> <div>“We have a lot of wonderful programs and systems in place; however, with the changing environment and demands we need support to carry on with this wonderful work,” says Chief Executive Officer Cindy Donovan.  “We recognize we need something more to help us all grow in our future journey.”</div> <div> </div> <div>For the team at Bethel, participation in the pilot is an opportunity for its hard-working staff to channel their passion for their work and for the community’s change vision. “There’s nothing more rewarding than watching people blossom in a collaborative way,” says Judson. </div> <h3 class="ms-rteElement-H3"><strong>Assessing The Process </strong></h3> <div>Planetree’s pilot sites are also testing a Multi-method Assessment Protocol (MAP), consisting of qualitative and quantitative measures of person-centeredness.</div> <div> </div> <div>The MAP includes focus group work, satisfaction survey data, and a self-assessment process. The final component of the MAP is a Quality Profile, which includes 36 measures categorized as operational, quality, and financial (see sidebar, for sample measures). </div> <div> </div> <div>For communities on the path to person-centered excellence, the designation criteria are providing guidance for establishing an infrastructure that positions their culture change journeys for long-term sustainability.</div> <div> </div> <div>According to Azura of Lakewood’s Heronimus, this infrastructure is creating a solid foundation for decision making and improvement processes based on what is best for their “guests” and alignment with the community’s change vision. This level of sustainability is indeed the ultimate test of the designation program. </div> <div> </div> <div>“The designation process is something you must commit yourself to doing every day, and not just for one year,” says Heronimus. “It is a commitment to now and to the future.”  </div> <div> </div> <div>Planetree is recruiting additional sites to participate in the pilot. </div> <div> </div> <div><em>Sara Guastello is director of designation and resource development for Planetree. For more information about the designation program, contact Heidi Gil, senior director of continuing care, at (203) 732-1365 or at </em><a href="mailto:hgil@planetree.org"><em><font color="#0072bc">hgil@planetree.org</font></em></a><em>. </em></div>Planetree’s designation program takes person-centered care to a new level with evidenced-based criteria and tested measures.2011-05-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0511/Planetree.jpg" style="BORDER:0px solid;" />Column5
Corporate Compliance: SNFs Must Get On Boardhttps://www.providermagazine.com/Issues/2011/Pages/0511/Corporate-Compliance-Essentials.aspxCorporate Compliance: SNFs Must Get On Board<div>​Today’s skilled nursing facilities (SNFs) see more acute patients than ever before, while government investigations of these facilities are increasing. Between 2005 and 2007, more than 91 percent of nursing facilities were cited for deficiencies during annual surveys, with quality-of-care deficiencies on the rise.</div> <h3 class="ms-rteElement-H3"><strong>Investigations Broadened</strong></h3> <div>Historically, Corporate Integrity Agreements (CIA), or agreements between the Office of Inspector General (OIG) and a health care provider as part of a settlement for alleged civil wrongdoing relating to federal health law, dealt almost exclusively with reimbursement and fraudulent practices related to billing. </div> <div> </div> <div>That all changed in 2000, when the first CIA that focused on quality of care went into effect. Since then, more than 35 nursing facility companies have entered into such agreements. Today, a typical quality-of-care CIA lasts between three and five years and can cost a provider anywhere from $250,000 to $5 million in settlement and litigation costs.</div> <div> </div> <div>According to David Zimmerman, professor of industrial and systems engineering at the University of Wisconsin-Madison, the emphasis on quality of care surfaced when OIG became concerned that providers under CIAs that were also facing bankruptcy might take shortcuts in quality of care.</div> <div> </div> <div>Also worth noting is the fact that the government has broadened its investigatory range to include nursing facility companies of all sizes. The federal government’s pursuit of more transparency within SNFs has gone beyond the annual survey. According to attorney Alan Schabes, of Benesch, Friedlander, Coplan & Aronoff, the government is now spending more and more time investigating possible claims against nursing facility providers based on violations of the federal False Claims Act (FCA). </div> <div> </div> <div>Such claims are frequently based on the assertion that the services that were provided were of such poor quality that they were “worthless services.” The government has also continued to leverage exclusion, or the revoking of a nursing facility provider’s right to participate in and receive payments, from Medicare and Medicaid programs.</div> <h3 class="ms-rteElement-H3"><strong>Health Reform Law Implications</strong></h3> <div>Citing clients who have spent upwards of $100,000 just on a single FCA investigation, Schabes says meeting today’s quality-of-care requirements means going above and beyond the annual survey. </div> <div> </div> <div>The health care reform law, also known as the Patient Protection and Affordable Care Act of 2010, mandated nursing facility compliance by 2013. This law also appears to require a mandatory compliance and ethics program for all physicians, small and large nursing facilities, pharmacies, medical equipment suppliers, and more. </div> <div> </div> <div>While the specifics of the new law have yet to be spelled out, the OIG compliance program guidelines for nursing facilities are likely to provide a model for compliance requirements. The law also requires a standardized training program for all compliant providers. Compliance training should reach the entire staff and have some ability to track its own effectiveness. Consistent and targeted training for care providers, managers, administrative staff, corporate officers, facility directors, and even family members at each level will further the culture of compliance throughout the organization and ensure training goals are met. </div> <div> </div> <div>Staff training should be provided in a practical way, such as through live in-person training, videos, and publications, depending on the employee’s needs. Training materials and methods should also take into account the skills, experience, and knowledge of each trainee. Simply put, the better trained the staff, the better the quality of care and the more compliant a facility will be. </div> <h3 class="ms-rteElement-H3"><strong>Staff Training Essential</strong></h3> <div>Zimmerman notes that training will play a key role in any compliance program “because compliance is necessary at all levels of the organization, right down to the caregivers that are the certified nurse assistants.” </div> <div> </div> <div>This is not something that is naturally taught in technical education programs or nursing schools, Zimmerman says, so organizations need to ensure that all employees are aware of what the rules are with respect to compliance with regulations.</div> <div> </div> <div>Effective training will not only instruct on care issues, but also on what needs to be reported, how it should be reported, and provide an overall review of an organization’s reporting process. </div> <div> </div> <div>Also important is the presence of an evaluation process to ensure that the training was effective, including the evaluation of clinical competencies associated with the training. Truly effective corporate compliance programs will include a thorough internal infrastructure of policies and procedures that include checks and balances at every level of the organization. </div> <div> </div> <div>As the penalties and liabilities for insufficient oversight rise and the 2013 compliance deadline approaches, SNFs will determine the best way to incorporate compliance into the day-to-day operations of their facilities. </div> <div> </div> <p><em>Tamar Abell is principal of Upstairs Solutions, Skokie, Ill., a provider-owned compnay that offers more than 130 online training courses specifically developed for senior care and an easy-to-use recordkeeping system to manage and track training, licenses, and competencies.</em></p>A meaningful compliance program that addresses quality of care and financial issues must be the cornerstone of every provider’s mission and culture.2011-05-01T04:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/clip%20art%20document%20fine%20print.jpg" width="150" style="BORDER:0px solid;" />Management;Survey and Certification;Quality ImprovementColumn5
Seniors Housing: Fog Lifting In Wake Of Recessionhttps://www.providermagazine.com/Issues/2011/Pages/0511/Fog-Lifting-In-Wake-Of-Recession.aspxSeniors Housing: Fog Lifting In Wake Of Recession<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 class="ms-rteElement-P">​Even as skilled nursing and assisted living providers see opportunities for growth, and financing experts talk of a new, albeit cautious optimism in the marketplace, the long term care business faces serious challenges to owner/operators’ bottom lines.</p> <p class="ms-rteElement-P">The challenges most front and center on provider minds are actual and proposed cuts in Medicaid reimbursement and figuring out what impact the adjustments under Medicare’s new Resource Utilization Groups-IV (RUGS-IV) and Minimum Data Set (MDS) 3.0 system will have. The Great Recession may officially be over, but aftershocks are being felt at all levels of government, notably in states where pre-recession revenue is not likely to return for some time. </p> <p class="ms-rteElement-P">The full pain of these budgetary woes was soothed for a time by federal stimulus dollars, but like most stop-gap measures put in place in 2009, beneficial adjustments to the FMAP (federal medical assistance percentages) program are ending, eliminating extra federal aid for ballooning state Medicaid commitments.</p> <div>Still, the potential pitfalls and talk of congressional rewriting of reimbursement policies in general have not dampened the views of many financial experts and providers who see a bright present and future for long term care. They note that the 24/7, round-the-clock care provided by skilled nursing facilities (SNFs) will be of even greater value as the baby boom generation swells the ranks of elderly Americans in the coming decade. </div> <div> </div> <h3 class="ms-rteElement-H3"><div><strong>Bullish But Braced For Changes</strong></div></h3> <div>The allure of the sector as a commodity was highlighted by Ventas Healthcare’s recent deal to spend $7.4 billion for Nationwide Health Properties, creating the largest real estate investment trust (REIT) in the nation, says Steve Gilleland, senior director for the healthcare real estate group at CapitalSource, a bank and major investor source for seniors housing based in Chevy Chase, Md. <img width="118" height="158" class="ms-rtePosition-2 ms-rteImage-2" alt="Steve Gilleland" src="/Issues/2011/PublishingImages/0511/Gilleland2.jpg" style="margin:10px;height:189px;" /><br><br>“I am very bullish,” he says, noting that even during the most trying times of 2009-2010, it was the long term care sector and its “need-driven” business that proved recession-proof in the financing markets. And, more of that need-driven business is on the horizon.</div> <div> </div> <div>Beyond the markets, however, there is a cold reality that caring for the nation’s elderly and frail, notably in small and rural communities, is a daily battle to stay afloat for some as reimbursement simply does not match the cost of providing care. Long term care, as highlighted below with a look at the Good Samaritan Society–Wagner, S.D., skilled nursing and assisted living facility (ALF), continues to face obstacles that force the administrator to find new ways of doing business to survive.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Most Markets In Recovery Mode</strong></h3> <div>For market experts, there is a mix of optimism, caution, and even some forbearance when asked about the state of the capital markets these days. The trauma of the recessionary months has left an indelible mark, but the fog is lifting in many areas, while others remain in an unsteady state.</div> <div> </div> <div>Doug Korey, managing director of Contemporary Healthcare Capital in Shrewsbury, N.J., sees a split picture, with parts of the market stabilized or improved and other parts just the opposite. </div> <div> </div> <div>“Certainly we are seeing more financing come into the market than in 2009/early 2010 for facilities with positive historical cash flow that are operated by management teams who are well known to the investment community,” he says. </div> <div> </div> <div><img width="223" height="322" class="ms-rteImage-2 ms-rtePosition-1" alt="Doug Korey" src="/Issues/2011/PublishingImages/0511/Korey.jpg" style="margin:10px;width:131px;height:200px;" />“However, for construction and turnaround lending we don’t see much improvement at all. After the capital markets crash in 2009, a number of finance companies stopped lending altogether, and banks pulled back sharply. Now, some of these finance companies are beginning to finance transactions with adequate historical cash flow, as are banks, but neither seems willing to take the risk of construction or turnaround facilities.”</div> <h3 class="ms-rteElement-H3"><strong>Banks More Cautious, But Have Cash</strong></h3> <div>Gilleland notices that banks are coming back to the SNF lending space on a more selective and sometimes more conservative basis. He says there are around 25 banks that currently lend to SNFs—per the National Investment Center (NIC) for the Seniors Housing & Care Industry’s Lender Locator.</div> <div> </div> <div>“If underwritten correctly and using historical guidelines, SNF loans provide above average yields and plenty of cushion in debt service coverage and other bank metrics,” Gilleland says. For Korey’s firm, today’s market has not forced it to change the basics, with Contemporary maintaining the same credit and pricing policies as before the crash, but that is not true for other players.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>“Since we have never been the least expensive lender in the industry, our pledge to our customers is to treat them the same whether the capital markets are healthy or not and to certainly not take advantage of them when the market turns on them,” Korey says. “That said, there are banks in the industry that relaxed pricing in 2007 and 2008 that have now increased pricing to reflect risk.”</div> <div> </div> <div>CapitalSource has seen a major difference in why it lends. From 2003 to 2008, 90 percent of loans were for acquisition financing and 10 percent for refinancing deals. For 2009 and 2010 there was an exact flip, with 10 percent for acquisitions and 90 percent for refinance, Gilleland says.</div> <div> </div> <div><img width="168" height="580" class="ms-rtePosition-1 ms-rteImage-2" alt="Richard Sutton" src="/Issues/2011/PublishingImages/0511/Richard-Sutton.jpg" style="margin:10px;height:167px;" />In California, Richard Sutton, vice president at California Bank & Trust, sees a rise in liquidity for banks and opportunities aplenty for “best-of-class” owners/operators.</div> <div> </div> <div>In a talk given at a NIC conference in Los Angeles in March, Sutton said while 157 banks shut operations or merged in 2010, of the 6,000-plus remaining, many are flush with cash, and some are selectively lending to the seniors housing industry.</div> <div> </div> <div>“We are seeking [at California Bank & Trust] ‘banking relationships’ with top-tier operators,” he says. One of the lender’s recent closings involved a $1 million working capital line to an operator taking over an underperforming property with an 85 percent advance rate on a new account receivable. The deal was done at the prime interest rate plus three-quarters of 1 percent, with a 5.5 percent floor.</div> <div> </div> <div>“I believe you will see the banks more involved in lending in 2011,” Sutton says.</div> <h3 class="ms-rteElement-H3"><strong>Outlook Includes Number Of Factors</strong></h3> <div>As far as Robert Kramer, president of Annapolis, Md.-based NIC, can see, the seniors housing sector felt less of an impact from the recession and thus has had a quicker recovery time per capital markets. SNFs and ALFs are recovering or maintaining their strength, though independent living has been more of a challenge, with more seniors postponing a move because of nervousness about selling their homes.</div> <div> </div> <div>For SNFs, it is paying to diversify by offering more services in the way of therapy and rehabilitation, attracting a new base of clients able to leave the facility in a matter of days and weeks instead of months or years, or permanent residence, Kramer says.</div> <div> </div> <div>“Additional revenue lines are being found in pharmacy, home health, and hospice” for the larger national and regional operators, he notes.</div> <div> </div> <div>Gilleland echoes this sentiment, saying it is definitely necessary to branch out. “You have to be less reliant on state funding. There is no way to build a Ritz-Carlton [modern facility] and only get paid meat-and-potato rates,” he says.</div> <div> </div> <div>SNFs are also finding value in shrinking the number of beds in their facilities, making room for more private rooms, rehabilitation wings, and short stays in general.</div> <div> </div> <div>“This means [total] occupancy is down, but that doesn’t mean overall financial performance has gone down,” Kramer adds.</div> <h3 class="ms-rteElement-H3"><strong>Changing Long Term Care Profile</strong></h3> <div>Another trend, at least for some of the larger players like Kindred Healthcare, is to tie together care, bringing a health system to bear in the dawning world of accountable care organizations. “This gives providers control over services, and all of this is tied back to unnecessary hospitalizations,” he says.</div> <div>Medicaid pressures will be intense over the near- and intermediate-term, not only with cuts but with longer-term policies designed to keep people in home- and community-based care and not in a nursing facility. </div> <div> </div> <div>This issue is going to be tricky at the state and local levels, Kramer notes, likening the situation to what happened to the de-institutionalization of people with mental illnesses in the 1980s, which resulted in scores of new homeless individuals living on the streets with no care.</div> <div> </div> <div>States and localities need strong services at the community level to even begin to make something like that work in the long term care sector, as in solid transportation and therapy programs, not to mention the medical attention the frail and elderly must have, Kramer says. “To say someone does not need 24/7 care doesn’t mean to say they don’t need any care,” he says. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>Get A Deal Now, Then Negotiate </strong></h3> <div>Contemporary is providing more gap and bridge financing than ever before, marking a trend in creative financing seen across the sector.</div> <div> </div> <div>“Borrowers obtain whatever level senior deal that they can get and then fill the gap with our mezzanine [a hybrid of debt and equity financing] and preferred equity,” Korey says. “A 50-70 percent LTV [loan-to-value] senior deal is better than nothing, and with our pre-payable mezzanine and equity products, that financing package is able to be refinanced as soon as the capital market becomes healthier.”</div> <div> </div> <div>His firm has also provided capital to complete a transaction from its mezzanine and equity funds. “This capital has been used to acquire or begin construction on time-sensitive transactions for several transactions this year and late last year,” he says.</div> <div> </div> <div>Borrowers immediately begin discussions with senior lenders to pare down such financing and get a better blend of rates. “We provide them with a certain amount of our loan with no prepayment fees to accommodate the senior transaction. As the construction or turnaround improves or stabilizes, that same senior lender can ratchet up its loan to take out more of ours, or the borrower can refinance the whole loan with a more conventional structure,” Korey says.</div> <div> </div> <div>“Either way, the borrower has taken advantage of the market in terms of getting in the ground with a new building or acquiring an underperforming or nonperforming facility at far less cost than waiting until a year or two from now.”</div> <div> </div> <div>Meanwhile, with little construction occurring in the market today, occupancies are quite high, even within older facilities, he says. “A new or substantially renovated facility in that market, regardless of the cost of capital to enter that market [if well operated] generally becomes the facility of choice,” Korey says. </div> <h3 class="ms-rteElement-H3"><strong>The Medicaid Threat</strong></h3> <div>If challenges to the long term care sector could be categorized like those used for hurricanes, proposed deep cuts in Medicaid in many states would be a looming Category 5 storm with the potential to rewrite forecasts and business plans in a dramatic way, watchers posit.</div> <div> </div> <div>Even the bullish Gilleland puts it bluntly. “The head wind is Medicaid cuts. Almost every state is looking at these; New York … Ohio has a potential 7 percent cut. Texas, there is talk there of a 30-33 percent cut,” he says. If that happens in Texas and is not mere posturing by lawmakers, “all bets are off,” Gilleland says, as up to 600 nursing facilities could be forced to shut without proper reimbursement for their Medicaid residents.</div> <div> </div> <div>Korey says the risks are both global and local in nature, meaning the global economy and unrest seen of late could derail growth for the overall economy, but it is the states and potential Medicaid cuts that are the top priority in need of addressing.</div> <div> </div> <div>“The next 12 months will continue to yield a certain wariness by lenders in general until budgets are passed and lenders can underwrite the full impact of any cuts made,” he says. “Lenders and investors can’t stand uncertainty, and until we see clarity in the jobs market, health care reform, inflation, and the recent global events [Middle East, Japan], no lender or investor will or should be lending or investing at terms based on ‘normal’ years,” he says.</div> <h3 class="ms-rteElement-H3"><strong>Texas Proposed Massive Cuts</strong></h3> <div>When Provider went to print, it was the talk in Texas that was making the most headlines, since the cuts there could be mind-boggling in size.</div> <div> </div> <div>Opponents of the cuts believe the ripple effect of a one-third reduction, pegged at around $7.6 billion to almost $10 billion of Texas’ Medicaid spending (for fiscal years 2012 to 2013), will not only hurt providers but endanger lives, eliminate jobs, and cost the state more money in the long run.</div> <div> </div> <div>On the economic impact alone, the numbers are large. A statistical analysis by the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) showed Texas in 2010 with 168,830 jobs directly tied to long term care, with that number growing to 239,300 overall jobs associated with the sector.</div> <div> </div> <div>Labor income topped $5 billion, and state and local tax revenue were at nearly $623 million, AHCA/NCAL said. The analysis examined the economic impact of long term care for the country as a whole, and individually in all 50 states.</div> <div> </div> <div>Texas is considering the Medicaid cuts and other changes to the reimbursement system to help close a $20 billion budget gap.</div> <div> </div> <div>Other states like Oregon and California are considering 10 percent-plus rate cuts, as 45 states had general fund expenditures below fiscal year (FY) 2009 levels. Even with improved revenue projections for FY 2011, the loss of FMAP-plus will dampen those numbers.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>State Budgets Just One Challenge</strong></h3> <div>The significant risk of Medicaid rate cuts and the use of provider taxes as a key funding source to maintain rates is just one issue providers will have to adapt to in coming months and years, says James Carlson, chief executive officer (CEO) and president of the Oregon Health Care Association.</div> <div>He listed the renewed push to home- and community-based services (HCBS), the waiver potential under federal health care reform, and more managed care initiatives that focus on dual eligibles as big issues. </div> <div> </div> <div>“The combination of budget pressures, federal emphasis on integration of care for dual eligibles, and potential waivers is pushing managed care proposals to the forefront of state strategies,” Carlson says.</div> <div> </div> <div>The ramifications of these trends will affect each provider differently, but it will pay to be abreast of market changes.</div> <div> </div> <div>“Smart organizations will continue to position themselves to serve the post-hospital, short-stay, transitional care patient, even for Medicaid,” he says. SNFs should look to make strategic alliances with acute care and HCBS providers, enhance clinical capabilities, provide modern physical plants, measure and track clinical outcomes, invest in information technology and electronic health records, and try to move away from Medicaid as the primary revenue source over the next five years, experts say.</div> <div> </div> <div>Repositioning is vital for providers in the evolving health care system, Carlson says.</div> <h3 class="ms-rteElement-H3"><div>Providers Diversify</div></h3> <div>Neil Pruitt, chairman and chief executive officer at Norcross, Ga.-based provider UHS-Pruitt, says the climate for his firm remains very challenging, noting the dual issue of adjusting to the Medicare payment system under RUGS-IV and MDS 3.0, as well as the state Medicaid pressures.</div> <div> </div> <div>“These increased pressures come at the same time we have higher-acuity patients,” Pruitt says. “We can’t take high-acuity patients if we are not paid appropriately.”</div> <div> </div> <div>UHS-Pruitt has 76 SNFs and four ALFs totaling more than 8,600 beds and units. The provider operates in North Carolina, South Carolina, and Florida, as well as in Georgia.</div> <div> </div> <div>Pruitt notes the company has an array of supplementary resources, including home health care, end-of-life care, rehabilitation, veteran care, and consultative pharmaceutical services. UHS-Pruitt also offers business-to-business services.</div> <div> </div> <div>These additional business lines help to offset concerns about reimbursement issues, while moving the provider into care management, ensuring continuity of care and high-quality services, Pruitt says.</div> <div>By offering more than just skilled nursing, UHS-Pruitt is also able to look at tie-ins with hospitals. “We are having thoughtful conversations with hospitals to partner together,” he says. “What we are really going to focus on at our company is the spectrum of services. We are also focused on getting rid of three-bed wards,” adapting to consumer demand for more services, such as rehabilitation, and an updated look and feel for buildings.</div> <div> </div> <div>“We have three small children, and we didn’t want to share a room with someone else when we were in the hospital” for their births, Pruitt says.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>A New World</strong></h3> <div>That spectrum of care continues to expand for many providers. The olden days of care were based on independent and assisted living, along with skilled nursing and acute hospitalization. Now, the spectrum consists of dozens of potential offerings, from health and wellness centers (preventative) to adult day care, dementia assisted living, palliative care, hospice, sub-acute rehab, and the list goes on.</div> <div> </div> <div>As for financing, Pruitt points out the availability of credit through government programs like the Department of Housing and Urban Development’s (HUD’s) 232 program, which offers “low rates for an extended period of time,” even when other credit outlets are tight.</div> <div> </div> <div>The HUD 232 program insures mortgage loans to facilitate the construction and substantial rehabilitation of nursing facilities, intermediate care facilities, board and care homes, and ALFs. The program allows for long-term, fixed-rate financing (up to 40 years) for new and rehabilitated properties and up to 35 years for existing properties without rehabilitation that can be financed with Government National Mortgage Association Mortgage- Backed Securities.</div> <div> </div> <div>“Traditional lenders are more cautious. Generally, though, they are open to good projects,” Pruitt notes, reflecting the views of the bankers mentioned above.</div> <h3 class="ms-rteElement-H3"><strong>What’s To Come</strong></h3> <div>As for the outlook ahead, Pruitt sees much opportunity, noting his company has expanded from 42 SNFs in 2002 to nearly 80 SNFs in 2011, a trend he wants to continue.</div> <div> </div> <div>“The potential for our profession is better than it’s ever been,” he says, stressing that quality improvements across the sector have made facilities more attractive for residents and their families.</div> <div> </div> <div>He does hope the implementation of health care reform, and the policy decisions around Medicare and Medicaid reimbursement, can find some sort of steady ground, Pruitt says. “What we really need is a system that is fairer and more stable.” </div>In spite of signs of better times, providers face the threat of Medicaid cuts and the day-to-day challenge of making ends meet.2011-05-01T04:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/Clip%20art%20newspaper%20markets%20section%20w%20dice.jpg" width="150" style="BORDER:0px solid;" />Management;Finance;ReimbursementColumn5
On The Road: LTC Providers A Steadying Force In Michigan Economyhttps://www.providermagazine.com/Issues/2011/Pages/0511/On-The-Road-Providers-A-Steadying-Force-In-Michigan-Economy-.aspxOn The Road: LTC Providers A Steadying Force In Michigan Economy<p>​<img width="198" height="709" class="ms-rteImage-2 ms-rtePosition-1" alt="Blaney Park in Michigan's Upper Peninsula" src="/Issues/2011/PublishingImages/0511/164-Blaney-Park-Wildflowersns.jpg" style="margin:10px;width:176px;height:269px;" /><br>Michigan’s economy has shown signs of life in recent months, and the second Provider On the Road article examines how the stability offered by long term care providers has not only helped lay the foundation for an economic rebound, but prompted skilled nursing and assisted living owners to change the way they do business.</p> <h3 class="ms-rteElement-H3"><strong>Nursing Care A Bedrock In Challenged Economy</strong></h3> <div>A large part of Michigan’s problems relate to the well-documented shrinking of the automaking sector, forcing closures of once-thriving factories and ancillary businesses tied to the Big Three. </div> <div> </div> <div>While manufacturing has retrenched, health care jobs, including long term care, have become even more important, notably to small and medium-size communities, says Charles Ballard, economics professor and author at Michigan State University. “It’s absolutely true [about the emergence of long term care in the economy]. We had such a bad decade in terms of the economy and employment. From the peak of employment in the summer of 2000 to the end of 2010, there was an 850,000 net job loss,” he says. “There were very few bright spots, except for the fact that health care grew in the state, and part of this is long term care facilities.”</div> <div> </div> <div>Gail Clarkson, chief executive officer (CEO) of Washington, Mich.-based MediLodge Group, says some of her 15 skilled nursing facilities and one assisted living facility (all in Michigan) are the largest employers in the counties in which they reside. <img width="173" height="289" class="ms-rtePosition-2 ms-rteImage-2" alt="Gail Clarkson" src="/Issues/2011/PublishingImages/0511/Gail-Clarkson.jpg" style="margin:10px;width:113px;height:158px;" /></div> <div> </div> <div>All told, MediLodge employs 3,000 and operates 2,500 beds, with clusters of facilities near its Detroit-area headquarters and others spread across the state’s Lower Peninsula, with MediLodge of Hillman in the northern reaches and MediLodge of Howell and MediLodge of Montrose closer to Michigan’s midsection west of Detroit.</div> <div> </div> <div>“The state’s downturn has seen additional skilled individuals available for us to employ, but the negative side is that people are putting off health care more and leaving themselves in a more vulnerable position,” Clarkson says. Indeed, the biggest change in care for her facilities is the fact people are coming to MediLodge either “very young,” around 65 to 75 and in need of short-term rehabilitation, or very old, above 85 and suffering severe illnesses like end-stage dementia.</div> <div> <img width="218" height="548" class="ms-rteImage-2 ms-rtePosition-1" alt="Modern public areas at MediLodge" src="/Issues/2011/PublishingImages/0511/31-DES10-5.jpg" style="margin:10px;height:156px;" /><br><strong>Medicaid Funding Message Vital To Providers</strong></div> <div>As in all states, the ability of providers to employ workers and create dozens of related jobs through vendors and contracted work relies on government funding of the Medicaid and Medicare programs. </div> <div> </div> <div>In Michigan, new Gov. Rick Snyder (R) has unveiled a sweeping reorganization, aimed at decreasing regulation and increasing business opportunity. His first budget for fiscal year 2012 did not cut the Medicaid program, a fact David LaLumia, president and CEO of the Health Care Association of Michigan (HCAM), says is very good news. “Despite the bad economy we are cautiously optimistic,” he says. “Our message has made sense to people. Medicaid as a safety net is valuable to people throughout Michigan.”</div> <div> </div> <div>Echoing Ballard, LaLumia sees nursing facilities as a great place for good jobs and good salaries and benefits. Besides advocating to the new governor and administration, he has seen support from a range of Michigan’s federal delegation to Congress, specifically noting the understanding of the long term care issue by Sen. Debbie Stabenow (D) and Reps. Dave Camp (R) and Fred Upton (R).</div> <div> <img width="77" height="869" class="ms-rteImage-2 ms-rtePosition-2" alt="MediLodge's Millford, Mich., facility after remodel" src="/Issues/2011/PublishingImages/0511/IMG_5800-copy.jpg" style="margin:10px;width:184px;height:260px;" /><br>On the economic forecasting front, Ballard expects long term care to continue to be a leader in the Michigan economy, considering the aging population and other trends. As for the general economy in Michigan, he notes, “Maybe the worst is behind us.”</div> <div> </div> <div><strong>Ciena Offers Care And Jobs </strong></div> <div>Ciena Healthcare is a major player in the nursing care business and Michigan economy, running 32 skilled nursing communities across Michigan (with four in Connecticut). Founded in 1998 by Mohammad Qazi and based in Southfield, Mich., near Detroit, Ciena employs around 4,500 people in the state, with 3,970 licensed beds.</div> <div> </div> <div>It is the largest privately owned manager and operator of skilled nursing and rehabilitation facilities in Michigan, and Qazi says the intention is to keep it that way. “Our focus is on building some new buildings and replacing the old ones,” he says, stressing the push in his properties for more private rooms and amenities for a new baby boomer generation that is just now beginning to require rehabilitative nursing care.</div> <div> </div> <div>“It’s been challenging here, times are tough. We are very fortunate to create a significant number of jobs, but it is starting to turn around in Michigan. Automakers are making great products, and they are doing substantially better. There is a new governor here, he has a strong background as a CEO, and expectations are high,” Qazi says.</div> <div> <img width="627" height="657" class="ms-rtePosition-1 ms-rteImage-2" alt="Mohammad Qazi" src="/Issues/2011/PublishingImages/0511/Qazi.jpg" style="margin:10px;width:122px;height:128px;" /></div> <div>Of the thousands he employs, there is now a lot more specialization at all levels of the care spectrum. “Nurses, social workers, dietitians … all of these jobs are focused in terms of rehospitalizations; that’s a big problem when elderly have to go back within 30 days—it is traumatic for them and costly to the system,” he says.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Mid Michigan’s Schnepp Center In Its 53rd Year </strong></h3> <div>For 32 years, the Prestage family has owned and operated the Schnepp Health Care Center in St. Louis, Mich., starting in 1978 when Lois and Richard Prestage, Sr., purchased the facility from Richard Schnepp. In 2002, Richard Prestage and his wife, Carol, bought the center from his parents and run the business today.</div> <div><img width="402" height="292" class="ms-rteImage-2 ms-rtePosition-2" alt="Private room at MediLodge" src="/Issues/2011/PublishingImages/0511/31-DES10-10.jpg" style="margin:10px;width:304px;height:183px;" /><br>Located smack in the middle of Michigan, the Schnepp center has grown over the years to employ 138 people in nursing and rehabilitative care. A rural community, Schnepp has 101 licensed beds and averaged about 94 residents last year. </div> <div> </div> <div>Big changes have occurred over the years, but Richard Prestage says the most distinct is the fact that “people stay home longer before coming for care and come to us later, with more significant health problems.” The weak economy has played an even greater role of late in how and if people come for care.</div> <div> </div> <div>“We’ve seen several times over the last year grandkids who have moved in to take over care of a grandma or grandpa,” Prestage says, reflecting the weak job market for the younger generation who may no longer be able to afford to live on their own and subsequently the lack of money for the older generation to seek 24/7 nursing care.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Medicaid The Primary Payer</strong></h3> <div>The biggest taxpayer in its community, Prestage says his Schnepp center relies heavily on the ability of its residents to use Medicaid funds for paying the bills. “Medicaid is around 65 to 70 percent of our business. We don’t make any money on [Medicaid] as it is, so it would be devastating to us with any cuts,” he says.</div> <div> </div> <div>Many of his workers have been around a long time, with one housekeeper on duty for three decades. “We pay very well and offer good benefits and health insurance. These are not minimum wage jobs,” Prestage says.</div> <div> </div> <div>Despite the challenges of the Michigan economy, Prestage has pushed the Schnepp name into the new era of person-centered care, notably by just completing a $1.6 million renovation project to revamp dining rooms and add enlarged physical therapy rooms, among other improvements.</div> <div> </div> <div><strong>Assisted And Skilled Nursing Adapt In Western Michigan </strong></div> <div>West Woods of Niles in Niles, Mich., is much closer to a famed Indiana institution, Notre Dame, than to its own state’s famous college towns of Ann Arbor or East Lansing, sitting only four miles north of the home of the Fighting Irish. </div> <div> <img width="359" height="216" class="ms-rteImage-2 ms-rtePosition-1" alt="West Wood of Niles throws a party" src="/Issues/2011/PublishingImages/0511/Carnival-2009-010.jpg" style="margin:10px;height:214px;" /><br><br></div> <div>At West Woods, a Peplinski Group-owned 121-bed skilled nursing facility, Chad Culver is the administrator. He is highly concerned about how Medicaid fares in the state, noting his 175-person staff won’t be able to count on wage increases or possibly face job cuts if budgets are trimmed.</div> <div> </div> <div>“It would present real hardship for the facility because 70 percent of our residents rely on [Medicaid] for nursing care,” Culver says. Like HCAM’s LaLumia, he says the long term care sector is cautiously optimistic reductions are not coming. “So far we have been very fortunate, even with a new governor, who doesn’t plan on making cuts,” Culver says.</div> <div> </div> <div>Not far from West Woods sits an assisted and independent living complex called Woodland Terrace of Longmeadow, also in Niles. Owned by the Dockerty family, as is the Woodland Terrace Bridgman closer to Lake Michigan, the facility has 60 units and just celebrated its first anniversary this past February. Half of the units are set aside for those with special needs, like mild to moderate dementia/Alzheimer’s, and for those with more extensive physical needs, reflecting the various levels of care residents can access. </div> <div> <img width="277" height="242" class="ms-rteImage-2 ms-rtePosition-2" alt="New addition at West Woods of Niles" src="/Issues/2011/PublishingImages/0511/brochure-pic2.jpg" style="margin:10px;height:208px;" /><br>The campus has a just-opened feel to it, and a piano player, as well as staff, greets visitors. Todd Dockerty, chief operating officer, says the business attracts new residents through open houses, free health screenings, and by making visits to doctor offices. Business has been good at the two facilities, and Dockerty is hopeful for the state’s reversal of fortunes. “It’s all very wait and see,” he says.</div> <div> </div> <div>The motto now in Michigan may be just that: Wait and see. For providers of long term care, however, it’s modernization and adaptation for the opportunities that await and advocacy to ensure adequate reimbursement streams in the years to come. </div>Heavy industry makes way for health care sector, including long term care, in Michigan.2011-05-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/POTR_logo_rollup.jpg" style="BORDER:0px solid;" />Reimbursement;ManagementColumn5




Consistent Assignment Creates Familial Bondshttps://www.providermagazine.com/Issues/2011/Pages/0611/consistent-assignment-creates-familial-bonds.aspxConsistent Assignment Creates Familial Bonds<div id="__publishingReusableFragmentIdSection"><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>Imagine this happening: A certified nurse assistant (CNA) accidentally drops a resident during a transfer. The frail, elderly individual is bruised, sore, and has a skin tear. When an investigation is conducted, the resident defends the CNA and refuses to blame her for the accident. She says that the caregiver always is conscientious and responsible and treats her with genuine care and concern. She states emphatically, “I will not help you fire her.” </div> <div> </div> <div>Or consider this story: A very elderly—over age 100—resident passes away. She has no family. She leaves behind a box of belongings, including photos and other personal items. Instead of discarding them and forgetting about a life and what it meant, the resident’s assistant asks to keep the items. She says that she wants to keep the woman’s memory alive. She says, “We are her family now.”</div> <div> </div> <div><div><div>​Click <a href="/Issues/2011/Pages/0611/Plain-Talk-From-Nursing-Staff.aspx">HERE</a> to see what nursing staff have to say about consistent assignment.</div> <h3 class="ms-rteElement-H3"><strong>A Family Affair</strong></h3></div></div> <div>These are true stories that epitomize the value of consistent assignment. A growing number of long term care facilities have embraced this concept and implemented it with great success, and the investment is reaping tremendous dividends—happier residents and families, fewer behavioral problems, greater staff stability and lower turnover, and more referrals. Staff, residents, and family members alike are so enthusiastic about consistent assignment that facility leaders are wondering, “Why didn’t we do this sooner?”</div> <div> </div> <div>While establishing and maintaining consistent assignment requires some work, many say it’s as easy as teamwork, flexibility, and trust. These elements not only help facilities move foreward with consistent assignment, they flourish as care becomes a family affair with everyone working together to create caring, safe, and homelike environment. </div> <div> </div> <p class="ms-rteElement-P">"The CNA gets to know the resident very well and is familiar with the person’s habits, routines, and behavior. If the resident’s behavior changes—however subtly—the CNA is the first one to notice," says Sister Pauline, administrator, Teresian House Center for the Elderly, a church-affiliated long term care facility in Albany, N.Y.</p> <div>The CNA’s familiarity with the resident also can prevent behavioral changes caused simply because an assistant doesn’t know about a resident’s routine, pet peeves, or preferences. Sister Pauline gives an example from her own family. “My mother [who is a resident at Sister Pauline’s facility] always wore a scarf, and her CNAs know this, so they make sure she always has a scarf.” </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Residents, Families, Staff Like It</strong></h3> <div>According to Barbara Baylis, RN, MSN, senior vice president of clinical and residential services for Kindred Healthcare in Louisville, Ky., “The residents and families like having someone they can depend on every day. And they don’t have to tell their story over and over again.” As a result of consistent assignment, she says, facilities can expect to see a decrease in resident and family complaints and concerns.</div> <div> </div> <div>The residents and families aren’t the only ones who benefit. “Consistent assignment makes it much easier and more pleasant to come to work,” Sister Pauline says. “They can plan their schedules according to their residents. They know who gets up early, stays up late, and so on. They know how their residents like their rooms and what they want on their beds. It makes for real harmony among everyone involved.”</div> <div> </div> <div>Consistent assignment also enables staff to detect problems earlier and devise individualized solutions to challenging situations. For example, Barbara Frank, MPA, co-founder of B&F Consulting, a Warren, R.I.-based company that works with nursing facilities and other organizations on staffing, culture change, and quality improvement, says, “I hear all the time from CNAs that they can anticipate residents’ needs all through the day and respond to them promptly and proactively.” </div> <div> </div> <div>She cites a story from long term care physician Al Power, MD, who was trying to prevent pressure ulcer development in a high-risk resident. The nursing facility team kept attempting to turn the woman on her side facing the window, and she kept turning back on her other side toward the door. Her CNA observed that the resident was a bird lover and suggested hanging a bird feeder outside the window. The team did as she suggested, and it worked.</div> <div> </div> <div>“Consistent assignment lets you intervene in a way that is likely to produce positive outcomes. And staff have a real sense of personal accountability when they work this closely with their residents,” Frank says.</div> <div> </div> <div>Starting on the road to consistent assignment is easier for most facilities than they realize. As Sister Pauline notes, “Many facilities have been doing it for awhile, but they didn’t have a name for it.” Baylis says, “We initiated this over three years ago when it became an <a href="/Issues/2011/Pages/0611/Advancing-Excellence-Tools-To-Build-Consistent-Assignment.aspx">Advancing Excellence </a>Campaign goal. It is rooted in primary nursing and based on a staffing model that has been around for about 30 years.” Currently, about 99 percent of Kindred facilities have consistent assignment.</div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Assess, Stabilize, Start</strong></h3> <div>A first step to establishing consistent assignment, says Dwight Tew, vice president, talent solutions, for Brookdale Senior Living in Brentwood, Tenn., is determining what staffing additions or changes are needed. Then it is essential to make sure that “you find the right people for each team and provide them with ongoing education.” </div> <div> </div> <div>Robin Arnicar, RN, CDONA/LTC, director of nursing at the Renaissance Gardens, Silver Spring, Md., adds, “You have to conduct an honest evaluation of your staffing numbers. If you don’t have enough staff, you need to do a root cause analysis of why.” Then, she says, the facility needs to start recruiting and hiring needed staffers.</div> <div> </div> <div>Establishing staff stability is key, agrees Frank, to improved performance. “It’s hard to maintain consistent assignment if you have to shift people around because you don’t have reliability. In addition, you need cohesive teams on each shift,” she says. “You have to establish effective ways for teams to resolve issues as they arise,” Frank continues, “otherwise, CNAs can feel stuck and alone in a challenging situation, and that is the kiss of death.”</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Barriers May Crop Up</strong></h3> <div>While consistent staffing requires leadership support and staff buy-in, the concept needs little selling. Most leaders and staff inherently understand the benefits. However, this doesn’t mean that there aren’t barriers to implementation. For example, says Frank, “CNAs may worry about being stuck with someone who is hard to care for. However, if you support CNAs, it alleviates people’s fears that they will be left alone to deal with a difficult situation.” </div> <div> </div> <div>Knowing that they have support can help give CNAs the patience and time to bond with and understand residents who—at first—may seem difficult. For example, Frank says, “There was a post-stroke resident in one facility whose stroke made it so she could only say ‘no’ to everyone about everything. When the organization established consistent assignment, the woman’s CNA got to know her and could tell from her eyes or other nonverbal cues when she actually meant ‘yes.’”</div> <div> </div> <div>Frank stresses, “It’s critical to maintain consistent assignments that staff perceive as fair. Staff have to trust the fairness of the process. You need to constantly trouble-shoot and make sure people get help when they need it.” </div> <div> </div> <div>Another barrier that needs to be overcome up front is the myth that it is better for staff to know all assignments so that they can work anywhere. “This concept seems so anti-relationship,” says Frank. She adds that most staff like knowing what to expect when they come to work every day.</div> <div> </div> <div>Baylis agrees. “CNAs don’t want to relearn everything all the time. They want to go to work and get started right away,” she says. “They like being efficient and feeling confident about their work.”</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Setting Up For Success</strong></h3> <div>Of course, preparation requires the resident’s involvement. As Sister Pauline says, “Before the resident is admitted, we do a pre-admission assessment in which we ask many questions such as what time they get up, what side of the bed they get up on, and what they like to eat for breakfast. We try to mimic their regular schedule so that their admission is seamless.” </div> <div> </div> <div>Later, the CNA and the resident make a care plan just between the two of them that is posted in the bathroom. The nighttime assistant does the same. “On the first evening, the CNA calls the family and tells them how the resident is doing. Then the daytime aide calls in the morning to tell them how their loved one spent the first night. Immediately, they learn about this relationship with the caregiver; and it puts their minds at ease,” Sister Pauline says.</div> <div> </div> <div>Arnicar suggests seeking out informal facility leaders—people who are influential in their units—and using them to establish a peer team. “These people can move a new program forward or be its demise. You need to recognize that they are influential and ask for their help in explaining the benefits of consistent assignment,” she says. </div> <div> </div> <div>Whatever plans a facility makes to implement consistent assignment, Arnicar suggests starting small and slow. “Don’t do the whole building in one day. Start with one unit or neighborhood, make it work there, and then move on to the next neighborhood,” she says, adding, “Empower staff to come up with and share ideas along the way.” But don’t forget to set rules and structure, she cautions. </div> <div> </div> <div>“I went to one building, and they had given staffing over to the staff but never gave them rules. They ended up with 55 different schedules, scheduling gaps, and tons of staff burnout and resident complaints.” Finally, as the facility implements consistent assignment, it must plan a way to measure results. Arnicar suggests tracking outcomes such as staff, resident, and family satisfaction; number of complaints; number of staff call outs; turnover; and clinical issues such as weight loss, falls, and use of antipsychotics.</div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Plugging Into Smooth Scheduling</strong></h3> <div>Solid organization and strong processes will enable the consistent assignment program to move forward more smoothly. One option to manage staffing is the use of scheduling software, such as a program that enables users to create an active schedule. It enables facilities to track staffing and account for vacations and call outs. </div> <div> </div> <div>These systems can be as simple or sophisticated as necessary. For example, they can be designed to send an automatic message to only specific individuals requesting coverage for a call out and enable a sudden absence to be filled by an appropriate substitute in 10 to 15 minutes. </div> <div> </div> <div>Mark Woodka, chief executive officer of OnShift Software, a Cleveland, Ohio-based scheduling software producer, says, “A facility can’t commit to consistent assignment and then implement the program in a disorganized way. People need to know the processes and trust that they will work. Otherwise, you will scramble when you run into conflict.” He notes that his company maintains a template of the master schedule for clients and helps keep it consistent month in and month out. </div> <div> </div> <div>Scheduling programs can help streamline scheduling and help facilities track staffing over time. They can contribute to cutting down on the use of agency CNAs or nurses, and they can take the burden off of busy managers. However, facilities should consider the costs of these systems and weigh the expenses with their specific needs.</div> <div> </div> <div>For example, facilities can purchase the license to use scheduling software for a few hundred dollars plus a subscription fee for regular updates. Or they can get the software subscription with a fully hosted service that includes customization, service, and support. Depending on the organization’s size, this could cost several hundred dollars annually or more.</div> <div> </div> <div>Whether or not a facility chooses to use specialized software or outside companies to manage scheduling, managers involved in setting and maintaining schedules need to be involved from the start. “The people are crucial, and you really need their buy-in. You need to help them understand that consistent assignment ultimately will make their job easier,” says Arnicar. She suggests having this person talk to a scheduler at another facility that has implemented consistent assignment successfully. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Maintaining The Momentum</strong></h3> <div>Teamwork among the CNAs is essential for consistent assignment. However, it doesn’t always happen quickly and easily, especially when people come from different backgrounds and experiences. Sister Pauline says at her facility, CNAs “meet weekly and do huddles as a shift. As a result, they work together and support each other.” </div> <div> </div> <div>They also make sure that new hires know what to expect and what is expected of them. She says, “When an employee comes in looking for a position, we first have them watch a video about working here.”</div> <div> </div> <div>Hiring the right people in the first place is essential to maintaining consistent assignment. As Tew says, “We stress to interviewees that we focus on health and wellness and making residents as functional as possible for as long as possible.” He says that they listen for personal stories or other indications that prospective employees “have a desire to work for the greater good and serve the elderly.” </div> <div> </div> <div>Tew talked to employees at one facility who stressed that they liked theri jobs because of the residents, the teamwork, and the leadership. They enjoyed an atmosphere where they’re caring for residents and having fun doing it. They look at it as something they want to do versus just a job they do for a paycheck," he says.</div> <div> <span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>Managers Must Take The Lead</strong></h3> <div>Tew says supervisors and team leaders have a strong role to play in ensuring the success of consistent assignment. </div> <div> </div> <div>“They need to create an environment where associates feel rewarded, encouraged, and understand their jobs and what is expected of them,” he says, adding, “Managers need to be able to motivate staff and make them feel that they are part of the organization. They need to create a safe environment where staff can suggest improvements and changes and where they share the same level of commitment as managers.” </div> <div>Not only do team members need to feel that they can express opinions and share observations, they also need to know that management will act on them. </div> <div> </div> <div>“If you ask for CNAs’ input, you have to take it seriously and respond to it,” says Frank. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Busting Burnout</strong></h3> <div>Even when facilities hire and keep great people, they need to protect them from burnout. There are many ways to accomplish this. For example, staff can volunteer to care for residents with whom they have established good relationships. </div> <div> </div> <div>Elsewhere, full-time relief workers might work strictly for two people—for example, the person consistently handles Mary’s three days off and Bob’s two.</div> <div> </div> <div>Facilities also should consider the demands of each resident in making assignments, Baylis says. “I may have nine residents, while you only have six because yours require more care and assistance. Assignments have to be equal not in number but in amount and level of care required. There needs to be equality and teamwork,” she says. </div> <div> </div> <div>Another way to maintain staff satisfaction with consistent assignment is not to force caregivers to work with particular residents. As Baylis says, “Very rarely, we have situations where the caregiver and the resident don’t click, and when that happens, we switch them out and someone else cares for the resident. We always try to make accommodations.” However, she notes, “team members usually develop strong bonds with the residents and families, and none of them want to change.”</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Crowing About Accomplishments</strong></h3> <div>Facilities that have established consistent assignment successfully are wise to promote them as part of their culture. “It’s a core business strategy for us,” says Tew. “It’s a consistent message being delivered from the top down.” </div> <div> </div> <div>He says that his company uses “a lot of people pictures” in recruiting and marketing materials. “It may seem corny,” he admits, but he notes that it reinforces the person-centered approach to care emulated by consistent staffing. </div> <div> </div> <div>Tew also says that staff themselves are the best advertisement. “When you see that people are smiling, friendly, and happy as you walk through the facility, that says a great deal.”</div> <div> </div> <div>Maintaining and promoting the individualized approach to care is key to successful consistent assignment. </div> <div>“If one resident leaves and that person showered in the morning, you don’t just put a new resident in the same routine just because it’s convenient. If you do, it can set you up for problems,” says Sister Pauline. “You need to involve the social worker and find the best place, the best routine for each resident.”</div> <div> </div> <div>The facility also needs to prepare residents for staff vacations and absences. As Sister Pauline says, “The resident’s personality can change on a day the aide isn’t there.” She suggests having CNAs tell residents when they’re leaving for the day and remind them when they will be out the next day. The relationships with the resident are so strong that even the family misses the caregiver when he or she is out. “Families will get upset if something happens and their family member has someone different caring for him or her. Often, they will visit more often and stay longer when the regular caregiver is out,” she says.</div> <div> </div> <div>The sense of family that comes from consistent assignment is very real. As Karyn Leible, RN, MD, CMD, chief clinical officer, Pinon Management in Colorado, and president of AMDA—Dedicated to Long Term Care Medicine, says, “Residents love it when staff bring in their kids or grandkids. It becomes an extended nuclear family.” Leible, who first practiced consistent assignment as a nurse many years ago, adds, “My son used to round with me when he was two. When I was listening to a resident’s heart with the stethoscope, he’d be sitting on the person’s lap with a toy stethoscope.” </div> <div> </div> <div>Another time, Leible brought her son into her facility on Christmas Eve. While she worked, he sang carols and baked cookies with the residents. “Many of these people don’t have anyone else. They like having someone special to care for them,” she says. “Connecting to others is a human need. These relationships are key, and consistent assignment builds powerful, caring, and important connections that have a real impact on everyone involved.” </div> <div> </div> A growing number of providers have embraced consistent assignment and implemented it with great success, reaping tremendous dividends. 2011-06-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/caregiver2_rollup.jpg" style="BORDER:0px solid;" />Caregiving;Quality;Management;Workforce;Culture ChangeColumn6
Focus On: Urinary Incontinencehttps://www.providermagazine.com/Issues/2011/Pages/0611/Focus-On-Urinary-Incontinence.aspxFocus On: Urinary Incontinence<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>​It is interesting to talk to health care professionals working in skilled nursing facilities about urinary incontinence. Many express frustrations over programs and plans with poor implementation, some look at the issue as a necessary evil with elder care, few can discuss the actual causes of the problem, and some still believe that it is a normal part of aging and should be tolerated with the use of absorbent products. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Under The Microscope</strong></h3> <div>There needs to be a unified focus on the issues surrounding urinary incontinence, including proper assessments, medical consultation, treatment options, training, and education of the staff about the issue and treatment options for elders in the post-acute care setting. So where do providers begin to examine the issues, and what steps can the clinical and interdisciplinary team (IDT) take to resolve the barriers to quality care?</div> <div> </div> <div>Quality care for elders in this area is so very important because of all the negative implications—both clinical and psychosocial—that can impact the outcome of the care delivery process if incontinence is not properly assessed and treated.</div> <div> </div> <div>The past five years have produced significant, clear clinical information about the topic, along with focus from nursing and medical professionals dedicating their practice to its identification and treatment.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>MDS 3.0 Changes Are Key</strong></h3> <div>The focus from the regulatory side of the industry on the treatment for urinary incontinence, as well as the change in the data required by the Centers for Medicare & Medicaid Services (CMS) related to the topic on the minimum data set (MDS) 3.0 and the Care Area Assessment process that precedes care planning, have created more interest and discussion.</div> <div> </div> <div>Survey agencies in all states are responding to the risk issues related to incontinence, such as skin rashes or breakdown, falls, social isolation, and psychological well-being and social interactions within the structure of the F-tag 315 requirements. </div> <div> </div> <div>Facilities must be sensitive to the issues related to the problem and review the data related to all residents who have CMS-defined incontinence. It is also important to review programs and services utilized with the knowledge that regulatory scrutiny in this area has been steadily increasing.</div> <div> </div> <div>There are solutions for residents and for the team that is providing care. There are two important issues to consider. First, what knowledge do the clinical team and caregivers possess concerning the causes and factors that impact continence? Second, how do caregivers assess, plan, and treat elders with urinary incontinence to promote independence and well-being? The topic is being discussed throughout the care delivery process. </div> <div> </div> <div>The change in the assessment data from the MDS 2.0 to the MDS 3.0 should lead the care team to discuss the definitions, assessment process, and treatment options that need to be coded, as well as the revised definitions of the levels of incontinence that need to be reported on</div> <div>the data set.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Review, Review, Review</strong></h3> <div>Every elder in the facility has assessments, and this issue will be coded according to the definitions in CMS’ “Long-Term Care Facility Resident Assessment Instrument [RAI] User’s Manual, Version 3.0,” Chapter 3, Section H. The entire team should review the definitions in the RAI manual that are required to be used at this time.</div> <div> </div> <div>Afterwards, have the team answer the following questions: What do the data say now? Who is coded at the various levels of urinary incontinence, and how are their plans set up to address the risk factors and improve their independence and well-being?</div> <div> </div> <div>Remember, the MDS is a reflection of a slice of time during a resident’s stay that is substantiated by data and information in the resident medical record. With this in mind, it is imperative that caregivers be certain that the clinical record accurately documents the assessment of continence and the type of incontinence a resident has. </div> <div> </div> <div>Leadership is also important. The clinical team must be led by individuals who understand the clinical and psychosocial issues connected with the problem. Providers are strongly advised to consult a newly published resource on urinary incontinence, titled, “Managing and Treating Urinary Incontinence,” a second edition by Diane Kaschak Newman and Alan J. Wein, 2009. It is a comprehensive clinical review of the problem, as well as a comprehensive discussion of assessment techniques, treatment options, and staff education strategies.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Barriers To Understanding Incontinence</strong></h3> <div>Although many clinical professionals know very little about incontinence, its physiology, treatment options, and the negative impact it has on elders, it is not entirely their fault. Little time is spent on the topic in professional preparation programs, and few exceptional resources have been available to bring the treatment options to the industry in general.</div> <div> </div> <div>However, the problem impacts the greatest majority of all the elders cared for in long term and post-acute care settings. In her book’s preface, Kaschak Newman says, “The lack of knowledge on the part of clinicians about the causes and management options, and their assumption that urinary incontinence and overactive bladder are not true medical issues, hinder the detection and treatment of these insidious conditions.” </div> <p class="ms-rteElement-P ms-rteThemeFontFace-2" style="text-align:left;">Frontline staff feel the pain and discomfort of the resident when they are incontinent, but they frequently do not have the opportunity to discuss the issue and bring their practical ideas or feelings about the situation to the clinical team. This needs to change. And with accurate assessments at the time of the completion of the MDS and increased information about the issues and causes of urinary incontinence, clincial professionals can change it.</p> <p class="ms-rteElement-P ms-rteThemeFontFace-2">Simply put, all caregivers must increase their knowledge at this time. It can begin with the information in the RAI manual about coding Section H of the MDS, Chapter 4 information pages 4-25 and 26 about the Urinary Incontinence and Indwelling Catheter Care Area Assessment, and then in Appendix C of the RAI manual, the Care Area Resource Guide, pages C-25 to 28. </p> <div class="ms-rteThemeFontFace-2">This is the basic structure of the assessment, definitions, basic information about the issue as a care delivery problem, and the related indicators and other issues that could impact the problem. </div> <div class="ms-rteThemeFontFace-2">The clinical staff and the medical staff need additional information related to the issue, and that can come from clinical practice guidelines, resources as quoted above, or from professional associations, such as the American Medical Directors Association and others. </div> <div class="ms-rteThemeFontFace-2"> </div> <div class="ms-rteThemeFontFace-2">Incontinence needs to be addressed on assessment and during planning, along with proper diagnostics, when indicated. Interventions must be individualized and specific so the care delivery staff are consistent with their interventions. </div> <div class="ms-rteThemeFontFace-2"> </div> <div>A thorough discussion of the anatomy and physiology of the lower urinary tract with learning materials must be provided for the lead clinical managers as well as a review of the interventions and programs that can reverse or impact the frequency of incontinent episodes.</div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>New Programs Can Help</strong></h3> <div>Intervention approaches are changing constantly, and many high-impact treatments and programs, are now proven and accessible in many areas. Urology programs throughout the country are researching and developing interventions with success. Mobile urology diagnostics are now available in a few areas of the country and have been met with great enthusiasm and success. </div> <div> </div> <div>Retraining and scheduled toileting programs are being offered with exercise programs, combining nursing and therapy disciplines. Restorative programs that include toileting programs with specific goals and interventions need to be developed along with strong clinical support and therapy input when necessary. </div> <div> </div> <div>All toileting programs need to be reviewed for efficacy and specifics for individualization in the plan, as well as MDS coding since the October 2010 3.0 transition. The coding on the MDS 3.0 has new definitions for urinary continence that include the outcome of toileting programs by counting episodes of continent voiding or episodes of incontinence during the look-back period, as well as the coding of the current toileting programs in item H0200-C.</div> <div> </div> <div>Review what the current MDS 3.0 database contains, and then review from there to check for accuracy. The guidance and definitions in the RAI manual, Chapter 3, Section H, must be discussed by the clinical and care planning team.</div> <div> </div> <div>Pay particular attention to the Planning for Care section on page H-3. This contains the regulatory references and a significant guidance on how to handle many issues. It lists three steps to ensure that the elder receives appropriate treatment to restore as much bladder function as possible </div> <div>(see box). </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>What Regulators Will Look At</strong></h3> <div>Regulators will have this direction as a reference when they review the services and outcomes related to incontinence and toileting programs. </div> <div> </div> <div>Examples of the comments in this section include a reference to programs that decrease incontinence, not necessarily eliminate it; consideration of reversible or treatable causes or issues; referral to practitioners specializing in diagnosis and treatment of bladder function and the programs needed for elders who do not respond to programs to maintain dignity; quality of care; and good skin care.</div> <div> </div> <div>The IDT should use this section of the RAI manual as a guide for discussions, as well as the Care Area Resource guidance on all comprehensive assessments.</div> <div> </div> <div>The clinical team should do a complete evaluation of the types of incontinence products being used by the facility, as well as the sizing options for the elders using products. A wide variety of product types and proper sizing are necessary to meet the needs of elders, and some toileting programs can utilize a mixture of retraining or scheduled programs and some product use as well. </div> <div> </div> <div>The RAI manual also has the Steps for Assessment of the Current Toileting Program or Trial, item H0200C in Chapter 3, page H-5. This manual instruction lists three requirements that need to be documented in the record for the toileting program to be included in the coding for this item. Care plan teams and clinical managers need to be certain that all the requirements are met before they identify the toileting program in the plan or on the MDS 3.0 in this section.</div> <div> </div> <div>On page H-6 of the RAI manual there is a list of programs that are not to be included in the coding for this section. This is important information for the MDS nurse and the clinical leadership on the unit. </div> <div> </div> <div>The definition of continence and urinary incontinence are in the RAI manual on page H-7, as well as specific guidance to plan and implement appropriate programs for all elders with urinary incontinence whether they respond to a toileting program or not.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Put The Guidance To Use</strong></h3> <div>The IDT and the clinical leadership of the facility must look at all the issues related to urinary incontinence and appreciate that the information from CMS in F-tag 315 and the updated MDS 3.0 manual for section H of the data set have a lot of specific guidance, definitions, and criteria that need to be used in the frontline documentation and the formulation of the toileting program.</div> <div> </div> <p class="ms-rteElement-P">Facilities need to evaluate the quality of the data in the 3.0 database now and see that the proper definitions have been used to identify the elder’s level of urinary incontinence and the programs that are being implemented. CMS has given a lot of guidance about the issue and the qualifications for a toileting program to be listed. This needs to be addressed in the records and nursing documentation.</p> <p class="ms-rteElement-P">This is a complicated issue and must be addressed by the IDT and the clinical team with specific focus on policy, CMS guidance through the F-tag 315, and the information in the RAI manual for coding section H of the MDS 3.0 data set. Clinical professionals need to have excellent current references related to urinary incontinence and be able to access diagnostics, as well as current treatment for the elders.</p> <p class="ms-rteElement-P"> </p> <h3 class="ms-rteElement-H3"><strong>Check Out New Protocols</strong></h3> <p class="ms-rteElement-P">Many new interventions are available now that were not tested or proven five years ago, so clinical leaders and medical directors need to identify availability in their area and begin to use high-quality consults and diagnostics that would identify the cause of the incontinence, as well as the proper interventions.</p> <div>The care plan should be individualized for the toileting programs, and outcome tracking is essential. If the elder does not respond to the toileting program or the cause is irreversible, then an individualized program of incontinence product sizing and product use should be implemented.</div> <div>The entire team, including the elder, need to assess, investigate options, properly document, and plan care that is focused on improving the continence status of the elder through programs and clinical interventions. The goal should be to interfere with as much incontinence as possible or manage the care so other risks stay low and the quality of life for the elder is as positive as possible. </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 th frail elderly. She can be reached at </em><a href="mailto:LeahKlusch@sbcglobal.net"><em>LeahKlusch@sbcglobal.net</em></a><em>. </em></div>Reducing risk and improving quality of care can be done simultaneously as providers face renewed scrutiny. 2011-06-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/elderly_woman_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality Improvement;ManagementColumn6
Rep. Gardner Seeks Solutionshttps://www.providermagazine.com/Issues/2011/Pages/0611/June-2011-Congressional-Profile.aspxRep. Gardner Seeks Solutions<div> </div> <div>Freshman Rep. Cory Gardner (R-Colo.) has a long way to go before he reaches the long term care-age range, being only 36, but he is attuned to the nursing care issue both as a lawmaker and a member of a family with vibrant elderly members.</div> <div> <img width="165" height="460" class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0611/Gardner.jpg" alt="" style="margin:10px;width:121px;height:175px;" /><br>Gardner says he has three grandparents over the age of 90, who while receiving some care still reside in their homes. “Yes, they are still out and about,” he says.</div> <div> </div> <div>More generally, Gardner says he knows the importance of caring for the elderly through his work in his district, Colorado’s 4th, which includes Fort Collins in a vast swath of land both east and north of Denver. </div> <div><div>“My constituents are really concerned about creating a health care system that is sustainable, allows for consumer choice, and increases quality," Gardner says. Long term care is a large part of that equation, and the focus should be on finding solutions to the problems patients and residents are experiencing, he says.</div></div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Focus On Telemedicine</strong></h3> <div>While a state legislator in Colorado, he worked on special programs to bring high-tech telemedicine to rural communities, like the ones that exist in his district. Telemedicine refers to the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.</div> <div> </div> <div>Videoconferencing; transmission of still images; e-health, including patient portals; remote monitoring of vital signs; continuing medical education; and nursing call centers are all considered part of telemedicine and the broader term, telehealth.</div> <div> </div> <div>The Colorado program had the goal of demonstrating that an integrated delivery system can extend its services into rural areas via telemedicine and deliver the same quality of care as if the care was provided face-to-face. “The pilot program did a great deal to help,” he says.</div> <div> </div> <div>Future legislation may be coming at the federal level to improve rural health across the country, Gardner adds.</div> <div> </div> <div>Gardner was elected to office partly on a platform of “repeal and replace” the Democratic-passed health care reform law, which he says will see its true test come the next election. </div> <div> </div> <div>Earlier this year he sponsored a budget amendment to defund part of the health care reform law. The amendment would prohibit paying the salaries of employees who help set up health insurance exchanges to be created by the reform law.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Health Reform Changes To Come</strong></h3> <div>“I think the biggest changes to the health care law will come in 2012, with possible changes in the Senate and White House [from Democratic to Republican control],” Gardner says. </div> <div> </div> <div>This seems all the more true now that the Republican leaders in the House and Senate have written off much chance of moving on health reform repeal for the forseeable future. </div> <div> </div> <div>On the powerful House Energy and Commerce Committee, Gardner is working to open more energy corridors in the United States and sees opportunities for the Obama administration to do more for easing sky-high energy prices.</div> <div> </div> <div>“There are permits [for more domestic drilling] that are being held up by bureaucracy,” he says. With additional reserves from domestic sources, a slice of the imports needed from Saudi Arabia and other nations could be curtailed, Gardner says. “My focus is on how we can build a stronger economy with the resources we have.”</div> <div> </div> <div>Before running and winning his current office, Gardner grew up working in his family’s farm implement dealership. After earning a law degree, he served as general counsel and legislative director for former U.S. Sen. Wayne Allard and worked for the National Corn Growers Association.</div> <div> </div> <div>He currently resides with his wife and young daughter in Yuma, Colo., in a house that once belonged to his great-grandparents.​</div> Colorado Rep. Seeks Solutions To Health Care Issues2011-06-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0611/Gardner_thumb.jpg" style="BORDER:0px solid;" />PolicyColumn6
Reminiscence Therapy Benefits Residentshttps://www.providermagazine.com/Issues/2011/Pages/0611/Reminiscence Therapy Benefits LTC Residents.aspxReminiscence Therapy Benefits Residents<div>​Remembering the past can bring a great deal of satisfaction and understanding for anyone. For the elderly, it is a way to affirm who they are, what they’ve accomplished in their lives, and a chance to relive happy times. For those who suffer with dementia, it is a way to talk easily about things they do remember. </div> <div> </div> <div>It is also a way for residents of assisted living facilities to become better acquainted with one another, which is helpful for caregivers as well as family. </div> <div> </div> <div>Reminiscing has taken place since the beginning of time through the storytelling of family histories across all nations. Modern gerontologists have studied the benefits of reminiscing with dementia patients because long-term memory is the last to go. By talking about their childhood and early adulthood, older adults who suffer with dementia are more confident about socializing and using their verbal skills. </div> <div> </div> <div>Reminiscence therapy (RT) is the process of recalling personal experiences from an individual’s past. The theory behind RT is that an individual’s function is improved by decreasing demands on impaired cognitive abilities and capitalizing on preserved ones. </div> <h3 class="ms-rteElement-H3"><strong>Props From The Past</strong></h3> <div>RT has been shown to be helpful in reducing reclusive tendencies that cause depression and anxiety. Additional benefits can include helping individuals come to terms with growing older, encouraging older people to regain interest in past hobbies and pastimes, increasing self worth and a sense of achievement, and reducing apathy and confusion, especially in people who are confused or disoriented.</div> <div> </div> <div>Therapy sessions may consist of individual or group settings or take place during everyday interactions and activities of daily living. Group sessions may meet weekly or bi-weekly in community-based settings or at residential settings like assisted living or nursing facilities. The sessions give clients an opportunity to bond, while becoming more familiar with each other. </div> <div> </div> <div>Preparation begins with the selection of several topics to discuss, which gives the moderator options if the conversation begins to dwindle on one of the topics. Some topics may require a little online research beforehand. For example, the topics of “wash days of long ago, trains, and art in your childhood home” were easy to use after discovering two stories online that were then recited in class. </div> <div> </div> <div>A physical prompt or prop is useful in recounting the story. An old clothes iron, a toy vintage tractor, and telephone line insulators are some examples. They are fun for participants to pass around as icebreakers. </div> <div>The moderator should ask questions related to each topic, but try to remain flexible and let the conversation take its own path.</div> <div> </div> <div>Relevant books that might interest the group can also be helpful to stories. For instance, “To Kill a Mockingbird” was used one week, while another time, the story of how “Gone With the Wind” was made became a good focal point for discussion. In addition, the latter had large photos that were easily shared with the group.</div> <div> </div> <div>RT sessions began at The Meadows, an assisted living facility in Elk Grove, Calif., in the spring of 2010. The venue for this group is a medium-sized room equipped with a long table and chairs. A circle of chairs would better accommodate the class, but it is nice to have the table to pass things around on. </div> <div> </div> <div>An older gentleman surprised the group recently by bringing in his mother’s “Guide for a New Bride” book. It was nearly 100 years old. It was a gift from the county of San Diego where his mother had been married. </div> <h3 class="ms-rteElement-H3"><strong>Make Eye Contact</strong></h3> <div>Making eye contact with each person in the group is essential. It is also important to ensure that everyone has a chance to share an experience related to one of the topics. </div> <div> </div> <p class="ms-rteElement-P">While there are three topics prepared for each class, the facilitator needn’t feel compelled to talk about all three unless it seems expedient. The website Good Old Days Stories (www.goodolddaysstories.com) contains a database of stories that help spark memories and discussion. Several stories from this site were retold to the Elk Grove elders to prompt recollections of wash days, trains, and art. </p> <div>The wash day story described how Mondays were usually wash days in one particular household, where water was heated in a big oval-shaped galvanized or copper wash boiler on top of a wood cookstove. </div> <div>“If our cistern had enough soft [rain] water, we’d heat that water. Then we’d dip the boiling water into the washing machine—a big round tub-like machine,” the story says. “We had a Briggs & Stratton gas motor to run the leather belt to make the dolly turn to rub the soil out of the clothes. The dolly was a paddle affair.</div> <div>“Nowadays, we can do laundry in cold water and not worry so much about colors mixing. It was a catastrophe if a red article that faded was washed with white underwear. Many a guy wore pink underwear!”</div> <div> </div> <div>The narrator of this story notes that he used an old broomstick handle to pull the hot clothes from the washer into the wringer. “A wringer had two hard rubber rollers that we put the clothes between to let most of the sudsy hot water run back into the washer.”</div> <div> </div> <div>The story was followed by questions to get the group talking, such as: How many of you used a rub board? Where did your water come from—the well outside, the creek, or indoor plumbing? How did you dry your clothes when you were young? How many sets of clothes did you own? How long did it take your mother to wash clothes? </div> <div> </div> <div>Residents recalled heating the water in a big kettle while their mothers worked the scrub board. Many of them agreed that the smell of their sheets that had dried in the sun is still a fond memory. </div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Sharing A Laugh </strong></h3> <div>During another session a toy tractor was brought in to stimulate conversation. One resident talked about her father teaching her to drive the tractor. The fields were laid out with fruit drying in the sun, and she worked all day with her father. She drove the tractor while he piled the wagon up with dried fruit. She smiled as she told the story and said with a bit of pride, “I was just eight years old!”</div> <div> </div> <div>Life accomplishments were another topic. All the women who were mothers said their children were their greatest accomplishment. One woman added, “After my children were raised, I went back to college and earned my degree in accounting. I was over 40 years old, but I did it. I was able to gain employment and was promoted into management many years before I retired.” </div> <div> </div> <div>Such recollections are beneficial for building and maintaining self-esteem.</div> <div> </div> <div>Participants have become better acquainted with their fellow residents, giving them a sense of camaraderie and community. Laughter is always a by-product of the sessions, which usually include an old-time sing-along and recitation of childhood rhymes. </div> <div> </div> <div><em>Karen Everett Watson, a reminensce facilitator, freelance journalist, and certified gerontologist, designs her therme-based sessions to engage seniors in the beneficial activitiy of remembering. Her website is </em><a href="http://www.legacywriter.me/"><em>www.legacywriter.me/</em></a><em>. </em></div>Facilitators can use resident memories to spur social interaction and aid in the treatment of dementia-related disease.2011-06-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/caregiver_rollup.jpg" style="BORDER:0px solid;" />Caregiving;QualityColumn6
The QIS Experthttps://www.providermagazine.com/Issues/2011/Pages/0611/The-QIS-Expert.aspxThe QIS Expert<p>​<strong>Q.  Does QIS address readmissions to hospitals?</strong></p> <p><strong>A.</strong>  In 2012 the provisions in the Patient Protection and Affordable Care Act for hospitals, where there is already public reporting of readmissions, will have financial risk for readmissions related to selected conditions. In addition, payment incentives in the Centers for Medicare & Medicaid Services (CMS) Nursing Home Value-Based Purchasing demo will be tied to hospitalization. </p> <p>Fortunately, QIS does address hospitalization of nursing facility admissions. The admission sample chart review that is conducted on a sample of 30 admissions to the nursing facility generates a properly calculated readmission rate for one of the Stage 1 Quality of Care and Quality of Life Indicators—QP058 Hospitalization Within 30 Days. The numerator is the number of residents in the randomly selected admission sample that are readmitted in 30 days, and the denominator is the total number of residents in that sample. </p> <p>If the threshold of 15 percent is exceeded, then a Stage 2 investigation is triggered for the care area of Hospitalization. This triggers review of the Stage 2 Critical Elements for Hospitalization or Death, which is used to assess compliance with the following CMS F-tags: F272: Comprehensive Assessment; F274: Resident Assessment When Required; F279: Comprehensive Care Plan; F282: Care Plan Implementation by Qualified Persons; F309: Provision of Care and Services; F157: Notification of Changes; F241: Dignity; F271: Admission Orders; F278: Accuracy of Assessments; F281: Professional Standards of Quality; F242: Self-Determination and Participation; F353: Nursing Services; F385: Physician Supervision; F501: Medical Director; and F514: Clinical Records.</p> <p>Thus, the Stage 2 Critical Element Pathway covers a broad range of issues that are relevant to hospitalizations that surveyors will be investigating.</p> <p>It is important to conduct Stage 1 assessments on a large enough admission sample to obtain information on hospital readmission that is useful. </p> <p>Given that, on average, about 17 percent of admissions are readmitted to a hospital, the average will be about 5 readmissions with a sample of 30. This is not an adequate number of readmissions to thoroughly assess care related to preventing readmissions. Hence, a skilled unit with large numbers of admissions should conduct the Stage 1 admission assessment on all admissions. </p> <p><br>To conduct the calculations correctly, managers should track the readmission rate and analyze issues like the units from where readmissions occur and how soon after admission the readmissions occur. Using the readmission rate and data in conjunction with a broader-based review of quality of care can help shed light on ways to reduce readmissions.</p>In 2012 the provisions in the Patient Protection and Affordable Care Act for hospitals, where there is already public reporting of readmissions, will have financial risk for readmissions related to selected conditions. In addition, payment incentives in the Centers for Medicare & Medicaid Services (CMS) Nursing Home Value-Based Purchasing demo will be tied to hospitalization. 2011-06-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/AKramer_rollup.jpg" style="BORDER:0px solid;" />Management;Survey and CertificationColumn6




ACOs: Will SNF Providers Be Welcomed?https://www.providermagazine.com/Issues/2011/Pages/0711/Integrating-Health-Care-Wave-Of-The-Future.aspxACOs: Will SNF Providers Be Welcomed?<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p class="ms-rteElement-P">With so much talk in health care circles focused on accountable care organizations (ACOs), what may be getting lost in the mix is the fact there is a larger trend at play moving the health care system, long term care included, toward integrated quality care and payment systems for Medicare beneficiaries, experts in the field say. </p> <p class="ms-rteElement-P">This trend to seek out new methods for curbing costs, improving quality, and coordinating or integrating care is progressing under the new health care reform law, marking a turning point for providers looking to a future much different than the present.</p> <p class="ms-rteElement-P">While post-acute care is not clearly part of the Centers for Medicare & Medicaid Services’ (CMS’) initial vision expressed in its proposed rule, every expectation is for the ACO model or something similar to it to be the way business is done in the future, says a leading provider.</p> <p class="ms-rteElement-P">“We must assume changes will be made, regardless of how ACOs evolve. The trend is toward integrated care and integrated payment. The practical reality is that Kindred will be involved with ACOs, and many and most parts of the country will see integrated care,” says Bill Altman, senior vice president of strategy and public policy for Kindred Healthcare, Louisville, Ky.</p> <h3 class="ms-rteElement-H3"><div><strong>ACOs A Hot Topic</strong></div></h3> <p class="ms-rteElement-P">The release this spring of a draft rule on ACOs (Medicare Shared Savings Program: Accountable Care Organizations) by CMS put the spotlight on the government’s design for the ACO model, fueling an already active boomlet of webinars, conferences, and white papers on the subject. Any major change to the way Medicare operates is, of course, a potential game changer, considering the 46 million or so beneficiaries in the system and the millions more to come in the future.</p> <div>The definition of what ACOs are may vary. At its core, however, they are provider collaborations that support the integration of groups of physicians, hospitals, and other providers in different ways around the opportunity to receive additional payments by achieving continually advancing patient-focused quality targets and demonstrating real reductions in overall spending growth for their defined patient population.</div> <div> </div> <div>ACOs are a form of managed care run by medical groups, not health insurance companies. The basic premise of the CMS draft and the subsequent final rule will be to allocate monetary rewards to provider teams that must be able to prove they can deliver high-quality care at lower costs. </div> <div> </div> <div>The deadline for making ACOs part of the Medicare system is the beginning of 2012, but for now, for long term care providers, the important thing is to see not only how their operations may fit into the ACO model, but also how other integrated health care options may be beneficial moving forward, say leading experts.</div> <div> </div> <div>“One of the important things to understand is there are trends in the market that are accelerating even in advance of ACOs on integrated care and payment,” Altman says. “Hospitals and health systems are already looking to beef up capacity to cover the entire care continuum.”</div> <div> </div> <div>“Assume that this trend toward integrated care and integrated payment is going to happen one way or another,” he adds.</div> <div> </div> <div>For Nancy Rehkamp, principal at accounting and consulting firm LarsonAllen, Minneapolis, it is all about setting new expectations. “Think of health care reform as developing a new athletic department where everything is started over with new rules and new expected outcomes. ACOs are one strategy, and if it fails, there will be another to achieve the goals of better care, better health, and lower total costs,” she says.</div> <div> </div> <div>Click <strong><a href="/Issues/2011/Pages/0711/Initial-Reaction-Raises-Criticism.aspx">HERE</a></strong> for more about criticisms of the ACO proposed rule.</div> <h3 class="ms-rteElement-H3"><strong>CMS Sets Eligibility Threshold</strong></h3> <div>Under the CMS proposal, an ACO is a legal entity recognized and authorized under applicable state law, identified by a Taxpayer Identification Number, and made of eligible ACO participants. These eligible groups are ACO professionals in group practice arrangements, networks of individual practices of ACO professionals, partnerships or joint venture arrangements between hospitals and ACO professionals, and hospitals with ACO professionals. </div> <div> </div> <div>ACO professionals include internists, family practice physicians, general practice physicians, and geriatric medicine physicians. CMS says that ACOs must also have the primary care capacity to care for at least 5,000 beneficiaries and structures in place to distribute shared savings, plus be prepared to enter into an agreement with the secretary of Health and Human Services for a three-year term. </div> <div> </div> <div>However, ACOs can resign from the program with a 60-day notification to CMS. Those terminating before the enrollment term is up forfeit “withholds.” CMS will withhold 25 percent of any shared-savings payment owed to the ACO to recover potential future losses. CMS will pay anything remaining from the withhold amount at the end of the three-year agreement term. </div> <div> </div> <div>As part of the application process, ACOs must demonstrate they have a beneficiary satisfaction survey in place, patient participation on the governing board, a process for evaluating the health needs of their patient population, systems in place to identify high-risk individuals, processes for individualized care plans, coordination of care mechanisms (including care coordinators on staff), and an electronic infrastructure sufficient to support such activities, according to the CMS draft.</div> <div> </div> <div>The proposed rule also offers two ways for an ACO to participate in shared-savings initiatives. Track 1, also called the “one-sided model,” starts as a no-risk shared-savings payment system by giving ACOs a chance to get up to speed before they share financial risk. Eventually, it converts to a risk-sharing payment system in the third year. CMS will make good on shared-savings payments annually for each of the first two years an ACO participates in Track 1.</div> <div> </div> <div>Track 2, or the “two-sided-model,” is a risk-sharing arrangement that forces an ACO to share its losses with the Medicare program from the first year of joining.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>Change May Come In Many Forms</strong></h3> <div>In a slide presentation she gave recently for a webinar put on by the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), Rehkamp said preparing for change in care and payment systems, be it ACOs or otherwise, was vital.</div> <div> </div> <div>The key strategies for long term care providers include understanding existing patient care delivery patterns, developing robust predictive measurement systems for quality and costs, developing capabilities for electronic health exchange, and implementing best practices and strategies by </div> <div>diagnoses.</div> <div> </div> <div>Providers should also determine processes for patient-centered care and patient-engagement approaches and build relationships. “Decide which way to go, but right now providers need to start building relationships with doctors and hospitals because they won’t even be invited to the table otherwise,” says Rehkamp.</div> <div> </div> <div>Most long term care providers have existing relationships and contacts with discharge planners and nursing staff at acute care facilities, but many may want to consider additional contacts at the chief executive officer level to cement business ties. “Patients [under ACOs] are still choosing wherever they want to go. You have to make sure you think of this as provider competition,” Rehkamp says.</div> <h3 class="ms-rteElement-H3"><strong>Performance Measures Altered</strong></h3> <div>Tracking performance under the reform law from which ACOs came into being is going to be much different than today’s methods, and providers need to understand the new terminology and goals to be successful.</div> <div> </div> <div>Today’s performance follows results of minimum data set (MDS) quality indicators, Nursing Home Compare, Home Health Compare, Certification & Survey Provider Enhanced Reporting (CASPER) reports, resident satisfaction surveys, staffing ratios, employee turnover, nursing facility survey, and fee-for-service, she says.</div> <div> </div> <div>Under ACOs, the world is changed. Performances will be judged by reduced hospital readmissions; reduced ambulatory-admissions; better resident/patient outcomes; chronic disease management; ability to manage, reduce, and know costs; elimination of health care-acquired conditions; reduced or eliminated medication errors; improved care transitions; and implementation of patient-centered care.  </div> <div> </div> <div>Financially savvy providers in the post-acute care space will have to develop capabilities and competencies to meet the ACO design, or some similar model. Some of these include being able to serve a wide a range of payers with multiple payment structures, integrate across sites of services, and coordinate care and health planning. Other competencies offer new services or lines of business, boost technology, and increase focus on patient-centered and patient-engaged care.</div> <div> </div> <div>ACOs or not, Rehkamp sees ACO-like changes in reimbursement and care delivery resulting in a decline in the total cost of care per beneficiary by price and volume reductions. This will result in intense competition among providers and between sites of service, Rehkamp says. Providers must articulate the value of skilled nursing facilities (SNFs) in a redesigned care model by showing progress in measuring costs, assessing quality under the new paradigm, and forging partnerships and collaborations with other providers in the care continuum, she says.</div> <div> </div> <div>Rehkamp notes that while ACOs are being debated and rolled out, there are numerous other pilot programs being readied or tested. These include the bundled payment pilot, which CMS is in the process of reviewing now and pulling together for release.</div> <h3 class="ms-rteElement-H3"><strong>Kindred Acting Now</strong></h3> <div>While ACO rules are finessed, Kindred is very interested in partnering with hospitals and managed care payers under new arrangements that may or may not lead to taking part in ACOs, Altman says. Kindred offers a full-service network of long term care and services and sees any number of these options as viable parts of an ACO or ACO-like care continuum. These range from long term acute care, sub-acute, SNFs, freestanding SNFs focused on rehabilitation, all the way to home care.</div> <div> </div> <div>“Kindred’s strategy is to continue the ACO’s residents’ or patients’ care in a seamless way,” Altman says. “Done correctly, quality care can produce savings for Medicare and private payers.” He notes the goal to increase quality and get patients home sooner should result from the reform law’s increased attention to integrated care, sharing of medical records, and improved tracking of which care setting is best for the individual patient as they move from one facility to the next or to their home. </div> <div> </div> <div>Altman’s initial reaction to the ACO draft rule, like many others, is that it may be difficult to achieve operationally without major changes and modifications, he says.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>“The infrastructure does not exist in all parts of the country for entities to take part in ACOs,” he says. Kindred is currently involved in a variety of arrangements, with integrated care as the goal, some with managed care payers using an episodic payment model to figure out the most appropriate setting of care.</div> <div>An example is in Las Vegas with a managed care company and a program for eight levels of care and eight levels of payment, “from high-end acute care hospitals to sub-acute to skilled nursing,” Altman says.</div> <div> </div> <div>A patient may be in need of rehabilitation at a nursing facility and thus be categorized for a short stay arrangement at a post-acute care setting, instead of being kept in the acute-care hospital where costs are higher. </div> <div> </div> <div>Kindred also has a close working relationship with the Cleveland Clinic, focused on different levels of post-acute care. Coordination is achieved by linked electronic health records, which helps to reduce re-hospitalizations. It is the goal of cutting down on costs that has brought so much focus on re-hospitalization in the reform law, providing an opportunity to coordinate care for long term care providers, according to Altman.</div> <p class="ms-rteElement-P">“Kindred is forging ahead with or without ACOs. This is how the health care system will work in the future. What we are doing today [in care integration] is preparation in the ACO framework,” he says. </p> <div>The Accountable Care Act (ACA) and proposed ACO rule define the criteria for eligible ACOs, the required organizational structures, quality and other reporting requirements, fee-for-service and benchmarking, the option of payment models other than fee-for-service, and treatment of savings. </div> <div> </div> <div>AHCA/NCAL said it is important to note that CMS is proposing an option for provider ACO eligibility that would allow for a wide variety of ACO configurations that allow for a correspondingly wide number of providers and suppliers, including post-acute care facilities.</div> <div> </div> <div>“We’re looking at how CMS [ultimately] designs it, so it doesn’t inadvertently affect out residents one way or another,” says David Gifford, MD, AHCA senior vice president, quality and regulatory affairs.</div> <h3 class="ms-rteElement-H3"><strong>New Quality Measures Planned</strong></h3> <div>The proposed ACO rule does not include any of the SNF short-stay (Medicare-based) quality measures, but CMS plans to expand the quality measures after its first year (in 2013) through additional rulemaking, to include highly prevalent conditions and frailty. So, for the first year of the ACO program starting in six months, there are no SNF-specific measures.</div> <div> </div> <div>“CMS plans to add measures for hospital-based care and for other settings such as home health services and nursing homes,” AHCA/NCAL said in an issue brief.</div> <div> </div> <div>Out of the proposed 65 quality measures in the ACO draft, 47 are related to group practice, seven are based on surveys, and 11 come from claims data. In the proposed rule, CMS is looking for comments on the implications of including or excluding any of the 65 proposed measures. CMS is also asking for suggestions on a process for retiring or adjusting the formulas for each measure.</div> <div> </div> <div>The advocacy group says it will offer comments to CMS related to the group’s concern about the use of only condition-specific measures like dehydration, congestive heart failure, bacterial pneumonia, chronic obstructive pulmonary disease, uncontrolled diabetes, and urinary infections for the patient population 65 and older.</div> <div> </div> <div>“The over 65-year-old population is at highest risk of having multiple chronic conditions, and measures for this population need to be included in the ACO program when it is first implemented in anticipation that the program will encompass other health care settings in the future,” AHCA/NCAL told CMS.</div> <div> </div> <div>Participation in ACOs is voluntary for both providers and patients. Unlike managed care, patients who receive care from ACO providers do not enroll in the network and can go outside of the network for care. Participating providers continue to be paid individually, on a fee-for-service basis.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>A Long Term Care Take On ACOs</strong></h3> <div>AHCA’s Gifford says the percentage of savings ACO participants receive from CMS will be determined by how well they perform on each measure. “Physician groups want to score as well as possible on quality measures,” he says.</div> <div> </div> <div>In the areas of hospitalizations and re-hospitalizations, there is clearly an area for nursing facilities to work with primary care physicians in ACOs as well as for measure related to diagnoses like heart disease and diabetes. In addition to quality measures, SNFs could help ACOs achieve cost savings, says Gifford. “All of this movement to ACOs is predicated on creating financial incentives to share in cost savings.” </div> <div> </div> <div>There are important characteristics of what ACOs would demand from any long term care provider interested in becoming active in one, he says. The CMS rule emphasizes electronic health records, making it possible for participants to share electronic data from laboratories, MDS data, and other aspects of care delivery. </div> <div> </div> <div>It is unlikely that nursing facilities will need to identify which patients in are in or not in an ACO, he notes.  “However, administrators should be asking all of the physicians providing care in their facility if they or their group plan to take part in an ACO,” Gifford says.</div> <h3 class="ms-rteElement-H3"><strong>Providers Take Note</strong></h3> <div>Gifford thinks long term care providers should be interested in ACO developments, if for no other reason than it represents a sea change in thinking at CMS.</div> <div> </div> <div>“This is the first really big statement from CMS on the changes that are going to happen from health care reform. ACOs may or may not make it, but if it’s not an ACO, then it will be something else such as bundled payments,” Gifford says, echoing a sentiment heard throughout the provider community.</div> <div> </div> <div>He lists three areas to keep in mind moving forward. There will be substantial payment changes coming, with real accountability for performance, and quality care as the model.</div> <div> </div> <div>Providers should be thinking of quality metrics and how to improve their scores on Nursing Home Compare and Home Health Compare, he says. They should also examine closely and in a sophisticated way what the costs are for each service being provided in their facilities, and compare them against the costs of neighboring facilities.</div> <div> </div> <div>“ACO is really just an organized structure for measuring performance, payment, and quality,” Gifford says. How post-acute care providers collaborate within the structure depends on how much they want to participate in innovative payment models.</div>ACOs take center stage in new world of integrated payment, care.2011-07-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/caregiver_rollup.jpg" style="BORDER:0px solid;" />Policy;Quality ImprovementColumn7
On The Road: Rural Long Term Care Facilities Underpin Economieshttps://www.providermagazine.com/Issues/2011/Pages/0711/On-The-Road-Rural-Long-Term-Care-Facilities-Underpin-Economies.aspxOn The Road: Rural Long Term Care Facilities Underpin Economies<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>​Provider <em>heads for rural stretches of three Mid-Atlantic states this month: Virginia, Pennsylvania, and Maryland.</em></div> <div> </div> <div>There are times when driving along the bi-ways and back roads of Virginia you can get lost from the modern world, surrounded by more trees and rivers than people and subdivisions. For long stretches, there are no fast-food restaurants or even advertising signs, not even a gas station pops up in some of the small communities west of Richmond and toward the south and border of North Carolina.</div> <div> <img class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/0711/POTR0711.png" alt="" style="margin:5px;" /></div> <div>Of course, there is no hiding from the present. The McDonald’s and Exxons of today’s America are actually very nearby even in rural Virginia, but to a stranger, commercial outlets seem few and far between compared with the metro areas of the populous northern parts of the commonwealth. </div> <div> </div> <div>The countryside of Virginia, Maryland, and Pennsylvania is where we went looking for long term care providers and ancillary businesses this month. Below, we hear from the providers themselves about how at a time of much debate on Medicaid reimbursement cuts, they face rising costs for gasoline and food caused by the long distances that have to be traversed for obtaining supplies and transporting residents.</div> <div> </div> <div>Rural areas in these three states have any number of long term care facilities, but they are few in number when compared with the wide geographic areas they serve. At the same time they provide care, the facilities employ up to hundreds of people at each site, giving local economies a job growth engine to accompany agriculture and other industries, especially in towns and counties where manufacturing plants have closed in recent years.</div> <div> </div> <h3 class="ms-rteElement-H3"><strong>Vital To Rural America’s Economy</strong></h3> <div>As important as nursing facilities are to more populated regions, they are even more vital lifelines in the <br><br>sparsely inhabited counties of the Mid-Atlantic, says Tracey Daniels, administrator at Envoy at the Meadows in Goochland, Va.</div> <div> </div> <div>“We’re the only nursing home in a big geographic area,” she says.</div> <div> </div> <div>Goochland County is in the Richmond-Petersburg region of Virginia, with a population of around 22,000. The county has a rich history dating back even before the United States came to be, forming in 1728. Goochland was the first county created after the original eight shires were carved out in the Virginia colony and named for a lieutenant governor, William Gooch.</div> <div> </div> <div>Recent economic data provided by the county government and Daniels shows her nursing facility as a top 10 employer, with just under 100 employees, slightly below the Food Lion and slightly above some local golf clubs. This in turn translates into vital tax revenue for the county and state from Envoy, totaling more than $21,000 combined in 2010 alone, Daniels says, citing data from her corporate parent Consulate Health Care.</div> <div> </div> <div>These numbers show the direct impact of Envoy’s operations in terms of the Goochland economy, but what they don’t show is the indirect benefits. Daniels notes that her facility tries to buy local goods as much as possible, while at the same time controlling costs for her heavily Medicaid population.</div> <div> <img width="227" height="348" class="ms-rteImage-2 ms-rtePosition-1" alt="Envoy at the Meadows in Goochland, Va." src="/Issues/2011/PublishingImages/0711/Envoy-(46).jpg" style="margin:5px;height:151px;" /><br>Being a rural locale, gas and food prices are the biggest budget eaters, making it imperative that other operations are as cost-conscious as possible. There is also the matter of utilities, which have increased exponentially. Daniels says her electric and gas bill for March 2010 was $6,600, which is cheap compared with the March 2011 tally of $12,100.</div> <div> </div> <div>Threats to state Medicaid reimbursement, especially with the recent expiration of the federal medical assistance percentage (FMAP) adjustment from the federal stimulus law, will and do hit hard, she says. This leaves Envoy to focus its attention on the necessities and not worry right now about the fact it has a well-worn 12-year-old van or other aging infrastructure, Daniels says.</div> <div> </div> <div>“Gas and food prices have really gone up. We’re in a rural area, of course, and even a local drive is 20 miles, and that’s a lot of fuel costs.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>Blackstone Facility Largest Employer</strong></h3> <div>Blackstone is a city of under 4,000 in Nottoway County, Va., about an hour’s drive directly south of Goochland on the way to the border regions of North Carolina and Virginia. The town has an active commercial strip made of restaurants, many of them fast food, and storefronts. </div> <div> </div> <div><img width="515" height="419" class="ms-rteImage-2 ms-rtePosition-2" alt="Residents and staff at the Heritage Hall Nursing Facility in Blackstone, Va., make ice cream sundaes." src="/Issues/2011/PublishingImages/0711/making-sundaes.JPG" style="margin:5px;width:302px;height:201px;" />Driving down the main drag, one eventually comes to the Heritage Hall nursing facility, a thriving center of care for the elderly and frail and the top employer in town. American HealthCare is the management company for the 16 Heritage Hall Healthcare and Rehabilitation centers across Virginia, including Blackstone. </div> <div> </div> <div>Betty Pomfrey, administrator at Heritage Hall-Blackstone, knows her facility and its 180-bed skilled nursing facility is important economically to her town, because the numbers say so. “We also use more lights and water than anybody in town, and we paid $27,000 in taxes,” she says. </div> <div> </div> <div>Over the past decade, the furniture and textile factories have shut their doors, leaving the nursing facility as the place to go for work for many locals. Pomfrey says Heritage Hall works hard in the community, like organizing a certified nurse assistant recruitment and training program in the local high school and fund raisers with the chamber of commerce, along with other charity events and sponsorships.</div> <div> </div> <div>Pomfrey says it is difficult for many lawmakers to visualize the work being done in nursing facilities unless they have personal experience to draw upon. “It is really hard for the people that make laws [determining reimbursement levels] to understand what the cuts will do if they never had a relative in a nursing home or visited someone in a nursing facility,” she says.</div> <div> </div> <div>So, part of her time she works to raise awareness with state elected officials on the need to protect and improve reimbursement under the Medicaid program, as well as related issues important to the skilled nursing and assisted living community she has worked in for decades.</div> <h3 class="ms-rteElement-H3"><strong>Funding Battle Looms Ever Larger</strong></h3> <div>Steve Morrisette, president of the Virginia Health Care Association, says this battle over funding in the state capital is a regular event, and one based on making sure state lawmakers understand the “big” numbers they see in the budget are well spent. Long term care providers of every size and shape, no matter if located in rural or urbanized settings, are impacted by the resulting decisions, he says.  </div> <div> <img width="365" height="353" class="ms-rteImage-2 ms-rtePosition-2" alt="Heritage Hall-Blackstone, Va. resident" src="/Issues/2011/PublishingImages/0711/hack1.JPG" style="margin:10px;width:290px;height:193px;" /><br>“Quite frankly, every year we have to ask for increased Medicaid reimbursement,” Morrisette says. “I think that because this is such a big number in every state budget, [lawmakers] think there must be fat. The truth is of course we don’t make money on Medicaid.”</div> <div> </div> <div>Finished for the year, Virginia legislators decided to cut by 1 percent the current Medicaid per diem rate for long term care starting July 1 for fiscal year 2011-2012, Morrisette says. In comparison to other states the number does not look too bad, but cuts are still cuts, he says. </div> <div> </div> <div>Virginia nursing care has a somewhat unique difference in that its activities of daily living acuity ratings by the Centers for Medicare & Medicaid Services scale to the highest acuity range. “People in Virginia SNFs [skilled nursing facilities] are as sick or actually ill as any in the country,” Morrisette says, noting the reason is the very strict eligibility criteria for Virginia Medicaid.</div> <div> </div> <div>This fact makes him bemused when he hears talk of the SNF to home- and community-based services policy trend, given what he sees in Virginia.</div> <div> </div> <div>“For patients in Virginia SNFs, it’s hard to imagine how to care for these residents at a less costly setting or with their level of acuity. They are too sick for another setting,” Morrisette says. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div><strong>Pennsylvania Values Its Rural Providers</strong></div> <div><strong></strong> </div> <div>Stuart Shapiro, president of the Pennsylvania Health Care Association/Center for Assisted Living Management, notes that his state, much to the surprise of many, is quite rural. Paraphrasing a James Carville quote, he notes that Pittsburgh is on one end, with Philadelphia on the other, and as Carville said, “Alabama in the middle.”</div> <div> </div> <div>“Pennsylvania is one of the oldest states by population in America, and they depend on nursing home care as they become older and frailer. Nursing homes in rural Pennsylvania are often an economic engine for their communities and thus have dual importance in their communities: one as caregivers and two as job creators,” Shapiro says.</div> <div> </div> <div>It is against this backdrop of providing care and making economies stronger that Shapiro and the nursing care and assisted living community have been working to correct a longtime gap in Medicaid reimbursement versus the actual cost of providing care.</div> <div> </div> <div>“Reimbursement under state Medicaid does not cover the true cost of Medicaid. As the recession has not yet bottomed out, more and more people are utilizing the Medicaid program, which increases the challenges of nursing homes, especially in rural areas where there are fewer Medicare patients,” he says.</div> <div> </div> <div>Shapiro hopes a budget that recognizes the importance of sufficient funding for Medicaid can be finalized by the end of June (after this publication went to press).</div> <h3 class="ms-rteElement-H3"><strong>Maryland Medicaid Dollars Shrink</strong></h3> <div>In Maryland, Joe DeMattos, president of the Health Facilities Association of Maryland (HFAM), says his state’s nursing and rehabilitative centers have been fortunate in the most recent years to avoid some of the more severe cutbacks in reimbursement that other health care providers have experienced, but the battles have taken their toll.</div> <div> </div> <div>“Working with Gov. Martin O’Malley [D] and his administration, we were able to avoid reimbursement budget cuts, in part because of increased provider assessments,” DeMattos says. </div> <div> </div> <div>The flat funding has come with more provider taxes, but, in fact, Medicaid dollars have been dwindling in recent times in Maryland, he says.</div> <div> </div> <div>A January study, “The Future of Health Care in Maryland: Nursing and Rehabilitation Centers, a Compelling Value Proposition,” prepared by Sage Policy Group for HFAM, showed that over time, while Medicaid spending in Maryland has grown steadily, the share of all Medicaid dollars provided to nursing facilities has declined significantly. </div> <div> </div> <div>“In 2000, over 20 percent of all Medicaid dollars in Maryland were allocated to nursing facilities. By 2008, just eight years later, approximately 18 percent of Medicaid dollars were devoted to nursing facilities,” the report says.</div> <div> <img width="246" height="351" class="ms-rteImage-2 ms-rtePosition-1" alt="Heritage Hall-Blackstone, Va. residents" src="/Issues/2011/PublishingImages/0711/olympic-team.jpg" style="margin:10px;width:324px;height:207px;" /></div> <div>“This reduction in the share of Medicaid payments directed to nursing facilities is a reflection of the fact that payments to skilled nursing facilities grew much slower than overall Medicaid payments [6.6 percent on average per year from 2000 to 2008 versus 8.1 percent].”</div> <div> </div> <div>The report noted that payments for combined inpatient and outpatient hospital services grew at a faster rate than other Medicaid payments, an annual rate of 8.4 percent. Outpatient hospital services grew much faster than inpatient hospital services (12.5 percent versus 7.4 percent). </div> <div> </div> <div>The fastest-growing payments were those to physicians, other care, home health, clinics, and outpatient hospitals, each growing at double-digit annual rates.</div> <div> </div> <div>“On the one hand, our facilities are providing efficient quality care for Marylanders and often are the largest employer in community, but that very economic viability is being challenged by state and federal cuts,” DeMattos says.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>Incomes Higher For LTC Workers</strong></h3> <div>The Sage Policy report had detailed information on the income levels for rural workers in the long term care setting versus those in other jobs. </div> <div> </div> <div>The numbers highlighted that in more rural areas of the state where incomes are significantly lower than the state average, the compensation available for skilled nursing facility workers “can provide solidly middle-income wages, and can even exceed the average compensation for all workers in a county, as is the case in Allegany, Garrett, and Wicomico counties,” the three most rural counties in Maryland, the report says.</div> <div> </div> <div>For example, in Garrett County the average wage for all workers is $29,395, but the average wage for </div> <div>SNF workers is $39,014—33 percent higher.</div> <div> </div> <div>DeMattos stresses that rural facilities in his state have done well to care for populations in western Maryland, the eastern shore, and southern tip. Many have taken up the slack for now-shuttered manufacturing plants, as in the case of the NMS Healthcare skilled nursing facility in Hagerstown, Md., which occupies a property formerly owned by now-defunct Fairchild Aircraft.</div> <div> </div> <div>“It was a corporate executive retreat for Fairchild and now is a nursing and rehabilitation center,” DeMattos says.</div> <h3 class="ms-rteElement-H3"><strong>Pennsylvania Supplier Finds More LTC Sales</strong></h3> <div>In addition to the impact that nursing facilities have on local and state economies, a wide range of suppliers also boost the sector, providing the products required to operate a building caring for the special needs of frail and elderly residents.</div> <div> </div> <div>One such business based in Ivyland, Pa. (population just over 1,000), is Medi-Dose/EPS. Family-owned since its inception in 1971, the firm markets to the provider community a number of products, including industry-leading medication dosing systems, complete with bar-coding technology to ensure accurate solid and oral dispensing.</div> <div> </div> <div>Robert Braverman, Medi-Dose/EPS co-owner with his brother Mark, is the director of sales and marketing. He notes that his 35 employees work with a network of vendors and the provider community to find, market, and distribute the latest products needed in the care community. Dosing systems are more popular in the acute-care sector of his business, with long term care facilities interested in the bag, bottle, and ancillary products at Medi-Dose/EPS. He markets directly to nursing facilities and to pharmacy providers.</div> <div> </div> <div>“What I can tell you is that because Americans are getting older, with the baby boomers reaching 65, we’re noticing an uptick in our business that we have from the long term care market.”</div> <div> </div> <div>Demographics will play a large role in expanding that business even more, as it will in the nursing and assisted living markets, where demand for services and housing could grow greatly in the next decade and beyond, he says.</div> <div> </div> <div>What will also grow is demand from rural residents for the same high-quality care the busier, more populated and commercialized locales receive.</div> <div> </div>As factories close, facility jobs take up the slack in rural stretches of Virginia, Pennsylvania, and Maryland.2011-07-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0711/Envoy-(46)_thumb.jpg" style="BORDER:0px solid;" />PolicyColumn7
Patients Equate EHRs With Higher Qualityhttps://www.providermagazine.com/Issues/2011/Pages/0711/Patients-Equate-EHRs-With-Quality.aspxPatients Equate EHRs With Higher Quality<p>​More than 81 percent of patients and 62 percent of physicians have a positive perception of electronic documentation, according to a new study from Sage Healthcare Insights.</p> <p>The survey, conducted to determine attitudes regarding the adoption of electronic health records (EHRs), examines the effect of implementing an EHR system on both physicians and their patients.</p> <p>According to the study, patients felt more comfortable with physicians who used an EHR system and, more importantly, felt that the information contained in the medical record was more accurate when they physically saw information being entered electronically. </p> <p>“What we learned is patients like to see their verbatim information entered into the record as they said it, not as the doctor interpreted it,” said Betty Otter-Nickerson, president of Sage Healthcare Division.</p> <p>About 42 percent of physicians use EHRs to document their patient care, and about one in three uses an EHR during a patient encounter.</p> <p>Among the respondents, 45 percent of patients had a “very positive” perception of their physician or clinician documenting patient care with a computer or other electronic device. More than 60 percent of physicians feel the best benefit to using EHR is the access they have to patient records in real time.</p> <p>The majority of survey respondents agreed with the statement that EHR will help improve the quality of health care—including 78 percent of patients and 62 percent of physicians.</p> <p>Both groups, however, expressed concerns about privacy and the security of EHRs (81 percent of patients and 62 patients of physicians).</p> <p>The most important benefits of EHR systems agreed upon by the two groups were that they give the physician access to patients’ medical records and history in real time; when appropriate, they help the physician securely and seamlessly share information with other doctors, pharmacies, and payers; and they help physicians make good decisions about patient care, ultimately driving the quality of patient care.</p> <p>“Patients who participated in the survey said they had greater confidence in providers who use electronic records. This suggests that there’s an opportunity for doctors to learn directly from their patients how to improve their practices and their patient relationships,” Otter-Nickerson said. </p>Survey examines perceptions of EHRs among patients and physicians.2011-07-01T04:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/clip%20art%20two%20men%20looking%20at%20computer%20in%20scrubs.jpg" width="150" style="BORDER:0px solid;" />Column7
Reducing Hospital Readmissionshttps://www.providermagazine.com/Issues/2011/Pages/0711/Reducing-Hospital-Readmissions.aspxReducing Hospital Readmissions<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>​When President Obama pitched his plan for health care reform in June 2009, few health care companies were surprised at his announcement that “almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month.” <br> <br>What did send ripples through the medical community, however, was Obama’s statement that “changing how Medicare reimburses hospitals…will save us $25 billion over the next decade.”<br> <br>SunBridge Healthcare has taken an active role in partnering with hospitals in various communities around the country to help identify the causes and decrease the percentages of readmissions. According to Sandy Gigandet, SunBridge’s regional director of clinical operations for Indiana and Ohio, “Our goal is to decrease our unplanned discharges back to the hospital to less than 10 percent, realizing that some components are beyond our control.”<br> <br>In fact, SunBridge has been using a hospital management system for more than four years that allows a review of hospital readmissions by time, date, provider, physician, and diagnosis/symptom and also in relation to admission and payer sources. <br> <br>This dynamic system allows for a thorough identification of trends at multiple levels, from individual centers to entire divisions. By examining a variety of trends revealed by the data, Jackie Strader, SunBridge’s regional director of clinical operations for Kentucky North, uncovered a variety of related causes. </p> <p>“If I had to sum up our findings in one word, I’d say education—of our staff, of our attending and on-call physicians, and even of our residents,” Strader says. In some communities where a specific clinical need is identified, SunBridge centers have developed services and supported their staff in receiving the unique training required to sustain these services. </p> <h3 class="ms-rteElement-H3">Community Partnerships</h3> <p>At Regis Woods Care and Rehabilitation Center, Louisville, Ky., for instance, the team consulted with staff at Baptist Hospital and learned that area nursing facilities didn’t provide total parenteral nutrition care (TPN). Armed with this knowledge, the clinical team at Regis Woods pursued training regarding appropriate TPN care and equipment. Now the center is able to admit and care for residents with these clinically complex conditions rather than having to discharge them back to the hospital. </p> <div>Other SunBridge centers are following suit, depending on the particular needs of their communities. Triad Care and Rehabilitation Center of High Point, N.C., is currently developing a stroke recovery unit, while Willows Care and Rehabilitation Center, Woodbridge, Conn., offers services like dialysis management.</div> <div><img class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/0711/Caregiving0711_SunBridge.jpg" alt="" style="margin:5px 15px;width:346px;height:276px;" /><br>Some SunBridge centers are taking a broader approach by partnering with local hospitals to address common diagnoses that frequently result in unplanned discharges. </div> <div> </div> <div>For example, Marilyn Morel, one of SunBridge’s clinical care specialists in New Hampshire, has been working with staff from Cheshire Medical Center/Dartmouth-Hitchcock Keene for several months to decrease unplanned discharges from nursing centers that result from congestive heart failure (CHF). Together they have created a “discharge order set” that helps increase communication among hospital physicians and nursing center staff. </div> <div> </div> <div>Morel praises the initiative, saying, “The discharge order set has not only helped with continuity of care but also helped build relationships between the hospital and center staff. That can only benefit the residents.”</div> <div> </div> <div>Cheshire is not the only hospital partnering with skilled nursing centers. Bedford Hills Care and Rehabilitation Center, in Bedford, N.H., for example, has adopted clinical CHF protocols. From hospital to nursing facility, these new protocols help ensure a continuity of care that benefits patients and lowers the number of readmits to the hospital, especially in the 30-day window after discharge. </div> <div> </div> <div>Since the protocols were implemented in February 2010, both Bedford Hills and Elliot Health System have been pleased to see the hospital readmission rate decrease to a mere 12 percent. “I view this move toward collaboration and accountability as a positive advancement, both for the staff and also for the patients,” says Malcolm Perry, director of Senior Health Services for Elliot Health System.</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><strong>Recognizing Changes</strong></h3> <div>One critical factor in decreasing unplanned discharges is early recognition of a change in condition in a resident. Part of SunBridge’s procedures includes a Change in Condition form, a tangible, useful tool that assists clinical staff in pulling together resident information such as vitals, general appearance, physical evaluation, recent lab results, and medications on a one-page reference sheet. </div> <div> </div> <div>In fact, centers are so adamant about recognizing a change in a resident’s condition that all clinical staff undergo training on this topic first during their initial orientation and then annually thereafter. Furthermore, staff development personnel at each center complete annual competency reports for all members of the clinical staff to help ensure that competencies in key skilled areas are being met. </div> <div> </div> <div><img width="272" height="308" class="ms-rtePosition-1 ms-rteImage-2" alt="Post-acute services can keep people out of the hospital." src="/Issues/2011/PublishingImages/0711/Caregiver-Photo.jpg" style="margin:10px;width:278px;height:315px;" />A very practical approach to care is implemented on a daily basis in SunBridge centers. Certified nurse assistants are trained to record their observations during every shift on a Nursing Assistant Worksheet and to report any changes in a resident’s condition to the licensed nurse on duty. The licensed nurse then completes an assessment using the Change of Condition form and also documents any changes on a 24-hour report sheet. </div> <div> </div> <div>In addition, the licensed nurse notifies the resident’s physician, making sure to document any new orders, and also notifies the resident’s family. After the new orders are implemented, the resident is monitored for improvement on each shift with oversight by the center’s director of nursing. </div> <div> </div> <div>Center administrators also play a role in helping to reduce hospital readmissions by reviewing their “top five” at-risk residents every morning in a stand-up meeting with their interdisciplinary teams. In addition, clinical staff review what’s known as the Radar Report, a minimum data set-based report that assists centers in identifying residents at risk as well as residents who have been evaluated to have a change in condition. </div> <div> </div> <div>This approach helps provide early identification of potential concerns, resulting in the opportunity for early intervention, staff education, and improved clinical outcomes. </div> <div> </div> <div>As hospitals have discharged their patients “quicker and sicker,” skilled nursing facilities have had to increase their abilities to care for these higher-acuity patients. “One way we’ve addressed that challenge,” Strader says, “beyond providing increased training for our existing staff, is to hire more registered nurses [RNs]. In SunBridge’s Kentucky North region, for example, we’ve increased the number of RN staffing positions by 17 percent in 12 months. During that same time frame, we have seen a decrease in unplanned discharges.”</div> <div> </div> <div>Bridge Point Care and Rehabilitation Center in Florence, Ky., reduced its unplanned discharges per month approximately 31 percent from the fourth quarter of 2009 to the first quarter of 2010. Not only did they focus on staff education but they also hired six additional RNs last year.</div> <div> </div> <div>Gigandet adds, “Each of our centers strives to have a nurse practitioner or physician’s assistant on board in addition to a medical director. Whenever possible, we prefer our physicians also practice a specialty at our referring hospitals to help ensure continuity of care upon admission into our centers. This approach allows us to continue the same protocols initiated in the hospital.” </div> <h3 class="ms-rteElement-H3"><strong>Promoting Physician Awareness</strong></h3> <div>Susan Coppola, SunBridge’s senior vice president of clinical operations, points out that it is often to the resident’s medical advantage to remain in the center rather than return to the hospital. “Our goal is to achieve continuity and meet our residents’ needs whenever possible while keeping them in place,” Coppola says.</div> <div> </div> <div>If this is true, then why do some physicians discharge their residents back to the hospital? In reviewing the data, Strader discovered that some of SunBridge’s unplanned discharges occurred because attending and on-call physicians were unaware of the centers’ capabilities. </div> <div> </div> <div>“We had to educate them as to our ability to provide stat labs, various diagnostic procedures, and specific medications from our pharmacies. Once they realized that we could provide these and other services, they were less anxious to readmit their residents to the hospital for the same services,” Strader says.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><strong>The Patient’s Role</strong></h3> <div>Yet another reason for hospital readmissions, especially within 30 days of discharge, is a lack of patient compliance by individuals who return directly home. In other words, patients are discharged from the hospital without any post-acute services, they do not see their primary care physicians within 30 days of being discharged, or they refuse to follow the diet and exercise protocols as established as part of their discharge instructions. </div> <div> </div> <div>SunBridge facilities are trying to address some of these factors by partnering with local hospitals to position the facilities as a viable post-acute services alliance that can help decrease preventable readmissions. Upon admission to a center, for instance, the resident and his or her family members are invited to a Customer First Post-admission Conference. </div> <div> </div> <div>“This conference is important not only for developing an appropriate plan of care,” says Coppola, “but also for establishing realistic expectations and for helping the resident and family understand the services we provide.”</div> <div> </div> <div>Having such a meeting creates a level of confidence in the resident and family so that, should a change in condition occur, the resident and family understand that a return to the hospital is not necessarily the first step in the process, Coppola says. </div> <div> </div> <div><em>Coleen Maddy is the publications editor for Sun Healthcare Group. She can be reached at coleen.maddy@sunh.com or (505) 468-6864.</em> </div> <p> </p>A rehab provider successfully lowers hospitalizations through community and hospital collaboration.2011-07-01T04:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/clip%20art%20hospital%20ER%20entrance.jpg" width="150" style="BORDER:0px solid;" />Caregiving;Clinical;Quality ImprovementColumn7




Hospital & Nursing Facility Team Up For Better Carehttps://www.providermagazine.com/Issues/2011/Pages/0811/Team-Up-For-Better-Care.aspxHospital & Nursing Facility Team Up For Better Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div>​ <div><img width="387" height="527" class="ms-rteImage-2 ms-rtePosition-1" alt="EPOCH fellow Andrea Berg, MD with resident" src="/Issues/2011/PublishingImages/0811/linderpix-25880.jpg" style="margin:10px;width:302px;height:199px;" />As the senior population grows, more individuals are seeking elder-specific medical care and treatment. This increased demand has revealed a frightening reality: The medical field is not keeping pace with the mounting needs of the aging and rapidly expanding senior population. </div> <div> </div> <div>According to the American Geriatrics Society, there is currently one geriatrician for every 2,699 Americans 75 or older. </div> <div> </div> <div>That ratio is expected to drop to one geriatrician for every 5,549 older Americans by 2030. The lack of doctors going into geriatrics has been making news both locally and nationally for years.</div> <div> </div> <div>But what can be done to combat this deficiency?</div> <div><h3 class="ms-rteElement-H3"><strong>Learning By Doing</strong></h3> <div>At EPOCH Senior Healthcare of Chestnut Hill in Massachusetts, officials have formed a partnership with doctors from Beth Israel Deaconess Medical Center to create a program designed that immerses young physicians in geriatrics. </div> <div> <img width="182" height="282" class="ms-rteImage-2 ms-rtePosition-2" alt="EPOCH fellow and resident" src="/Issues/2011/PublishingImages/0811/linderpix-25717.jpg" style="margin:10px;width:252px;height:168px;" /></div> <div>More elderly hospital patients are being discharged to post-acute care for both long-term stays and short-term rehabilitation. And yet geriatricians at those hospitals often do not witness this transition, nor do they see their patient at the senior care facility directly. This can lead to less than satisfactory care. </div> <div> </div> <div>The partnership between EPOCH and Beth Israel, a teaching hospital of Harvard Medical School, is filling that missing link by exposing young doctors to nursing facility care firsthand. </div> <div> </div> <div>Not many nursing facilities have teaching programs, says Virginia Cummings, MD, who runs the program and leads the geriatrics program at Beth Israel. </div> <div> </div> <div>The Division of Gerontology at Beth Israel is one of the oldest and largest academic programs on aging in the country. It includes clinical and research faculty from Hebrew SeniorLife, one of the nation’s leading clinical research centers in gerontology.</div> <div> </div> <div>“So many discharges from the hospital go to a nursing home,” she says. “It’s important for doctors to be familiar with the nursing home setting, and few of them are. This program is unique in trying to remedy that.”</div> <div> </div> <div>Three doctors, who are completing year-long fellowships through the Harva<img width="280" height="322" class="ms-rteImage-2 ms-rtePosition-2" alt="EPOCH fellows are immersed in all of the transitions" src="/Issues/2011/PublishingImages/0811/linderpix-25913.jpg" style="margin:10px;width:299px;height:199px;" />rd Medical Hospital Division on Aging, are currently enrolled in the program at EPOCH. The goal of the program, Cummings says, is to immerse the doctors, or fellows, in all aspects of the hospital-to-nursing facility transition, as well as in rehabilitation, Alzheimer’s care, administrative duties, and other subjects, such as medication management and nuances of Medicare and Medicaid insurance. </div> <div> </div> <div>The fellows obtain a big picture view of the elder care environment and also work directly with residents and their families.</div> <div> </div> <div>In addition, Harvard Medical students visit EPOCH during their third and fourth year geriatrics elective. The goal is to expose students to all aspects of geriatric care in hopes that some of them will be motivated to pursue training in geriatrics. Fellows also speak to fellow students about their experience in the nursing facility environment, in effect expanding the reach of the program through peer interaction.</div> <div> </div></div> <div> <span id="__publishingReusableFragment"></span></div> <div><h3 class="ms-rteElement-H3"><strong>Misconceptions </strong><strong>Dispelled </strong></h3> <div>Many of the students are not familiar with elder care and have misconceptions about the nursing facility environment, Cummings says. Medicare and Medicaid are foreign concepts for many of them, as are the intricacies of medication interactions among the elderly. </div> <div> </div> <div>“Learning how an incision or wound heals in a senior versus a young person, or how an elderly patient with trouble swallowing can improve with speech therapy, these are important nuances to elder care that will help them be better in their work,” Cummings says.</div> <div> </div> <div>Residents and families of EPOCH Senior Healthcare of Chestnut Hill are aware of the fellows program and appreciate the effort and care the student physicians bestow on the residents. </div> <div> </div> <div>“The residents enjoy these students, as they are able to spend more time with the residents than a <img class="ms-rtePosition-1 ms-rteImage-0" src="/Issues/2011/PublishingImages/0811/table1.gif" alt="" style="margin:15px 5px;" />typical visiting doctor who must move quickly to accommodate many patients,” Cummings says.</div> <div> <br>Fellow Tia Kostas of Boston has been visiting EPOCH since July 2010 as part of Cummings’ program and looks forward to her time at the community. “We see long term care patients who have been there for awhile, as well as the short-term rehab patients. It’s nice to get the two different perspectives,” she says. “It’s a fun environment. They do a lot of activities. It’s nice to interact with patients. The aides and nurses help them enjoy life to the fullest.”</div> <div> </div> <div>Kostas says the program has strengthened her desire to work in the geriatrics field. While she is not sure if she wants to work specifically in a senior living health care facility, her experience has given her insight into the variety of care options for seniors.</div> <div> </div> <div>“[My time in the program] has had only a positive impact on me. I feel so lucky we get to go,” Kostas says. “The nursing staff really know their patients. They notice the little things, like if a patient is not eating quite the same, or if their gait is a little bit off. That sort of attention is really helpful as a doctor.”</div> <h3 class="ms-rteElement-H3"><strong>F<img class="ms-rteImage-0 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0811/table2.gif" alt="" style="margin:5px 10px;" />acility Rewards</strong> </h3></div> <div><div>Though the fellows benefit from the program, the rewards do not end there. EPOCH staff get to interact with, learn from, and teach the fellows in a one-on-one setting. The constant refresher in current techniques and best practices is valuable to staff members, the fellows, and, of course, residents. </div> <div> </div> <div>The fellows are young and curious—they provide a fresh set of eyes that residents and family members appreciate. The entire community benefits from knowing EPOCH is helping address a significant problem in elder care.</div> <div> </div> <div>Fellows have been visiting EPOCH for about two years for this program, with each batch completing their year-long rotation on June 30. EPOCH hopes to continue this partnership for as long as possible, given the numerous benefits for all parties involved. </div> <div> </div> <div>The need for more doctors specializing in geriatrics is a very real concern, particularly for the baby boomer generation. This active, youthful generation will not go quietly into the night. Physicians will need to understand the complex issues, both medical and psychological, surrounding aging for this determined and active generation. </div> <div> </div> <div>Providing avenues to address the challenges facing the growing senior population is imperative if their needs are to be met. </div></div> <div> <em><img width="96" height="111" class="ms-rteImage-2 ms-rtePosition-2" alt="Ellen Alperen" src="/Issues/2011/PublishingImages/0811/EllenAlperen.jpg" style="margin:10px;width:84px;" /><br><br>Ellen Alperen, PhD, is administrator at EPOCH Senior Healthcare at Chestnut Hill and a senior adjunct professor for Graduate Studies in Health Care Management at Cambridge College. She can be reached at: (617) 243-9990.</em></div>As the senior population grows, more individuals are seeking elder-specific medical care and treatment. This increased demand has revealed a frightening reality: The medical field is not keeping pace. 2011-08-11T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0811/caregiving_rollup.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalColumn8
LTC Nurses Leading The Wayhttps://www.providermagazine.com/Issues/2011/Pages/0811/LTC-Nurses-Leading-The-Way.aspxLTC Nurses Leading The Way<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​<img class="ms-rtePosition-2" alt="Nurse Educator Session 2 students" src="/Issues/2011/PublishingImages/0811/Nurse-Educator-Session-2.jpg" style="margin:10px;width:312px;height:234px;" />Experienced nurses who consistently provide high-quality care are often promoted in recognition of their clinical skills. These valuable employees are appointed to be supervisors or managers, with the expectation that they will be able to apply their outstanding nursing skills in a leadership role. <br> <br>But how many nurses, especially in long term care, are actually given the opportunity to develop supervisory skills? Do they know how to manage personnel, oversee policies and procedures, and facilitate effective meetings? Are they familiar with the regulations of human resources and the guidelines for conducting agency investigations?<br> <br>The Foundation for Quality Care in Albany, N.Y., has established the Nurse Leadership Institute for the purpose of cultivating leadership skills in nurses who are employed in long term care facilities.<br> <br>Affiliated with the New York State Health Facilities Association, the foundation began with one course for directors of nursing (DONs) and now offers at least 11 courses per year for DONs, licensed nursing home administrators (LNHAs), staff development coordinators/nurse educators, and first-line nurse managers.<br> <br>Participants in the courses are screened for their work experience, references, and motivation to move up the career ladder and lead. Both new and experienced nurses enroll in the courses, which require four to eight weeks of full-day classes.<br> <br>All of the courses have close to 100 percent attendance, not only because of the quality of the course content and instruction, but because of employers’ commitment to releasing the participants for the day.<br> <br>The New York State Nurses Association has approved contact hours for most of the courses, and the National Board of Administrators also provides continuing education credits. The State University of New York Institute of Technology has been an active partner and provides college credit for three of the courses—for nurse educator, DON, and advanced DON programs.<br> <br>“Effective leadership drives quality care,” says Richard Patterson, executive director of the foundation, in describing the purpose of the institute. <br><br>“Not only do the nurses develop supervisory skills that build their competence and confidence, their staff benefit from strong leaders who focus on teamwork, communication, and high standards of care.”<br> <br><strong>Tailored Topics</strong><br>All of the courses focus on the basic competencies of leadership in long term care settings, such as coordinating quality improvement, solving problems effectively, and managing time and stress. <br> <br>All other topics are tailored to the level of leadership. For example, participants in the DON program also discuss finance and corporate compliance, legal and ethical aspects of nursing service management, and coaching and evaluation models for improved employee performance.<br> <br>A new Advanced Director of Nursing program was developed for experienced DONs. Participants explore topics such as root-cause analysis, systems and policies to enhance clinical and financial operations, and human resource issues.<br> <br>The course for first-line managers, based on eight instructional days, is interactive and realistic. Participants benefit from sharing problems and solutions with their peers, discovering that the same situations show up in many long term care facilities. <br> <br>As testimony to the effectiveness of the program, 100 percent of the participants have utilized the skills developed in the program, and more than 65 percent cite that their participation in the course has directly influenced their desire to remain in their leadership roles. <br> </p> <p><span id="__publishingReusableFragment"></span><br><strong>Recharging Administrators</strong><br>The Nursing Home Administrator Leadership course is designed for LNHAs and is not limited to nurses. Participants include administrators who are new to the job, as well as administrators who have been managing long term care facilities for 20 years and are seeking a refresher course. <br> <br>As basic leadership skills are reviewed, the topics include the 1987 nursing facility reform law (the Omnibus Budget Reconciliation Act) and up-to-date information about state and federal regulations that guide the care of residents. <br> <br>The federal survey review process is discussed in depth, as are current systems to manage Medicare and Medicaid reimbursement and other financial topics. <br> <br>In the words of one veteran administrator, “I always left these classes ready to go back to my facility with loads of new ideas.”<br> <br>The course designed for nurse educators and professional development coordinators is the one with the longest waiting list. In four packed training days, participants learn about principles of teaching, adult learning theory, program and instructional planning, and assessment strategies. <br> <br>All participants prepare a complete training program that can be used by their colleagues in their home facilities. <br> <br>As participants noted in the course evaluations, “I have 18 new presentations that I can use to provide education for my staff,” and “I learned a lot from the instructors and other participants. It was worth the time away from my job because now I’m prepared to be more effective.”<br> <br><strong>Assessments Show Value</strong><br>All course participants complete assessments to determine increase in knowledge in the topics. The results have shown an overwhelming increase in knowledge. <br> <br>A surprising result was the number of participants who entered a class believing that they were knowledgeable about a subject and then discovered that they had more to learn. <br> <br>Senior-level managers were most likely to think that they were up to date and then realized that their peers and instructors could enhance their knowledge.<br> <br>“I’ve been involved with the development of the Leadership Institute from the very beginning because I felt that it was desperately needed in all areas—DONs, supervisors, and nurse managers,” says Patrick Martone, chief executive officer of Capital Living and Rehabilitation Centres. “Many nurses have strong clinical skills, but they also need leadership skills and to have a global view of what they will be facing in their everyday work life to become strong leaders in the facility.”<br> <br>By hearing from experts and experienced instructors, says Martone, class participants get a broader perspective and the tools to handle areas in which they have limited experience. “They get to understand the direct linkage between finances and clinical capabilities.”<br> <br>Evaluations from completed programs indicate that the participants value the substantial amount of content provided in the courses, but they especially appreciate the opportunity to meet and network <img class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/0811/FLM-Long-Island.jpg" alt="" style="margin:15px;width:269px;height:202px;" /><br>on a regular basis with their peers. <br> <br>“This is one of the best things I’ve ever done in my career,” says former student Lisa Volk, RN, an administrator and former DON. “The communication and coaching activities, especially the real-life scenarios, gave [students] the opportunity to practice basic skills, play out the problems and solutions, and build confidence so they could go back to work and use the skills successfully.” <br> <br>Since its inception, the institute has graduated more than 1,100 nurses from the courses.<br></p> <p><strong>Spreading The Wealth</strong><br>The foundation is interested in connecting with nurse training programs in other states to assist them in replicating the Nurse Leadership Institute and to establish possible partnerships for expansion. <br> <br>Martone notes that replicating the institute’s courses in other states will take “strong support from the top levels of the organization so that participants can be released to enroll in the entire program.”<br> <br>“It is important to select the right people with the ability to teach—and leaders who have been in the trenches and have the ability to establish a climate of openness and honesty.” <br><br><em>Nancy Leveille, RN, MS, is senior director at the New York State Health Facilities Association (NYSHFA) in Albany and the program coordinator for the institute. Karen Morris, RN, MS, is director of clinical and quality services for NYSHFA and instructor at the institute; and Anne O’Brien Carelli, PhD, is principal with Carelli & Associates, which does program development, instruction, and evaluation for the institute. Contact Leveille for curriculum outlines and information about the courses: (518) 462-4800, ext. 20.</em></p>Long Term Care Leadershp Institute cultivates leadership skills.2011-08-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0811/nurse_feature_rollup.jpg" style="BORDER:0px solid;" />Caregiving;Management;WorkforceColumn8
A Look At New LTC Physician Modelshttps://www.providermagazine.com/Issues/2011/Pages/0811/A-Look-At-New-LTC-Physician-Models.aspxA Look At New LTC Physician Models<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><img width="434" height="409" class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/0811/a1618s1771_large.jpg" alt="" style="margin:10px;height:248px;" /></div> <div>Changes to long term care are coming at a rapid-fire pace—accountable care organizations, health care reform, person-centered care, and medical homes. In response to these changes and in preparation for an unpredictable future, organizations increasingly are seeking ways to ensure successful care transitions, streamline communication, increase cost effectiveness, and improve outcomes. </div> <div> </div> <div>Toward this end, there is a trend of increasing the physician presence both at the corporate and facility levels. Today, a physician as an employee is not an alien concept in long term care. In fact, it is becoming a way of life.</div> <h3 class="ms-rteElement-H3"><strong>Responding To Change—Proactively</strong></h3> <div><div>So what is driving this trend toward physician employees? “Health care reform will call for us to go from a volume-based to a value-based system,” says James Avery, MD, chief medical officer of Golden Living, Plano, Texas. </div> <div> </div> <div>“Health care organizations, hospitals, or nursing homes will be judged by the value of care patients receive,” he notes. </div> <div> </div> <div>As one thinks in those terms, he says, “We realize that we will need more physician involvement. Dealing with the volume to value change in the practical context of patients coming to our nursing facility to continue treatment for their acute illness, we realized that we needed more physician engagement, presence, and alignment.” </div> <div> </div> <div>“There is an increasing demand for physician presence in the nursing home setting,” says Matthew Wayne, MD, CMD. “We have health care reform sitting in front of us. Regardless of what form it ultimately takes, there are some basic elements that will move forward. One of these is accountable care. Outcomes, patient experiences, and cost-effectiveness all will be looked at, and these data will be used to drive reimbursement,” says Wayne, who is medical director at several Cleveland, Ohio-area nursing facilities. “For me, this is exciting. If we can increase effectiveness, there is a real opportunity to improve care and financial outcomes for the physician, the nursing home, and the health care system as a whole.”</div> <div> </div> <div>Another driver, says Avery, is that long term care centers increasingly are becoming post-acute centers. “Patients once were called residents. They came and stayed for years. But now the average stay is a few weeks or a few months,” he says. “The goal for these patients is to get them home or to an assisted living facility. This has forced us to ask: How do we design a new setting for recovery care? How do we provide the level of care they need? How do we get them back in their community at as high a functional level as possible?” </div></div> <div><h3 class="ms-rteElement-H3"><strong>Physicians In Executive Positions</strong></h3> <div>To help build the infrastructure necessary to meet these changes, Golden Living has a physician chief executive officer, Neil Kurtz, MD. The company also has division medical directors and is developing a plan for regional medical directors. Physician alignment at the corporate level can accomplish much, Avery says. </div> <div> </div> <div>“Having these practitioners internally changes the way we think. In fact, it leads the organization to see physicians as partners and build information systems to communicate and facilitate these partnerships,” he says. “This information exchange is the currency of the partnership.”</div> <div> </div> <div>Avery believes that having physicians in leadership roles sends a positive message to other clinicians. “They see that the organization appreciates and values its physicians. It can improve communication dramatically,” he says. “Physicians have a unique language and are more likely to communicate easily and openly with each other than with others.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>Louisville, Ky.-based Kindred Healthcare currently has four full-time physician leaders at the corporate level to liaise with the medical communities they serve. The company is also beginning to explore and develop a more robust physician services infrastructure, says Keith Krein, MD, CMD, chief medical officer.</div> <div> </div> <div>“Kindred has a physician whose job it is to explore the development of a ‘management services organization’ so that we would be able to offer physicians employment opportunities and back-office functions like billing services, credentialing, and insurance,” Krein says, adding that his company is also considering expanding the number of physicians in leadership and management positions by year’s end. They also plan to hire more physicians in the future for direct patient care. </div> <h3 class="ms-rteElement-H3"><strong>Quality Commitment</strong></h3></div> <div><div>Kindred’s commitment to an increased physician presence in leadership positions “puts more teeth” into areas like quality improvement, clinical guidelines, pharmacy utilization, and ancillary expense control. </div> <div> </div> <div>“We feel it is imperative to bolster physician services as both the volume and acuity of admissions increase, in order to improve care transitions between hospitals and skilled nursing facilities and move more swiftly at the time of admission in areas like medication management and care planning,” says Krein. “We also are putting more horsepower into medication reconciliation as patients leave the facility.” </div> <div> </div> <div>Additionally, as more physician <a title="Specialization Hits Long Term Care" href="/Issues/2011/Pages/0811/Specialization-Hits-Long-Term-Care.aspx" target="_blank">specialists</a> provide consultation services or supervise specialized clinical programs in the skilled nursing setting, Kindred is committed to having physician leaders oversee the process. </div> <div> </div> <div>Perhaps the most obvious benefit of having physician employees is that they work with the mission of the company in mind. “If a physician has a private practice, those demands will always come first,” says Kevin O’Neil, MD, CMD, chief medical officer for Brookdale Senior Living, Brentwood, Tenn. “Doing what I do now, I actually can change systems of care.” </div> <div> </div> <div>He admits that this can be a bit of shift for physicians who may not be used to thinking about a whole system of care and how they can support the organization and its medical directors in their efforts. However, he stresses that it is well worth the investment. It also can be a very exciting role change for these physician leaders. </div></div> <div><h3 class="ms-rteElement-H3"><div><strong>The Power Of Physician-To-Physician Encounters</strong></div></h3> <div>Externally, having physicians talking to physicians in other organizations and agencies can have a powerful impact. </div> <div> </div> <div>“We got involved in a health information exchange in Indiana because we had our physicians talking to physicians at the state level. This enabled an exchange of clinical information between our facilities and acute care settings in the state; when our patients went to the emergency room, their information was readily accessible to the treatment team there. From health care systems to medical centers, this type of communication is fundamental,” says Avery.</div> <div> </div> <div>“I spend a great deal of time talking with managed care medical directors and going to the hospital to talk about physician services and medical oversight. And some state surveyor agencies have physician medical directors,” says  Karyn Leible, MD, CMD, chief clinical officer, Pinon Management, Lakewood, Colo. “Having a clinical knowledge base that other physicians can relate to is very helpful in these interactions.” </div> <div> </div> <div>Avery also offers a personal experience that showed the value of having physicians as part of the facility’s team. </div> <div> </div> <div>He was senior medical director at a hospice in a state that had very low rates of hospice utilization. To bring in more patients, Avery hired full-time physicians and had them dictate notes. These, in turn, were sent to physicians at medical centers to increase communication between settings. “Once our physicians started talking to other physicians, integration started to occur. In five years, our census quadrupled,” he says.</div> <div> </div> <div>When clinical excellence is part of the organization’s mission, “you have to get physicians involved internally,” says Avery. Golden Living has medical director town hall meetings. “These are conference calls where the physicians at our nursing facilities tell physician leaders what is working well and where they need assistance,” he says.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div>These meetings have led to several innovations. For example, the medical directors expressed a need for more guidance in their roles, so Golden Living developed a Medical Director Handbook. The physicians also indicated that they didn’t know what to do during state surveys, so the company came up with a medical director survey checklist with specific tasks that a medical director should complete before, during, and after a state survey. </div> <div> </div> <div>“One medical director told us that nurses sometimes confuse very early pressure ulcers with rashes, so we were able to identify this as a possible gap in training and address it promptly,” says Avery.</div> <div>This kind of ongoing communication is essential to establish and maintain medical director communication, competency, and engagement. “We want them to be seen and to see themselves as part of the leadership team,” Avery says. </div> <div> </div> <div>To encourage this, the company pays for American Medical Director Association (AMDA) membership for its physicians, gives a stipend for physicians who attend the AMDA annual symposium, and offers incentives to medical directors who pursue the certified medical director (CMD) certification. </div> <h3 class="ms-rteElement-H3"><strong>Facility Physicians: An Early Trend</strong></h3></div> <div><div>“We’re engaged in discussions about hiring physicians in our homes. It’s not that far off,” says Leible. There are many drivers behind this effort, but it is especially appealing in rural areas where it is difficult to attract physicians for visits. </div> <div> </div> <div>Wayne says, “If we have physicians with reliable hours in the nursing home, we will improve communication, relationships, and outcomes. The better the care, the less likely we will have issues such as inappropriate hospitalizations. Moving in this way, we have a chance to create wins across the board.” He predicts that there will be a move toward fewer but more committed clinicians practicing in facilities. </div> <div> </div> <div>“Our goal is to hire a full-time physician for each of our nursing homes across the country. The reason is simply to provide the best quality of care we can for our residents,” says Kenneth Scott, DO, corporate medical director at Life Care Centers of America. “The employed physician not only attends to the medical needs of the patients, this practitioner also helps educate the staff within the facility and provides meaningful insight into processes within the building to improve care and coordination of care,” he says. </div> <div> </div> <div>The physicians play a direct role in communication with physicians in private offices and hospitals to ensure safer care transitions, as well as being active in improving patient and family satisfaction. </div> <div>There is a cost associated with hiring physicians at the facility level. “Obviously, physicians don’t come cheap,” says Scott, adding, “It is somewhat less expensive, however, to add them to your employee pool of benefits, compared to covering the cost of an independent practitioner who must go out independently and obtain his or her own benefits—often at a higher cost.”</div></div> <h3 class="ms-rteElement-H3"><strong>Gauging The Pluses</strong></h3> <div><div>At the same time, offsetting the costs are numerous advantages. “We hope to do our part in answering the call for higher quality of care at less cost. We know that great physician involvement will result in better care,” Scott says.</div> <div> </div> <div>There are numerous advantages to having physicians who have regular schedules in the facility; a relationship with staff and patients; and a buy-in regarding policies, procedures, processes, and protocols. “This is an opportunity to hire physicians who share your standards of care,” says Leible. She adds that improving census is another benefit, and while it may be the one that drives some organizations to embrace an increased physician presence, it likely will be only one of many positive outcomes. <br></div></div> <div>“Over time, it will help enable fewer hospital readmissions, increase regulatory compliance, reduce antipsychotic use, and [reduce] medication errors. Ultimately, it will help improve the finances of the facility,” Leible says. But to make this happen, she notes, the organization has to be forward thinking and realize the value of investing in physicians.</div> <h3 class="ms-rteElement-H3"><strong>Benefits For Doctors</strong></h3> <div><div>There also are benefits for the physician. As Scott says, “There is a sense of belonging. Being part of a larger group or company provides security. Many doctors are seeking to be employed in the face of an ever-changing health care landscape that provides no security for an independent practitioner.” He adds, “The SGR [sustainable growth rate] formula threatens to bankrupt many practices overnight if [further] cuts are implemented. There is some relief for physicians to know that their salaries are guaranteed and that they can truly focus on good patient care.” </div> <div> </div> <div>Physicians also like the idea that the cost of health information technology—such as electronic medical records (EMRs)—will come out of the company’s pockets and not theirs. </div> <div>“The requirement to have meaningful use of EMRs is daunting for many solo practitioners and threatens to lower their income through penalties for not conforming. A uniform system provided by the company, such as hospitals are incorporating, relieves the individual practitioner of the burden,” says Scott.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3"><div><strong>Does Physician Involvement Make A Difference?</strong></div></h3></div> <div><div>Clearly, there is much anecdotal information to suggest that a commitment to physicians at the corporate and facility levels has a positive impact on care, outcomes, and costs. But organizations are starting to measure the results. For example, Golden Living uses a medical director assessment tool that enables nurses and others in the facility to evaluate the medical director. </div> <div> </div> <div>“We want to reward those who are doing well and assist those who need help,” says Avery. The tool has made a difference. The results from its second year of use showed a dramatic increase in physician participation and engagement over the first year. </div> <div> </div> <div>One study found that nursing facilities that had a CMD serving as a physician leader provided higher-quality care. Analysis of nationwide data showed that quality scores represented a 15 percent improvement for facilities that had CMDs at the helm. </div> <div> </div> <div>As more organizations bring physicians into leadership roles, there likely will be formal studies relating their involvement to outcomes and costs. </div> <div> </div> <div>In the meantime, some groups are focusing on defining the skill set needed to practice in this setting. These don’t apply just to physician employees but also to those physicians who specialize to some degree in long term care. </div> <div> </div> <div>Wayne is working with AMDA to develop such competencies. “Some people think of long term care as geriatrics. But while there is an overlap, it is different,” Wayne says. “My sense is that the overlap is in medical management.” </div> <div> </div> <div>However, he notes that while most physicians with an internal or family medicine background have some exposure to the evaluation and management of dementia, delirium, and other diseases common in the elderly, there is more to long term care patients. “These aren’t just older adults. They are mostly medically complex and frail elders—a distinct subset of geriatrics,” says Wayne. “In this setting, you also need to skill set to manage a higher level of acuity in transition, including medically complex patients with profound functional impairment, and address goals of care for these individuals.” </div> <div> </div> <div>These physicians also need an understanding of the unique long term care regulatory environment. “There is a real need to define what a successful physician in long term care looks like and what skill sets they should have,” Wayne says. He emphasizes that an overriding theme of the approach to this is inclusiveness. “We have psychiatrists, surgeons, <a title="Learning From Hospitalists" href="/Issues/2011/Pages/0811/Learning-From-Hospitalists.aspx" target="_blank">hospitalists</a>, and others working as long term care physicians. Our intent is to welcome any and all of these people with open arms—with the caveat that they must have a passion to care for this population and a willingness to ensure they have the necessary skill sets.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div></div> <div><div><h3 class="ms-rteElement-H3"><strong>Using Their Skills</strong></h3></div> <div>Wayne gives an example of  when having the right skill sets for long term care made a positive difference. One of his facilities admitted a man for rehab. He had advanced cardiac and renal disease, and once in the facility, he experienced exacerbations of heart failure and developed Clostridium difficile diarrhea. </div> <div> </div> <div>“There were times that I needed the skill sets to manage higher acuity. The patient required two to three visits per week to maintain medical stability,” he says. “It became apparent that his disease states were end stage, so we moved into palliative care mode and had discussions with him and his family about what he wanted and how to keep him comfortable.” </div> <div> </div> <div>The patient and his family ultimately embraced hospice, and the result was a winning situation for all involved, according to Wayne.</div> <div> </div> <div>“It was a win for the patient because his needs were met without unnecessary testing and hospitalization, and for the family because they felt involved and informed. It was a win for the facility because he wasn’t transferred to the hospital and for me because I was able to be efficient and effective. The hospital won because he wasn’t readmitted, and Medicare won because we avoided the expense of an additional hospitalization. If we raise the bar and do this consistently, everyone walks away with a win,” he says.</div> <div> </div> <div>The skill sets are only the first part of the conversation, Wayne stresses. The second piece is the model of how these practitioners will work, he says. </div> <div> </div> <div>With regular times and days in the facility and consistent processes and protocols to follow, the practitioner is “more effective the minute he or she walks into the building.” Physicians also need to understand the importance of establishing other logistics such as how they will communicate with patients and families and how to make the facility an alternate office setting.</div> <h3 class="ms-rteElement-H3"><strong>Physicians And Care Transitions</strong></h3></div> <div><div>Some organizations are involving physician employees in overseeing and improving care transitions. Brookdale has made this a priority through a care transitions improvement project in Cleveland with Wayne. He is working on developing protocols and checklists for physicians and staff. The goal is to have a system in place that prevents issues and information from falling through the cracks. </div> <div>Wayne also is working with nurse practitioners in skilled and assisted living environments to promptly address changes of condition. </div> <div> </div> <div>Elsewhere, Brookdale is working with Joseph Ouslander, MD, professor and senior associate dean for Geriatric Programs at the Charles E. Schmidt College of Medicine and executive editor of the Journal of the American Geriatrics Society, to develop a curriculum around the use of INTERACT (Interventions to Reduce Acute Care Transfers) tools. “This is an important area to focus on. I’ve always felt that mass collaboration is the key to the future of effective care transitions,” says O’Neil.</div> <div> </div> <div>With accountable care organizations coming fast and furious and care transitions continuing to attract national attention, the growing role for physicians is more than a trend. According to industry leaders such as Leible, “It’s the way of the future. As we have more medically complex residents and there is more emphasis on outcomes and quality improvement, physicians can help achieve desired results.” </div></div> <div> </div> <div><em>Joanne Kaldy is a feelance writer and communications consultant based in Harrisburg, Pa.</em>​</div>Changes to long term care are coming at a rapid-fire pace. Organizations increasingly are seeking ways to ensure successful care transitions, streamline communication, increase cost effectiveness, and improve outcomes. 2011-08-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0811/August_cover.jpg" style="BORDER:0px solid;" />Caregiving;QualityColumn8
The QIS Experthttps://www.providermagazine.com/Issues/2011/Pages/0811/Checking-In-On-The-QIS-Rollout-Status.aspxThe QIS Expert<p>​<strong>Q. Is the QIS rollout proceeding as scheduled?</strong><br><br><strong>A.</strong> The new contract year for Nursing Home Quality’s QIS training and implementation contract began on July 1, 2011, and QIS has already been initiated for all of the Band Two states, plus the District of Columbia. Thus, 22 states have undergone QIS training.  Of these, 11 states are fully implemented, which means all surveyors are trained and all surveys are now QIS surveys. Several more states are predominately QIS and will be fully implemented by the end of this year. </p> <p>Six new states from Band Three are scheduled for QIS implementation between July 1, 2011, and June 30, 2012. Hawaii, Oklahoma, and Tennessee will be trained by the end of this year. Arkansas, New Jersey, and South Carolina will be trained in the first half of 2012.</p> <p>Full implementation of QIS, however, requires more than the training of all state surveyors. The Centers for Medicare & Medicaid Services (CMS) has undertaken several other activities that will continue through this contract year. Most importantly, CMS began a concerted effort to train substantially more regional office surveyors to conduct QIS survey oversight activities in parallel with the expansion into new states.</p> <p>Regional office surveyors have now been trained in every region, in numbers proportional to the number of QIS-trained state surveyors. One change from early QIS implementation is that all of these regional office surveyors are now trained in teams instead of being embedded in state agency trainings. Regional office training is an essential part of ensuring consistency across and within regions through both comparative and oversight surveys.  </p> <p>As of November 2010 the upgraded federal QIS software was implemented following training of all QIS surveyors, which, among other changes, has streamlined QIS. </p> <p>A top CMS priority is completion of QIS software for complaint surveys, revisit surveys, and extended surveys. Interim QIS procedures are in place for these types of surveys now but the software should result in greater consistency in these activities. The new software will also facilitate faster and more regular QIS updates as needed. </p> <p>Although minimum data set (MDS) 3.0 is used for QIS sampling, QIS surveys continue to be successfully conducted without MDS 3.0 quality-of-care and quality-of-life indicators (QCLIs) or quality measures. As providers are aware, the other Stage 1 assessments, including the interviews, observations, and chart reviews, cover the majority of regulatory domains in a resident-centered manner. A subset of MDS 3.0 QCLIs is expected to be used during surveys in the next six months.<br><br><em>Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).</em></p>The new Quality Indicator Survey has already been initiated for all of the Band Two states, plus the District of Columbia. Thus, 22 states have undergone QIS training. Of these, 11 states are fully implemented, which means all surveyors are trained and all surveys are now QIS surveys. 2011-08-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/AKramer_rollup.jpg" style="BORDER:0px solid;" />Survey and CertificationColumn8
Communication Reduces Cultural Barriers In LTChttps://www.providermagazine.com/Issues/2011/Pages/0811/Communication-Culture-Long-Term-Care.aspxCommunication Reduces Cultural Barriers In LTC<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div>​ <div><img width="166" height="224" class="ms-rteImage-2 ms-rtePosition-1" alt="Robert Kubacki, JD" src="/Issues/2011/PublishingImages/0811/Kubacki.jpg" style="margin:10px;width:134px;height:175px;" /><br>Culture is one of many factors that affects how people communicate with each other. As diversity increases in long term care communities nationwide, culture plays an ever-increasing role in communicating. </div> <div> </div> <div>As communication is filtered through a person’s culturally influenced expectations, aware care providers can look beyond differences to find common ground and reduce stress at the same time.<br></div> <div>In most conversations, there is an unconscious expectation that communication preferences are the same as everyone else’s. Without cultural awareness, people are likely to criticize others for interrupting, speaking too loudly or too quietly, or attacking or ignoring. <br></div> <div>In order to increase the likelihood that people understand to each other, communication should be viewed as an adventure of discovery. <br></div> <div>In addition, care providers would benefit by recognizing the following five culturally influenced expectations: </div> <ul><li>How to display genuine concern;<br></li> <li>How to establish trust;<br></li> <li>How to determine acceptable speaking patterns;<br></li> <li>How to identify problems; and<br></li> <li>How to determine the degree of relationship connection.</li></ul> <div><h3 class="ms-rteElement-H3"><strong>Lost In Translation</strong></h3> <div>Communication is an interaction between two or more people using verbal or nonverbal methods for the purpose of transmitting information necessary to satisfy personal or group needs. It begins with translating a thought, a feeling, or an idea into a message using words or physical gestures. </div> <div> </div> <div>The message sender expects that the person receiving the message will recognize its meaning and respond appropriately. If the words or physical gestures mean something different to the listener, the sender might consider the response back to be inappropriate, nonresponsive, or nonsensical. </div> <div> </div> <div>At its best, communication energizes, satisfies, and strengthens relationships. At its worst it is exhausting, induces stress, and undermines relationships.</div> <div> </div> <div>A person’s culturally influenced social etiquette and communication preferences are acquired as a result of growing up in a particular social, socio-economic, or ethnic group. In any cultural context, the appropriate ways to be seen, heard, and have needs met are learned through social contact. </div> <div> </div> <div>Once formed, these culturally influenced values and ways for socializing and communicating remain, to varying degrees, throughout one’s life. The stronger a person identifies with their culture, the more it serves as a comfort zone or provides a sense of belonging. Yet not everyone from the same culture or family behaves similarly. </div> <div> </div> <div>It is important to avoid stereotyping (one person’s behavior reflected in an entire group). Within cultural or ethnic groups, individual styles and communication preferences vary due to many factors, such as personality, life experiences, socio-economic status, and physical or mental attributes.</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div></div> <div><h3 class="ms-rteElement-H3"><strong>Communication Styles Vary</strong></h3> <div>When two individuals share the same culturally influenced expectations, they will use and understand the same rules, meaning of words, gestures, silence, or pauses during their conversation. When the communication rules for one or the other are different, then their conversation becomes frustrating and stressful because both speaker and listener are sending and receiving messages whose meaning they do not understand.</div> <div> </div> <div>The first culturally influenced expectation is how one displays genuine concern. Culture establishes rules for expressing emotions in an acceptable voice volume or the use, or nonuse, of hand and facial gestures while talking. With such rules, culture determines how to display genuine concern for another or an issue. </div> <div> <img width="422" height="443" class="ms-rteImage-2 ms-rtePosition-1" alt="Illustration by DrAfter123" src="/Issues/2011/PublishingImages/0811/mgmt-illust.jpg" style="margin:10px;width:239px;height:191px;" /></div> <div>At one end of this spectrum are cultures where speaking in a loud voice, displaying emotions like anger or joy in an obvious way, or using hands or facial expressions when talking are appropriate. </div> <div> </div> <div>At the opposite end are cultures where displaying concern requires speaking in a low-volume voice that is calm and steady with no or minimal hand or facial gestures, and with restrained emotional expressiveness. </div> <div> </div> <div>While both are appropriate in their respective cultural settings, when mismatched they clash. For example, if Robin Williams and Prince Charles were conversing, Williams would demonstrate his passion and concern openly with a variety of vocal variation and physical expression, while Prince Charles would keep an even tone of voice with little or no physical display or expression.</div> <h3 class="ms-rteElement-H3"><strong>Establishing Trust</strong></h3> <div>Establishing trust is the second culturally influenced expectation. Every culture has its own ways to ensure the survival of its members by providing guidance on how to determine if a person is trustworthy. Trust can be determined based on demonstrating relationship connectivity and establishing competency. </div> <div> </div> <div>While both are important to establishing trust, culture advises which is most important. If a relationship is most important, trust building relies upon familiar appearances, customs and relationship connections. Once this relational information is established, then competency is considered. </div> <div> </div> <div>If competence is most important, trust is established by a person’s knowledge or demonstrated skills, and relationship inquiries follow later. It is what one knows, not who someone is that counts. </div> <div> </div> <div>Picture a conversation between Dolly Parton and Bill Gates, two savvy business people. Parton may begin talking about people they may know in common and then get down to business. On the other hand, Gates might begin wanting to know about Parton’s knowledge of the business deal on the table before talking about whom they both know.</div></div> <div><h3 class="ms-rteElement-H3"><strong>Speaking Patterns </strong></h3> <div>The third culturally influenced expectation encompasses acceptable speaking patterns. Who speaks when, and how often do they speak? Speaking patterns are similar to rules of the road. When two drivers come to a four-way stop or a rotary, which one has the right of way? </div> <div> </div> <div>If speaker and listener know the four-way stop rules of talking, then the pace of their conversation has a clear beginning and end, and neither will interrupt the other. </div> <div> </div> <div>If speaking is like a rotary, the speaker and listener know and expect that whoever wants to enter the conversation can do so at any time. They are comfortable with talking over and interrupting each other. </div> <div> </div> <div>Frequently changing the subject gives life to the conversation. An imaginary on-screen exchange between Humphrey Bogart and Bob Hope might reveal that Bogart’s character would speak in succinct sentences with pauses, while Bob’s character would talk non-stop, interrupt Bogart’s character mid-sentence, and switch subjects.</div></div> <div><h3 class="ms-rteElement-H3"><strong>Problem Identification</strong></h3> <div>The fourth culturally influenced expectation is problem identification. Over the course of human development, people who lived in close proximity to each other developed elaborate processes for how to identify and talk about a problem without ever actually naming it. </div> <div> </div> <div>This “don’t talk about the problem” approach allows people living close together to preserve relationships by using stories, allegories or indirect references while addressing the problem by not talking directly about it or enlisting the aid of a third party.</div> <div> </div> <div>People who lived together, but not in such close proximity to each other, resolved disputes by distancing themselves and picking up the matter at another time or place. This allowed for the option to talk specifically and directly about the problem by “saying what they meant and meaning what they said.”  </div></div> <div><h3 class="ms-rteElement-H3"><strong>Expectation</strong></h3> <div>The fifth culturally influenced expectation, degree of relationship connection, concerns how individuals perceive themselves in relationship to their community. Is a person an individual whose sense of self and self-esteem is inextricably dependent upon their connection to their community, or an individual who belongs to, yet is independent of, their community? </div> <div> </div> <div>Imagine if Mother Teresa were alive and she hosted “The Apprentice” instead of Donald Trump. Their respective perspectives would create two different shows. Communitarian cultures emphasize that without a community connection the individual will not survive. The group is owed the individual’s loyalty and assistance to ensure the group’s survival. </div> <div> </div> <div>Individualistic culturally oriented groups, on the other hand, inform their members that each individual has the capacity to go out on their own, determine their own fate, and an ability to “pull themselves up by their bootstraps.” In doing so, the individual contributes to their group’s survival. </div> <div> </div> <a title="Tips, Resources, and Triggers" href="/Issues/2011/Pages/0811/Tips,-Resources,-And-Triggers.aspx"><div>Tips, Resources, and Triggers</div></a></div> <div> </div> <div><em>Robert Kubacki, JD, a part-time lecturer at Northeastern University in Boston, teaches classes on diversity and intercultural communications. He earned his JD from Western New England College School of Law and a Masters of Public Administration from Clark University. He can be reached at </em><a href="mailto:rwkubacki@gmail.com"><em>rwkubacki@gmail.com</em></a><em>.</em></div>An expert offers tips for overcoming cultural differences to improve caregiver-resident relationships.2011-08-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0811/Mgmt_rollup.jpg" style="BORDER:0px solid;" />Management;WorkforceColumn8
Don’t Miss Anything AHCA/NCAL Has To Offerhttps://www.providermagazine.com/Issues/2011/Pages/0811/Don’t-Miss-Anything-AHCANCAL-Has-To-Offer.aspxDon’t Miss Anything AHCA/NCAL Has To Offer<p>A major event in the long term care industry’s calendar is almost here. The Annual Convention & Expo of the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) will be held Sept. 18-21 in Las Vegas. From an opening session featuring New York Times best-selling author Daniel Pink talking about his “A Whole New Mind: Why Right Brainers Will Rule The Future,” to closing speaker Tony Hsieh’s advice on how to achieve happiness, the convention is packed with more opportunities to learn the latest trends, techniques, and technologies than in any year past.</p> <p>Sunday, Sept. 18, is becoming an “extra” convention day. For the fourth year, NCAL Day holds a series of sessions cov<img width="243" height="185" class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/0811/MandalayBay.jpg" alt="" style="margin:15px;width:190px;height:167px;" />ering all things assisted living: Becoming the Totally Responsible Leader: Serving and Empowering Others; the Seven Keys to Exceptional Customer Service; Advanced Rapport and Communication Skills; Maximizing Return on Your Training Investment; and much more for a total of six possible CEUs.</p> <p>Joining NCAL Day on Sunday this year is a Regulatory Mega Session featuring an update from AHCA leaders and a segment on preventable hospitalizations led by AHCA’s David Gifford, MD, along with Steven Jencks, MD, a recognized expert in the field.</p> <p>Next comes three days full of a wide array of symposia, with time set aside for viewing the wares of 300 vendors on the trade show floor.</p> <p>Following are a few examples of the sessions being offered.Administrator Roundtable Discussion<br>Leaders: Donald Wilson, executive director, The Village at Northrise, Las Cruces, N.M.; Bob Lanza, executive director, Genesis HealthCare, Kennett Square, Pa.; Angela Moore, RN, Sharon Lane Health Services, Shawnee, Kan.; Lisa Evans, administrator, Lynwood-ManorCare, Lynnwood, Wash.; and Peggy Connorton, manager, LTC Trend Tracker, AHCA</p> <div>This first-time opportunity will give administrators the chance to network with peers from across the country about common operational issues and concerns such as census, labor, and leadership and share best practices to deal with them.</div> <div> </div> <div>A number of sessions deal with survey. Among them are:</div> <h3 class="ms-rteElement-H3">S-1 F441 Infection Control: An Outbreak of Citations</h3> <div><em>Leader: Karen Hoffmann, RN, MS, CIC, associate director, NC Statewide Program for Infection Control and Epidemiology, and clinical instructor, Division of Infectious Diseases, University of North Carolina, Chapel Hill, N.C.</em></div> <div> </div> <div>There are a high number of F441 tags nationally due to emphasis by the Centers for Medicare & Medicaid Services (CMS) on zero-tolerance events such as hospital-acquired infections and rehospitalizations. Effective partnerships among health care providers are vital for the protection of patients and the facility.</div> <div> </div> <h3 class="ms-rteElement-H3">S-4 F322, F329, and F333 Medication Tags: Push the Cart But Mind the Speed Bumps</h3> <div><em>Leader: Linda Jennings, director of clinical services, Tennessee Health Care Association, Nashville, Tenn.</em></div> <div>With government interest in medication issues and the elderly, it is likely that CMS’ emphasis on these particular tags will only increase. This session is designed to help providers evaluate and minimize their risk by identifying potential opportunities for errors in the medication pass process and developing systematic strategies to reduce their occurrence.</div> <div> </div> <h3 class="ms-rteElement-H3">Measuring Person-Centered Care: Origins and Emerging Developments</h3> <div><em>Leaders: Mary Tellis-Nayak, vice president, quality initiatives, My InnerView, Chicago, and Michael Lepore, PhD, research associate, Brown University, and director of quality research and evaluation, Planetree, Derby, Conn.</em></div> <div><em></em> </div> <div>Creating a home-centered environment is a goal of many providers, and this session discusses the strategy for implementing culture change methods. Planetree, My InnerView, Brown University, and the IDEAS Institute have partnered to establish criteria and measures for identifying the achievement of person-centered excellence in long term care. Participants will learn how the tool works, how they can apply it in their own facilities, and how to market their communities based on their culture change initiatives.</div> <div> </div> <h3 class="ms-rteElement-H3">Quality Improvement Through Staff Stability and Engagement: What You do Matters</h3> <div><em>Leaders: David Farrell, director of organizational development, SNF Management, West Hollywood, Calif.; Barbara Frank, co-founder, B&F Consulting, Warren, R.I.; and Cathis Brady, co-founder, B&F Consulting, Canterbury, Conn.</em></div> <div> </div> <div>This session presents a new approach to leadership that offers proven, practical strategies participants can immediately implement to achieve sustained stability, engage their staff, improve care, and achieve high performance. Leaders will explore how specific management practices generate positive staff, resident, and organizational outcomes.</div> <div> </div> <h3 class="ms-rteElement-H3">What is an ACO? A Bundle? A Medical Home? How Does Post-acute Care Fit <br>Into The New Models?</h3> <div><em>Leaders: John Richter, CPA, executive principal, principal-in-charge, LarsonAllen, Charlotte, N.C.; Jill Mendlen, chief executive officer (CEO), LightBridge Hospice, San Diego, Calif.; and Nancy Rehkamp, principal, health care, LarsonAllen, Minneapolis</em></div> <div> </div> <div>The future involves innovative post-acute and long term care payment reform and care models and involves partnering with hospitals and other post-acute providers. This session will help providers understand the new concepts and, most importantly, help them </div> <div>to react to changes and develop vital strategies.</div> <h3 class="ms-rteElement-H3">Making Data Work For You: Practical Strategies For Applied Business Intelligence</h3> <div><em>Leaders: Mark Pavlovich, director operations analysis, SavaSeniorCare Administrative Services, Atlanta, and Steven Littlehale, executive vice president, healthcare and chief clinical officer, PointRight, Lexington, Mass.</em></div> <div> </div> <div>This session was designed for the person who is drowning in data, understands the importance of it, but needs strategies for maximizing what the data say and turning them into actionable goals. </div> <div>This presentation will provide practical strategies for implementing Business Intelligence into the everyday workplace and demonstrate how fact-based decision making turns data into action.</div> <h3 class="ms-rteElement-H3">Maximizing the Impact Of Environmental Staff</h3> <div><em>Leaders: Susan Gilster, PhD, executive director, and Jennifer Dalessandro, assistant administrator, Alois Alzheimer Center, Cincinnati</em></div> <div> </div> <div>The success of an organization is dependent upon all employees—on every shift and in every department. To think otherwise is to doom the organization to mediocrity and prevent staff from achieving high levels of performance in the future.</div> <div> </div> <div>This session will discuss the impact and roles of environmental staff in long term care and share a means of integrating them into the organization, breaking down silos, and facilitating true teamwork. Cost-effective, sustainable programs will be shared.</div> <h3 class="ms-rteElement-H3">Administrator And Physician: A Partnership That Must Happen</h3> <div><em>Leader: Keith Krein, MD, chief medical officer, Kindred Healthcare, Louisville, Ky. </em></div> <div> </div> <div>A successful relationship with physicians is critical to maintaining census and generating desired clinical outcomes. </div> <div> </div> <div>Understanding is the first step in building relationships and impacting both strategic business opportunities and clinical practice at the facility. </div> <div> </div> <div>It is critical for nursing facility administrators to act strategically and take the lead on understanding physician concerns and how this will impact the quality of care and referral patterns in the marketplace. The session will offer a variety of different physician engagement models and tips for working well with doctors.  </div>From an opening session featuring New York Times best-selling author Daniel Pink talking about his “A Whole New Mind: Why Right Brainers Will Rule The Future,” to closing speaker Tony Hsieh’s advice on how to achieve happiness, the convention is packed with more opportunities to learn the latest trends, techniques, and technologies than in any year past. 2011-08-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0811/welcometoVegas_thumb.jpg" style="BORDER:0px solid;" />QualityColumn8
Nursing Website Unveils New Learning Moduleshttps://www.providermagazine.com/Issues/2011/Pages/0811/Nursing-Website-Unveils-New-Learning-Modules.aspxNursing Website Unveils New Learning Modules<p>​</p> <p>The American Association for Long Term Care Nursing (AALTCN) has launched a new interactive Learning Community in the form of a new section on the association’s website.<br></p> <div>The modules, found in the Education section of <a href="http://www.ltcnursing.org/">www.LTCNursing.org</a>, offers a number of resources covering a variety of topics relevant to long term care nurses.</div> <div><strong></strong> </div> <div><strong>Many Conditions Covered</strong></div> <div><div>Learning Community topics include diabetes, safety, culture change, incontinence, infection prevention, safe-patient handling, transitioning home safely, and wounds. Facts, data, and statistics have been gathered from industry professionals for presentation in this new central location. </div> <div>Downloadable quick-fact sheets are also easily accessible. </div> <div> </div> <div>AALTCN said the Learning Community is unique because of its several interactive features. These include: Ask the Diabetes Nurse Specialist, Ask the Wound Coach, the Coaching Corner, and Ask the Incontinence Experts pages. Each of the pages gives readers platforms for submitting questions and receiving timely responses from industry experts.</div> <div> </div> <div>The AALTCN Learning Community is made possible by grants offered by the Wound Care Education Institute, Diabetes CareWorks, Tranquility Incontinence Products, Cleanwaste, SafetyNet America, Romedic, Health Education Network, and others.</div> <div> </div> <div>AALTCN works to provide relevant educational resources that bridge current best practices with bedside practice, bring visibility and respect to long term care nursing caregivers, advocate for them, and support and promote excellence in care for consumers of long term care.</div> <div> </div> <div>The culture change module offers a list of six downloadable fact sheets, which include one on core competencies for nurses in culture change.</div></div> The modules, found in the Education section of www.LTCNursing.org, offers a number of resources covering a variety of topics relevant to long term care nurses.2011-08-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/comp_nurse_thumb.jpg" style="BORDER:0px solid;" />Column8




2011 AHCA/NCAL Annual Awardshttps://www.providermagazine.com/Issues/2011/Pages/0911/2011-Annual-Awards.aspx2011 AHCA/NCAL Annual Awards​<div>​The American Health Care Association and the National Center for Assisted Living proudly announce the 2011 Volunteers of the Year—Adult, Young Adult, and Group; NCAL Administrator and Noble Caregiver of the Year; Assisted Living Nurse of the Year; Assisted Living Week Programming Award; Developmental Disabilities Hero of the Year; and Not-for-profit Community Benefit Program of the Year. The individuals who have earned this recognition give the greatest gift of all—time spent with and for others.</div> <div> </div> <h2 class="ms-rteElement-H2B">Doyle Smith, Adult Volunteer of the Year</h2> <div>“Doyle Smith is a man of service,” says Jack Whitaker, executive director of Willow Health Care, which oversees a network of senior services and housing, including the 90-bed Mountain View Healthcare, Mountain View, Mo., where Doyle volunteers.</div> <div> </div> <div>What does Doyle do to earn such accolades? Just about everything asked of him, it seems. “Anything you need or want done, Doyle is there,” says Mountain View Administrator Roy Pace, RN. </div> <div> <img class="ms-rteImage-2 ms-rtePosition-1" alt="Doyle Smith, Adult Volunteer of the Year" style="margin:15px 10px;" /></div> <div style="text-align:left;">At Mountain View, Doyle does what everyone should do—listen, care, and give a helping hand. He can be a baker, server, grounds keeper, friend, transporter, shopper, and fundraiser extraordinaire. </div> <div> </div> <div>As president of the volunteer program, Doyle spreads the volunteer spirit communitywide and not just to his friends, but to local businesses and organizations like the Veterans of Foreign Wars, of which he is a member. Doyle’s nomination form for this award read like a yearly summary of a facility’s activities program, with events too numerous to list. When it comes to what the residents think, there is no hesitation: Lucille McAlister says Doyle is a “very kind man and can converse on almost all topics.” </div> <div> </div> <div>Buster Davis says, “Doyle could be fishing or hunting, but he chooses to hang out with us old folks.” </div> <div>Blanche Cook thinks Doyle can cook burgers and hot dogs really well, but his pancakes are the best!” </div> <div style="text-align:right;">–Tom Burke</div> <div style="text-align:left;"> <span class="ms-rtestate-read ms-reusableTextView">:##:</span></div> <h2 class="ms-rteElement-H2B">Robin Aman, NCAL Administrator of the Year</h2> <div style="text-align:left;">Robin Aman exemplifies the qualities of a committed and heartfelt administrator of an assisted living community, successfully leading her staff in enriching the lives of their residents.  </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Located in Stevenson, Wash., Rock Cove Assisted Living is a nonprofit, affordable assisted living community for seniors and individuals with disabilities.  </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Rock Cove residents benefit from Aman’s love and dedication to the greater community. “When someone moves in, we don’t just help tend to their needs, we adopt them as family,” she says.   </div> <div style="text-align:left;">Aman is currently working on a grant to enhance Rock Cove’s intergenerational program between local school students and her residents. She tries to keep the residents active in the community, whether it’s Easter egg hunts, an annual wine-tasting fundraiser, or taking residents out to judge the Christmas tree lights. Thanks to Aman, every Stevenson town event involves the Rock Cove residents.</div> <div style="text-align:left;"><img class="ms-rteImage-2 ms-rtePosition-2" alt="Robin Aman, NCAL Administrator of the Year" src="/Issues/2011/PublishingImages/0911/SA_Robin-Amin.jpg" width="434" height="514" style="margin:15px 10px;width:356px;height:308px;" /><br>Within Rock Cove, she works with residents to involve them in meaningful activities and adventures. For example, she took a resident on a hot air balloon ride for a 90th birthday celebration. She’s taken an 87-year-old-resident to a horse ranch so the resident could go horseback riding after not having ridden for 20 years.</div> <div style="text-align:left;"> </div> <div style="text-align:left;">“This award is not something that is earned by one person; it is earned together as a team,” Aman says. “I have the most wonderful team of staff that work hard and well together to achieve great things. I know my staff commitment toward our residents comes from their hearts.  </div> <div style="text-align:left;"> </div> <div style="text-align:left;"> “There are challenges every day, but I believe in tackling them with a smile and a positive attitude,” she says. “There is nothing we can’t accomplish together.”</div> <div style="text-align:left;"> </div> <div style="text-align:left;">Aman loves her life’s work at Rock Cove. “To see the tears of joy in residents’ eyes and make them sparkle again is so heart warming.  </div> <div style="text-align:left;"> </div> <div style="text-align:left;">“They make my life complete,” she says. “So to be recognized for our hard work, fun, and dreams is an accomplishment beyond my expectations.” </div> <div style="text-align:right;">–Lisa Gelhaus</div> <div style="text-align:right;"> </div> <div><div><h2 class="ms-rteElement-H2B">Eugene Ring, Noble Caregiver in Assisted Living</h2></div></div> <div style="text-align:left;">During the day, Eugene Ring is the Heritage at Dover’s (Del.) environmental engineer. In the summertime, he might be grill master, and at Christmas time he’s Santa Claus.</div> <div style="text-align:left;"><img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/SA_Eugene-Ring.jpg" width="264" height="396" alt="" style="margin:15px 10px;height:176px;" /><br>Ring received the award because he has demonstrated outstanding person-centered care that contributed to the well-being of his colleagues and residents. His former supervisor, Executive Director Vickie Cox, gives him great praise.</div> <div style="text-align:left;"> </div> <div style="text-align:left;">“In the five years Eugene has been with us,” Cox says, “he has improved the well-being and overall morale of this community with his everyday outgoing attitude, demonstration of initiative, and by going above and beyond his regular duties.”</div> <div style="text-align:left;"> </div> <div style="text-align:left;">For instance, every year he hosts residents and staff for an annual picnic at his home. He started a resident men’s group and takes the male residents out to breakfast once a month. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Ring builds wooden cases for residents and staff to display their handmade quilts and helps them move furniture when he’s supposed to have a day off. He responds to residents’ alarms going off and calms their fears without complaint, Cox says. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Ring has implemented changes within the residence that increased residents’ safety by removing hazards that could cause them to fall.</div> <div style="text-align:left;"> </div> <div style="text-align:left;">Ring’s outstanding demonstration of customer service extends to his co-workers. For example, he performs home repairs for co-workers who can’t afford to hire someone. He helped a co-worker’s widow with her vegetable garden, which delivers locally grown vegetables to residents and staff. </div> <div style="text-align:left;">“His work is his life, his life is his work,” Cox says. </div> <div style="text-align:right;"> –Lisa Gelhaus</div> <div style="text-align:right;"> </div> <div style="text-align:right;"><span class="ms-rtestate-read ms-reusableTextView">:##:</span> </div> <h2 class="ms-rteElement-H2B">Rachel Ellis, NCAL Assisted Living Nurse of the Year</h2> <div style="text-align:left;">Rachel Ellis is assistant administrator of resident care at Gardens at Osage Terrace, a 45-unit assisted living facility in Bentonville, Ark., that serves seniors with low incomes who are Medicaid-eligible.  </div> <div style="text-align:left;"><img class="ms-rteImage-2 ms-rtePosition-1" alt="Rachel Elis, NCAL Assisted Living Nurse of the Year" src="/Issues/2011/PublishingImages/0911/SA_Rachel-Ellis.jpg" width="185" height="156" style="margin:15px 10px;width:156px;" /></div> <div style="text-align:left;">“Her everyday work ethic, compassion, empathy, and heartfelt care make a difference in the lives of seniors,” says Kim Goins, administrator of the Gardens. “Anytime you see Rachel with residents, family members, other staff, or physicians, you can tell she is mindful about them.” </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Ellis’ outstanding compassion and person-centered care was demonstrated when, after a resident’s daughter died, Ellis took the afternoon off and took the resident out for some ice cream just like her daughter used to do. Ellis helped the resident grieve by listening and reminiscing with her. Ellis is often found checking in on residents to make sure things are going well.</div> <div style="text-align:left;"> </div> <div style="text-align:left;">“We are so proud because Rachel truly demonstrates leadership qualities that inspire her staff members to deliver care and services that the residents find highly satisfying,” says Donna Childress, executive director of the Arkansas Health Care Association/Arkansas Assisted Living Association. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Ellis’ commitment to the betterment of others transcends her role as a supervisor into a role model and mentor of staff. “She knows that caring for the elderly, a team must run smoothly, have the desire to work as a unit, be well trained, and have the support they need,” Goins says. “Residents and staff in our community describe her as guiding, outgoing, respected, strong-willed, and a truly rare person.”</div> <div style="text-align:left;"> </div> <div style="text-align:left;">“True heartfelt emotions are not something you learn, it is a gift,” Goins says. “Ellis displays this attitude to everyone, and because of that she is an amazing role model, mentor, and supervisor.”</div> <div style="text-align:right;">–Lisa Gelhaus</div> <div style="text-align:left;">  </div> <h2 class="ms-rteElement-H2B">Beth Atkinson, Developmental Disabilities Hero of the Year</h2> <div style="text-align:left;">Beth Atkinson is the director of person-centered living at Seven Hills Pediatric Center, Groton, Mass. She takes that title very seriously and is an ardent advocate for culture change. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">“Beth seeks out the best in residents and is capable of teaching others to see these qualities as well,” says Holly Jarek, administrator and vice president of this 83-bed facility. So much so that she put the town’s Memorial Day parade on the activities schedule but not just to watch, to participate. </div> <div style="text-align:left;">One of Beth’s visions, honed over a 22-year career, is to demonstrate that life for her residents is not just about medical care and “medical problems.” Under her guidance, social isolation is a rare thing at Seven Hills. </div> <div style="text-align:left;"><img class="ms-rteImage-2 ms-rtePosition-2" alt="Beth Atkinson, Developmental Disabilities Hero of the Year" src="/Issues/2011/PublishingImages/0911/SA_Beth-Atkinson.jpg" style="margin:15px 10px;" /><br>That Memorial Day parade, with staff and clients participating, is emblematic of Beth’s focus on community. She knows that parades make everyone feel a sense of belonging and that everybody has a role—including Seven Hills. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Her goal was to be seen as part of the community, not in a passive role, but as active participants in an important community event. To everyone’s surprise, the facility’s entourage received a standing ovation from spectators that fine May Day and earned a new sense of belonging and of pride.  </div> <div style="text-align:left;"> </div> <div style="text-align:left;">There is a lot more to Beth’s tenure at Seven Hills. For example, she originated a facilitywide “Into the Community” program whereby residents go to classes and programs at public schools at least twice a week. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">“Her insight and passion is a major factor in our culture that embraces empowering individuals and families,” says Mary Cassidy, director of education and therapy. “She is a role model for staff, a teacher for many, and a loving and compassionate person.” </div> <div style="text-align:right;">–Tom Burke</div> <div style="text-align:left;"> </div> <h2 class="ms-rteElement-H2B"> <span class="ms-rtestate-read ms-reusableTextView">:##:</span></h2> <h2 class="ms-rteElement-H2B">Maplewood Volunteers-In-Partnership Group Volunteers of the Year</h2> <div style="text-align:left;">The Cheektowago, N.Y.-based Maplewood facility’s volunteer group, Volunteers-in-Partnership (VIP), includes more than 60 people who collectively give new meaning to the idea of being beacons of hope. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">“Where would we be without them?” says Administrator Scott West. When asked about what the VIPs do, West is definitely not lost for activities: cooking, baking, crafting, playing games, hosting themed parties, holding ethnic dinners, organizing outings, organizing pastoral services, operating the gift shop, pet visiting, friendly visiting, delivering mail and newspapers, and, in general, “ensuring that residents’ wishes come true.” </div> <div style="text-align:left;"> </div> <div style="text-align:left;">The VIPs give residents voices and choices and encourage residents to think independently. The group sounds so busy, yet David Sortisio, son of a resident, beams. “The volunteers spend quality time with my mom and get her involved. I can’t say how much this means to me,” he says. “They are a great group!” They also provide those same qualities to the staff, along with the pleasure of knowing the “community” is in the house. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">“I consider it a privilege to count them as part of our activities team,” says Debbie Peters, director of activities at Maplewood.</div> <div style="text-align:right;">–Tom Burke</div> <div style="text-align:left;"> </div> <div style="text-align:left;"> </div> <h2 class="ms-rteElement-H2B">Maple Leaf Health Care Center Not-for-profit Community <br>Benefit Program of the Year</h2> <div style="text-align:left;">“Life may change, but it never gets old,” is not part of the vision or mission statement at Maple Leaf Health Care Center, Manchester, N.H., but it certainly gives a glimpse into its culture. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">The Maple Leaf program is a bi-monthly Healthcare Wellness Clinic, free to participants, where individuals can access clinicians and general health care services such as blood pressure, heart rate, and weight monitoring. </div> <div style="text-align:left;"><img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/SA_Maple-Leaf.jpg" alt="" style="margin:15px 10px;width:155px;height:117px;" /><br>Program-wise, even after all these years, flexiblity is the watchword for Maple Leaf.</div> <div style="text-align:left;"> </div> <div style="text-align:left;">“They have been very responsive designing programs based on resident input, specific need, and general feedback, observes Dick Dunfey, executive director of ElderTrust of Florida, which manages the property. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Maple Leaf’s staff have the knowledge and resources to incorporate and manage new programs seen as needed. </div> <div style="text-align:right;">–Tom Burke</div> <div style="text-align:left;"> </div> <h2 class="ms-rteElement-H2B">Ponderosa Retirement<br>National Assisted Living Week Programming Award</h2> <div style="text-align:left;"> </div> <div style="text-align:left;">Living life is just what the residents of the Ponderosa Assisted Living Community, in Yakima, Wash., did during the 2010 celebration of National Assisted Living Week. Thanks to the residents, family members, and Ponderosa staff, everyone had a good time. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">This recognition means that Ponderosa successfully incorporated the 2010 National Assisted Living Week (NALW) theme, “Living Life,” into their activity plans. </div> <div style="text-align:left;"><br>The theme of the first day of NALW events was “Living Life: Family Food Vacation!” Family was celebrated with a kids’ carnival that allowed several generations to share in the experience of watching grandchildren get their faces painted or getting their photos taken behind a face cutout placard. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Monday’s theme was “Living Life: Our Own Community Involvement!” During lunch, staff hosted a trivia contest about state and local news events. Another trivia game, titled, “Who Are Your Representatives,” featured questions about federal, state, and local lawmakers. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Ponderosa’s own residents, DeWitt McAbee and Bill McDowell, sang songs afterward. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">“Living Life: Frugally and Financially Responsibly in Order to Live Luxuriously” celebrated how saving money can allow people to enjoy luxuries in life. After a morning scavenger hunt, resident price-watchers showed off their skills in a trivia contest about the best buys of today, food prices, and tax-deductible items. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">The day ended with a lavish social hour and gala dinner.</div> <div style="text-align:left;"> </div> <div style="text-align:left;">The week ended with “Living Life: Gratitude to Those Who Serve!” A staff appreciation brunch was held. Women received facial treatments, manicures, or massages, and men took a day trip to the Yakima Flight Museum. </div> <div style="text-align:right;">–Lisa Gelhaus</div> <div style="text-align:left;"> <span class="ms-rtestate-read ms-reusableTextView">:##:</span></div> <div style="text-align:left;"> </div> <h2 class="ms-rteElement-H2B">Braden Stover, Young Adult Volunteer of the Year</h2> <div style="text-align:left;"><img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/SA_BradenStover.jpg" width="323" height="212" alt="" style="margin:15px 10px;height:218px;" /><br>Tag this volunteer a “Rising Star.” In 2007, Braden Stover was named the volunteer of the year at the Clarksburg Nursing and Rehabilitation Center, in Clarksburg, W.V. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Now, in 2011, at the age of 16, he is the Young Adult honoree at both the state (West Virginia Health Care Association) and national levels. And in between these honors Braden has continued entertaining the residents at the Clarksburg facility, while also advancing his singing and songwriting career, which includes being an American Idol contestant, recording songs in Nashville, and performing at events.</div> <div style="text-align:left;"> </div> <div style="text-align:left;">“Despite his success and hectic schedule, Braden still makes time to perform for his second love, our residents,” says Linda Curry, activities director. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Braden has performed at the facility, guitar in hand, since he was eight years old, and residents nurture and encourage his budding musical career. Not surprisingly, his Sunday afternoon concerts are extremely popular and have helped him hone a style and maturity beyond his years. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">“You could not find a brighter, more active advocate for our residents,” says Phillip Donnelly, executive director of the facility. </div> <div style="text-align:left;"> </div> <div style="text-align:left;">Residents Martha and Betty summarize his value to the residents: “He is a wonderful human being who is also talented—and cute!”  </div> <div style="text-align:right;">–Tom Burke</div>The American Health Care Association and the National Center for Assisted Living proudly announce the 2011 Volunteers of the Year.2011-09-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0911/SA_Robin-Amin_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality AwardsAHCA/NCAL Annual Awards9
Acts Of Kindnesshttps://www.providermagazine.com/Issues/2011/Pages/0911/Acts-Of-Kindness.aspxActs Of Kindness<div>​​For more than 15 years in Southern California, Arnold Bresky, MD, has been forging the way in dementia research and successfully treating patients, some of them well into their nineties. As an integrative physician, he believes that pills and surgery are necessary but are not sufficient. </div> <div> </div> <div>Moreover, he believes in Western medicine, but some of his prescriptions might sound a bit unusual. They include laughter, music, art, dancing, random acts of kindness, and even knitting. </div> <div> <img width="328" height="699" class="ms-rteImage-2 ms-rtePosition-2" alt="Arnold Bresky, MD" src="/Issues/2011/PublishingImages/0911/Dr-Bresky.jpg" style="margin:10px 15px;width:205px;height:308px;" /><br>His scientific, evidence-based, and durable whole-person-centered care began in Southern California where he treats thousands of older adults who suffer from various forms of dementia. “I marry hope to science,” said Bresky, 71. </div> <div> </div> <div> “My methods are preventive in nature and are designed to delay Alzheimer’s disease, which is our national epidemic, and slow the process of cognitive decline through behavior modification.”  </div> <h3 class="ms-rteElement-H3">Connecting Both Sides Of The Brain </h3> <div>Bresky believes that depression and a lack of meaning and purpose in life are huge factors in cognitive decline. It was this belief that inspired the Hands of Kindness program, which he started within an Alzheimer’s assisted living facility in Pasadena, Calif. He asked his patients to knit blankets for the homeless that would be distributed by the local fire department personnel. </div> <div>  </div> <div>The results even surprised Bresky. </div> <div> </div> <div>The goal of Hands of Kindness is to deliver lovingly handmade knitted or crocheted items by residents of senior living communities to charitable organizations. In the process, connections are made between the seniors’ skills and the recipient adults and children. </div> <div> </div> <div>According to the organization’s website, “this humanitarian project will include assistance and cherished moments of giving. It can incur positive change in people as they work together and create fulfilling lives.”</div> <div> </div> <div>“Research has shown that working with numbers and patterns can improve cognition,” says Bresky. “The numbers are on the left side of your brain, the patterns are on the right side. What I’m doing is connecting the two sides. It was like my patients were slowly waking up and recognizing where they were. They began smiling more often and laughing. That’s powerful medicine.” </div> <div> </div> <div>There are now two chapters of Hands of Kindness, one in Southern California and one in the Fresno area. Bresky hopes that senior facilities across the nation will promote new chapters, which he believes will bring community awareness to the plight of dementia sufferers while easing their symptoms and improving their quality of life by erasing invisibility.  </div> <h3 class="ms-rteElement-H3">Purpose And Pride </h3> <div>Judi Magarian-Gold heads up the Central Valley chapter of <a href="/Issues/2011/Pages/0911/Start-a-Chapter.aspx">Hands of Kindness</a>. “We started with four assisted living groups in November of 2008,” she says. “Now we have 11.” </div> <div> </div> <div>Magarian-Gold’s own mother suffered from dementia but continued to participate in needle crafts. “She was able to remember the motor skills involved and was quick to fix mistakes,” she says.</div> <div> </div> <div><img width="236" height="232" class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/feature_Hands-of-Kindness-2.jpg" alt="" style="margin:10px;" />Bresky says that science has proven that having purpose in life and performing simple acts of kindness can help prevent cognitive decline in older adults and significantly delay the devastating signs and symptoms of Alzheimer’s. “It’s also an outreach to the community,” he says. </div> <div> </div> <div>“The needy and sick get handmade caps and blankets, and the community becomes more aware of those who suffer with dementia.”</div> <div>Magarian-Gold says the program encourages the residents to participate, and while they knit, crochet, and make blankets, they’re also socializing with one another, which, in itself, fosters self-confidence. </div> <div> </div> <div>The project also gives the participants a sense of purpose and pride. “Many of them tell me how good it makes them feel to help others,” she says. “The recipients also feel great to receive a handmade item.” </div> <div> </div> <div>Karen Everett Watson is a freelance journalist and a certified gerontologist through her company Legacy Letters. She facilitates reminiscence sessions at local assisted living facilities and is also a regular blogger for Cisco & Co., a mature market advertising firm. She may be reached at Watson@softcom.net.</div>For more than 15 years in Southern California, Arnold Bresky, MD, has been forging the way in dementia research and successfully treating patients, some of them well into their nineties. As an integrative physician, he believes that pills and surgery are necessary but are not sufficient. Moreover, he believes in Western medicine, but some of his prescriptions might sound a bit unusual. They include laughter, music, art, dancing, random acts of kindness, and even knitting. 2011-09-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0911/feature_Hands-of-Kindness-thumb.jpg" style="BORDER:0px solid;" />Caregiving;Management;Quality;Culture ChangeColumn9
New York Lawmaker In Touch With Health Care Debatehttps://www.providermagazine.com/Issues/2011/Pages/0911/Congressional_Profile_0911.aspxNew York Lawmaker In Touch With Health Care Debate<p>​<img width="276" height="1127" class="ms-rteImage-2 ms-rtePosition-1" alt="Nan Hayworth" src="/Issues/2011/PublishingImages/0911/Nan-Hayworth.jpg" style="margin:5px 10px;width:175px;height:263px;" />Even the most experienced lawmakers in Washington realize these are not easy times for making political decisions on how to reduce spending while at the same time preserve the Medicare and Medicaid programs that most Americans view as a sacred trust between the people and government. </p> <p>For newcomer Nan Hayworth, MD, the freshman Republican representative from upstate New York’s 19th district, these past months have only solidified her belief that solutions exist for maintaining obligations to seniors and at the same time rein in out-of-control government spending.</p> <p>Indeed, even as a first-termer, she became a leader in this summer’s debt ceiling debate in the House, speaking to the need for solving problems in this current era of charged political rhetoric.</p> <p>“I didn’t come here with any preconceived notions. I have just concentrated very hard on the job and have been inspired by the fact so many men and women [in the House and Senate] are dedicated to doing the right thing. We have to do what is best for our country as a whole,” Hayworth says, noting the ceiling had to be raised to prevent serious economic consequences, but not paid for by raising taxes.</p> <p>She voted for her party’s budget proposal last spring, which did not get anywhere in the Senate, to tighten government spending, partly by converting the Medicare program to a premium support format. Under this model, the current Medicare program would be replaced by a system of competing public and private health plans, with the federal government contributing a set amount toward the purchase of Medicare coverage, based on the premiums charged by the different plans.</p> <p>“The House majority plan preserves Medicare in ways the Accountable Care Act [health reform law] does not,” Hayworth says, noting that the current system puts limits on what providers can be reimbursed for, hurting the ability of doctors to do their jobs while remaining in the program. Medicare losing doctors and making access for seniors difficult is a growing problem, she notes.</p> <p>An opthamologist by profession, Hayworth is in tune with the health care debate in Congress more than most legislators. She has first-hand experience with caregiving; navigating federal and state reimbursement systems; and dealing with a myriad of medical, labor, and legal issues tied to modern doctoring. “A lot of my patients received Medicare,” she says.</p> <p>She has definite opinions on the reform law, saying she supported repeal when the House approved such action in January, while at the same time suggesting the goals of the reform effort are worthwhile. “It’s just bad mechanisms” within the president’s plan that make it way too costly, she says, adding, “it costs far more than it will benefit us.”</p> <p>In her congressional district, health care, and care for the elderly are big issues. She says it is inevitable with the aging of the population as a whole that long term care is a priority issue in Washington. </p> <p>The daughter of World War II veterans, both father and mother, Hayworth says it is true that the generation that survived the Great Depression and won the war requires proper care in their old age, through programs like Medicare and Medicaid. </p>The daughter of World War II veterans, both father and mother, Hayworth says it is true that the generation that survived the Great Depression and won the war requires proper care in their old age, through programs like Medicare and Medicaid. 2011-09-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0911/Nan-Hayworth_thumb.jpg" style="BORDER:0px solid;" />PolicyColumn9
Constructive Approaches to Common Problems in Skilled Nursing Facilitieshttps://www.providermagazine.com/Issues/2011/Pages/0911/Constructive-Approaches-to-Common-Problems.aspxConstructive Approaches to Common Problems in Skilled Nursing Facilities​<div>​<img width="470" height="362" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/0911/coverstory.jpg" alt="" style="margin:10px;height:335px;" /><br>The “same old” approach to persistent disease conditions in long term care isn’t good enough any more, experts say.</div> <div>The patient population in this setting is different than it was 10 or 20 years ago, and so is how such conditions are addressed. Developments and promising trends in treatments, medications, and diagnostics are designed to improve outcomes and increase efficiency. </div> <div>Expect to see more such innovations, as accountable care and penalties for rehospitalizations and the occurrence of “never events” become the norm and facilities wrestle with cost, coverage, and reimbursement cuts.</div> <div>At the same time, long term care has entered a new age of technology, clinical discovery, and <a href="/Issues/2011/Pages/0911/Sitting-Down-To-Desktop-Medicine.aspx"><font color="#0072bc">personalized care</font></a> that will have a growing impact on care and outcomes. </div> <h3 class="ms-rteElement-H3">The New Model</h3> <div>What kinds of innovations are happening in long term care? “There definitely is an increasing recognition of the need to develop better systems of care,” says Jason Karlawish, MD, professor </div> <div>of medicine and medical ethics, University of Pennsylvania. </div> <div> </div> <div>William Day, DPh, FASCP, president and chief executive officer, Pharmaceutical Consulting Services of America, New Orleans, adds, “As we move to practicing more person-centered care, we increasingly are approaching care from a global perspective. We’re seeing an emphasis on systems that involve all appropriate team members—with the patient at the center—and set goals accordingly.”</div> <div> </div> <div>Since the average long term care resident has multiple chronic conditions, it isn’t surprising that he or she also is taking several medications—an average of eight or more. But there currently is a focus on making medications just part of treatment, not the central or main component. Many of the recent innovations have to do with early diagnosis and prevention, Karlawish notes. </div> <div> </div> <div>“There will be more vigorous debates in the coming years about whether drugs are cost-effective.” He says, “Professionally, I’m glad that we are having these debates. I think we will look increasingly at patient-reported outcomes; that is, if people taking medications actually do better.”</div> <h3 class="ms-rteElement-H3">Diabetes: Slipping Away From Sliding Scale</h3> <div>Formerly the standard of care, prolonged use of sliding scale insulin (SSI) therapy generally is now not recommended in long term care facilities, and practitioners increasingly are moving patients from SSI to basal bolus insulin therapy. </div> <div> </div> <div>According to the AMDA—Dedicated to Long Term Care Medicine—“Clinical Practice Guideline on Managing Diabetes in the Long Term Care Setting,” widespread use of SSI results in greater patient morbidity and increased nursing time because patients’ blood glucose levels must be monitored more frequently, and more insulin injections must be given. Additionaly, the patient’s activities and quality of life may be compromised.</div> <div> </div> <div>John Morley, MB, BCh, Dammert professor of gerontology and director of the division of geriatric medicine, St. Louis University, says, “Sliding-scale insulin generally isn’t good for various reasons. You’re really giving someone insulin after the fact.” Hypoglycemia actually occurs more often with SSI therapy than it does using a basal-bolus regimen, he says.</div> <div> </div> <div>Reducing waste and unnecessary costs is one driver behind a move away from SSI in long term care. “Many providers now recognize that there is significant waste in the way the insulin vial is “sized.” On average, a facility wastes about 40 percent of the insulin it purchases in vials,” says Fred Wendt, RPh, a long term care pharmacist. </div> <div> </div> <div>He explains, “A vial contains 1,000 units, so if you multiply the average 20-unit dose by 28 days [the time period in which an open vial of insulin must be used], you have only 560 units administered. The rest is waste.</div> <div> </div> <div>“That’s about a $52 expense per vial, and that’s unconscionable.” This is propelling facilities to look at insulin pens more, says Wendt, because they have 300 units in them. For patients receiving average or less doses of insulin, these can be more cost effective. “The savings are enough to overcome the extra cost associated with needles for the pens,” he says.</div> <div> </div> <div>Dennis Stone, MD, CMD, MBA, a chief medical officer in Louisville, Ky., and former president of AMDA, agrees that waste is a big concern. “There is a clear issue with waste, and that is one reason we moved to the pen,” he says. “We expect to save tens of thousands of dollars or more.”</div> <div> </div> <div>However, cost isn’t the only issue driving the move to the pen. “It is a wonderful tool for the discharged patient going home,” says Wendt. With an emphasis on effective care transitions and ensuring that patients are not readmitted to the hospital after discharge due to avoidable problems, this is a plus for both patients and providers. </div> <div> </div> <div>“We see it all the time—we try to educate patients on insulin administration, and they have difficulty with it. Because the pen is easier to use, it is a confidence builder, especially with geriatric patients who are being discharged home,” Wendt says.</div> <div> </div> <div>Since the pens allow for more accurate dosing, they can contribute to better outcomes. </div> <div> </div> <div>“Hypoglycemia certainly is a concern with diabetes patients,” Wendt says. While this condition usually is mild and can be treated quickly, it can lead to confusion or dizziness that can result in a fall. At its most severe, hypoglycemia can lead to seizures or coma. It can be fatal. Better control means fewer instances of hypoglycemia and its consequences, Wendt says.</div> <div> </div> <div>Morley says that there are situations in which SSI is acceptable. However, Stone notes, “Except in the brittle diabetic and rare other instances, long term use of SSI is just not ‘good medicine.’ It’s not fair to the patient and takes time away from nursing that could be used to address other care needs.”</div> <div><span class="ms-rtestate-read ms-reusableTextView">:##:</span> </div> <h3 class="ms-rteElement-H3">Reassessing Tight Control</h3> <div>Another issue gaining attention in long term care is when tight control is appropriate. Morley stresses that tight control of diabetes in elderly patients may not always be an appropriate or realistic goal. In general, in fact, a hemoglobin A1C level between 7 and 8.5 is considered acceptable for most patients, including the elderly, says Morley; and not every patient necessarily should be held to the ideal goal of 7. </div> <div> </div> <div>As Stone says, “If I have a younger patient with a 20- to 30-year prognosis, he or she deserves tight control. But if I have an 85-year-old with multiple comorbidities, tight control may not be an appropriate or necessary goal. It really depends on the prognosis.” However, Stone says, “Elevated blood sugar does long-term damage to virtually every organ system in the body. The more patients learn about this, the more the ones with a good prognosis want to keep tighter control.”</div> <div> </div> <div>This move away from tight diabetes control in all cases is a big change, but it fits in with the philosophy of person-centered care. “You have to talk to patients about reasonable control, diet, lifestyle, and risks. If looser control doesn’t put them at great risk of hypoglycemia or other problems and he or she wishes to have a piece of cake, the patient’s wishes should be respected. At the same time, those who have had diabetes for years and are used to tight control should be allowed to continue this if they wish to do so,” says Day.</div> <div> </div> <div>Wendt agrees that individualized treatment—as part of person-centered care—is key to successful diabetes management. “While a Hemaglobin A1C of 7 is a good standard, a patient might not feel good at this level; so you have to do what is best for him or her,” he says. “Astute clinicians won’t just look at the A1C. They’ll consider the results of eye, foot, and skin exams. If you have a patient with an A1C of 8 who looks good, feels good, and is in generally good condition, why would you foist therapies on them that they don’t want or need?” </div> <div> </div> <div>Setting flexible goals also can help with patient compliance, says Wendt. “If you tell a patient with an A1C of 10 that they have to get it to 7 and he or she works really hard and only gets it to 9, that patient is more likely to give up. But if we say, ‘Great—you’re at 9, let’s try for 8,’ this lets the patient celebrate a small victory and is more likely to provide the incentive to keep trying,” he says.</div> <div> </div> <div>While older patients with diabetes with better controlled blood sugar are less likely to experience complications such as vision loss, heart attacks, strokes, or kidney failure, a new study seems to support the trend toward looser control. </div> <div> </div> <div>Researchers determined that older patients with the lowest blood sugar levels have a slightly higher chance of dying than those whose control is in the normal A1C level of 7-8, according to a 2001 study reported in Diabetes Care.  </div> <div> </div> <div>While they couldn’t determine whether increased risk of death was related to low blood sugar, the treatments or medications used to control the patient’s diabetes, or other factors, the authors say the data do suggest that aggressive control or treatment isn’t necessarily the appropriate goal for elder patients.</div> <div> </div> <h3 class="ms-rteElement-H3">A Personal Choice</h3> <div>Jonathan Marquess, PharmD, CDE, president of the Institute for Wellness and Education in Woodstock, Ga., says, “For people with diabetes, it is all about individualize, individualize, individualize.” He adds, “The goal is to get diabetes in control and not have huge swings up or down. </div> <div> </div> <div>We’re trying to get medications to patients that work more like their bodies’ own insulins and don’t just correct blood sugars reactively. Increasingly, this is a team activity that involves physicians, family members, and patients proactively. They share a common aim of helping the patient feel better and have a better quality of life.”</div> <div> </div> <div>Diabetes care also is at the center of recent efforts to improve care transitions. As Marquess says, “There is a greater understanding that patients who come to the nursing home from the hospital on sliding scale need attention. I have more medical directors consulting with me and saying, ‘We’re getting a patient from the hospital on SSI. We will keep him on that for a week, and then we want you to reevaluate.’” </div> <div> </div> <div>He adds, “I’m changing many of these patients to basal insulin and having success with that.”</div> <div>While the approach to diabetes treatment has evolved, new developments may lead to additional changes in the future. For example, an experimental drug designed to improve levels of “good” cholesterol improved blood sugar control in diabetic patients on statins, in one new study by the American Heart Association. While the medication was not as effective in managing diabetes as drugs commonly used to treat that condition, it did reduce the adverse impact on blood sugar commonly seen with statin use. </div> <div> </div> <h3 class="ms-rteElement-H3">Infection Control Takes Center Stage</h3> <div>There are many developments that could positively impact how infections are prevented and managed in long term care and other settings. Among them is Food and Drug Administration (FDA) clearance for the first test for Staphylococcus aureus (S. aureus) infections that can diagnose and distinguish methicillin-resistant infections (MRSA) from methicillin-susceptible (MSSA) ones. </div> <div> </div> <div>The KeyPath MRSA/MSSA Blood Culture Test can determine whether bacteria growing in a person’s positive blood culture sample are MRSA or MSSA in approximately five hours from the time bacterial growth is seen in the sample. The test doesn’t require any special instruments—beyond blood culture equipment—to get results, so it practically can be performed in any laboratory. Ideally, this test will enable practitioners to diagnose these conditions quicker and promptly implement precautionary measures to prevent spreads or outbreaks.</div> <div> </div> <h3 class="ms-rteElement-H3">Other Conditions Have New Remedies</h3> <div>Elsewhere, FDA recently approved Dificid (fidaxomicin) tablets for treating Clostridium difficile-associated diarrhea (CDAD). Two trials involving a total 564 patients with CDAD compared Dificid with the antibiotic vancomycin. The clinical response was similar between the two groups in both studies. However, more patients treated with fidaxomicin were still symptom-free after three weeks than those in the vancomycin group. </div> <div> </div> <div>To maintain the new drug’s effectiveness and avoid development of a drug-resistant bacteria, fidaxomicin should be used only to treat infections caused by or strongly suspected to be linked to C. difficile, according to FDA. The drug’s most common side effects are nausea, vomiting, headache, abdominal pain, and diarrhea. </div> <div> </div> <div>In another drug-related development, an old osteoporosis drug may be effective in killing influenza viruses, including the H5N1 bird flu virus, according to Reuters Health Information. Pamidronate boosts a class of human immune cells and causes them to attack flu virus-infected host cells. </div> <div> </div> <div>Antiviral drugs target flu viruses, which can be problematic as viruses often mutate and become resistant. However, this isn’t a concern with pamidronate because it targets cells and not the viruses. </div> <div>To date the drug has been tested for this purpose only with mice specially bred with human immune systems. It is too early to tell the potential use of pamidronate in humans, no less older adults. However, if it is proven to produce positive outcomes in human subjects, the drug could be particularly useful in a pandemic when typical flu medications are in short supply.</div> <div> </div> <div>Indeed, preparing for pandemics and vaccine shortages have been focuses for researchers in recent years. In another study, by A. Pollack, reported in the New York Times, scientists have developed a flu vaccine made by a new, faster method to make flu vaccines. </div> <div> </div> <div>The new process involves growing influenza virus in animal cell cultures, rather than in chicken eggs. This could prevent problems such as the 2009 swine flu pandemic, during which large quantities of vaccines weren’t available until after the height of the flu season. The new vaccine could become available in the United States within a few years.  </div> <div> <span class="ms-rtestate-read ms-reusableTextView">:##:</span></div> <h3 class="ms-rteElement-H3">Positive News For Infection Control</h3> <div>Standard precautions haven’t changed much over the years. However, a new precautionary measure could have a positive impact on reducing infections. </div> <div> </div> <div>According to a recent study, antimicrobial copper surfaces in intensive care unit rooms reduced the risk of hospital-related infections. In the Department of Defense-funded study, sites replaced frequently touched areas, including bed rails, over-bed tray tables, nurse call buttons, and poles, with antimicrobial copper. One site experienced a 97 percent reduction in surface pathogens in rooms that replaced existing surfaces with copper.</div> <div> </div> <div>If further studies produce similar results, this could have tremendous repercussions in nursing facilities, where the spread of infections is a constant concern and traditional precautionary measures aren’t always enough.  Of course, facilities will have to weigh the cost of installing copper surfaces with the potential benefits.</div> <div> </div> <div>Another recent study could lead to an additional change in precautionary measures. Researchers in Rhode Island studied 7,700 adult patients in a hospital setting and found that using antiseptic-laced washcloths lowered the risk for MRSA and vancomycin-resistant Enterococcus better than traditional soap and water.  </div> <h3 class="ms-rteElement-H3">Unraveling The Parkinson’s Mystery</h3> <div><img width="150" height="150" class="ms-rteImage-3 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/coverstory_thumb.jpg" alt="" style="margin:15px 10px;" /><br>While there have been no recent innovations in Parkinson’s disease (PD), several studies have delved into PD’s causes and how to keep patients with the illness safer and more comfortable. For example, one recent study showed a connection between the use of two pesticides (rotenone and paraqual) and PD, as reported in Environ Health Perspective.</div> <div> </div> <div>According to the study results, people who used either pesticide developed PD about 2.5 times more often than those who didn’t use the chemicals. Still another new study reported in Health Day suggested that methamphetamine abuse increases the risk for PD by up to 76 percent.</div> <div> </div> <div>Another recent study reported in Health Day has suggested a change that needs to be made to better protect PD patients. According to the results, antipsychotic drugs are still being prescribed for many PD patients, despite a six-year-old warning that the drugs can worsen symptoms. In fact, between 2002 and 2008, the rate of antipsychotic prescriptions for PD remained consistent in spite of the warning issues in 2005. </div> <div> </div> <div>While there was a shift toward better-tolerated antipsychotics, researchers stress that these medications aren’t necessarily safer or more effective. </div> <div> </div> <div>“We still need to learn more about the origins of PD. Until we have more insights on this, treatment isn’t likely to change much. In the meantime, we are focusing on keeping patients with the disease as safe and comfortable as possible,” says Day. Another focus is identifying patients who are experiencing drug-related Parkinsonism from antipsychotics and other medications, he says.</div> <div> </div> <div>With antipsychotic use receiving growing national attention, this will be an area of focus for facilities and prescribers alike—for PD patients and others taking these drugs. Karlawish says, </div> <div>“We need to use antipsychotics carefully. We also need to develop and implement better ways to treat these problems. We are seeing greater attention to implementing systems to monitor medication usage and scrutinize med records.” Increasingly, prescribers will need documentation to support the use of various medications, and payers will be scrutinizing records for cost inefficiencies and medications deemed unnecessary, observers say. </div> <h3 class="ms-rteElement-H3">Pressure Ulcers: Ways To Promote Healing</h3> <div>Preventing and treating pressure ulcers is always a top priority in long term care facilities, and some new research and developments may make this easier. For example, European researchers have determined that negative-pressure wound therapy may not promote healing in chronic persistent and complex wounds any better than conventional wound care.</div> <div> </div> <div>Negative-pressure wound therapy, which involves covering the wound with an airtight film and placing an electric pump over the wound to drain exudates, can be costly and time-consuming. So with the current emphasis on cost cutting, it is important to understand what treatments are most cost effective. </div> <div> </div> <div>At the same time, researchers at Loyola University Health System have determined that it might be possible to promote wound healing by suppressing neutrophils and natural killer T (NKT) cells. </div> <div>While these cells kill bacteria and other germs that can cause wound infections, they also can be harmful—producing enzymes that digest surrounding tissue, cause scar tissue to develop, and hinder healing. </div> <div> </div> <div>Scientists from the United States, Israel, and Japan have developed an inexpensive nanometer-sized drug that can treat foot ulcers and other chronic wounds. Several growth factor proteins have been shown to speed wound healing, but purifying these proteins is expensive, and they don’t last long on the injured site. </div> <div> </div> <div>Now, scientists have used genetic engineering to produce a “robotic” growth factor protein. Because these respond to temperature, dozens of these proteins can fold together into a nanoparticle more than 200 times smaller than a human hair. This simplifies protein purification, making it inexpensive to produce and enabling the protein to remain at the wound site longer.</div> <div> </div> <div>In general, wound care really hasn’t changed much in many years, says Carolyn Brown, BS, Med, LTC-RN, a clinical consultant for Advanced Tissue, a Medicare Part B billing service company located in Little Rock, Ark. </div> <div> </div> <div>“As far as treatments go, we are seeing more and more collagen products.” These provide a moist wound-healing environment with the benefits of collagen. However, Brown suggests that facilities focus more on “good basic skin care.” </div> <div> </div> <div>“Good incontinence care, good nutrition, and other basics of skin care continue to be the key to pressure ulcer prevention. I’ve seen people taken care of at home by family members, and their skin is healthy—despite the fact that they’re 95 and homebound. The difference is care,” she says.</div> <div> </div> <div>“We’re focusing on disease states that put people at high risk for skin breakdown and making sure that—whenever possible—patients aren’t on drugs that can affect their nutritional status,” says Day. “We are stressing prevention and ways to protect skin and prevent breakdown in the first place.”</div> <div> <span class="ms-rtestate-read ms-reusableTextView">:##:</span></div> <h3 class="ms-rteElement-H3">Alzheimer’s Work</h3> <div>Not surprisingly, the diagnosis and treatment of Alzheimer’s disease (AD) and dementia continue to evolve. As Karlawish says, “The field of Alzheimer’s increasingly is recognizing and understanding the biology of the disease with the practical goal of diagnosing the disease at the earliest onset or even before significant symptoms present, and then use these same insights to target interventions and treatments.” </div> <div> </div> <div>An expanding focus on diagnostics, says Karlawish, has led to a “relaxation of interest on developments of symptomatic treatment. This is a change from 10 to 15 years ago when the focus was on medications.” In long term care, decisions about medications often involve how long to continue treatment. </div> <div> </div> <div>As Karlawish says, “If patients are on medications designed to slow the disease’s progress, we need to decide if they should stay on these as Alzheimer’s advances.”</div> <div> </div> <div>Clearly, AD is a common diagnosis in long term care. However, according to one study, the diagnosis of AD may not always be accurate. Researchers found that only about one-half of over 200 subjects diagnosed with AD were determined on autopsy to have brain conditions associated with the disease. Instead, they had other brain abnormalities, including generalized brain atrophy, according to a study reported in HealthWorks Collective.</div> <div> </div> <div>While the authors admitted that larger studies are necessary to confirm their findings, this could lead to new ways to diagnose the disease and to ensure that patients aren’t being treated inappropriately or unnecessarily. </div> <h3 class="ms-rteElement-H3">Isolating Risk Factors</h3> <div>Other recent studies have suggested factors that determine one’s risk for AD. For example, a Swedish study published in Neurology has determined that extra weight during middle age (defined as having a body mass index of 25 to 30) could lead to a greater dementia risk in later life.</div> <div> </div> <div>Another, conducted in Germany and involving 3,200 German seniors age 75 years or older, indicated that elderly adults whose alcohol intake is approximately two drinks daily have a significantly lower risk of developing AD and dementia than nondrinkers. In fact, they estimated that the risk for dementia is 30 percent lower and the risk for AD reduced by 40 percent. </div> <div> </div> <div>Another study also has suggested a link between lifestyle and AD. University of Alabama researchers determined that an epigenetic eating regimen—a diet that includes soybeans, cauliflower, broccoli, cabbage, green tea, fava beans, kale, and grapes—may suppress gene aberrations that ultimately can cause diseases such as AD. </div> <div> </div> <div>Confirming that AD may run in families, a recent study also published in Neurology indicated that a person’s risk for developing AD is higher if one’s mother—rather than one’s father—had the disorder.  </div> <h3 class="ms-rteElement-H3">New Treatment Options</h3> <div>Other recent studies may help lead to identifying—and treating—AD earlier than ever before. One study indicated that the liver, as opposed to the brain, actually may be the source of the amyloid that leads to brain plaques associated with AD. If confirmed, these data could change how clinicians approach diagnosis and treatment. </div> <div> </div> <div>Elsewhere, scientists have taken a potential step forward in AD treatment by discovering how to turn human embryonic stem cells and a type of human skin cell into the kind of brain cells lost to AD, reported in Stem Cells 2011. The new study suggested that perhaps scientists someday may be able to produce a supply of these cells in a laboratory setting and test different drugs on them to see which ones keep the cells alive. This, in turn, could aid in the development of drugs to combat AD. </div> <div>Looking further into the future, this technology eventually might be used to transplant healthy cells back into AD patients’ brains to treat the disease.</div> <div> </div> <div>Of course, drugs are still a part of AD treatment; and Karlawish notes that there are several drugs in later phases of clinical trials that “we will hear results of in the next 24 months. All have a common approach—addressing the accumulation of amyloid plaque in the brain.” He says, “We’ll know when the results come out if this approach is successful.”  </div> <h3 class="ms-rteElement-H3">Geriatric Research Lags</h3> <div>While much has changed regarding how common conditions are treated in long term care, one thing hasn’t changed. Clinical trials still fail to involve older patients to any significant degree. One in five studies still excludes many patients simply because of their age; about half of the remaining trials employed criteria that were likely to eliminate older adults from involvement. This is according to a study analyzing over 100 studies published in <em>The Journal of the American Medical Association, The New England Journal of Medicine, Lancet, Circulation, The British Medical Journal,</em> and others, according to a report in the <em>New York Times.</em> While the average age of participants in the trials included in the study was 61, many excluded nursing facility residents and patients with physical disabilities or existing medical conditions. </div> <div> </div> <div>“We just don’t have the data on how medications affect geriatrics as much as we should. We are still dealing with trial and error,” says Day. “We really need more studies specific to this population.” </div> <div>Considering that the geriatric population is growing exponentially, says Day, this is a key issue that calls for national attention. </div> <div> </div> <div>He says, “More and better studies addressing this population are likely to influence how we manage conditions such as PD, AD, pressure ulcers, and others in the years to come.” </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div>The patient population in nursing facilities is different than it was 10 or 20 years ago, and so is how such conditions are addressed. Developments and promising trends in treatments, medications, and diagnostics are designed to improve outcomes and increase efficiency. 2011-09-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0911/coverstory_thumb.jpg" style="BORDER:0px solid;" />Clinical;CaregivingColumn9
Meaningful HIT Aids Frontline Caregivershttps://www.providermagazine.com/Issues/2011/Pages/0911/Meaningful-HIT-Aids-Frontline-Caregivers.aspxMeaningful HIT Aids Frontline Caregivers<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Health information technology (HIT), while an increasing priority for long term care providers, often triggers questions about whether the potential is more promise than reality. HIT is expected to help make daily work more smooth and efficient for clinicians while supporting improvements in delivery of care and associated resident outcomes. In practice, however, there are often unexpected challenges. </div> <div> </div> <div>Learning how to use technology takes time and considerable effort, and, once mastered, the technology may disappoint frontline caregivers who struggle with integrating the new HIT into daily practice. </div> <div> </div> <div>Described in this article is an approach for implementing HIT by showing frontline staff how to leverage it to support clinical decision making. This approach makes a clear connection between HIT use and quality improvement (QI) and focuses on care process improvements to impact outcomes.  </div> <div><h3 class="ms-rteElement-H3">An Approach That Works</h3> <div>Known as Quality Improvement Integrated into Information Technology (QI-IT™), it is an approach based on principles of QI, information analytics, clinical workflow reengineering, and more than 10 years of experience working with more than 100 skilled nursing facilities to implement quality improvement strategies as part of HIT implementation. </div> <div> </div> <div>The purpose of this article is to describe the QI-IT approach and better explain why and how quality improvement considerations should be explicitly integrated into the process of implementing HIT in skilled nursing facilities to help narrow the gap between clinician expectations and reality. </div> <div> <img class="ms-rteImage-3 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/tech_chart2.gif" alt="" style="margin:15px 10px;" /></div> <div>For organizations that may be struggling to gain user acceptance of newly installed HIT, disappointed with the results, or struggling with establishing an explicit link between HIT and improved clinical processes and outcomes, this article may offer helpful insights.</div> <div> </div> <div>At the core of the QI-IT approach is the idea that when specific quality improvement goals, clinical processes, and outcome improvements are integrated into facility strategies and plans for using information technology, then there is a clear QI-IT link and expectation that HIT will support the hands-on caregiver team using clinical best practices on a routine basis. </div> <div> </div> <div>By employing specific QI objectives, the HIT implementation discussions take on an added dimension, and frontline staff are encouraged to think about HIT’s purpose beyond automating paper processes. </div> <div> </div> <div>For example, implementing HIT to promote earlier identification of residents at risk for pressure ulcers, falls, or hospital transfers is a tangible goal, versus implementing to improve resident clinical care in general. Confirming the specific care processes and outcomes to improve sets a framework that frontline staff understand and helps identify particular aspects of processes that will impact resident care. </div> <div> </div> <div>There are three guiding principles of the QI-IT approach. While these principles might be intuitive, the extent to which they are considered simultaneously with HIT implementation plans should be objectively assessed in order to maximize the potential of HIT and gain user acceptance. </div> <div>The principles are: Focus on QI objectives, improved processes, and outcomes first; leverage capabilities of HIT to support specific QI objectives; and be strategic when integrating HIT into workflow.</div> <div> </div> <div>An important factor embedded in all three principles is involvement of multiple disciplines and frontline staff throughout, whereby the entire care team focuses on QI goals, processes, and information needs and how HIT supports them. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div></div> <div><h3 class="ms-rteElement-H3">Applying QI-IT</h3> <div>Two scenarios illustrate the impact of QI-IT. In the first scenario, a facility automates its admission assessment form as part of a plan to automate all nurse assessments. To this end, the facility team creates a replica of the existing admission assessment forms in the new computer system. Minor revisions are made to the online admission assessment, but it appears very similar to the paper forms. </div> <div> </div> <div>The team is pleased with the new electronic admission assessment and is optimistic that nurses will adapt readily to completing the form online because the form will be familiar to nurses, requires no change to workflow, and does not entail new learning. </div> <div> </div> <div>The electronic system provides updates to the automated assessments, and the facility is pleased to have the ability to see progress of the assessments, which aids in the management of outstanding work or overdue or incomplete documentation. </div> <div> </div> <div>The nurses find the online admission assessment form easy to use, medical records staff monitor status and follow up with nurses who have not completed admission assessments, and work has been streamlined. </div> <div> </div> <div>However, the team is not able to say that HIT is helping to identify resident needs or risks in a more timely manner, nor are they able to say that they are better coordinating care with physicians and other disciplines. </div> <div> <img width="451" height="253" class="ms-rteImage-3 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/tech_chart1.gif" alt="" style="margin:10px 15px;height:263px;" /><br>In another scenario, QI-IT is used. The facility automates its admission assessment process with the goal of using HIT as a tool to promote earlier identification of high-risk factors for new admissions, ensure appropriate care plan interventions are in place, and improve communication to the entire care team.</div> <div> </div> <div>Applying QI-IT principles prior to implementing HIT prompts the multidisciplinary team to review the admission assessment form, including the information that is recorded, the processes used to complete them, and how other disciplines use the assessment information. </div> <div> </div> <div>Opportunities for process improvement are explored throughout the review. One commonly identified improvement is the management of risk factors for new admissions. Specifically, the team would like to ensure resident risks are identified upon admission and communicated among disciplines in a more timely manner. </div> <div> </div> <div>In addition, they want appropriate risk assessments completed in a timely and consistent manner and appropriate care plan interventions to be in place for each risk identified during the admission assessment process. </div> <div> </div> <div>The team discussion also expands to consider the HIT dynamic and analytic capabilities. </div> <div> </div> <div>For example, the discussion centers on how HIT can prompt the ongoing review of high-risk factors on a consistent basis. In this process, the high-risk factors assessed on admission are confirmed, and the team ensures that the risk elements are included when designing the admission assessment. Input from multiple disciplines and users of admission assessment data help identify information gaps, and workflow issues are uncovered. </div> <div> </div> <div>The HIT implementation discussion broadens to a review of care process and information needs and how HIT supports frontline caregiver practices. Disciplines involved in the management of each risk are invited to participate. Discussion with the HIT vendor includes a review of the facility’s requirements for admission assessment data entry as well as how information will be used.</div></div> <div><h3 class="ms-rteElement-H3">A Different Perspective</h3> <div>Too often, facilities start HIT implementation by automating existing paper and paper processes. What is often overlooked is that current processes are not set up to use HIT optimally. As illustrated in the scenarios above, rather than simply automating existing forms or reports, the QI-IT approach encourages facility teams to think about implementing HIT from a different perspective—one that looks at how HIT is supporting improvements in the care delivery process.</div> <div> </div> <div>Spend time up front to review current practices, drill into the details of information and communication flow, and identify where and how best practices can be integrated into frontline daily work. </div> <div> </div> <div>Linking HIT to specific QI goals makes where and how HIT is used very concrete. It becomes a tool for improved information access and synthesis, clinical decision making, and care coordination. </div> <div> </div> <div>Computers alone simply automate data processing without fundamentally impacting the way information is used or the quality of care. By embedding quality improvement principles into the implementation of HIT, data  can be harnessed for greater purposes, including the improvement of daily workflow routines, the effective monitoring and evaluation of resident progress, and clinical decision support tools that support delivery of care based on clinical best practices. </div> <div> </div></div> <div><em>Sandy Hudak, MS, RN, and Siobhan Sharkey, MBA, are principals at Health Management Strategies, a health care consulting group focused on quality improvement and HIT implementation. Michal Engleman, PhD, a consultant working with HMS, is a professor in the Department of Sociology at the University of Chicago.</em></div>Health information technology (HIT), while an increasing priority for long term care providers, often triggers questions about whether the potential is more promise than reality. HIT is expected to help make daily work more smooth and efficient for clinicians while supporting improvements in delivery of care and associated resident outcomes. In practice, however, there are often unexpected challenges. 2011-09-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/nurses_comp_thumb.jpg" style="BORDER:0px solid;" />Quality;TechnologyColumn9
Med Pass Makeoverhttps://www.providermagazine.com/Issues/2011/Pages/0911/Med-Pass-Makeover.aspxMed Pass Makeover<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>An award-winning twice-daily (BID) medication pass program pioneered by The Pines, an Easton, Md.-based skilled nursing facility that is part of a Genesis HealthCare companywide medication administration initiative, has changed the lives of residents and staff alike by reevaluating the medication administration process and reducing the frequency of medications administered to residents. As a result, residents have experienced improved sleep, socialization, and overall quality of life. The program has also resulted in increased job satisfaction for caregivers.  </p> <h3 class="ms-rteElement-H3">Implementing The Program</h3> <p>Any medication pass system has a tremendous impact on a resident’s sleeping and waking hours, meals, and general psychological well-being. “Residents in long term care are often subjected to polypharmacy that places them at risk for adverse drug reactions, medication errors, increased costs, and decreased quality of life,” says Michael Crowley, MD, medical director of The Pines. </p> <div>The process began with a thorough evaluation in 2010 of medication administration in the long term care units at The Pines. Based on the annual survey of residents in April 2010, the facility’s Quality Improvement Committee met to discuss the results, which indicated resident dissatisfaction with the sheer volume of medications as well as the amount of time they were spending waiting each day to receive their pills. </div> <div> <img width="453" height="291" class="ms-rteImage-4 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/Rx-Graph.png" alt="" style="margin:15px;height:313px;" /><br>“It was not uncommon for residents to be approached up to nine times per day in a 24-hour period. It was an institutional approach, everything centered around pill times,” says Crowley. </div> <div> </div> <div>Residents had to sit in their rooms for hours on end awaiting the arrival of the pill cart and often missed recreational activities or time spent with friends. </div> <div> </div> <div>An interdisciplinary team was formed, which included the administrator, director of nursing, medical director, nurse practitioner, pharmacist, staff nurse, and the medication aide.</div> <div> </div> <div>The goal for the project was to individualize each resident’s drug regime, eliminate unnecessary and nontherapeutic drugs, and establish two medication delivery times of 8:00 a.m. and 8:00 p.m. daily. </div> <div>Delivery times were deliberately moved away from peak recreation and dining times. With the cooperation of the pharmaceutical team, each resident received a new schedule of medications that most effectively managed his or her care, while also streamlining their medication administration throughout the day.</div> <div> <img width="471" height="344" class="ms-rteImage-4 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/Before-Staff-Time-Graph.png" alt="" style="margin:15px;height:345px;" /></div> <div>In some cases, residents were prescribed longer-acting medications in order to eliminate med passes. Most residents were able to easily transition to a twice-daily administration and were overwhelmingly pleased with the resulting schedule. </div> <h3 class="ms-rteElement-H3"> Improved Quality Of Life</h3> <div>The resulting success of the med pass program has brought about great changes for the residents of The Pines. Enhanced dining services and more time for social activities have left residents feeling as though life no longer revolves around medication. </div> <div> </div> <div>Alfred Wilson, a resident of The Pines for many years, has experienced a significant improvement in his daily routine. “I love that I can participate in whatever is happening that day, without having to worry about missing the medication cart. I know it will be coming at certain times, before and after most of my meals and events during the day,” he says. </div> <div> </div> <div>Medication is no longer administered during activities for most patients, and mealtimes occur long before and after the designated times, freeing residents and nursing staff to focus on the events of the day. </div> <div> </div> <div>On the secured dementia unit, the medication aide was transitioned to a direct care position. These additional hours enabled all staff to be responsible for the unit’s activities, and licensed nurses have more time to identify and assess residents and plan for the appropriate treatment. Finally, the medication carts have been put away to create a more residential atmosphere in each nursing unit. </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">Staff Satisfaction</h3> <div>Improved staff satisfaction and performance have been unexpected byproducts of the med pass program. Interviews with staff members reveal an increase in job satisfaction due to the increase in direct care activities.</div> <div> <img width="472" height="356" class="ms-rteImage-4 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/After-Staff-Time-Graph.png" alt="" style="margin:15px;height:340px;" /></div> <div>Staff felt “chained to the medication cart” and felt the existing medication system was an inefficient use of anyone’s time.  </div> <div> </div> <div>The annual employee opinion survey reflected a significant increase in overall employee satisfaction, with the number of employees reporting excellent/good overall job satisfaction up by 12 percent from the prior year. </div> <div> </div> <div>The culture change toward more resident-centered care has allowed staff at The Pines to do what they do best: interact with residents. </div> <div> </div> <div>While there has been no significant change in medication costs, the hours normally spent “pushing the pill bus” have been reallocated toward direct resident care.</div> <div> </div> <div>The med pass program has been life changing for staff and residents of The Pines. </div> <div> </div> <div>“[It] exceeded expectations, and we were able to convert 90 percent of our long-term residents to the twice-daily medication pass. As a result, the number of prescriptions per residents dropped by 10 percent on average, the amount of time dispensing medications dropped by almost 50 percent, and resident satisfaction increased by 8 percent,” Crowley says.</div> <div> </div> <div>This program is replicable and sustainable in other nursing centers, as no additional staff were added to achieve these outcomes nor were there additional expenditures.  </div> <h3 class="ms-rteElement-H3"><div>Award-Winning Approach</div></h3> <div>The Pines’ innovative approach gained the recognition of AMDA—Dedicated to Long Term Care Medicine, which awarded The Pines its 2011 Evercare Award, one of only three centers in the entire country to win the award this year. </div> <p> </p> <p>For tips on how to iniative a BID med pass program in your facility, click <a href="/Issues/2011/Pages/0911/Tips-For-Starting-A-Twice-Daily-Med-Pass-Program.aspx">HERE</a>.</p> <p><em>Stacey Radcliffe, senior administrator of The Pines, a 185-bed Genesis HealthCare skilled nursing facility in Easton, Md., can be reached at </em><a href="mailto:Stacey.radcliffe@genesishcc.com"><em>Stacey.radcliffe@genesishcc.com</em></a><em>. Marylee Grosso, RPh, a senior director of operations for Genesis, responsible for corporate medication therapy management initiatives, can be reached at </em><a href="mailto:Marylee.grosso@genesishcc.com"><em>Marylee.grosso@genesishcc.com</em></a><em>.</em>​</p>An award-winning twice-daily (BID) medication pass program pioneered by The Pines, an Easton, Md.-based skilled nursing facility, has changed the lives of residents and staff alike by reevaluating the medication administration process and reducing the frequency of medications administered to residents. 2011-09-01T04:00:00Z<img alt="" height="150" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/Clip%20Art%20pill%20packs.jpg" width="150" style="BORDER:0px solid;" />CaregivingColumn9
Long Term Care In The Pacific Northwesthttps://www.providermagazine.com/Issues/2011/Pages/0911/On-The-Road_0911.aspxLong Term Care In The Pacific Northwest<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​<img width="283" height="529" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/0911/OTR_8.jpg" alt="" style="margin:10px;height:225px;" />The natural beauty that is the Pacific Northwest is obvious to the eye, with rolling views of mountain ranges seemingly at every turn in a drive around Portland, Ore. Mount Hood lies to the east of town and Mount Saint Helens and Mount Ranier north into Washington, making the region a dictionary definition of the word scenic.</p> <p>Oregon is where <em>Provider </em>Senior Editor Patrick Connole spent most of his time for this edition of On the Road, looking at how the state is handling budgetary pressures and with it provider reimbursement rates for the Medicaid program. Providers here, like elsewhere, keep one eye firmly glued on what lies ahead for payment, while at the same time continuing to care for residents in the most efficient way possible in a sluggish economy.</p> <p>Van Moore, senior vice president for Westcare Management based in the Oregon capital of Salem, operates two facilities in the state. He says the leadership of the Oregon Health Care Association (OHCA) has fended off deep Medicaid cuts, at least for the short term.</p> <p>“OHCA and Jim Carlson [association president] have done a stellar job for us. In this year that everybody has suffered with huge cuts, nursing homes were held harmless [with no cut],” Moore says.</p> <p>"This is recognition by the legislature of the importance of long term care, not only the work we do for our frail and elderly but the amount of jobs we provide.”</p> <p>Oregon’s legislature will revisit the provider reimbursement rates for nursing care next year, and if the economy does not mend faster, there could be debilitating results, he says.</p> <div>“If revenue falls short, we could be looking at as much as a 19 percent cut in rates next year [July 1, 2012, to July 1, 2013],” Moore says.  </div> <h3 class="ms-rteElement-H3">Money Matters Impact Business</h3> <div>Westcare operates the 51-bed Myrtle Point Center skilled nursing facility, which lies along the Oregon coast region. The company also has been contracted by the Veterans Care Centers of Oregon to operate the Oregon Veterans Home in The Dalles, Oregon. That facility has 150 beds.</div> <div> </div> <div>The general sentiment with providers like Moore is that state residents are taking their time in moving family members to long term care because of the uncertain economy.</div> <div> </div> <div>“People get laid off from their jobs, and when they think of ways to make ends meet, they look at mom and dad and delay decisions until they are physically unable to take care of their family anymore. This really harkens back to the pre-Johnson [President Lyndon Johnson] days before Medicaid, when more families were nuclear and took care of their own,” Moore says.</div> <div> </div> <div>The unique nature of providing nursing care in Oregon is that the state is a flat reimbursement state, a fact that Moore says dissuades the building of new facilities. </div> <div> </div> <div>“Since I moved here 22 to 23 years ago, I think there have been three standalone nursing homes built in the state,” he says, adding that the flat $212 per day Medicaid reimbursement does not incentivize the building of new buildings. </div> <h3 class="ms-rteElement-H3">Oregon In Search Of Health Care Solutions</h3> <div><img width="207" height="200" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/0911/OTR_3.jpg" alt="" style="margin:10px;width:157px;height:118px;" />Betsy Johnson, state senator for the 16th district in Oregon’s legislature and owner of a helicopter business, is intently interested in health care for her constituents, serving on the Oregon Health and Sciences University Foundation and the Oregon Senate Ways and Means Committee.</div> <div> </div> <div>She founded a helicopter company that ferried members of the U.S. Geological Survey back and forth to the Mount St. Helens site after the eruption in 1980. Her motto is, “your wallet, we haul it,” she jokes.</div> <div> <img class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/0911/OTR_1.gif" alt="" style="margin:5px;" /></div> <div>Johnson says policymakers are eager to reform the state’s health care system. Oregon Gov. John Kitzhaber (D), a former emergency room doctor, recently signed into law changes to the Oregon Health Plan meant to coordinate care and reduce costs. </div> <div> </div> <div>The state faced an $860 million budget gap between available funds and costs for the Oregon Health Plan. Reduced provider reimbursement rates and increased hospital provider taxes will make up most of the deficit, with the remainder paid for by the reorganized health plan. </div> <div> </div> <div>The governor said the goal is to get state residents better care at lower costs.</div> <div> </div> <div>Johnson says the new law is a start but more “meat will go on the bones” of the measure when the legislature reconvenes in February. </div> <h3 class="ms-rteElement-H3">Avamere Seeks Growth Amid Uncertainty</h3> <div>A major player in the provider community in Oregon is the Avamere Family of Companies. Based just south of Portland in Wilsonville, Ore., Avamere ranked 38th in the Provider magazine Top 50 Largest Nursing Facility Companies in 2011, with more than 2,400 beds. Avamere also ranked 39th in the magazine’s Top 40 Largest Assisted Living Companies, with a total assisted living occupant capacity of 573.</div> <div> </div> <div><img width="174" height="257" class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/OTR_2.jpg" alt="" style="margin:5px 10px;width:171px;" /><br>Rick Dillon, president of Avamere, says the company has 4,500 employees, 3,500 in Oregon alone. In many of the locales where Avamere has facilities, they are the largest employer in town, he notes. Dillon sees what is going on at the statehouse in Salem and in the U.S. Congress in Washington, D.C., as major concerns for his employees and his residents.</div> <div> </div> <div>“It has been so difficult to plan ahead when you don’t know what you are going to be paid,” Dillon says.</div> <div> </div> <div>Echoing Moore, he says long term care providers were fortunate in the last go-round, when the state decided to “flat-fund” skilled nursing and assisted living. There was, however, a $3 per day increase from July 1 in the provider tax.</div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">Assisted Living Holds Its Own </h3> <div>Many assisted living facilities have seen potential clients take to the sidelines waiting for improvement in the housing market, says Nicollete Merino, Avamere regional director of operations.</div> <div> </div> <div>“Individuals that might need assisted living may well have sold their homes in previous times, but a lot of people can’t sell their homes now,” she says. So, with the economy the way it is many people in need of care put it off until later, when their health may weaken as they grow older.</div> <div> </div> <div>This results in a cascading effect. Assisted living becomes more like what a nursing facility used to provide in the way of care and services, and nursing facilities become more about sub-acute care.</div> <div>The level of care and need for assistance in assisted living is growing every year, Merino says.</div> <div> </div> <div>“We are seeing many Medicaid clients in our buildings. More and more are coming in on Medicaid, probably around 30 to 40 percent,” she says.</div> <div> </div> <div>The changes in the type of care taking place in assisted living affects who works in a facility. </div> <div>“It does make for changes for who works in the buildings. Five or six years ago you didn’t have to deal with something like bladder issues, it was walking around with a walkie-talkie. So, you are getting a different type of caregiver, more direct-care oriented,” Merino observes.</div> <div> </div> <div>Better training has also resulted from this higher level of care with a lot of additional educational requirements in Oregon, she adds. </div> <h3 class="ms-rteElement-H3">Oregon Firm Ties Aerospace To Long Term Care</h3> <div>The Pacific Northwest is known for being home to the cutting-edge technology of the aerospace industry, feeding off the long-time presence of Boeing Corp. and scores of related firms fulfilling the supply needs of a business in which the United States remains a world leader.</div> <div> <img width="268" height="355" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/0911/OTR_4.jpg" alt="" style="margin:10px;height:202px;" /><br>At a time the government is transitioning the health care system into one based on providing high-quality care at low cost, and demanding providers measure their results in achieving these goals, it is firms like Scappoose, Ore.-based Low-G Technologies that are positioning themselves for this changing environment.</div> <div> </div> <div>Low-G is a privately held company that makes the Low-G® Skin Pressure Protection System, an overlay for beds that aids in the prevention of pressure ulcers, a constant threat to the well-being and even survival of residents in nursing facilities. The technology used in the overlay comes from the materials and knowledge acquired from a separate aerospace company (Oregon Aero) that the founders of Low-G have run for decades and that provides seating, helmet padding, and other related products for clients, including the U.S. military. </div> <h3 class="ms-rteElement-H3">From Pilots To Nursing Residents</h3> <div>At the start of the first Gulf War, the wide-scale adoption of aerial refueling for U.S. military combat aircraft was started. The average mission length for many air crew members was extended from an average of 90 minutes to more than eight hours. </div> <div> </div> <div>Pilots in turn started to exhibit serious pain and discomfort from the longer missions, with some developing pressure ulcers caused by aircraft seats and flight helmets. These injuries would often leave aircraft crew members off-duty for months at a time to deal with the problem.</div> <div> </div> <div>This problem sounds all too familiar to nursing care providers.</div> <div> </div> <div>Around 11 percent of nursing facility residents experienced a pressure ulcer in 2004, according to a study for the National Center for Health Statistics. The cost of treating an individual pressure ulcer ranges from $5,000 for a Stage I to $70,000 for a Stage IV.</div> <div> </div> <div>The total annual cost to hospitals nationally for the treatment of pressure ulcers is hard to quantify but ranges from $2.2 billion to $10 billion. The Agency for Healthcare Research and Quality said in 2006 there were 503,300 hospitalizations with pressure ulcers noted as the injury in the diagnosis.</div> <div>In more stark terms, people’s lives are lost to pressure ulcers.</div> <div> </div> <div>The national Pressure Ulcer Advisory Panel reports that as many as 60,000 people die every year as a direct result of pressure ulcer complications. That is roughly equivalent to a 767 airliners crashing each day. </div> <h3 class="ms-rteElement-H3">It Starts In Scappoose</h3> <div>The facility at the Scappoose airport contains the brains of the operation, with designers and machine operators piecing together a number of products, all focused on keeping the body comfortable and healthy.</div> <div> </div> <div>“We are in the business of preserving human tissue,” says Casey Dennis, who acts as director of marketing and client support for Low-G. He adds that what makes the firm’s bed overlay unique is its origin in a high-tech world where performance has always been measured by keeping air crews at ease under the most trying of conditions.</div> <div> </div> <div>Nursing care is well-accustomed to trying conditions as well, with residents often in a bed for long periods, creating friction on the skin, along with fermenting heat and moisture in the process.</div> <div> <img width="472" height="214" class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/0911/OTR_5.jpg" alt="" style="margin:10px;width:284px;" /><br>From a broader perspective, a bed overlay is not a cure-all for the state’s budgetary challenges, but it could play a role in reducing costs while bolstering an Oregon company and growing jobs in a tough economy, lawmaker Johnson says. “We are eager to advance the innovation economy [in Oregon].”   </div> <h3 class="ms-rteElement-H3">Making The Case For more acute Care</h3> <div>The picture in Oregon looks similar to many states: a large population of elderly and frail in need of care in an increasingly more acute state of health. The state is trying to figure out how to revamp its programs to meet these needs in the lowest-cost environment as possible, while caring for increasing demands brought on by federal health care reform.</div> <div> </div> <div>The common denominator is quality care and low cost, from provider to lawmaker to manufacturer, that is the driving force, the mantra of a new age. Bringing some high-tech help from the world of flight may be one way to help stem the tide. </div> <p> </p>The natural beauty that is the Pacific Northwest is obvious to the eye, with rolling views of mountain ranges seemingly at every turn in a drive around Portland, Ore. Mount Hood lies to the east of town and Mount Saint Helens and Mount Ranier north into Washington, making the region a dictionary definition of the word scenic.2011-09-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/POTR_logo_rollup.jpg" style="BORDER:0px solid;" />PolicyColumn9
Residents, Staff Attest To Qualityhttps://www.providermagazine.com/Issues/2011/Pages/0911/Residents,-Staff-Attest-To-Quality.aspxResidents, Staff Attest To Quality​​ <div>​<img width="427" height="1030" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/0911/MIV_supp.jpg" alt="" style="margin:5px;width:245px;height:330px;" />Myths, legends, proverbs, and folklore—each nation, community, and profession uses them to dress up its history, filter reality, and color facts. Whether benign or malignant, they permeate all aspects of modern health care, nowhere more so than in long term care and nowhere as negatively as in nursing facility care.</div> <div> </div> <div>Along with the prevalence of stories about the long term care profession, there is also an astounding amount of data. It is with the intent of discovering the true narrative of nursing facilities today that the team at My InnerView has developed the “2010-2011 National Survey of Consumer and Workforce Satisfaction for Nursing Facilities” (National Report).</div> <div> </div> <div>This rapidly expanding repository of data offers ample evidence that complements both legend and practical wisdom to better understand the long term care industry and the insight to be gained from the voice of its customers and employees.</div> <div>While our analyses have led to several discoveries and more than a few surprises, we will focus on only a couple of interesting points in this brief article, highlighting what the data tell us about some of the most important, and often most misunderstood, parts of the story—the perceptions of residents, their families, and employees from approximately 5,500 nursing facilities. The full National Report contains a more in-depth and comprehensive compilation of information about the voice of residents, families, and caregivers, as well as data-driven insights about the long term care profession. </div> <h3 class="ms-rteElement-H3">Residents, Families Rate Nursing Facilities Favorably </h3> <div>One fact about nursing facilities is indisputable and has been reaffirmed year after year by a variety of sources: Residents and families hold their nursing facilities in high regard.</div> <div> </div> <div>The My InnerView national data repository includes resident and family feedback on 22 areas of experience across three broad categories, including quality of life (safety, privacy, dignity, choice, and other aspects of well-being), quality of care (staff and care practices in regard to adequacy, competence, and a caring attitude), and quality of services (meals, laundry, maintenance, and more).</div> <div> </div> <div>The responses pose a direct challenge to a negative popular belief about nursing facilities. Four out of five families and an even greater proportion of residents rate their nursing facilities as “Good” or “Excellent” (see Chart 1). Similarly, in overwhelming numbers, both families and residents say they would recommend their nursing facility to others as an “Excellent” place to receive care (see Chart 1). </div> <div><img src="/Issues/2011/PublishingImages/0911/MIV_supp_chart1.gif" alt="" style="margin:10px;" /><br><br>And for the most part, this high praise remains consistent throughout the resident’s stay (see Chart 2).<br><img src="/Issues/2011/PublishingImages/0911/MIV_supp_chart2.gif" alt="" style="margin:10px;" /><br></div> <div> </div> <div>Such soaring accolades, so out of step with popular preconceptions, have engendered doubts at times. The message of the customer has often been sidelined by skeptics as uninformed or compromised. But skepticism loses its credibility when faced with the power of simple evidence. </div> <div> </div> <div>First, it is unconscionable to question the authenticity of nearly 150,000 families and almost 100,000 residents who voluntarily responded to the survey, answered it privately, and were promised confidentiality by an independent third party conducting the survey.</div> <div> </div> <div>Second, responding families were far from being uninformed and unengaged; two out of three had visited multiple nursing facilities before choosing one for their relative and, after placement, four out of five families visit their relative at least weekly. We also can gain insights from the data about what drives satisfaction, which further reinforces the importance of looking to information rather than anecdotes. For both families and residents, the top two factors that influence the likelihood to recommend a facility are the competency of staff and the care (concern) of staff. Clearly, employees are another key piece of the puzzle to better understand the true picture of the nursing facility profession. </div> <div><span class="ms-rtestate-read ms-reusableTextView"><font style="background-color:#e0e0e0;">:##:</font></span> </div> <h3 class="ms-rteElement-H3">Commitment Of Caregivers</h3> <div>Unfortunately, a Google search on nursing home quality will result in references to more negative information than positive. Directly and by implication, nursing facility staffs are routinely depicted in all-too-familiar negative stereotypes—detached, apathetic, uncaring, and abusive. But the question remains, what evidence supports the common belief that nursing facility staffs provide unloving care?</div> <div> </div> <div>Popular opinion may give these caregivers a bad reputation, but evidence supports that beneficiaries of their care have a considerably different view. In rating 22 areas of experience on a Poor to Excellent scale, residents and families score caregivers with much higher than a passing grade across the board. </div> <div> </div> <div>Families and residents agree on two of the strongest areas of performance among nursing facility staffs: the respect that they demonstrate and the quality of care provided, specifically by registered nurses (RNs) and licensed practical nurses (LPNs) (see Chart 3).</div> <div> <img class="ms-rtePosition-3" src="/Issues/2011/PublishingImages/0911/MIV_supp_chart3.gif" alt="" style="margin:10px;" /><br><br>These caregivers also have a higher level of overall job satisfaction and a greater opinion of their employers, both as a place to work and as a place to receive care, than uninformed observers might imagine (see Chart 4). For both certified nurse assistants (CNAs) and RNs, the attentiveness and concern (care) of management rank as the top two drivers that affect the likelihood to recommend the facility as a place to work. As an indication of the value that nurses and CNAs place in their work and their commitment to residents, 85% of RNs and 86% of CNAs rate the sense of accomplishment associated with their jobs as Good or Excellent. </div> <div> <img class="ms-rtePosition-3" src="/Issues/2011/PublishingImages/0911/MIV_supp_chart4.gif" alt="" style="margin:10px;" /><br><br>This data point, especially partnered with families’ and residents’ rating of the care (or concern) of the staff (88% and 89%, respectively, for combined Excellent and Good scores), debunks the myth that nursing facility staffs are detached from the importance of their role and from the residents and other customers that they interact with on a daily basis. </div> <h3 class="ms-rteElement-H3">Conclusion</h3> <div>The consumer age has demystified the sacred, the mysterious, and the forbidden in religion, politics, and professions. All of us cling to some beliefs and practices and often resist testing them against evidence. But as data become more available and more accessible, rationality challenges dogma and questions the authority of tradition. We may be inching toward a data-driven, evidence-based approach to life.</div> <div> </div> <div>Respect for facts, pursuit of evidence, and grounding practice on proven protocols—this is the heart of the evidence-based approach. By listening to caregivers, it is possible to tune in to the perspectives of the communities at the heart of long term care and better inform decisions for organizational success. </div> <div> </div> <div>By listening to our customers, we understand their messages and formulate proper responses that will put us on a definite road to evidence-based excellence.</div> <div> </div> <div><em>This article was written by Vivian Tellis-Nayak and Christine Lang of My InnerView (<a href="http://www.myinnerview.com/"><font color="#0072bc">www.myinnerview.com</font></a>), a division of National Research Corp. and an applied research company that promotes evidence-based management practices in U.S. senior care organizations.</em> </div> Myths, legends, proverbs, and folklore—each nation, community, and profession uses them to dress up its history, filter reality, and color facts. Whether benign or malignant, they permeate all aspects of modern health care, nowhere more so than in long term care and nowhere as negatively as in nursing facility care. 2011-09-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/0911/MIV_supp_thumb.jpg" style="BORDER:0px solid;" />Column9




A Place To Call Homehttps://www.providermagazine.com/Issues/2011/Pages/1011/A-Place-To-Call-Home.aspxA Place To Call Home<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>​<br>A woman who had previously lived in a trailer with no running water, no heat, and a bucket for a toilet now has a warm and comfortable home at a Maine assisted living community. An elderly woman, who was deaf and in need of assistance that her daughter could no longer provide, was welcomed into her new home by housemates and staff who communicated in her native sign language. Then there's a man who was seriously injured in a motorcycle accident but previously had no one to help him get dressed in the morning.</p> <p>These individuals have found their homes in assisted living communities, and all are supported by Medicaid and/or Social Security in some form. </p> <p>The communities that support these residents and thousands of others like them are scattered across the country, from Oregon to Maine, and their missions are to offer solace, support, and a place to call home. In many cases, these individuals need care and services that do not rise to the level of skilled or long-term nursing but include some type of round-the-clock assistance.</p> <p>Although the extent to which assisted living providers have opted to take on <a href="/Issues/2011/Pages/1011/Proposal-Threatens-Specialty-Care.aspx">specialty care </a>is not known, anecdotal evidence suggests that many have recently embraced the concept and carved out niche service offerings for clients with specific diagnoses or for those who simply want to stay in their homes for as long as possible. </p> <p>To that end, these providers are, in many cases, meeting unmet housing needs for people who might otherwise be homeless or in a nursing facility. And many of their residents have grown to adulthood and beyond and no longer have parents or loved ones to care for, supervise, or support them.</p> <p>Because these communities are filling the gaps left by housing shortages, they are often full and have long waiting lists to get in.</p> <p>The individuals who are making their homes in these communities have diagnoses that range from severe mental illness, Parkinson’s disease, HIV-AIDS, acquired brain injury, multiple sclerosis, autism, and those who are deaf and deaf-blind.</p> <div>In these pages,<em> Provider </em>takes readers into several communities for a look at how they have successfully taken the road less travelled and why they will never turn around. </div> <h3 class="ms-rteElement-H3">Mission-focused Assisted Living Staff </h3> <div>Employees of specialty care homes are generally not shy about professing their love for the residents. The staff of Washington Manor, an assisted living community located in the tiny hamlet of Washington, Maine, is no exception. They don’t work there for the money; they do it for the residents—individuals with acute mental illnesses—who most likely could not live on their own in a meaningful way. </div> <div> <img width="470" height="343" src="/Issues/2011/PublishingImages/1011/Washington-Manor-3.jpg" alt="Washington Manor" class="ms-rteImage-2 ms-rtePosition-1" style="margin:10px;width:350px;height:270px;" /></div> <div>Home to 34 residents between 20 and 90 years old, Washington Manor serves individuals with diagnoses that range from schizophrenia and bipolar disorder to personality disorder and even autism.</div> <div> </div> <div>Before hiring someone to work at the home, owner and Administrator Janice Nelson-Kroesser preps prospective employees with what she says is her “spiel.” </div> <div> </div> <div>“We provide services to the poor, and we don’t pay very well,” she says. “So I tell them that if they want to work here, they should do it not for the money but for the desire to help the people who live here.” </div> <div> </div> <div>Despite the less-than-optimal wages, turnover at Washington Manor is quite stable, Nelson-Kroesser says. “We have people who have been here a long time and are dedicated to the residents. I feel fortunate to have employees who otherwise could be making a lot more money somewhere else.” </div> <div> </div> <div>Nelson-Kroesser herself has been at the job for more than two decades, first as an employee, then as owner after purchasing the building through her company in 2003. </div> <div> </div> <div>The community’s focus on providing homes only to adults with mental illnesses is a benefit to the residents and to the community, says Nelson-Kroesser. </div> <div> </div> <div><strong>Focus On Specialty Care</strong></div> <div>“Most other assisted living communities that serve mental illnesses have a ‘mixed’ population that also includes elderly individuals,” she says. </div> <div> </div> <div>“In our case, we are able to focus on behavior modifications and interventions designed for this population. We also have a nurse on staff who specializes in psychotropic medications and conducts our medication reviews, and we have a very good rapport with the psychiatrist.”</div> <div> </div> <div>In addition to creating an individual service plan for each resident, there is round-the-clock supervision to ensure that residents’ needs are met. </div> <div> </div> <div>Activities are very important at Washington Manor, says Nelson-Kroesser. “We have a pool table here as well as Wii games, and the residents often have tournaments.”</div> <div> </div> <div>The activities director also plans outings such as fishing, bowling, and hiking on their nature trail. Annual events include a “haunted trail” on the grounds each Halloween, complete with spooky music and a fog machine, to which the community is invited to enjoy.</div> <div> </div> <div>Nelson-Kroesser is emphatic in her belief that Washington Manor is a community-based setting. “This is their home,” she says. </div> <div> </div> <div>“They vote; they have every opportunity that anyone else would have if they lived in the actual community.”</div> <div> </div> <div>In fact, she says, many, if not all of the residents have a better life at Washington Manor than they would have living on their own. </div> <div> </div> <div>Nelson-Kroesser notes that the woman who lived in a trailer, in subhuman conditions, now calls Washington Manor her home.</div> <div> </div> <div>What’s more, she adds, some of our residents are at high risk for entering the penal system without such housing and supervision. “The residents are very proud of their home.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Beyond Dementia Care</h3> <div>Another provider that has a very grateful clientele is Peach Tree Acres, an assisted living community in Harbeson, Del., which offers a structured, supervised setting for persons with acquired or traumatic brain injury.</div> <div> </div> <div>Located on a large and tidy plot of grassy land, amid miles of flat farmland, Peach Tree is just 15 or so miles from the shore town of Rehoboth Beach. </div> <div> </div> <div>The community opened in 1998 in a small brick house that now sits next door to the main facility. </div> <div>The current president of the nonprofit’s board of directors is Peach Tree’s founder, whose own child had suffered a brain injury years ago but had no place to help her live independently.</div> <div> </div> <div>Twenty individuals, ranging in age from 29 to 64, reside in the new building, which was constructed in 2001 and has a waiting list of at least five years. </div> <div> </div> <div>Each of the residents has a roomy private suite with a large bathroom and expansive views of the farm fields that flank the buildings.</div> <div> </div> <div>According Chris Malaney, Peach Tree’s director for the past five years, residents’ injuries include aneurysms, falls, and automobile accidents.</div> <div> </div> <div>Residents are better off with private rooms, she says, because many have tendencies that compel them to maintain their rooms in a certain way and their possessions in a certain place or space. </div> <div><img width="539" height="505" src="/Issues/2011/PublishingImages/1011/Peachtree-1.jpg" alt="Peach Tree resident with Cuddles, the cat." class="ms-rteImage-2 ms-rtePosition-1" style="margin:15px 10px;width:241px;height:181px;" /><br>In addition to residential care, Peach Tree also offers a “day habilitation” program aimed at providing medical care, educational support, social skill-building exercises, and personal independence to people who are not living at Peach Tree.</div> <div> </div> <div>Among the staff are three full-time certified nurse assistants (CNAs) who work day shifts and three who work the night shift. A full-time registered nurse works during the day, and a licensed practical nurse covers the night shift. </div> <div> </div> <div>Peach Tree, like many specialty providers, relies solely on Medicaid funding, according to Malaney. </div> <div>Activities include weekly bowling outings, Wii games, regular trips to the boardwalk in Rehoboth Beach, visits to nearby Fenwick Island and Dover Air Force Base, and music and art therapy.</div> <h3 class="ms-rteElement-H3">Main Goal Is Independence</h3> <div>Malaney stresses that the philosophy and model of Peach Tree is to “promote, above all, independence, privacy, and dignity for our residents.” She adds that the community utilizes a social model of programming and services that emphasizes involvement in activities of life to whatever level is possible or desired with medical support.</div> <div> </div> <div>“Our role is not to do for our residents, but to assist with each resident’s needs,” she says. </div> <div>Grounded in this principle is an activity that educates residents about the brain. Called “neurobics,” Malaney, who is the only known certified nursing home administrator that is also a certified brain injury specialist, helps residents gain insight into how the brain works and how their injuries impact their health and behavior. </div> <div> </div> <div>Approximately 600,000 people in the United States are deaf, according to the Gallaudet Research Institute, and more than half of these individuals are over the age of 65. In addition, another 6 million people report having “a lot of trouble hearing,” and, again, half of them are elderly.</div> <div> </div> <div>Although many deaf individuals do not believe they have a handicap, the provision of housing that caters to the elderly deaf, hard of hearing, and deaf-blind community has ramped up in recent years. </div> <div>According to a new resource guide published by Deaf Seniors of America (DSA), there are 10 assisted living residences that cater to deaf individuals in the United States and one in Toronto. </div> <div> </div> <div>Lowry Park Assisted and Independent Living, in Denver, only recently gained its renown among the elderly deaf community, according to Lisa Case, director of community relations for Lowry Park.</div> <div> </div> <div>She says the realization that Lowry Park had become a draw for deaf and hard-of-hearing individuals didn’t hit her until about year ago. It came after a woman who was moving from California to Colorado was desperately searching for a place for her mother to live. </div> <div> </div> <div>The woman found Lowry Park by happenstance, says Case, through a forum on an obscure website she had found, likely after trolling the Internet for hours. </div> <div> </div> <div>Since then, Lowry Park has acquired a number of deaf-friendly resources for residents, including lights that flash on and off for doorbells and phone calls and staff training in American Sign Language. </div> <div>Also relatively new to the community are videophones that help residents communicate with far-away relatives and friends, while wall posters placed throughout the community help staff and visitors use sign language instead of speaking. </div> <h3 class="ms-rteElement-H3">Communities Create Families</h3> <div>Similar to Lowry Park, Chestnut Lane assisted living in Gresham, Ore., serves the deaf and deaf-blind community. Residents from all corners of the country have trekked to Oregon to live at Chestnut Lane because it is highly touted among the deaf community as a warm and inviting place for deaf adults. Many residents have made the commitment to live there, despite having never seen it before. </div> <div> </div> <div>Founded in 2003 by a woman who had run a foster home and whose parents were deaf, Chestnut serves 74 individuals, most of whom are elderly, although the community is licensed to accept individuals 18 and older. </div> <div> </div> <div>Chestnut Lane’s layout, which includes a fourth-floor dining room vista of Mt. Hood, includes spacious, open areas that provide the visibility residents need to sign to each other from across the room. </div> <div> </div> <div>Each staff member is committed to communicating with residents in sign language, some of whom are deaf themselves. </div> <div> </div> <div>Sherry Andrus, executive director of Chestnut and a sign language interpreter for the past 25 years, says the deaf culture is very group-oriented, similar to Japanese society, “so they communicate widely among each other. This is how word spreads about housing as well,” Andrus says. </div> <div> <img width="590" src="/Issues/2011/PublishingImages/1011/Chestnut-Signing-News.jpg" alt="Chestnut Lane staff and residents using ASL." class="ms-rteImage-2 ms-rtePosition-2" style="margin:15px 10px;width:399px;height:267px;" /><br>“We have a resident who has cerebral palsy and developmental disabilities, and is deaf, but she was welcomed by the others as if she was a member of the family,” says Andrus. “It’s really like a big family here.”</div> <div> </div> <div>Many activities at Chestnut are similar to those of typical assisted living communities—casino visits, winery tours, exploring Multnomah Falls in the Columbia River Gorge, holiday parties, picnics, bowling, and shopping. However, when it comes to activities for deaf and deaf-blind residents, staff often do double-duty to ensure that all are able to participate. Not a simple feat for a community that relies mostly on Medicaid to operate. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Staff Offer Special Assistance </h3> <div>Says Andrus, “We play bingo and other games, but it requires a lot of communication happening.” Some residents, especially those who are deaf and blind, need one-one-one assistance and signing in order to play, while the remaining participants also need someone to sign at the front of the room.</div> <div> <img width="337" height="415" src="/Issues/2011/PublishingImages/1011/Chestnut-Bingo-for-low-vision-Deaf.jpg" alt="Chesnut Lane bingo" class="ms-rteImage-2 ms-rtePosition-1" style="margin:15px 10px;height:226px;" /><br>Many of the residents also need additional assistance in navigating the health care system. “They have problems accessing health care because their doctors do not know how to sign or the residents cannot read lips,” Andrus says. “So we help them with things like that as well.” </div> <div> </div> <div>Church is another activity that is difficult to access for many in the deaf community, so Andrus has a deaf pastor come to her residents regularly. She also found a local hairdresser who is deaf and therefore able to communicate with the residents to find out how they want their hair styled. </div> <div> </div> <div>She notes that because the deaf community is so tightknit, and there are generally very few accessible activities for them in the larger community, “whenever we have an event, we get people of all ages” showing up.</div> <div> </div> <div>Staff members commonly take on the role of surrogate family member with residents, Andrus explains. “Since most of the residents’ families live far away, we don’t have many family-related events; we’re all they have.”</div> <div> </div> <div>DSA’s resource document includes a list of names, addresses, phone numbers, and websites for various types of seniors housing facilities, including independent/retirement, assisted living, nursing, and others, as well as a list of senior clubs for deaf seniors who travel extensively. Go to: <a href="http://www.nad.org/seniorresources">www.nad.org/seniorresources</a>.  </div> <h3 class="ms-rteElement-H3">New Home For Adults With Autism In N.J.</h3> <div>According to a 2009 report from Southwest Autism Research & Resource Center, between 400,000 and 500,000 Americans with autism-spectrum disorders will enter adulthood over the next 15 years. The report notes that many adults with autism are being cared for by aging parents who are not likely to outlive their children, thereby leaving them limited options for lifelong support. </div> <div> </div> <div>“This growing new subset of the developmentally disabled population is too old for continued support through the special education services of a public school system and too fragile to live without support in the larger world,” the report says. This means their families are likely to face a “complicated system of vocational rehabilitation services, Medicaid, disconnected government agencies, and a lack of appropriate residential care options beyond the obvious ones of keeping them at home or within institutional settings.” </div> <div> </div> <div>Indeed, the obvious options were not what Chelsea Senior Living had in mind when it developed plans to build a community that will serve adults with autism-spectrum disorders. Having broken ground this past June, Mt. Bethel Village, Warren, N.J., is scheduled to open its doors in about one year. </div> <div> </div> <div>The brainchild of Chelsea Chief Executive Officer Herb Heflich and Paul Abend, MD, Mt. Bethel’s mission is to enable moderately and more independent adults with developmental disabilities the opportunity to further advance their skills, independence, purpose, and self-esteem through a comprehensive array of quality services, supports, advocacy, and collaboration with families. </div> <div> </div> <div>“We think it will be amazing,” Abend said at the groundbreaking ceremony in June. “And the ideas we have—horticulture therapy with professors from around the world, organic farming—I have no doubt this will be off the charts.”</div> <div> </div> <div>Chelsea spokesperson Tom Kranz says the community is aimed at filling consumer needs and helping to alleviate the housing crisis for adults with autism in New Jersey and surrounding states. </div> <div> </div> <div>Built to house 41 individuals in one-bedroom units located in four separate neighborhoods, amenities at Mt. Bethel will include a gym; a workshop; a greenhouse; a computer lab; full medical and dental exam rooms; rooms for physical, behavioral, and vocational specialists; and resident monitoring technology.</div> <div> </div> <div>“We believe Mt. Bethel will give residents the potential to be as independent as possible,” says Kranz, who notes that it comes at a time when housing for those with developmental disabilities is at a crisis point. </div> <div> </div> <div>Additional services will include life skills training, case management, vocational services, yoga, massage, and 24-hour staff support.</div> <div> </div> <div>Prompted by the epidemic of autism in New Jersey and the rest of country, Chelsea saw a need that it could fulfill through a traditional assisted living model, which relies on choice, independence, dignity, individuality, a homelike environment, and privacy.</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">It’s All About Continuity</h3> <div>On the far west side of Michigan, not far from Lake Michigan, is Holland, home to an annual Tulip Festival and to LakeSide Vista, an upscale independent and assisted living community that recently opened a new transitional housing building on its campus. </div> <div> <img width="320" height="342" src="/Issues/2011/PublishingImages/1011/Delph-Haus.jpg" alt="Delph Haus" class="ms-rteImage-2 ms-rtePosition-2" style="margin:15px 10px;height:240px;" /><br>Called Delph Haus, it seeks to bridge the gap between hospital and home for campus residents and for others in the community who may need a place to go for short-term care. </div> <div> </div> <div>“Delph Haus is for those individuals who have a hospital stay that may not qualify for Medicare but still need a transition from hospital to home,” says Daniel Charpentier, vice president of LifeHouse Management Services, the company that operates LakeSide Vista. </div> <div> </div> <div>He describes Delph Haus as having a “hotel-like” atmosphere in a “cottage-style building, where clients can get back on their feet before returning home.”</div> <div> </div> <div>The building has room for 18 individuals, most of whom are expected to stay for several days to a week, although clients can stay for up to a month, Charpentier says.</div> <div> </div> <div>In addition to a gym for rehab and physical therapy, Delph Haus has private rooms with flat-screen televisions. “All you need is your clothing,” he says.</div> <div> </div> <div>The reason for creating this model in an assisted living setting, says Charpentier, was to meet the needs of their existing residents and the surrounding community.</div> <h3 class="ms-rteElement-H3">Community Brings Aging In Place To Its Residents </h3> <div>Howie Groff, president of Tealwood Care Centers in Bloomington, Minn., is excited about his latest endeavor. And, similar to others highlighted in this article, it appears to be part happenstance and part ingenuity that birthed a new concept that is working well for his residents. </div> <div> </div> <div>Dubbed Care Suites, the concept is part of his assisted living communities.</div> <div> </div> <div>The idea came when Groff was presented with a problem: Several residents in the assisted living apartments had mild dementia and some chronic conditions that threatened their ability to stay in their homes. </div> <div> <img width="392" height="480" src="/Issues/2011/PublishingImages/1011/Tealwood-Care-Suites-2.jpg" alt="Tealwood Care Suites" class="ms-rteImage-2 ms-rtePosition-1" style="margin:15px 10px;height:339px;" /></div> <div>Groff says he came up with the concept of a Care Suite when he and his team were brainstorming about how to solve these residents’ concerns. By converting two apartments into a larger three-bedroom apartment, the first suite was born, says Groff. </div> <div> </div> <div>“Essentially, we took two side-by-side apartments, knocked down the adjoining wall, took out one of the kitchens, and created a living space for three individuals,” says Groff, who notes that the suites cater to clients who require services that cannot be met living in their own individual apartments.</div> <div> </div> <div>Each suite is staffed 24 hours a day and has a high employee-to-client ratio, he says. </div> <div> </div> <div>“We’re able to offer residents comprehensive services to enhance their physical and psychosocial well-being while they remain a part of the larger senior community.”</div> <div> </div> <div>Similar to Delph Haus’ concept of bringing home care into the building where the residents are staying, Groff devised a way to let his medical care staff provide the home care to the client, so that he can stay in his apartment instead as he receives care.</div> <div> </div> <div>“We engaged the agency to come into the assisted living facility, where our staff deliver the care, and Medicare reimburses us,” Groff says. </div> <div> </div> <div>“It’s saved a lot of wear and tear on family members because it has become a kind of self-contained continuing care community. We bring the services to them.”</div> <div> </div> <div>Groff says he had a lot of fun developing the concept and helping his residents remain in their homes. </div> <div> </div> <div>The idea has become so popular that the company is building more of them, which are scheduled to open next year.  </div>A woman who had previously lived in a trailer with no running water, no heat, and a bucket for a toilet now has a warm and comfortable home at a Maine assisted living community. An elderly woman, who was deaf and in need of assistance that her daughter could no longer provide, was welcomed into her new home by housemates and staff who communicated in her native sign language. Then there's a man who was seriously injured in a motorcycle accident but previously had no one to help him get dressed in the morning. These individuals have found their homes in assisted living communities, and all are supported by Medicaid and/or Social Security in some form. The communities that support them and thousands of others like them are scattered across the country, from Oregon to Maine, and their missions are to offer solace, support, and a place to call home. In many cases, these individuals need care and services that do not rise to the level of skilled or long-term nursing but include some type of round-the-clock assistance.2011-10-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1011/Chestnut-Signing-News_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ManagementColumn10
Difficult Behaviors Decodedhttps://www.providermagazine.com/Issues/2011/Pages/1011/Difficult-Behaviors-Decoded.aspxDifficult Behaviors Decoded<p>​<img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1011/angry_senior2.jpg" alt="" style="margin:10px;" /><br>Loud screams echo in the hallway. A nurse’s attention shifts from the chart she was working on to the room from which the screams are coming. She runs toward the resident and provides verbal reassurance, coupled with physical comfort of rubbing his arm and shoulder. The screams cease. The nurse walks away and resumes charting when the screams echo again.</p> <div>This scenario routinely occurs in long term care settings, with many challenging behaviors such as screaming out, aggression, and sometimes hitting. Such behaviors can increase over time, with staff often habituating a behavior-response pattern. </div> <h3 class="ms-rteElement-H3">The Functions Of Behavior</h3> <div>Behavior is everything that a person does. Waving hello, walking down the street, talking to a neighbor are all behaviors. These behaviors serve as a function for an individual: waving hello to gain the attention of anther person, walking down the street for exercise, and talking to a neighbor for social interaction. </div> <div> </div> <div>Residents in long term care settings may exhibit maladaptive behaviors such as verbal abuse, physical aggression, elopement, noncompliance, or socially disruptive behaviors for a purpose, a specific function. Determining the function of the behavior will help staff assist the resident in exhibiting positive behavioral repertoires.</div> <div> </div> <div>From an applied behavioral analysis perspective, there are four functions of behavior. The most easily understood function is attention. In the example above, loud screams echo the hallway from a resident. The staff response is to approach and provide physical and verbal comfort. The screams cease when attention is given. The screams reemerge once the staff member has left. </div> <div> </div> <div>This interactive exchange between the resident and staff has taught the resident that by screaming, he will gain staff attention, and when the screaming stops, the attention stops. This behavior response pattern will increase the likelihood of the behavior of screaming to become more frequent. </div> <div> </div> <div>The second function of behavior is called escape. Demands placed upon a resident, such as showering, taking medicine, or changing clothes, can be viewed as aversive, which can manifest into verbal abuse or aggression. These behaviors serve as a function to ultimately escape from the desired task. </div> <div> </div> <div>The most common scenario is when staff are delivering care. A resident may often yell or strike out in an attempt to terminate and “escape” from the activity. If the response from staff is to stop the activity, the resident is more likely to continue to strike out during care to escape.</div> <div> </div> <div>The third function of behavior is tangible. Residents often yell, curse, or strike out at staff when access to a particular tangible item is limited, such as the desire for more food at mealtime. </div> <div> </div> <div>The last function of behavior is sensory. This occurs when the behavior serves as an automatic reinforcement independent of the environment. The resident’s behavior is self-stimulatory, such as scratching oneself.  </div> <h3 class="ms-rteElement-H3">Preventing Reinforcement </h3> <div>So how can staff effect behavioral change? Well, it could be as obvious as staff giving a directive, or it can be as obscure as fixing a crooked painting on the wall. </div> <div> </div> <div>While there are many variables that may influence challenging behaviors like these, including genetics, physical limitations, biological needs, and others, what is often not realized is that the environment—in this case, the staff’s reaction to the challenging behavior—plays a vital role in the resident’s behavior and, more importantly, can increase the future likelihood of the behavior. </div> <div> </div> <div>This process is called reinforcement. </div> <div> </div> <div>Reinforcement is a consequence that influences behavior. It increases the likelihood that the behavior will occur again under those similar conditions Data paint a picture. Data give the what, when, where, and how regarding a behavioral event. The “what” is what most people focus on, such as what happened? Staff might interpret this as “he struck the CNA [certified nurse assistant].” But is that the whole picture? Does that really describe what happened? </div> <div> </div> <div>To be more specific, it is best to know what happened right before the resident exhibited the behavior. Something in the environment set up the event that compelled the resident to strike the CNA. This is a key component in understanding resident behaviors.</div> <div> </div> <div>Whatever it may be, having data to interpret will help put interventions in place to reduce challenging behaviors. </div> <div> </div> <div>How does one know if something is reinforcing the behavior it follows? One of the best ways is to look at the ABCs of an incident: Antecedent, Behavior, and Consequence.</div> <div><img class="ms-rteImage-1" src="/Issues/2011/PublishingImages/1011/Caregiving1.gif" alt="" style="margin:15px 5px;" /> </div> <div>An antecedent is the first link in this chain of events. It tells caregivers what happened right before the behavior of concern. </div> <div> </div> <div>In the example above, the antecedent was the resident sitting alone in the bedroom. The behavior is what follows. The behavior was the resident screaming; following the behavior is its consequence. The consequence was staff rushing to the resident, providing a great deal of tactile stimulation, such as rubbing the resident’s arm or shoulder, coupled with verbal calming, such as “It’s okay; can I help you?” What happens after the behavior—the response to it—is what strengthens or weakens the behavior or increases or decreases the likelihood of that behavior reoccurring in the future. </div> <div> </div> <div>It is the future response that should be controlled, based on the behavioral approach.  </div> <h3 class="ms-rteElement-H3">Documenting The ABCs</h3> <div>While there are several methods for determining the antecedents and consequences of a behavior, the most basic, yet effective, tool is an ABC descriptive analysis sheet. It captures the time, location, antecedent, behavior, and immediate consequence. </div> <div><img class="ms-rteImage-1" src="/Issues/2011/PublishingImages/1011/Caregiving2.gif" alt="" style="margin:15px 5px;" /><br><br>This tool is simple but effective in gathering pertinent information to identify components that influence behavior.</div> <div> </div> <div>Behavior is a form of communication. Taking the example of a resident striking a staff member following assistance with an activity of daily living, one can determine that hitting is a form of expression of not wanting to participate in that activity.</div> <div> </div> <div>If the response or consequence to that behavior is to leave the resident alone, the behavior of hitting will increase, as the resident has learned that the striking behavior is successful in allowing them to escape from that particular demand. </div> <h3 class="ms-rteElement-H3">Proven Solutions</h3> <div>Following are some proven solutions for reducing this behavior:</div> <div> </div> <div><strong>1. Noncontingent Reinforcement. </strong>This has been proven to be an effective intervention with attention-seeking behaviors. This procedure involves providing reinforcement, such as attention from staff via verbal praise or high fives on a fixed schedule (every 15 minutes, every hour) or at random, completely independent of the behavior. In the example of the resident screaming, staff would provide social praise every hour, regardless if the resident is exhibiting screaming behavior or not. </div> <div> </div> <div><strong>2. Functional Communication Training.</strong> This strategy is useful to teach the resident functional communication skills to replace problem behavior. </div> <div> </div> <div>Teaching the resident to either say, “Come talk to me,” or gesture, “Come,” with his hand when he would like a staff member’s attention, staff will provide the attention and verbally praise him for appropriately expressing himself. This social reinforcement will increase the likelihood of the resident verbalizing the phrase, “Come talk to me,” as opposed to yelling out for attention. Staff should continue to provide attention every time the resident appropriately asks for it. Repeat the procedure as necessary.</div> <div> </div> <div><strong>3. Behavior Momentum.</strong> This technique is helpful to assist with compliance. A staff member presents a series of easy-to-follow requests for which the resident has a history of compliance. When the resident complies with several high-probability requests in sequence, the staff member immediately gives the target request, such as taking medications, and uses the momentum of the high-probability response in assisting with compliance of the low-probability request of taking medication. </div> <div> </div> <div>Following is an example of how this might work:</div> <ul><li>Staff member: “Hey, give me a high five!” (a high-probability request).</li> <li>Resident: Slaps the staff member’s hand.</li> <li>Staff member: “Great job!” or “Throw the ball to me” (a high-probability request).</li> <li>Resident: Throws the ball to staff member.</li> <li>Staff member: “Awesome, let’s take your medications” (low-probability request).</li> <li>Resident: Takes medications.</li></ul> <div>These are just a few interventions that have been proven to be successful when implemented to help shape behavior.</div> <div> </div> <div>However, with any event that nursing facility staff are faced with, collecting data will help formulate an effective treatment plan to reduce these challenging behaviors.</div> <div> </div> <div><em>Danielle Russo, MA, is neurorehabilitation program director at Kindred Rehabilitation and Nursing of Braintree in Braintree, Mass. She can be reached at (781) 794-5308.</em> </div>Loud screams echo in the hallway. A nurse’s attention shifts from the chart she was working on to the room from which the screams are coming. 2011-10-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1011/angry_senior_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalManagement10
Nurse Retention Reviewhttps://www.providermagazine.com/Issues/2011/Pages/1011/Nurse-Retention-Review.aspxNurse Retention Review<div>​<img width="364" height="182" class="ms-rteImage-1 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1011/HR_iStock_000009955305Medium.jpg" alt="" style="margin:10px;width:273px;" /><br>Nursing is considered to be one of the most recession-proof professions around. In fact, according to the U.S. Bureau of Labor Statistics, health care is one of the few industries that continued to show growth among employment during the recession. </div> <div> </div> <div>More than 170,900 jobs were created in the health care industry in the frist seven months of 2011, with 31,300 new jobs created in the month of July alone.</div> <div> </div> <div>Despite these figures, there is still a tremendous gap between supply and demand. As the current nursing population retires and as the baby boomers age, this gap will only widen.  </div> <h3 class="ms-rteElement-H3">Gap Threatens Supply</h3> <div>This increasingly wide margin may potentially leave long term care facilities with a shortage of trained nurses, which some experts expect to reach up to 500,000 by the year 2025.</div> <div> </div> <div>Contributing to this shortage is the inability of nursing schools to produce graduates fast enough to keep up with the rising demand of applicants. </div> <div> </div> <div>Although the American Association of Colleges of Nursing (AACN) reported an increase in nursing school enrollment throughout the past decade, qualified nursing school applicants continue to be turned away from colleges and universities. </div> <div> </div> <div>AACN reports that in 2009, nursing schools rejected nearly 55,000 qualified applicants. Faculty shortages, budget constraints, and increasing job competition from clinical sites have all contributed to the limited number of graduates produced.</div> <div> </div> <div><a href="/Issues/2011/Pages/1011/Expensive-Replacements.aspx">Nurse burnout </a>also plays a huge role in the nursing shortage. Working in a highly stressful and demanding environment can take a toll on nurses—especially those who are new to the field. One national study shows that about one in five newly licensed nurses quit within the first year. And with a lack of support from employers and the confidence that comes with experience, nurse burnout is only heightened. </div> <div> </div> <div>Even more startling is the impact that nurse burnout can have on patient care. Findings published in the New England Journal of Medicine in March 2011 indicate that inadequate nurse staffing correlates to higher patient mortality. </div> <h3 class="ms-rteElement-H3">Mentoring Program Works</h3> <div>In hopes of maintaining its new nurse graduates, Brattleboro Memorial Hospital in Vermont implemented a nurse mentoring program, pairing new nurses with senior nurses. </div> <div> </div> <div>The goal of the program was to provide the new nurses with a mentor who could serve as an active listener, providing support, enthusiasm, and nurturing in a nontraditional learning environment. Two years into the initiation of the program, the hospital reported that nearly all of the nurse participants have remained at the facility. </div> <div> </div> <div>Another successful program was implemented in Scottsdale, Ariz., where the Mayo Clinic has developed a program for nurses affected by the daily stresses on the job. The program teaches nurses how to recognize stressors and decrease them in the moment. It also teaches breathing techniques and methods to evoke positive emotions as a response. </div> <div> </div> <div>Nurses who have participated in the program report decreases in stress and fatigue, as well as fewer aches and pains, due to the new techniques.</div> <div> </div> <div>In addition to providing training and support programs, many employers are turning to voluntary benefits as a means of retaining employees. MetLife’s “8th Annual Employee Benefits Trends Study” found that among employees highly satisfied with their benefits packages, 81 percent were also satisfied with their jobs. Consequently, increasing total reward offerings can help create a more loyal, productive workforce.</div> <div> </div> <div>Originally limited to insurance-related products such as disability, life, and accident coverage, voluntary offerings have since evolved to include more nontraditional benefits. Examples include employee purchase programs, pet insurance, wellness initiatives, and prepaid legal services. </div> <div>Employees typically pay for these services and products on their own through payroll deductions. </div> <h3 class="ms-rteElement-H3">Low-Cost Benefits </h3> <div>Because most voluntary plans come at little or no direct cost to the employer, they serve as a perfect alternative for those looking to re-evaluate their benefit offerings, but don’t wish to add costs to the facility. </div> <div> </div> <div>In an effort to retain and recruit top talent, Valley Baptist Health System in Harlingen, Texas, wanted to provide the most comprehensive benefits package to its employees. Valley Baptist Health offers a payroll deduction purchase program, as well as other value-added voluntary benefits, such as supplemental life insurance for the employee and dependents, accident, critical illness, cancer, prepaid legal, and long term care insurance. </div> <div> </div> <div>It has been able to implement these programs without affecting the hospital’s bottom line.</div> <div>Voluntary plans also allow employers to offer the depth and breadth of choices that employees want and need.  </div> <h3 class="ms-rteElement-H3">What Employees Want</h3> <div>A recent employee survey found that employees want and value choice. Of those surveyed, 88 percent said that choices are “important” or “extremely important” when it comes to benefits packages. Therefore, it is important that employees be able to select the benefits that suit their own individual and family needs. </div> <div> </div> <div>Today’s employees come from multiple generations, each with its own working style, its own needs, and its own expectations about the workplace. In order to successfully use benefits to develop a healthy, working relationship with employees, employers need to take a look at what generations are represented in their workplace and consider a variety of benefits, as opposed to a one-size-fits-all package. </div> <h3 class="ms-rteElement-H3">Meeting Multiple Needs</h3> <div>Additionally, employers tend to find voluntary benefits attractive because they provide tangible benefits that employees can enjoy almost immediately. </div> <div> </div> <div>For example, many of these types of benefits help promote a healthy work-life balance by providing responsible purchase options to help families stay within a budget, or discounted gym memberships to promote a healthy lifestyle. </div> <div> </div> <div>These unique products can help set a benefits package apart, making the employer more appealing and more competitive. </div> <div> </div> <div>It’s also important to remember that improving communications can lead to a more engaged employee base. Just as one benefits package no longer meets the needs of every employee, neither does one communication strategy. </div> <div> </div> <div>Using a variety of communication vehicles like e-mail, posters, and even home mailers can help the provider communicate the true value of all the benefits it makes available to its employees. </div> <div>“Today, employees range from baby boomers to Generation X to Generation Y,” and being able to reach these different segments’ needs is very important, Halkos says. </div> <div> </div> <div>Health care is a significant part of the nation’s economy and will continue to be a major employment sector in both good and challenging times. If the demand for nurses is to be met, many issues will need to be resolved, but while industry leaders are addressing these challenges, long term care facilities must proactively work to not only attract, but retain a skilled nursing workforce. </div> <div> </div> <div><em><img width="250" height="377" class="ms-rteImage-1 ms-rtePosition-1" src="/Issues/2011/PublishingImages/1011/HR_ElizabethHalkos.jpg" alt="" style="margin:5px 15px;width:126px;height:143px;" />Elizabeth Halkos is chief marketing officer for Purchasing Power (www.purchasingpower.com), an Atlanta-based voluntary benefits company that offers a program that makes it possible for employees of participating organizations to purchase computers, electronics, and home appliances through payroll deductions. She can be reached at (877) 723-2798 or ehalkos@purchasingpower.com. </em></div>Nursing is considered to be one of the most recession-proof professions around. In fact, according to the U.S. Bureau of Labor Statistics, health care is one of the few industries that continued to show growth among employment during the recession. 2011-10-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1011/HR_ElizabethHalkos_thumb.jpg" style="BORDER:0px solid;" />Workforce;ManagementColumn10
Residents' Volunteerism Lifts Mood, Dampens Depressionhttps://www.providermagazine.com/Issues/2011/Pages/1011/Residents-Volunteerism-Elevates-Moods-Dampens-Depression.aspxResidents' Volunteerism Lifts Mood, Dampens Depression<div><img width="395" height="244" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1011/Mission-View7.jpg" alt="" style="margin:5px;width:325px;" />Nursing facilities have made tremendous strides in the past 25 years. An abundance of truly compassionate, highly trained caregivers is common in most facilities, and many facilities provide state-of-the-art services with deluxe accommodations.</div> <div> </div> <div>Having highly competent staff working around the clock, being provided more choices in their daily lives, and having ample opportunities to socialize and engage in activities, it would seem that residents have everything they need, right? So why, according to the American Geriatrics Society, do nearly half of all nursing facility residents experience apathy and depression?</div> <div> </div> <div>Historically, nursing facilities have borrowed the acute hospital model of care—clinical excellence and compassionate care. Both are needed and fundamental to what hospitals and nursing facilities do. This model works well in the acute-care setting where people are soon going back to their homes. However, for nursing facility residents, this model leaves them in the long-term position of a “care receiver.” </div> <div><br>Even if the care is of the highest caliber and staff are beyond wonderful, residents are left with their greatest fear realized: “No one needs me anymore; I am now just a burden on society.” <br></div> <div>Without an opportunity to give back in a real and meaningful way, the stage is set for apathy and depression.</div> <h3 class="ms-rteElement-H3">Making The Switch</h3> <div><div>In 2008, staff members at Mission View Health Center in San Luis Obispo, Calif., were brainstorming about why their residents seemed unfulfilled and unhappy, in spite of excellent treatment and care—they didn’t have that spark in their eyes. Kathy, a resident, had recently asked the administrator, “Isn’t there something I can do? Any way I can help? I am bored to tears—and I mean tears.” </div> <div> </div> <div>A nurse assistant commented that his “life would suck if all I had to look forward to every day was thanking everyone for helping me and no one needed me anymore.”</div> <div> </div> <div>For the first time, it struck the group that the residents really were relegated to the role of “care receivers,” no matter how good the staff were as “caregivers.” As a result, Mission View adopted a <a href="/Issues/2011/Pages/1011/Implementing-A-Service-based-Program.aspx" target="_blank">service-based </a>approach to health care, allowing residents to give as well as receive. </div> <div> </div> <div>In order to accomplish this goal, Mission View would align itself with the needs of the local community. By partnering with <img width="313" height="410" class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/1011/Mission-View1.jpg" alt="" style="margin:15px;height:224px;" />a local homeless shelter, Mission View staff set the wheels in motion for their first resident service opportunity to feed the homeless in their community. </div> <div> </div> <div>To support this venture, residents use the activities budget to make Helping Hands Homemade Soap and sell it at the local farmers market. </div> <div> </div> <div>At first, residents weren’t particularly excited about what they considered another arts and crafts activity. However, when the residents understood the bigger picture of feeding the homeless, there was a change of heart. They realized they were needed and could make a real difference in their community. </div> <div> </div> <div>Today, residents with dementia use water color to decorate the soap wrappers, three residents in their 90s hawk the soap at the farmers market, while residents with vision problems and physical disabilities help prepare the meals.</div> <div> </div> <div>Six of the residents serve food onto the plates of 150 men, women, and children at the shelter every month. </div> <div> </div> <div>Clearly, for the residents, the activity was not about making and selling soap, but about making a difference in their community. Because the shelter truly depends on them, the residents experience purpose and meaning in their lives, as well as the joy and fulfillment of service. </div> <h3 class="ms-rteElement-H3">Giving More</h3></div> <div><div>Following the success of Helping Hands, Mission View began working with a local hospice agency. Within two weeks, the first seven-week resident training was underway, enabling residents to become certified hospice volunteers, helping other residents who sometimes simply needed someone to hold their hand. </div> <div> </div> <div>Staff at Mission View started seeing that residents were regaining that spark in their eyes; after all, when they roll out of their room as a hospice volunteer to visit another resident, they are a hospice volunteer, not a resident, and have a hospice badge to prove it. </div> <div> </div> <div>The service-based approach extends to facility activities as well. Even with physical and cognitive challenges, residents are more capable than commonly believed. </div> <div> </div> <div>For example, a very unhappy and cranky resident who had suffered a stroke and left-sided paralysis changed his attitude when staff realized he was bilingual and called on him to become the facility Spanish instructor. </div> <div> </div> <div>He now spends his week planning his class and making sure he is clean-shaven and looking sharp for his lesson. Residents love his class and can be seen practicing their Spanish up and down the halls. </div></div> <div><h3 class="ms-rteElement-H3">Word Has Spread</h3> <div>Initially at Mission View, staff could not picture their residents feeding the homeless, opening a food bank distribution point at the facility, or running a nonprofit business like Helping Hands Handmade Soap. And yet, it is actually happening. </div> <div> </div> <div>It’s easy to underestimate the potential of nursing facility residents, especially when they are in a depressed and apathetic state. It is important to focus on what they can do and remind them that they can still be valuable members of their community. </div> <div> </div> <div>Today, 40 to 50 percent of all Mission View residents are actively involved in service projects. With Mission View’s success, additional nursing facilities under the Compass Health umbrella are adopting similar programs. </div> <div> <img width="232" height="178" class="ms-rtePosition-2" src="/Issues/2011/PublishingImages/1011/MIission-View2.jpg" alt="" style="margin:15px;height:173px;" /></div> <div>Residents in one facility are baking and selling dog biscuits to help rescue elderly dogs from a local shelter. Another group is selling handmade jewelry to buy backpacks and stock them with school supplies for local underprivileged children.</div> <div> </div> <div>Having heard about the program, another provider with 30 facilities is adopting the same program for its residents. </div> <div> <br>The cost of this culture change? It’s virtually free, with a little time and effort. </div> <div> </div> <div>Rev. Martin Luther King Jr. once said about service, “Everybody can be great, because anybody can serve … you only need a heart full of grace.” </div> <div> </div></div> <div>To purchase the residents’ Helping Hands Handmade Soap, go to <a href="http://www.missionview.etsy.com/">www.missionview.etsy.com</a>. To view a documentary about Mission View's work, click here: <a href="http://www.youtube.com/watch?v=nE1A5SLqHro">http://www.youtube.com/watch?v=nE1A5SLqHro</a> </div> <div> </div> <div>M<em>atthew Lysobey, MPH, LNHA, has worked in the long term care industry for more than 15 years and spearheads the Compass Health service-based approach in San Luis Obispo, Calif. Lysobey can be reached at </em><a href="mailto:matthew@compass-health.com"><em>matthew@compass-health.com</em></a><em>. </em></div>When residents of a California nursing home become the service providers they find a powerful antidote for loneliness and depression in the process.2011-10-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1011/Mission-View1_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn10
The QIS Experthttps://www.providermagazine.com/Issues/2011/Pages/1011/The-QIS-Expert.aspxThe QIS Expert<p>​<strong>Q. Does using the QIS process for quality improvement lead to better survey performance?</strong><br><br>A.We now have data on the pattern of use by nursing facility providers so that we can determine the use characteristics that resulted in improved survey results. </p> <p>The study looked at the following three groups of facilities over three annual survey cycles: facilities with substandard quality before using the system (n=117); facilities with good quality that used the system continuously and at a high level (n=168); and facilities with good quality that used the system at sporadic and low levels (n=166). </p> <p>Facilities ranged from single facility organizations to members of large multifacility organizations and represented multiple states. </p> <p>Facilities with prior substandard survey results had an average reduction of 3.4 survey deficiencies after using all of the QIS assessments continuously at a moderately high level for at least one year. Facilities with prior good survey results had an average reduction of 1.5 survey deficiencies with continuous high level of use for at least one year. Facilities with prior good survey results had no change in average survey deficiencies with sporadic and low-level use. </p> <p>Results of this study strongly suggest that both facilities that are struggling with quality of care and high-performing facilities can improve using a Quality Assurance and Performance Improvement (QAPI) system based on QIS methods. </p> <p>The study also showed that improvement takes a commitment to continuous use by facility staff involved in patient care, rather than the “mock survey” approaches during a survey window, such as the sporadic users. </p> <p>Not surprisingly, it took more comprehensive QAPI to achieve additional quality improvements in already high-performing facilities; however, this group with high use on average achieved a 22 percent improvement in one year. </p> <p>It should also be recognized that it took more than simply conducting the Stage 1 assessments to have an impact. Successful organizations used the root-cause analysis and investigation methods included in the system to conduct their QAPI process. Thus, it appears that nursing facilities have the tools available to them to improve survey results; the challenge is to engender staff commitment to consistent adherence with a QAPI program.</p> <p><em>Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).</em></p>Does using the QIS process for quality improvement lead to better survey performance? We now have data on the pattern of use by nursing facility providers so that we can determine the use characteristics that resulted in improved survey results. 2011-10-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/AKramer_rollup.jpg" style="BORDER:0px solid;" />Management;Survey and CertificationColumn10
Idaho Goldhttps://www.providermagazine.com/Issues/2011/Pages/1011/Idaho-Gold.aspxIdaho Gold<div>For three years, Administrator Maryruth Butler and her 90 employees and 23 volunteers worked to get the Louisville, Ky.-based Kindred Healthcare-owned Kindred Nursing and Rehabilitation - Mountain Valley in Kellogg, Idaho, to the highest rung of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) National Quality Award ladder.</div> <div> </div> <div>Three times they received feedback from master examiners on how to improve on an already strong performance, but for the years 2008-2010 they did not hear the magic words that the Gold was theirs.</div> <div><br>That all changed this year when Butler and her team became the one AHCA/NCAL gold recipient for 2011, the first time such an award was given to an Idaho skilled nursing facility or a Kindred residence.<br><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1011/FISHING.jpg" width="317" height="281" alt="" style="margin:5px;height:238px;" /><br>“We became better,” Butler says, crediting the examiner feedback on areas to improve upon with helping to show everyone at Mountain Valley in what direction they needed to go.</div> <div><br>“They gave us a different look from their lens, and the feedback proved an opportunity for improvement,” Butler says. </div> <div> </div> <div>Some of the specific areas where Butler’s team learned to change for the better included customer satisfaction surveys. Feedback from the 2008 award application said the center did not segment customers in an efficient way, dividing people between short and long stays for instance.</div> <div> </div> <div>“We had a 36 percent response rate in 2008” to customer satisfaction surveys, Butler says. “That made us ask if we even had actionable information from so few returned surveys.”</div> <div> </div> <div>To get better, the team made the survey a more important part of interactions with families and pushed harder for responses. The result was a 92 percent customer survey response in 2010. “This is feedback we could use for performance improvement,” Butler says.</div> <div> </div> <div>This feedback led to more changes in unexpected areas. The male population in the facility let it be known that the interior decoration was too feminine. Like in many homes, Mountain Valley’s 68 beds were majority female, but the men felt they needed a more masculine touch.</div> <div> </div> <div>“The short-termers wanted a place to get a beer. So from the feedback we created a type of a man cave, with a pool table, and no flowers,” Butler says. The activity program also added a poker night. </div> <div> </div> <div>These shifts to satisfy residents were a microcosm of how the facility was improving its chances to be a gold recipient, Butler notes. “Every year we got better,” she says. </div> <div><h3 class="ms-rteElement-H3">Staff Buy In To Effort </h3> <div>Other facilities looking for advice on how to tackle the mammoth task of reaching Gold status should take Butler’s words to heart.</div> <div> </div> <div>“It really does seem a bit overwhelming,” she says, referring to the voluminous application process. Putting into words all of the systems and processes employed at the facility; of what staff do on a daily basis; and how to involve nurses, doctors, and all employees in the documentation effort is quite a task.</div> <div> <img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/1011/SpringFling.jpg" width="322" height="402" alt="" style="margin:15px 10px;height:215px;" /><br>“It is amazing how workers become joyful in telling our story,” Butler says.</div> <div> </div> <div>At first it seemed like the application process was for senior staff like her to tackle, but as time went on, everyone took ownership. “When we sent the application off to AHCA, it was like sending my daughter off to college all over again,” she says.</div> <div> </div> <div>Butler has been administrator for 10 years and worked a total of 15 at Mountain Valley. She is a local woman, having grown up and been educated in the area. She has noted some changes in what her work entails, especially over the past five years or so with the changing face of skilled nursing care.</div> <div> </div> <div>First off, resident stays are shorter, and the people are sicker. “What we are dealing with in skilled nursing facilities today is what they used to deal with in hospitals. And, in turn, the assisted living facilities used to be what skilled nursing dealt with,” she says.</div> <div> </div> <div>Being in rural America also poses challenges, with the major hospital centers a good distance away, making transportation and logistics that much more important, Butler adds.</div> <div> </div> <div>Together, the work her facility achieves on a daily basis has left Mountain Valley as a model for all long term care facilities to emulate, and it got that way because Butler, her staff, and the facility’s entire care community paid attention to the details by first listening and learning.</div> <div> </div> <div>“It’s not just about talking the talk, but walking the walk,” Butler says. It is Mountain Valley’s “walk” that turned to Gold in 2011.</div> <h3 class="ms-rteElement-H3">A Record Of Achievement</h3></div> <div><div>It’s not like Mountain Valley was unaccustomed to being honored for its high-level work in caring for its frail and elderly residents.</div> <div> </div> <div>The facility won the AHCA/NCAL Bronze award in 2005 and Silver award (the only Idaho facility to ever reach that level) in 2007, before focusing on the journey to Gold, culminating in this year’s achievement.</div> <div> </div> <div>“In 2010, our center was one of only 173 in the nation and the only Idaho center to be ranked by U.S. News and World Report as ‘Best Nursing Homes in the Nation,’” Butler says.</div> <div> </div> <div>“Also, for 2010-2011 we received the Idaho Health Care Association quality award based on 2010 quality outcomes in our activity program, improved and sustained over a six-year period … and in 2011 for our customer satisfaction outcomes rating in the top 10 percent of the nation as ranked by My InnerView.”</div> <div> </div> <div>The honors didn’t stop there. </div> <div> </div> <div>Mountain Valley staff won the state of Idaho’s Skilled Nursing Employee of the Year for 2010 and 2011, plus the state’s Resident of the Year for 2011 and Volunteer of the Year for 2010. </div> <div> </div></div> <div><h3 class="ms-rteElement-H3"><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/ahca_qualityaward_national.jpg" width="127" height="168" alt="" style="margin:5px;width:179px;height:179px;" />What Defines The AHCA/NCAL Award Program</h3> <div>The AHCA/NCAL National Quality Award Program has three progressive step levels. Applications are judged by trained examiners who provide feedback on opportunities for improvement to support continuous learning. Facilities must achieve an award at each level to progress to the next level. </div></div> <div><h3 class="ms-rteElement-H3 ms-rteThemeForeColor-8-4">Bronze: Commitment To Quality</h3> <div>Bronze applicants begin their quality journey by developing an organizational profile, including vision and mission statements, an awareness of their environment and customers’ expectations, and a demonstration of their ability to improve a process. </div></div> <div><h3 class="ms-rteElement-H3 ms-rteThemeForeColor-1-5">Silver: Achievement in Quality</h3> <div>These applicants demonstrate a level of achievement in their quality journey through good performance outcomes that have evolved from how they embrace the core values and concepts of visionary leadership, focus on the future, resident-focused excellence, management by innovation, and focus on results and creating value. </div></div> <div><h3 class="ms-rteElement-H3 ms-rteThemeForeColor-10-0">Gold: Excellence in Quality</h3> <div>Gold applicants must show superior performance over time that is based on their systematic approaches to leadership, strategic planning, focus on customers, measurement, analysis and knowledge management, workforce focus, process management, and results. These applicants address the complete Health Care Criteria for Performance Excellence.</div> <div> </div> <div> </div> <div><h3 class="ms-rteElement-H3"><span class="ms-reusableTextView ms-rtestate-read"></span>Mary Ousley Receives Quality Honor</h3> <div>AHCA/NCAL has named Mary Ousley recipient of its 2011 Friends of Quality Award. She was scheduled to receive the award during the association’s annual convention in Las Vegas in September.</div> <div> <img class="ms-rteImage-2 ms-rtePosition-2" alt="Mary Ousley" src="/Issues/2011/PublishingImages/1011/MaryOusley.jpg" width="135" height="509" style="margin:5px;height:202px;" /><br>Ousley works for the Centers for Medicare & Medicaid Services (CMS) as the advisory provider representative to the agency’s policy and regulatory development of OBRA 1987 Survey, Certification, Enforcement, and Medicare.</div> <div> </div> <div>“In the field of expertise in quality care, Mary Ousley is second to none,” said Gov. Mark Parkinson, president and chief executive officer of AHCA/NCAL. “Our profession has made advancements in quality that simply would not be possible without her knowledge and commitment,” he said.</div> <div> </div> <div>The AHCA/NCAL award is given to a person or organization that has made a significant national contribution to advancing quality performances in the long term care field. Recipients must consistently advocate for quality approaches, while demonstrating the ability to educate and advocate for a systems approach to quality improvement, among other requirements.</div> <div> </div> <div>Ousley has also sat on the CMS and Quality Improvement Organization’s Nursing Facility Technical Expert Panel on the development and implementation of a quality improvement model for long term care.</div> <div> </div> <div>She currently is on the technical expert panel for the standards and regulatory development of Section 6102 Quality Assurance & Performance Improvement of the Patient Protection & Affordable Care Act.</div> <div> </div> <div>Over the previous two decades, Ousley has been appointed and made recommendations for the U.S. General Accounting Office Health Policy Advisory Committee, the Joint Commission, and the National Commission on Nursing and has frequently provided congressional testimony regarding health care policy.</div></div></div>For three years, Administrator Maryruth Butler and her 90 employees and 23 volunteers worked to get the Louisville, Ky.-based Kindred Healthcare-owned Kindred Nursing and Rehabilitation - Mountain Valley in Kellogg, Idaho, to the highest rung of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) National Quality Award ladder.2011-10-03T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1011/redhats_thumb.jpg" style="BORDER:0px solid;" />Quality Awards;QualitySpecial Feature10




Agency Fine-Tunes MDS 3.0https://www.providermagazine.com/Issues/2011/Pages/1111/Agency-Fine-Tunes-MDS-3-0.aspxAgency Fine-Tunes MDS 3.0<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div><a href="/Issues/2011/Pages/1111/The-MDS-Changes.aspx">Changes​</a> made by the Centers for Medicare & Medicaid Services (CMS) for the Minimum Data Set (MDS) 3.0 system effective Oct. 1, 2011, will add more assessments for skilled nursing facilities and make some significant alterations to group therapy provisions and other measures, according to experts in the field.</div> <div><img width="300" height="169" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1111/coverstory.jpg" alt="" style="margin:5px;width:333px;height:228px;" /></div> <div>The bottom line is that providers must keep track of the changes and meet the requirements or suffer incorrect, inadequate, or misdirected payments and possible CMS scrutiny or even investigation. </div> <div> </div> <div>The evolution of MDS 3.0 and related systems is an ongoing process for the nursing home profession, and what happens next is as important to know now as it was when CMS shifted the paradigm from MDS 2.0 to the present calculation in October 2010, experts say.</div> <h3 class="ms-rteElement-H3">Adjusting Anew</h3> <div>By now skilled nursing operators realize the changes CMS made to MDS for fiscal year 2012, which have been the subject of CMS outreach efforts and training for some months, as well as trade association educational programming. Even days before the Oct. 1 trigger date, CMS was making clarifications to help providers navigate the changes.</div> <div><br></div> <div>To help explain the issues swirling around assessments, Kindred Healthcare’s Darlene Thompson and Tami Johnson recently made a presentation to the American Health Care Association (AHCA) and its members, titled, “CMS Changes Related to MDS Completion and SNF Medicare Billing,” which reviewed the most important changes contained in the CMS prospective payment system (PPS) final rule.</div> <div><br></div> <div>Their theme was simple: Providers have successfully dealt with the changes that came when MDS 3.0 started in 2010, along with the Resource Utilization Group (RUG) IV transition, and so the latest CMS adjustments will be overcome as well.</div> <div><br></div> <div>“Our industry is resilient and has a demonstrated track record for adapting to change,” Thompson and Johnson said.</div> <div><br></div> <div>Their outline reviewed the key points of the rule, including the fact that CMS adjusted the case mix index and associated rates, which grabbed national headlines with the sharp “correction” in payments to skilled nursing facilities by a negative 12.6 percent. The adjustments, which were met with sharp criticism by AHCA and the entire long term care community, targeted the nursing component of the rehab RUGs. </div> <div><br></div> <div>CMS also applied a positive 2.7 percent market adjustment, but reduced that by 1 percent as mandated by provisions in the Affordable Care Act health care reform law. Overall, the Medicare reimbursement reduction is 11.1 percent.</div> <h3 class="ms-rteElement-H3">Changes Take Toll</h3> <div>“The biggest thing CMS has done is set up a system where the patient is evaluated essentially every seven days, which has the potential to increase assessments 10 to 25 percent,” says Johnson, Kindred’s director of care management.</div> <div><br></div> <div>“This represents the second time in two years we’ve had an increase in the number of assessments,” she says.</div> <div><br></div> <div>Johnson is referring to the fact that when CMS switched from MDS 2.0 to 3.0 last year, there was a 30 percent jump in the number of assessments. Now, with the changes in place for 2012, there is a potential for an increase of more than 40 percent over two years.</div> <div><br></div> <div>This rise in the number and depth of assessments has a real impact at the facility level, with more time being spent by various staff members to fill out electronic versions of MDS forms instead of doing other productive tasks in caring for residents, Johnson says.</div> <h3 class="ms-rteElement-H3">Paperwork On Paperwork</h3> <div>The people inside a facility most affected by the paperwork battle are logically the MDS coordinator, or multiple coordinators in the case of larger buildings, social workers, nutritionists, rehab therapists, and activities directors. At its larger buildings, there can be as many as four MDS coordinators, Kindred said.</div> <div><br></div> <div>“It takes away time from nurses to be at the bedside or teaching,” says Thompson, Kindred’s vice president for clinical information systems and training.</div> <div> </div> <div>The reason for the higher volume of assessments is the result of CMS wanting nursing facilities to prove their rehab services are indeed needed at the higher rates seen in recent years. The skilled nursing sector understands that rehab is a larger and larger chunk of its business, but the government has not caught on, Thompson says.</div> <div><br></div> <div>“CMS, in their words, believes they are paying for rehab services that are not being delivered. In some of our conversations [with CMS], they still have the perception that we are running nursing facilities like they were run 10 to 20 years ago,” she says.</div> <div><br></div> <div>In fact, in the modern nursing care world, Louisville, Ky.-based Kindred discharges 50 percent of its residents, reflecting the sea change in the industry for shorter stays and more rehab.</div> <div><br></div> <div>Asked why there is this disconnect with CMS on what actually goes on in today’s nursing homes, Johnson says it is a lack of expertise in the new long term care world that is resulting in the misdirected policies.</div> <div><br></div> <div>“They have people with long term care experience; however, they have experience from 15 to 20 years ago and haven’t been in the field recently enough,” Johnson says.</div> <div><br></div> <div>If you added all the time spent at Kindred’s 225-plus skilled nursing facilities, it would amount to 37,000 hours every month on filling out MDS forms, she says. “And it is extremely technical work. In an average month, one Medicare patient with us for 30 days will have had three assessments,” Johnson says.</div> <div>​​​​​​<span id="__publishingReusableFragment"></span>​<br></div> <h3 class="ms-rteElement-H3">Benefits Seen In New System </h3> <div>MDS 3.0 is not a negative experience except for the paperwork, Johnson notes. The improvement from MDS 2.0 is significant, with the direct resident input helping to drive a more successful care plan. “It’s just the constant repetition of information,” she says.</div> <div><br></div> <div>Thompson expands on that sentiment, saying the CMS effort to create a more resident-centered care plan is a good idea. She sees any further changes to MDS 3.0 to make it more efficient happening over an extended period of time. </div> <div><br></div> <div>“It has to be more of a day by day reaction to taking care of the patient,” she says for her hopes of a future, less burdensome, assessment process.</div> <div><br></div> <div>Certainly, the negative part of the revisions for 2012 was the steep Medicare reimbursement reduction, says Lori Opfer, executive director of Covenant Care-owned Edgewood Manor Nursing Center in Port Clinton, Ohio.</div> <div><br></div> <div>Her 99-bed skilled nursing facility is stepping up its efforts to market its services and fill as many beds as possible to make up for lost reimbursement from Medicare, she says.</div> <div><br></div> <div>As for the work it takes to meet the requirements of MDS 3.0, Opfer says her staff is handling it well. </div> <div>“We’ve been able to meet requirements, thanks to a lot of corporate training. It is going extremely well,” she says.</div> <div><br></div> <div>The shift last year from MDS 2.0 to 3.0 saw the inclusion of patient input into the assessment process, a change that Opfer feels is worthwhile. To collect assessments in the more patient-centered 3.0 program takes a lot more time.</div> <div><br></div> <div>“There is a lot more paperwork, but we have the staff totally dedicated to MDS to make it work. There also is a lot more time for social services to get involved with the assessment, but it is up to the MDS coordinator to be totally involved, of course,” she says.</div> <div><br></div> <div>The biggest changes she sees for 2012 are in therapy classification and scheduling, but right ahead of the Oct. 1 deadline she echoed the sentiments of a lot of providers when it comes to MDS. <span class="Apple-tab-span" style="white-space:pre;"> </span></div> <div>“We are prepared for it,” Opfer says.</div> <h3 class="ms-rteElement-H3">MDS And Care Planning </h3> <div><img class="ms-rtePosition-1" src="/Issues/2011/PublishingImages/1111/SteveLevenson.jpg" alt="" style="margin:10px;width:103px;height:119px;" /><br>If there is one person who knows about the MDS system and its development in the Resident Assessment Instrument (RAI) it is Steve Levenson, multifacility medical director for Genesis HealthCare, Kennett Square, Pa. This summer marked his 30th year in the long term care sector, most of which saw him logging extensive time helping to develop regulations and guidelines included in the “RAI Manual,” in which the MDS resides.</div> <div><br></div> <div>He calls the changes made by CMS for 2012 “not radical” in nature and limited in scope. Levenson has worked out a training program for providers showing how to use the data from the MDS/RAI for providing better care planning.</div> <div><br></div> <div>“I talk about what to do with the information,” he says. “How do you determine a system, and how do you identify if it’s a problem.” This is where the MDS/RAI can be used for evidence-based medicine, to be used as a tool for caring for residents and eliminating some of the faulty assumptions about what ails residents.</div> <h3 class="ms-rteElement-H3">Depressed? Or is it Something Else?</h3> <div>If a resident is unhappy, does that mean the individual is depressed? “If depressed, do they need a treatment?” Levenson asks as part of his example. There is no evidence that for mild and moderate forms of depression that antidepressants help, he says. The evidence actually shows antidepressants are only better than placebo for severe or very severe depression.</div> <div><br></div> <div>Still, antidepressants are used for almost half of residents in nursing facilities for even minimal symptoms. Levenson wants the assessment process to be part of a new way of making adjustments to a resident’s care based on reality, not assumption.</div> <div><br></div> <div>Levenson advocates for correcting these flaws by using MDS assessments and RAI to cut down on guesswork, look for the causes of resident symptoms, and put historic details of the patient into the care plan. </div> <div><br></div> <div>“History is all-important to causation. You gather facts in bits and pieces,” he says. He likens the process to that of common everyday occurrences and how people go about figuring out the causes of problems. If your roof leaks, he says, you examine what is making it leak. Is it the wind? Is it the rain or something else?</div> <div><br></div> <div>Besides depression, other common topics that call out for better use of evidence-based care are hydration, hypothyroidism, dementia, delirium, pneumonia, pain management, bowel obstruction, and risk of aspiration, among others, he says.</div> <h3 class="ms-rteElement-H3">It’s A Tool</h3> <div>The MDS is a tool, Levenson says, but to be used effectively in individualizing a care plan, it must first be mastered. “You can walk into a Home Depot, but that doesn’t make you a builder. This is a tool that needs to be understood. It’s not just a check-off option,” he says.</div> <div><br></div> <div>Providers need to be careful of making mistakes in administering the MDS process, he says. It is not good if staff are not trusted to help with the assessments, if the process is all turned over to an MDS coordinator. He also says facilities should seek out causes for symptoms and have a care process as a result of the data set being built for each resident.</div> <div><br></div> <div>Levenson conducts seminars across the country on the assessment process and focuses on what to do with all the information CMS and the states want gathered. “The focus of the talk is what does it all mean, how do you decide toward a care planning process,” he says. </div> <div>​​​​​​​<span id="__publishingReusableFragment"></span>​<br></div> <h3 class="ms-rteElement-H3">RAI Has Its Uses, Limits </h3> <div>The gist of the discussion is on the uses and limits of the RAI. It is a meaningful and helpful process when used correctly for intended purposes, but can be a problem if used without proper understanding or used outside of its intended design, he notes.</div> <div><br></div> <div>Levenson says RAI use cannot serve in every situation, like with a resident suffering from complex and multiple symptoms. Additional information beyond MDS is needed for care, Levenson says.</div> <div>MDS covers three key dimensions: physical, like a person’s weight, skin condition, medical condition, and vision; functional, ADLs and behavior; and psychosocial, like preferences, beliefs, goals, interests, and family interactions. The 3.0 version of MDS has greatly improved the details of a resident’s personal preferences and choices and has better screening tools. It also gives a foundation for clueing in on possible issues and concerns that may require more review.</div> <div><br></div> <div>The remainder of the RAI allows care area assessments (CAAs) and utilization guidelines to start the process of thinking about areas for possible investigation, whether findings represent a problem or risk requiring further intervention, causes and risk factors related to a triggered care area, and formulating a care plan.</div> <div><br></div> <div>Levenson says the CAAs are indentified by responses to items on the MDS and reflect conditions, symptoms, and other areas that could need review and investigation. </div> <div><br></div> <div>“If certain responses on the MDS occur, then CAA is triggered because an item may be associated with the possible presence of a condition, concern, risk, or problem. </div> <div><br></div> <div>“Further assessment is needed to determine the significance because MDS findings alone cannot guide effective clinical problem solving and decision making,” Levenson says.</div> <div><br></div> <div>Examples of MDS as a screening tool are for tuberculosis, depression, and fall risk.</div> <h3 class="ms-rteElement-H3">Steps To Evidence-based Care Include History</h3> <div>To get beyond MDS and to individualized patient-centered care, Levenson lays out a case for long term care facilities to take a history of residents. </div> <div><br></div> <div>Delving into residents’ histories will allow staff to discover symptoms; get accurate descriptions; secure a chronology of events; and determine how an illness, impairment, or psychosocial concern has changed their lives.</div> <div><br></div> <div>“MDS data are often at the level of a chief complaint [headache, vomiting, coughs when eating] or isolated finding, missing important detail,” he says.</div> <div><br></div> <div>“It is important to avoid premature interpretation such as failing to record seemingly irrelevant symptoms or events, and it may be problematic to assume the conclusion and fail to seek additional information.”</div> <div><br></div> <div>Using the basics of the famed researcher Richard DeGowin, it is important for providers to insist that residents describe their symptoms in their own words, not using medical jargon. </div> <div><br></div> <div>If several conditions are suggested from this process, notice how there may be some symptoms missing from the direct descriptions offered by the resident, making it clearer to diagnose what is wrong.</div> <div><br></div> <div>Levenson says some common widespread advice is to believe whatever the resident tells a nurse and accept the resident’s word on pain. But, this does not mean a resident’s answers cannot be questioned for accuracy and to act just on what the resident says.</div> <h3 class="ms-rteElement-H3">The Opportunity Of MDS </h3> <div>MDS 3.0 is a great chance to rethink what an assessment means and implies, Levenson says. It is also a chance to rethink other areas of the care process, like the use and limitations of the tools in MDS 3.0 and how RAI fits in the context of the entire clinical problem-solving and decision-making process.</div> <div><br></div> <div>The steps to use RAI components are critical to develop individualized care planning and follow-on care, Levenson says. </div> <div><br></div> <div>This sentiment for patient-centered care through the RAI/MDS system coincides with the CMS shift to promoting evidence-based care and the agency’s requirements that providers give more explanation on how they provide care and why they should be reimbursed for such services.</div> <div><br></div> <div>The mantra for providers and their staff is to be able to change with the times and look for opportunities to continue to improve quality for the nation’s frail and elderly. ​</div> ​​​​ <div>Click here for more on<a href="/Issues/2011/Pages/1111/MDS-And-MDS-3-0.aspx"> MDS and MDS 3.0.​</a></div> ​​Changes made by the Centers for Medicare & Medicaid Services (CMS) for the Minimum Data Set (MDS) 3.0 system effective Oct. 1, 2011, will add more assessments for skilled nursing facilities and make some significant alterations to group therapy provisions and other measures, according to experts in the field.2011-11-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1111/Coverstory_thumb.jpg" style="BORDER:0px solid;" />Culture ChangeColumn11
Compassionate Care Eases Final Dayshttps://www.providermagazine.com/Issues/2011/Pages/1111/Compassionate-Care-Eases-Final-Days.aspxCompassionate Care Eases Final Days<p>More than half of patient deaths in the populations served in nursing facilities result from progressive, chronic illnesses and are, therefore, predictable in their timing. By recognizing the advanced stages of terminal disease, health care professionals (physicians, nurses, physician assistants, and nurse practitioners) can greatly impact the circumstances surrounding their patients’ deaths. </p> <p>But meeting a patient’s needs and expectations for an “optimal” end-of-life experience generally requires planning.</p> <div><h3 class="ms-rteElement-H3">The Burden Of Not Planning</h3> <div>In the absence of conscientious physician and nurse involvement, the natural history of terminal disease includes a progressive or sudden decline, such as a sentinel event, followed by crisis intervention, such as emergency hospitalization, cardiopulmonary resuscitation, or the initiation of life support. </div> <div><br>These events are unfortunate and often counterproductive for patients and their families. Most interventions are stressful, resource consuming, and, most of all, ineffective at meeting patients’ goals. </div> <div><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1111/caregiving1.gif" alt="" style="margin:5px 15px;" /></div> <div>The burden on the patient can be even greater when the cycle becomes repetitive. The majority of a patient’s remaining lifespan could actually be spent away from family. What’s more, end-of-life wishes and preferences may be ignored if caregivers are not cognizant of them. </div> <h3 class="ms-rteElement-H3">Compassionate Care </h3> <div>Most individuals prefer death to arrive expectantly, quietly, and without pain. But too often, patients and their families are “surprised” when death is near, causing anxiety and often anger toward the physician and the facility’s staff.<br><br></div> <div>As the end of life approaches, significant psychosocial and, often, spiritual needs of patients and their families are manifested. </div> <div> </div> <div>Patients may require comfort care, including the management of pain and other physical symptoms, such as shortness of breath.</div> <div> </div> <div>Families may also be faced with significant financial (and bureaucratic) burdens.</div> <div> </div> <div>The responsibility for ensuring that patients and families receive required treatments and support services in a compassionate manner should be shared broadly among the entire health care team, including the physician(s), nurses, nurse assistants, therapists, social services, and even the facility administrator.</div> <div> </div> <div>Lead members of the care team should set expectations and carefully document the wishes of the patient and family, as follows:</div> <div><ul><li>​The patient’s code status;</li> <li>The use of chest compressions, intubations, and mechanical ventilation;</li> <li>The use of feeding tubes;</li> <li>Hospital transfers;</li> <li>Pain management;</li> <li>Antibiotics; and</li> <li>Blood transfusions.</li></ul></div> <div>Studies and surveys have repeatedly shown that most individuals do not want an inevitable death prolonged through artificial means. Survival from cardiopulmonary arrest in this population is very poor (< 5 percent) and, for the few survivors, associated with a high degree of morbidity, including persistent vegetative state (14 percent), chronic heart failure (49 percent), seizures (40 percent), and rib fractures (18 percent), research shows.</div> <div><br>Of the cardiopulmonary resuscitation survivors, 87 percent die soon after in the hospital. Intubation and mechanical ventilation create tremendous anxiety when the difficult decision of extubation is finally made. </div> <div><br>Feeding tubes are considered by most individuals as artificial and undesirable, and their use does not decrease the risk of aspiration. With the patient’s permission, obtaining a hospice consultation may be helpful in addressing a person’s needs and wishes.<h3 class="ms-rteElement-H3">Convey Expectations</h3></div> <div>Truly compassionate care requires health care professionals to help patients and their families understand the risks and benefits of available interventions near the <a href="/Issues/2011/Pages/1111/How-To-Identify-Patients-Near-End-Of-Life.aspx">end of life</a>, which are typically unlikely to significantly prolong life or a meaningful existence and may cause pain and suffering during the final moments.<br><br></div> <div>When death arrives unexpectedly, without the opportunity for the patient and family to organize their thoughts and their estates, anxiety and, often, anger ensue. Sometimes this anger is misdirected toward the physician and the facility in the form of legal action. <br></div> <div><br>Certainly, some claims are based purely on greed, and only a few have real merit. The burden, capable of consuming great amounts of time and money, falls on the physician and the facility to prove that they served the patient in a manner consistent with the standards of care. A caregiver’s personal testimony is helpful; however, the only solid evidence is the medical record.<br></div> <div><br>Many health care professionals document only the episodic care that they provide on a given visit and fail to discuss the patient’s overall condition. Due to their personal beliefs, lack of comfort, or inexperience, some clinicians do not recognize (or choose to ignore) that the end of life is near. This is especially true when the patient does not have a preexisting, documented terminal disease, such as Stage IV lung cancer. <br></div> <div><br>Take, for example, an actual recent lawsuit from the daughter of a 92-year-old nursing facility resident, which states that her mother died “unexpectedly and prematurely.” <br></div> <div><br>Despite a one-and-a-half-year downward clinical course, including end-stage Alzheimer’s, seven episodes of urosepsis, two episodes of aspiration pneumonia, two pressure ulcers, and functional decline due to a nonambulatory status, the patient’s daughter believes she was given some hope for meaningful recovery of her mother through multiple hospitalizations and intravenous antibiotics. Upon review, no documentation of the patient’s limited life expectancy was found in the nursing facility or hosptial record. The case was subsequently settled in favor of the complainant through arbitration.<br></div> <div><br>Clearly, it is imperative that health care professionals document the determination that the end of life is near and all conversations with the patient and family in that regard. Examples of such documentation could include: “The inevitable effects of aging are in place;” “the patient’s life expectancy is limited;” “multiple organ system failures are occurring;” and “the patient’s quality of life will continue to deteriorate.”<br></div> <div>Statements such as these should appear frequently in a long medical record;  preferably, shortly after admission and then at least monthly as applicable.</div> <div><h3 class="ms-rteElement-H3">Timing And Hope</h3></div> <div>A word on timing: The care plan meeting (at which the family is present) may be the most appropriate time to compassionately discuss and document the patient’s long-term prognosis, set expectations, determine end-of-life wishes, and offer clinical options to enhance comfort.<br></div> <div><br>When discussing a poor prognosis and setting expectations with patients and families, health care professionals should focus on shifting a family’s hope from recovery to a comfortable, pain-free end-of-life experience.<br></div> <div><br>All individuals desire an “optimal” end-of-life experience. Through the provision of compassionate care, setting of expectations, and planning, physicians and other health care professionals working in concert can make this a reality for many patients.</div> <div> </div> <div>In addition, careful and consistent clinical documentation of these issues may also help provide protection against frivolous lawsuits. </div> <div><br><em>Maximo Diamond, MD, is a health care consultant for Diamond Medical Associates, Laguna Beach, Calif. He can be reached at (949) 315-1169 or at DoctorDiamond@cox.net. ​</em></div></div>More than half of patient deaths in the populations served in nursing facilities result from progressive, chronic illnesses and are, therefore, predictable in their timing. By recognizing the advanced stages of terminal disease, health care professionals (physicians, nurses, physician assistants, and nurse practitioners) can greatly impact the circumstances surrounding their patients’ deaths. 2011-11-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/hospitalbed_thumb.jpg" style="BORDER:0px solid;" />Clinical;CaregivingColumn11
Future Retirees Underestimate Health And Cost Challengeshttps://www.providermagazine.com/Issues/2011/Pages/1111/Future-Retirees-Underestimate-Health-And-Cost-Challenges.aspxFuture Retirees Underestimate Health And Cost Challenges<p><img width="506" height="215" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1111/News-Retirees.jpg" alt="" style="margin:10px;width:321px;" />People who have not yet retired think retirement will be easier than it actually is, according to a new poll by National Public Radio, the Robert Wood Johnson Foundation, and the Harvard School of Public Health. The poll shows stark differences between what pre-retirees think retirement will be like and what retirees say is actually the case.</p> <p>“Those of us over 50 and working are optimistic about our future health and health care, but that optimism is not necessarily shared by those who have already retired,” said Risa Lavizzo-Mourey, president and chief executive officer of the Robert Wood Johnson Foundation. </p> <p>“Many people who have already retired say their health is worse, and they worry about costs of medical treatment and long term care. Insights from the poll can help policymakers and others think about how to meet the needs of aging Americans. There are changes we can make to our health care system, finances, and communities that might help ensure that our retirement years will be as fulfilling as we hope.”</p> <p>Findings show that a large majority of retirees say life in retirement is the same (44 percent) or better (29 percent) than it was during the five years before they retired. Many retirees say their stress is less, their relationships with loved ones are better, their diet is improved, and the amount of time they spend doing favorite activities is increased—yet 25 percent of retirees say life is worse.</p> <p>The poll shows only 14 percent of pre-retirees predict that life overall will be worse when they retire, compared with the 25 percent of retirees who say it actually is worse. Only 13 percent of pre-retirees thought their health would be worse, while 39 percent of retirees say it actually is. </p> <p>Less than a quarter of pre-retirees (22 percent) predict their financial situation will be worse, while a third of retirees (35 percent) said it actually is. </p> <p>Findings also show that pre-retirees expect to retire later than those who are already retired, and some expect never to fully retire. Sixty percent expect to retire at age 65 or older, while only 26 percent of current retirees said they waited to retire at 65 or older.</p>People who have not yet retired think retirement will be easier than it actually is, according to a new poll by National Public Radio, the Robert Wood Johnson Foundation, and the Harvard School of Public Health. The poll shows stark differences between what pre-retirees think retirement will be like and what retirees say is actually the case. 2011-11-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1111/News-Retirees_thumb.jpg" style="BORDER:0px solid;" />Management;WorkforceColumn11
One Company Achieves Speedy EMR Implementationhttps://www.providermagazine.com/Issues/2011/Pages/1111/One-Company-Achieves-Speedy-EMR-Implementation-.aspxOne Company Achieves Speedy EMR Implementation<div><br></div> As today’s competitive health care market evolves toward a model of episodic bundled payments, those producing the highest-quality outcomes, the lowest cost per episode, and the lowest readmissions back to the hospital will have a significant competitive advantage. <div><br><div>Contracts will be negotiated with providers willing to be held accountable for superior, data-driven outcomes. </div> <div><br></div> <div>As a result, the rush is on to drive electronic medical records (EMRs) as deeply as possible into operations to increase visibility and access to reportable information on which accountability will increasingly depend. </div> <div><br></div> <div>Diversicare Management Services, Brentwood, Tenn., recognized in May 2010 that it would need an EMR program focused on driving higher-quality care. Diversicare provides rehabilitation and long term care services in 46 nursing centers across eight states, but at the time, had just one nursing center running EMRs. </div> <div><h3 class="ms-rteElement-H3">The Secret Sauce</h3></div> <div>The real question was how could they get the rest of their nursing centers quickly up to speed with full EMR? </div> <div><br></div> <div>The answer: Assembling a team that would leverage internal staff with institutional knowledge and a committed software partner with deep expertise in workflows and training. </div> <div><br></div> <div>The result: Diversicare collaborated with a technology company to develop a plan to deploy EMRs across its remaining nursing centers. And with amazing speed, the company deployed a full EMR system across 45 centers in less than 18 months. </div> <div><br></div> <div>While other EMR systems would have resulted in complexity, cost, and extra staff needed for integrations, Diversicare utilized an integrated EMR application and received a clean database for connecting all types of systems, from therapy and pharmacy to health information exchanges. </div> <div><br></div> <div>But what was the “secret sauce” for rolling out the full EMR so quickly? People fear what they don’t understand, so they must be continuously sold on the value, celebrate each milestone of success, and have the end-game in mind. This formula keeps the rollout true to driving quality outcomes.</div> <div><h3 class="ms-rteElement-H3">The Need for Speed</h3></div> <div>Using great leadership, a committed staff, and strategic partnerships, Diversicare has embraced the digital EMR revolution and set the bar of success high for the rest of the profession. </div> <div><br></div> <div>Diversicare has seen spectacular early clinical results, putting the value of EMR in a whole different light. With the implementation of EMR, Diversicare’s success rate with its medication administration system jumped to 99.9996 percent. In addition, the team immediately observed laser-focused insights into opportunities for improvements. </div> <div><br></div> <div>Beyond the system itself are people and processes. Training staff ensured that the company could smooth details during implementation. A proactive platform was created to take quality care to new heights, and improved agility and competitive positioning were achieved. </div> <div><br></div> <div>Today, Diversicare enjoys positive outcomes such as improvements to quality indicator scores and enhanced documentation. </div> <div><br></div> <div>“As the industry grows more connected, we positioned for future integrations without introducing cost and complexity by using an integrated EMR application and database,” says David Houghton, chief information officer for Diversicare. </div> <div><br></div> <div><em>David Houghton, chief information officer at Diversicare Management Services, Brentwood, Tenn., can be reached at dhoughton@advocat-inc.com. Lisa Martens, vice president of quality management and clinical services for Diversicare, can be reached at lmartens@advocat-inc.com. Teresa Chase, president of American HealthTech, Ridgeland, Miss., can be reached at tchase@healthtech.net.​</em></div> <div><em><br></em></div></div> <div>Click here for <a href="/Issues/2011/Pages/1111/Five-Steps-To-A-Quick-And-Effective-EMR-Rollout.aspx">Five Steps To A Quick And Effective EMR Rollout</a>.</div>As today’s competitive health care market evolves toward a model of episodic bundled payments, those producing the highest-quality outcomes, the lowest cost per episode, and the lowest readmissions back to the hospital will have a significant competitive advantage. Contracts will be negotiated with providers willing to be held accountable for superior, data-driven outcomes. 2011-11-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/Miscellaneous%20Images/comp_nurse_thumb.jpg" style="BORDER:0px solid;" />TechnologyColumn11
Online Program Dramatically Boosts RN Certificationshttps://www.providermagazine.com/Issues/2011/Pages/1111/Online-Program-Dramatically-Boosts-RN-Certifications.aspxOnline Program Dramatically Boosts RN Certifications<p>​A program to increase the number of registered nurses (RNs) passing the gerontology certification exam and becoming nationally certified as gerontological nurses (RN-BC) has proven effective in its two-year pilot phase, and is now being rolled out nationally to providers as an online offering, according to Gero Prep Course sponsors at the University of Nebraska Medical Center College of Nursing.</p> <p>Only around 1 percent of RNs currently have the national certification, a number that is woefully low and counterproductive to the skilled nursing sector, says Catherine Bevil, RN, EdD, professor and director of continuing education and evaluation at the college and administrator of the Gero Prep Course program.</p> <p><img class="ms-rteImage-2 ms-rtePosition-1" alt="Catherine Bevil" src="/Issues/2011/PublishingImages/1111/News-Bevil.jpg" style="margin:10px;" />“If a huge percent of nurses become certified, there will be a huge payoff for providers,” says Bevil. She notes that in addition to increasing the knowledge of the RNs about their field, the nurses who become certified stick with their jobs, cutting dramatically the nurse turnover rate for facilities.</p> <p>The program just ended a two-year pilot funded by the Robert Wood Johnson Foundation in which the latest results showed 98 percent of the 100 nurses participating got certified by the American Nurses Credentialing Center (ANCC). </p> <p>Vetter Health Services, a major player in the Gero Prep pilot, saw its own certifications rise to 43 percent by offering the course to its RNs.</p> <p>Overall, Bevil says that facilities that participated in the pilot saw RNs raise their skill level, professionalism, job satisfaction, and retention. In addition, the facilities saw quality care elevated and the fostering of long-term operations success and care continuity.</p> <p>The result is that RNs learn how to communicate better with older adults as individuals in therapeutic ways, focus on the role of the expert gerontological nurse as the leader of the nursing care team and collaborator with other team members, and prepare for and pass certification, she adds.</p> <p>Now that the pilot program is complete, the Gero Prep Course is being offered to providers directly for $400 per nurse. The program is not being marketed directly to nurses. Bevil says the process to become certified is expensive for individual nurses, with not only the $400 for the course, but the $395 cost for the actual certification exam. However, the certification is for five full years, and the costs are more than offset for providers looking to bolster their nursing staff, she says.</p> <p>“Certified nurses have fewer adverse events, like falls, and turnover is much less. When an RN leaves, it costs way more than a year of salary to make up for that,” Bevil says.</p> <p>The American Health Care Association/National Center for Assisted Living is partnering to market the Gero Prep Course to its members. <br></p>​A program to increase the number of registered nurses passing the gerontology certification exam and becoming nationally certified as gerontological nurses has proven effective in its two-year pilot phase.2011-11-01T04:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1111/News-Bevil_thumb.jpg" style="BORDER:0px solid;" />Management;Workforce;Survey and CertificationHuman Resources11





Providers Take Brunt Of Medicaid Cost Cuttinghttps://www.providermagazine.com/Issues/2011/Pages/1211/Providers-Take-Brunt-Of-Medicaid-Cost-Cutting.aspxProviders Take Brunt Of Medicaid Cost Cutting<br>State Medicaid spending is projected to rise 28.7 percent this fiscal year to make up for the loss of enhanced federal matching payments, which had bolstered the program for over two years, from October 2008 through June 2011, according to a new report from the Kaiser Commission on Medicaid and the Uninsured.<br><br>With the expiration of funding from the American Recovery and Reinvestment Act, or stimulus package, which had buoyed state Medicaid programs during the economic crisis, states are turning to provider payments for cuts that will offset the spike in states’ share of the expenditure, Kaiser reported.<br><br>Nursing facilities rates are in the eye of the storm, with a total of 30 states reporting restricted rates for these providers in fiscal year 2011. Twenty-four states froze rates and six states cut them, said the 136-page report on Medicaid spending, coverage, and policy trends, based on a survey of all 50 states.<br><br>The trend continues in fiscal year 2012, with 17 states planning to freeze nursing facility rates and 14 planning rate cuts, the report said.<br><br>Providers are particularly vulnerable to Medicaid rate cuts during a budget crisis, because “rate changes have an immediate impact on state budgets,” Kaiser said.<br><br>While states are beginning to see positive signs of economic recovery, they continue to experience “the impact of the worst economic downturn since the Great Depression,” Kaiser reported.<br><br>States continue to seek additional authority and flexibility to manage their Medicaid programs, as reflected in a Sept. 22 letter from the National Association of Medicaid Directors (NAMD) to the Joint Select Committee on Deficit Reduction, or so-called “super committee.”<br><br>The letter urged lawmakers to give states unfettered authority to enroll any beneficiary population into managed care, without first seeking a waiver or “special permission” from CMS, calling such a move “one of the most important changes Congress could make.” <br><br>The dually eligible population, which NAMD said “represents an unnecessarily high proportion of state health care costs,“ stands to benefit the most from improved management and coordination of services, yet statutory, regulatory, and financial barriers have impeded these very changes.Column12
Aquatic Therapy Gains Steamhttps://www.providermagazine.com/Issues/2011/Pages/1211/Aquatic-Therapy-Gains-Steam.aspxAquatic Therapy Gains Steam<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div>Public speaking may statistically top the list of “the most common fears,” but a physical therapist working with older adults who have balance issues knows that fear of falling can be stronger than any other worry. Certainly, it’s easy to understand the patients’ concerns; after all, falling can cause injuries leading to complications, additional health problems, and even death. </div> <h3 class="ms-rteElement-H3">Fear of Falling</h3> <div>The reasons why aging individuals fall are varied: decreased range of motion, balance, and gait patterns can all be culprits. And so can medical conditions such as arthritis and degenerative joint disease. </div> <div> </div> <div>Unfortunately, traditional physical and occupational therapies do not work as well as they would if the patient were not terrified of falling. For instance, if a 70-year-old woman with balance issues and a history of falling is expected to complete physical or occupational therapy exercises, she will have to be supported the entire time, lest she fall or stop working because she’s too frightened. </div> <div> </div> <div>Most likely, she’ll be relegated to performing rehabilitative exercises while sitting or lying down, which will limit her progress. More than likely, the exercises will be passive, static, and short in duration. </div> <h3 class="ms-rteElement-H3">Attitude Adjuster</h3> <div>So what is the answer for this type of patient? In the experience of some rehabilitation practitioners, it’s aquatic therapy.</div> <div><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1211/Caregiving1.jpg" alt="" style="margin:10px;width:352px;height:236px;" /><br>Aquatic therapy isn’t a new concept in rehabilitation, and it’s gaining momentum year after year. </div> <div> </div> <div>Warm-water environments were prescribed centuries ago to ease ailments like joint pain and, ironically, they’re still prescribed today. But the soothing temperature of the water isn’t the only benefit to investing in a high-end therapy pool with underwater treadmill and variable floor depths.</div> <div><br></div> <div>By far, one of the greatest advantages to offering patients aquatic therapy is the way it changes patients’ attitudes. <br><br></div> <div>Often, when patients realize they are surrounded and buoyed by water, they tend to put forth a better amount of effort than they would during land-based rehabilitation. Thus they wind up physically stronger and more secure.</div> <div> </div> <div>The innate scientific properties of water are without a doubt a physical or occupational therapist’s best friend when working with patients with balance challenges. <br><br></div> <div>In an aquatic environment, the body is supported up to 90 percent, depending upon the height of the water, which is why a therapy pool with an adjustable floor is best. This relaxes everyone involved, as falling becomes nearly impossible. <br><br><span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><span><h3 class="ms-rteElement-H3"><span><h3 class="ms-rteElement-H3"><span><span><h3 class="ms-rteElement-H3"><span><h3 class="ms-rteElement-H3"><span><h3 class="ms-rteElement-H3"><span><span><img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2011/PublishingImages/1211/Caregiving1.gif" alt="" style="margin:0px 15px;width:139px;height:720px;" /></span></span></h3></span></h3></span></h3></span></span></h3></span></h3></span>Multiple Benefits</h3> <div>Physical or occupational therapy in a pool has a plethora of other benefits as well, including: increased muscle relaxation, decreased muscle spasms, increased ease of joint movement, decreased sensitivity, increased muscle strength and endurance, increased peripheral circulation, decreased pain, improved body awarenessand balance, and improved proximal trunk stability.<span><span style="font-weight:bold;"><br><br></span></span></div> <div>Some patients find it so positive that they continue exercising in the pool for pleasure and health long after their therapy has ended.</div> <div> </div> <div>While aquatic therapy works on a wide variety of patients, it is especially useful on those with limited range of motion, decreased daily living activities, impaired trunk stability, postural abnormalities, decreased strength, decreased balance, impaired mobility, pain, edema, and gait abnormalities.</div> <div> </div> <div>However, aquatics may not be suitable for those who have had cardiac failure, have open wounds or infectious diseases, are extremely weak (due to system changes), are incontinent, have abnormal blood pressure levels, or have low vital lung capacities.</div> <h3 class="ms-rteElement-H3"><span><span></span></span>Reward Is In The Results</h3> <div>There’s little doubt that adopting aquatic therapy as part of a clinic or facility’s offerings leads to more confident patients who are apt to come back for sessions and work hard to achieve success. When an 85-year-old man with a history of falls starts rehabbing using aquatic therapy techniques, he is able to take traditional physical and/or occupational exercises to a whole new level.</div> <div> </div> <div>This leads to faster healing, a renewed sense of freedom, and better results for him on land. And from a physical or occupational therapist’s point of view, watching the transformation of an adult from fearful to secure is one of the most highly rewarding aspects of the job. </div> <div> </div> <div><em>Kathleen Kristoff, OTR/L, CHT, is a director of rehabilitation services at an outpatient rehabilitation center in Ohio. Kristoff has been nationally recognized as an expert in aquatic therapy methodologies and has been asked to speak at many conferences as a result. She can be reached at (440) 279-2423.</em> <br><br>Read more about <a href="/Issues/2011/Pages/1211/Spike-Expected-In-Total-Knee-Replacements.aspx">osteoarthritis.</a><br></div>Public speaking may statistically top the list of “the most common fears,” but a physical therapist working with older adults who have balance issues knows that fear of falling can be stronger than any other worry. Certainly, it’s easy to understand the patients’ concerns; after all, falling can cause injuries leading to complications, additional health problems, and even death. 2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1211/Caregiving2_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn12
CMS Seeks To Ease Risk, Capital Concerns With Revamped ACO Rulehttps://www.providermagazine.com/Issues/2011/Pages/1211/CMS-Seeks-To-Ease-Risk.aspxCMS Seeks To Ease Risk, Capital Concerns With Revamped ACO Rule​The Centers for Medicare & Medicaid Services (CMS) in October released a final rule for establishing Accountable Care Organizations (ACOs), replacing key parts of its much-scorned ACO draft rule proposal with more financial enticements and a reduction in the number of quality measures in the plan. <br><br> “The final rule strikes a better balance,” said Jonathan Blum, CMS deputy director and director of the Center for Medicare, referring to modifications made to ease bottom-line concerns of stakeholders with new financial incentives, while at the same time maintaining quality improvement models.<br>The major changes from the draft include CMS reducing by half the number of quality measures from 65 to 33, the elimination of the electronic health records requirement, and the introduction of a payment model that allows ACOs to share on the first dollar once a minimum savings rate has been established.<br><br>The Medicare Shared Savings Program (MSSP), or ACO program, is expected to save $940 million over three years. CMS estimates 50 to 270 organizations will take part in the first reporting period of the program. <br><br>Mark Lutes, a partner in the Washington, D.C., law office of Epstein Becker Green, thinks CMS made a positive move with the final rule, listening to the concerns of most stakeholders on the unwieldy nature of the draft plan.<br><br>“I certainly think it is a step in the right direction. There are now a number of intriguing possibilities for provider groups to contemplate,” Lutes says.<br><br>In addition to the changes listed above, CMS also changed the way it would assign Medicare beneficiaries to ACOs, offering a preliminary prospective assignment method where beneficiaries would be identified on a quarterly basis. The draft rule proposed retrospective assignment of beneficiaries based on utilization of primary care services, with prospective identification of a benchmark population.<br><br>Eligibility provisions were also altered from the draft. The final rule allows federally qualified health centers and rural health clinics to both form and participate in an ACO. CMS also said it listened to the concerns of rural providers and physician-owned entities by extending “advance payments” to help these organizations receive up-front funding that would be recouped as these ACOs implement savings.<br><br>“Today we have taken another step to improve health care for people with Medicare,” said Health and Human Services Secretary Kathleen Sebelius. “We are excited to give doctors, hospitals, and other providers the flexibility and support they need to work together and focus on making sure patients get the care they need.<br><br>“This model of delivering care may not be right for everyone, but it provides new incentives for doctors, hospitals, and other health care providers to work together in new ways.” <br><br>CMS said MSSP will provide incentives for participating health care providers who agree to work together and become accountable for coordinating care for patients. Providers that band together through this model and that meet certain quality standards based upon, among other measures, patient outcomes and care coordination among the provider team, may share in savings they achieve for the Medicare program. The higher the quality of care providers deliver, the more savings the providers may keep.<br><br>“As a physician I understand the complexities of caring for a patient who may have multiple providers,” said Donald Berwick, MD, CMS administrator.<br><img width="150" height="150" class="ms-rteImage-2 ms-rtePosition-2" alt="Donald Berwick, CMS administrator" src="/Issues/2011/PublishingImages/Headshots/Berwick_thumb.jpg" style="margin:5px 10px;" /><br>“This opportunity to coordinate care among providers could greatly improve the quality of care Medicare beneficiaries receive.” <br><br>The CMS rule implements Section 3022 of the Affordable Care Act relating to Medicare payments to providers of service and suppliers participating in ACOs. Under these provisions, providers of suppliers and suppliers of services can continue to receive traditional Medicare fee-for-service payments under Parts A and B and be eligible for additional payments based on meeting specified quality and savings requirements. <br><br>ACOs are designed to act as networks to increase efficiency by bringing more doctors and hospitals onto one team with incentives from insurers to keep people healthy and costs down.<br><br>Post-acute care facilities would be eligible to take part in new ACOs as soon as quality measures for care are finalized.<br><br>The Shared Savings Program is at <a>www.ofr.gov/inspection.aspx</a>. The Advanced Payment solicitation is at:<a href="http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/advance-payment/">http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/advance-payment/</a>. The Centers for Medicare & Medicaid Services (CMS) in October released a final rule for establishing Accountable Care Organizations (ACOs), replacing key parts of its much-scorned ACO draft rule proposal with more financial enticements and a reduction in the number of quality measures in the plan.2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/Headshots/Berwick_thumb.jpg" style="BORDER:0px solid;" />PolicyColumn12
Dual Eligibles Pose Funding Challengehttps://www.providermagazine.com/Issues/2011/Pages/1211/Dual-Eligibles-Pose-Funding-Challenge.aspxDual Eligibles Pose Funding Challenge<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div><div> </div> <div style="text-align:center;"><img class="ms-rtePosition-4" src="/Issues/2011/PublishingImages/1211/CoverStory1.jpg" alt="" style="margin:5px;width:532px;height:266px;" /></div> <div> </div> <div>State Medicaid plans across the country are laying the groundwork for introducing managed care into their long term care programs, spurred by federal initiatives to integrate care and funding for the segment of enrollees known as “dual eligibles.”</div></div> <div> </div> <div>These beneficiaries, who qualify for both Medicaid and Medicare benefits, have become a focal point for savings and other policy reforms due to their high costs and complex medical needs.</div> <h3 class="ms-rteElement-H3">A Prime Target For Savings</h3> <div>In 2008, the nation’s 9. 2 million dual-eligible beneficiaries were “among the most chronically ill and costly individuals enrolled in both the Medicare and Medicaid programs,” says an August 2011 fact sheet from the Centers for Medicare & Medicaid Services (CMS). </div> <div> </div> <div>Dual-eligible individuals comprised 15 percent of total Medicaid enrollees, but accounted for 39 percent of combined state and federal spending, or $120 billion, in 2007, according to CMS. On the Medicare side, in 2006, the dual-eligible population made up 16 percent of the program’s beneficiaries and accounted for 27 percent of all Medicare spending, CMS reports. </div> <div> </div> <div>More than half of dual-eligible beneficiaries have incomes below the poverty line, while 43 percent have at least one mental or cognitive impairment, and 60 percent have multiple chronic conditions, according to CMS.</div> <div> </div> <div>As federal and state governments grapple with the fallout of the nation’s economic crisis and search for ways to plug gaping budget deficits, policy initiatives aimed at reducing the cost of care for the dual-eligible population have won broad appeal. “Dual eligibles are getting a lot of attention because they are exceedingly costly on both the Medicare and Medicaid sides,” says James Verdier, senior fellow at Mathematica Policy Research and lead author of a series of reports on dual eligibles. “Looked at from just a cost point of view, it’s an issue that’s hard to ignore.”</div> <h3 class="ms-rteElement-H3">CMS Solicits State Plans </h3> <div>To achieve savings and improve the coordination of care for this small but costly population, CMS has launched two major initiatives aimed at integrating primary, acute, and long term care services for dual eligibles. </div> <div> </div> <div>In July, the agency solicited states to develop and test one of two “financial alignment models” for dual eligibles. One model is a capitation, in which states, health plans, and CMS will enter into a three-way contract, with plans receiving a “blended capitated rate for the full continuum of benefits provided to Medicare-Medicaid enrollees across both programs,” said a July 8, 2011, letter in which CMS described the initiative. </div> <div> </div> <div>Alternatively, states could choose a managed fee-for-service model, in which states would receive a “retrospective performance payment” if they met savings and quality targets. States would still have to offer integrated care management for the full continuum of Medicaid and Medicare services.</div> <div> </div> <div>Thirty-nine states responded to the Oct. 1 deadline with letters of intent to begin the planning process. Implementation of the models is targeted for late 2012. </div> <div> </div> <div><div><div><div>CMS is also working with 15 states that received $1 million each to design new approaches for coordinating care for dual eligibles. The states have submitted initial proposals and will submit final designs next April. CMS will then choose which plans to implement. <br></div> <h3 class="ms-rteElement-H3">Creating A Single Entity</h3></div></div></div> <div>Integration for the dual-eligible population envisions a system in which a single entity “is accountable for the full continuum of [beneficiary] needs, ensuring a person-centered and seamless care experience,” CMS says in a document that responds to frequently asked questions about the initiative. </div> <div> </div> <div>The agency’s integration efforts, which promote and encourage managed care models for service delivery and payment, are being launched on such a large scale that it is expected to open the floodgates to Medicaid managed long term care, a movement that until now has never gotten far off the ground. </div> <div> </div> <div>As of fiscal year 2012, only nine states included long term care in their Medicaid managed care programs, up from four states the previous year, according to a survey conducted by Health Management Associates for the Kaiser Commission on Medicaid and the Uninsured. That number is expected to ramp up dramatically, however, as states adopt integrated managed care models for dual eligibles.</div> <div> <img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1211/CSChart1.gif" alt="" style="margin:15px 5px;" /><br>“This is a new horizon for us,” says Steven Gregory, director of Medicaid reimbursement and research at the American Health Care Association. Describing the magnitude of managed care’s impending advance into Medicaid long term care programs, Gregory says, “a tsunami” is coming. </div> <div> </div> <div>The public policy push to address the integration of Medicaid and Medicare service delivery, care coordination, and funding for dual eligibles can be traced to the Affordable Care Act (ACA), the health care reform statute that was signed into law in March 2010. </div> <div> </div> <div>The ACA established two new entities within CMS to advance, test, and implement new payment and service models. <br><br></div> <div>The Medicare-Medicaid Coordination Office (MMCO) is dedicated to ensuring that “dual-eligible beneficiaries have full access to seamless, high-quality health care and to make the system as cost effective as possible,” says the website description. The MMCO goals include: simplifying access for beneficiaries, improving quality for this population, eliminating regulatory conflicts between Medicaid and Medicare program rules, and improving the quality and continuity of care. The office is integral, for example, to the oversight and administration of CMS’ dual-eligible integration initiatives. </div> <div> </div> <div>A second office, the Center for Medicare and Medicaid Innovation, “has the resources and flexibility to rapidly test innovative care and payment models and encourage widespread adoption of practices that deliver better health care at lower cost,” according to the center’s Web page. In addition to testing new dual-eligibles models, the center will be engaged in such issues as the development of payment innovations like bundling and accountable care organizations (ACOs).<br><span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">Push for Managed Care</h3> <div>Both offices were created “to push the envelope,” says AHCA’s Gregory. “The direction we’re seeing this going in is a lot of advancement with managed care concepts,” including care coordination, case management, and capitation, he says. The new offices within CMS are “breaking down the silos” that separate the Medicare and Medicaid programs, he adds. “They are operationalizing that through managed care concepts.”</div> <div> </div> <div>Since enactment of the ACA, change is on a fast track, Gregory says. Previously, demonstrations projects would have to be evaluated, and it would have taken many months to accomplish what can now happen much more quickly. Advocates for the integration of Medicaid-Medicare service delivery and payment for dual eligibles say it has the potential not only to curb costs, but improve care by alleviating the fragmentation that results from providing care through two disparate programs.</div> <div> </div> <div>Medicare, which covers acute and primary care services, and Medicaid, which provides the lion’s share of long term care for dual eligibles, “have different benefits, billing systems, enrollment, eligibility, and appeals procedures, and often different provider networks,” said an August report on states’ integration proposals from the Kaiser Commission on Medicaid and the Uninsured. </div> <div> </div> <div>Misalignment keeps beneficiaries in “treatment silos, connecting with one provider at a time—even when they have five doctors—and getting one prescription at a time—even when they take 15 different pills a day,” said a 2009 policy brief in support of integrated care for dual eligibles by the Center for Health Care Strategies.</div> <div> </div> <div><div><div>Lack of coordination means that beneficiaries, who tend to be sicker and less educated than the general population, must navigate a health care system that is “mind-bogglingly complex,” Verdier says. “There are a substantial number of things you can do to improve care for dual eligibles, and improve their experience of care, by doing a better job integrating Medicare and Medicaid services,” he says. </div> <h3 class="ms-rteElement-H3">The Arizona Experience </h3></div></div> <div>At the 190-bed Apache Junction Health Center in Apache Junction, Ariz., most of the residents are covered by the Arizona Long Term Care System (ALTCS), one of the few Medicaid managed care programs for long term care in the country.</div> <div> </div> <div>Administrator George Jacobson says the 190-bed facility contracts with four plans that operate in Maricopa County and Pinal County, where Apache Junction is located.</div> <div> </div> <div>“Each of those plans has a separate case management function and separate reimbursement. It’s like dealing with a health plan,” Jacobson says. While providers in most states transmit information to their <a href="/Issues/2011/Pages/1211/Dual-Eligibles-Pose-Funding-Challenge.aspx?ControlMode=Edit&DisplayMode=Design">Medicaid</a> agency for payment, Jacobson says his billing office deals with all four payers each month.</div> <div> </div> <div>The process takes “more coordination and in some cases more time compared to working with a single Medicaid agency,” he says. Jacobson, who is president of the Arizona Health Care Association’s board of directors, has been a health care administrator for more than 25 years. As an operator in the state with the longest-running and most comprehensive statewide Medicaid managed care program in the nation, Jacobson has a unique understanding of the changes providers will face, as states transition their Medicaid programs to an integrated managed care model for dual-eligible beneficiaries.</div> <div> </div> <div>One of the biggest differences, he says, is managed care organizations’ (MCOs’) heightened focus on ensuring that people are placed in the least restrictive, least costly setting, Jacobson says. The plans monitor that more intensively than a state Medicaid agency, he adds, resulting in higher acuity and resource needs for the residents who remain in nursing facilities.</div> <div> </div> <div>Jacobson says he supports appropriate home- and community-based placement and appreciates the need for related cost savings.</div> <div> </div> <div>“That’s a good thing,” he says. “The problem is that coupled with that, the nursing facility needs to be paid commensurate with the resource intensiveness of the people who do end up in a nursing facility.”</div> <div> </div> <div>This year, the state cut Medicaid rates 5 percent across the board, on top of a three-year freeze already in place for ALTCS rates.<br><br></div> <div>“We’re losing ground each year of the freeze,” Jacobson says. At some point, the market is going to respond to unsustainable revenue losses, he adds.</div> <div> </div> <div>“One of the things we are seeing in the market in Arizona is facilities that specialize in Medicare-only post-acute care,” Jacobson says. “That’s the market talking and saying we choose not to accept the financial losses that participation with Medicaid results in.”<br><br></div> <div>Kathleen Collins Pagels, executive director of the Arizona Health Care Association, says a central concern in a managed care system is that the “currency for negotiation is a vulnerable elder.” The greatest challenge, she says, is that “not all of the incentives are aligned.”</div> <div> </div> <div>Managed care companies receive a <a href="/Issues/2011/Pages/1211/States-Propose-Managed-Care,-Capitation-For-Dual-Eligibles.aspx">capitated rate for care.</a> “It’s in their financial best interest to place people in the least costly setting, but it’s not necessarily in the patient’s best interest,” she says. It is “absolutely critical that both parties keep the patient’s or resident’s best interest at the core of their mission. That has to do with aligning incentives properly.” </div> <div> </div> <div>Pagels says the integration of Medicare and Medicaid for dual-eligible beneficiaries “makes great sense from a clinical perspective.” But the transition must also make sense from a payment standpoint, she says.</div> <div> </div> <div>“If providers don’t have adequate resources to care for [dual-eligible residents], it doesn’t make sense,” says Pagels. “We see the advantage of continuity of care for dual eligibles, but there needs to be a close examination of the challenges that places on the provider for payment.”</div> <h3 class="ms-rteElement-H3">The Competitive Edge</h3> <div>Operating in a managed environment also challenges providers to sharpen their competitive edge and adapt to shifting policies and expectations, say Jacobson and Pagels. </div> <div> </div> <div>“Our facilities have become very savvy in dealing with the complex diversity of payers,” says Pagels. “We may have one facility with four managed care payers and over 10 subacute commercial Medicare plans in one building,” she says. </div> <div> </div> <div>The plans have different quality assurance requirements, different three-day authorization codes, and a wide range of individual demands, Pagels adds. “These are very idiosyncratic plans with unique qualities,” she says. “Providers have had to learn how to deal with that.” </div> <div> <br><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1211/CSChart2.gif" alt="" style="margin:5px;" />Providers have also learned to be responsive to the wider marketplace. For example, Apache Junction has modified its practices to support local hospitals as they work to reduce readmission rates, Jacobson says. A new Medicare initiative, which takes effect Oct. 1, 2012, will penalize hospitals whose 30-day readmission rates are deemed too high for certain conditions—heart failure, heart attack, and pneumonia. </div> <div> </div> <div>“Hospitals have become very interested in working along the continuum to make sure we are synchronizing with them in terms of what kind of community care and follow up we can give to reduce readmission levels,” Jacobson says. One hospital wants Apache Junction to follow up with residents who are discharged to the community to ensure that people are keeping their doctor appointments, filling prescriptions, and receiving the home health services that have been ordered for them. </div> <div> </div> <div>The facility doesn’t have a home- and community-based services (HCBS) division, but it does arrange for home health and equipment needs and has begun making follow-up calls to residents for three weeks after their discharge “to keep tabs on folks so that fixable barriers don’t get in the way of the services and care they need,” Jacobson says.</div> <div> </div> <div>“One thing the managed care environment has prepared us for is we have to meet different expectations from different partners,” Jacobson says. “Some plans are aggressive on length of stay, some plans are aggressive on certain formulary restrictions.”</div> <div>The range of expectations means providers must be flexible and responsive, he adds. “We’re in a mindset of adapting to challenges.”</div> <div> </div> <div>During the early managed care evolution, providers struggled, and many went out of business, Pagels says. Over time, however, providers “not only survived but thrived,” she says.<br><br><span id="__publishingReusableFragment"></span><br></div> <h3 class="ms-rteElement-H3">Raising The Bar</h3> <div>Long term care providers face the likelihood of operating in a wider Medicaid managed care marketplace at a time when the Medicare program is also making game-changing policy shifts, such as the development of  ACOs, payment bundling, and implementation of a program that will penalize hospitals for excessive readmission rates.</div> <div> </div> <div>As these changes come to fruition in the marketplace, providers will have to adapt to new performance expectations, forge new relationships with providers along the continuum of care, and respond to competitive pressures that may lead them to seek out new opportunities in the marketplace, experts say.</div> <div> </div> <div>Whether the expansion of managed care comes from “Medicare pilots, such as ACOs or bundling, which we are going to see more of,” or from traditional managed care plans, providers operating in this evolving marketplace “will have to sell themselves from a quality perspective,” says Darryl Nixon, director of reimbursement for the California Association of Health Facilities (CAHF). Nixon says CAHF is encouraging providers to strengthen current and develop new relationships with hospitals and managed care plans in order to be able to compete as these new models of care take shape.</div> <div> <span><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1211/CSChart3.gif" alt="" style="margin:15px 5px;" /></span></div> <div>In addition, providers will need the capability to gather and analyze data.</div> <div> <br>“Whether it’s knowing your hospital readmission rates or knowing what it costs to care for a specific diagnostic condition, you have to have the ability to gather analytics internally,” Nixon says. </div> <div> </div> <div>“You also have to have the ability to analyze outside competitors and partners.” </div> <div> </div> <div>Providers must also be able to look at their quality indicators and manage those in order to maximize their performance and enhance relationships with other providers along the continuum. </div> <div> </div> <div>“A lot of that will have to go on to survive,” Nixon says.</div> <h3 class="ms-rteElement-H3">New Competitive Models</h3> <div>Some providers are ahead of the curve. In Oakland, Calif., Windsor Healthcare has turned around an under-performing 94-bed skilled nursing facility and positioned for future success by identifying niche opportunities and strengthening ties with physicians and local hospitals.</div> <div> </div> <div>Windsor Healthcare, a division of SnF Management with 34 nursing facilities in California, took ownership of the inner city Oakland facility in August 2010, says David Farrell, director of organizational development and regional director of operations.</div> <div> </div> <div>“We began to implement strategies necessary to survive and stay open, and step one was an organizational shift to person-centered care,” says Farrell, a licensed nursing home administrator for 25 years and a member of the Pioneer Network Board of Directors.</div> <div> </div> <div>The facility took the strategic step of developing specialized wound care, a service that local hospitals and the wider community needed, says Farrell.</div> <div> </div> <div>“Hospitals want to discharge patients with wounds to only trusted providers,” he says. “We sent our nurse to become a certified wound specialist and began to market our commitment to healing wounds with data in hand to local hospitals.”</div> <div> </div> <div>The relationship is a win-win: Windsor Healthcare Center of Oakland provides needed care that enables the facility to grow its Medicare census, and the hospital is able to discharge these patients sooner than they otherwise would.</div> <div> </div> <div>The facility took the added step of hiring a prominent wound care physician in the local area for consultation rounds, teaching on-site, and participation with the QI team each month. The wound care program, made possible by “real partners who are strategically aligned,” has allowed the facility to have a more balanced mix of payers, which in turn gives it the resources to provide higher quality charity care, Farrell says.</div> <div> </div> <div>The facility has recently launched a second program focusing on congestive heart failure, a condition with a high rate of hospital readmissions. Windsor has recruited two local physicians who specialize in the condition to be part of their QI team.  </div> <div> <span><img class="ms-rtePosition-2 ms-rteImage-2" src="/Issues/2011/PublishingImages/1211/CSChart4.gif" alt="" style="margin:10px 5px;" /></span></div> <div>“Now we’re positioning ourselves to be another solution to hospitals” and are aligning niches with their needs for ACOs or any model that enters the marketplace, Farrell says. </div> <div> </div> <div>“We’re not a separate cog in the health care community, we’re part of the local health care continuum,” Farrell says. </div> <div> <br>“If we’re going to have a 14-day-stay patient, we have to make sure that the home health care provider we transition the patient to is a quality provider and can be trusted, because if they fail, and the patient is re-hospitalized, then we fail in the eyes of the hospital.” </div> <div> </div> <div><em>Lynn Wagner is a freelance writer based in Shepherdstown, W.Va.</em></div>State Medicaid plans across the country are laying the groundwork for introducing managed care into their long term care programs, spurred by federal initiatives to integrate care and funding for the segment of enrollees known as “dual eligibles.” These beneficiaries, who qualify for both Medicaid and Medicare benefits, have become a focal point for savings and other policy reforms due to their high costs and complex medical needs.2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1211/CoverStory1_thumb.jpg" style="BORDER:0px solid;" />Policy;Management;ReimbursementColumn12
Medicaid Experts Caution Against Cutshttps://www.providermagazine.com/Issues/2011/Pages/1211/Medicaid-Experts-Caution-Against-Cuts.aspxMedicaid Experts Caution Against Cuts​Attempts to cut Medicaid now would be akin to cutting the Federal Emergency Management Agency during a disastrous storm, said Tim Westmoreland, a Georgetown University law professor and former director of Medicaid for the Centers for Medicare & Medicaid Services (CMS), speaking at a Hill briefing on Nov. 10.<br><br>“Cutting Medicaid in the middle of a recession is anti-stimulus,” Westmoreland said, adding that the program for people who are poor and those with disabilities acts as a stimulus for state and local economies. “It’s exactly the wrong plan at exactly the wrong time,” he said. <br><br>With less than two weeks to the congressional super committee’s deadline for submitting a proposal to find $1.5 trillion in deficit reductions to the president, the panel of Medicaid experts was unable to come up with firm suggestions.<br><br>In fact, there was general consensus that there were no low-hanging fruits among the actions the super committee is likely to consider in its efforts to squeeze savings from Medicaid. <br><br>“If anything,” Westmoreland said, “now is the time to increase FMAP [the federal matching rate for state Medicaid programs].”<br><br>In a report released last month, the Government Accountability Office (GAO) shared Westmoreland’s sentiment. “Congress could consider enacting an increased FMAP formula that targets variable state Medicaid needs and provides automatic, timely, and temporary assistance in response to national economic downturns,” the report said.<br><br>GAO offered a prototype formula for a temporary FMAP boost that is triggered after a threshold number of states show a sustained decline in their employment-to-population ratio—which compares the number of employed persons in a state to the working age population aged 16 and older.<br><br>Like many states seeking to save precious Medicaid dollars, Kansas recently introduced managed care to new populations, said panelist Andy Allison, Kansas Medicaid chief. In addition, the state has integrated dual-eligible beneficiaries through a shared-savings model. <br><br>“Spending reductions are the new normal in state Medicaid programs,” Allison said. He predicts that states will expand managed care dramatically and that states need more tools to address cost growth.<br>But DeAnn Friedholm, campaign director for the Consumers Union and a former Medicaid director for Texas, cautioned states’ enthusiasm for taking up managed care in an effort to cut Medicaid spending. She implemented managed care in Texas in the early 1990s with little success, she said. “It’s not a panacea,” she said.Attempts to cut Medicaid now would be akin to cutting the Federal Emergency Management Agency during a disastrous storm, said Tim Westmoreland, a Georgetown University law professor and former director of Medicaid for the Centers for Medicare & Medicaid Services (CMS), speaking at a Hill briefing on Nov. 10. 2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1211/Capitol_RJ_thumb.jpg" style="BORDER:0px solid;" />PolicyColumn12
Medicare Beneficiaries Sue U.S. Over ‘Observation Stays’https://www.providermagazine.com/Issues/2011/Pages/1211/Medicare-Beneficiaries-Sue-US-Over-‘Observation-Stays’.aspxMedicare Beneficiaries Sue U.S. Over ‘Observation Stays’<div> </div> <div>Medicare beneficiaries and their families have filed a class-action lawsuit against the federal government to stop the “observation stay” process that the group says deprives beneficiaries of Medicare Part A coverage for their hospital stay and after care in post-acute care facilities.<br><br>The suit (Bagnall vs. Sebelius) was filed in a U.S. district court in Hartford, Conn., and asks the court to stop Health and Human Services Secretary Kathleen Sebelius from authorizing doctors to place Medicare hospital patients on “observation” status rather than admitting them for inpatient care.<br><br>“The plaintiffs are Medicare beneficiaries who received inpatient hospital services but were improperly classified as outpatients, often referred to as ‘observation status,’ and therefore deprived of Medicare Part A coverage for their hospital stay and after care,” according to the Center for Medicare Advocacy and co-counsel, the National Senior Citizen Law Center. <br><br>“The misapplication of ‘observation status’ deprives Medicare beneficiaries of their coverage rights and may cause them to absorb significant hospital costs that otherwise would be paid for under Medicare Part A.”<br><br>The two groups filed suit on behalf of seven individual plaintiffs who represent a nationwide class of people harmed by the allegedly illegal “observation status” policy and practice.<br><br>Currently, it is required for patients to be admitted into a hospital as an inpatient for three days in order to be eligible for skilled nursing facility (SNF) care through Medicare after they are discharged. However, classifying a hospital patient as on observation stay status is a common, clinically appropriate practice to treat and assess whether a patient requires further treatment or whether they are able to be discharged. <br><br>Plaintiff Lee Barrows of Connecticut said her husband experienced the negative impact of the observation policy after his five-day stay in a Connecticut hospital as an observation patient and denial of Medicare payment for his subsequent nursing care. <br><br>“After five days of treatment in the hospital, my husband’s neurologist, physician, and social worker ushered me into the hallway to tell me that my husband was never admitted. I was stunned with disbelief and tearfully blurted out that I would fight this,” said Barrows. “His doctors then indicated that this happens once or twice a week.”<br><br>The lawsuit follows a late October congressional briefing on “observation status,” which sought support for bipartisan legislation, the Improving Access to Medicare Coverage Act of 2011, which has been filed in both houses. <br><br>There was also a call for an administrative resolution.</div> Medicare beneficiaries and their families have filed a class-action lawsuit against the federal government to stop the “observation stay” process that the group says deprives beneficiaries of Medicare Part A coverage for their hospital stay and after care in post-acute care facilities. 2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/gavel_thumb.jpg" style="BORDER:0px solid;" />LegalColumn12
Quality Assessment, Assurance Made Easierhttps://www.providermagazine.com/Issues/2011/Pages/1211/Quality-Assessment.aspxQuality Assessment, Assurance Made Easier<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div>Didn’t we just have a quality assessment and assurance (QAA) meeting? Where did the month go? Do we have all of our data? Did you follow up on your action items? Will you be ready to give an update? Is it time to invite the outside consultants to give their report? Sound familiar?</div> <div> </div> <div>In 2009, Skilled Healthcare, LLC, created a task force to tackle these issues and to further its goal to enhance the value of the facility QAA committee. Task force participants included a wide range of stakeholders—administrators, clinical, and operational consultants. Along the way, further input came from facility medical directors and interdisciplinary team members. </div> <div> </div> <div>Skilled Healthcare, LLC, is an administrative service provider to long term care facilities and does not own or operate long term care facilities.</div> <h3 class="ms-rteElement-H3">Getting Feedback From Centers</h3> <div>The first step the task force took to ensure that the voice of the customer was heard was the creation and distribution of a simple five-question survey for facilities (see box, below).<br><img class="ms-rtePosition-2 ms-rteImage-2" src="/Issues/2011/PublishingImages/1211/Mgmt1.gif" alt="" style="margin:25px 15px;width:455px;height:363px;" /><br>Using survey feedback along with information from the centers’ 2567s statement of deficiencies when F-Tag 520 (QAA) was cited, the task force focused on revamping the current forms, as well as data collection tracking and trending tools, standardizing the format for the facility QAA committee meeting, while continuing to preserve patient confidentiality and statutory QAA privileges. </div> <div> </div> <div>And to further enhance process efficiency, the QAA tools were automated.</div> <div> </div> <div>Considerable time was spent developing the specifications for the programmer. While some programmers have a clinical background, most do not. Sketches were developed not only regarding the layout of the screens in which the data would be entered, but also the resulting look of the reports. </div> <div> </div> <div>To have screens that were “clean” and free of visual distractions, tools were incorporated. By placing the user’s mouse over a predefined prompt, the QAA committee members are cued as to what areas should be considered for discussion topics during the meeting.</div> <div> </div> <div>In developing this QAA program, it was important that the end product be streamlined and user friendly. Real-time analysis allows for intuitive navigation as, while user guides are always handy in a pinch, the task force wanted to avoid unnecessary and time-consuming tutorials on how to use the software. <br><br>Taking cues from issues inherent with new software, helpful features were added, such as prompts for the user to save the document before closing to minimize the need for rework. And the reports self-populate other QAA reports, which completely eliminates the need to input information into the QAA minutes more than once. </div> <div> </div> <div>As a result, the QAA Version 1.0 was thoroughly tested and piloted in a number of centers prior to being rolled out in 2010. </div> <div> </div> <div>In the spirit of continuous quality improvement, six months into its use, the task force again sought feedback: What do you like about QAA Version 1.0? What can be improved? With this additional feedback, QAA Version 2.0 was developed and rolled out in 2011. </div> <div> <span id="__publishingReusableFragment"></span></div> <div>The current program consists of:<br><ul><li><strong>Monthly Quality Indicator Trend Report</strong></li></ul></div> <div>This report reflects quality measures and quality indicators. The entire year’s data are reflected on the same page for ease of tracking and trending. In addition, national, state, and other facilities’ benchmark data are included for comparison.<br></div> <div><ul><li><strong>QAA Agenda And Minutes Report</strong></li></ul></div> <div>There are four main sections in this report: Care, Operations, Customer Satisfaction, and Other. These four sections are comprised of 94 prompts used for identifying issues. Ideally, after a prompt is discussed by the QAA committee, it is marked as either “reviewed” or “concern,” at which point a narrative note may be recorded in a drop box. In addition, when an area is marked as “concern,” a QAA Action Item drop box appears.<br><br></div> <div>The QAA Action Item box is where commitments to develop and implement appropriate plans of action can be recorded.<span></span><br><br></div> <div>Each area of concern has its own process owner, and each action item has its own completion date field. Until all action items are completed, this box will continue to come up from one QAA meeting to the next.</div> <div style="text-align:left;"><ul><li><strong>QAA Minutes Action Plan</strong></li></ul></div> <div><span><span><span><span><img class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1211/Mgmt1.jpg" alt="" style="margin:5px 10px;width:328px;height:219px;" /></span></span></span></span>This report self-populates from the QAA Agenda and Minutes Report. It reflects areas of concern and action items the center is currently addressing. Having this report at their fingertips enables administrators to bring the report to their stand-up or department head meeting and ask the process owner for an update on how their action items are progressing. The intention of this report is to help ensure that the action items are being worked and not forgotten.<br><span><span><span></span></span></span><br></div> <div>The DSDs can also find this report helpf<span><span></span></span>ul. By reviewing this report when planning in-services, the goal is for the DSD to identify what issues the center is addressing and pull resources (that is, training materials) to further assist the center in achieving performance improvement.</div> <div><ul><li><strong>Calendar Of QAA Items Discussed</strong></li></ul></div> <div>Feedback the Task Force received in 2009 included centers finding it cumbersome to keep track of what QAA items were discussed from month to month. The QAA Task Force cannot dictate which areas and how often something should be discussed, as each center is unique. Some prompts may be reviewed monthly, others quarterly, and still others, such as contracts, may be reviewed annually.<br></div> <div>The Calendar of QAA Items Discussed also self-populates from the QAA Agenda and Minutes Report. When utilized, the QAA committee can see at a glance when an area was last discussed and whether it was “reviewed” or a “concern.”</div> <div><ul><li><strong>QAA Specific Query Item Look Up Report </strong></li></ul></div> <div>The intention of this report is to allow the user to pull up a chronological report of specific QAA items discussed. Although QAA is privileged information, during a survey a center (after consulting with legal) may decide to pull up all notes from their QAA meetings for the last three months that focused on falls to show surveyors that a falls issue had been self-identified and action items were in the process of being implemented and monitored. <br><br></div> <div>Automation of the QAA has improved the effectiveness of the QAA process: </div> <div><ul><li>Kevin Bellinger, administrator at Baldwin Healthcare and Rehabilitation Center, LLC, Baldwin City, Kan., says, “QAA Version 2.0 is much more efficient than the paper version because it pulls clinical information from various sources, which allows the team to spend more time brainstorming ideas and solutions to concerns or issues.</li></ul></div> <div>I really like how the system lets you click on each area you want to review during the QAA meeting and then directly input concerns and the plan of correction.” </div> <div><ul><li>Rashonda Caldwell, RN, DON, at Clairmont Longview, LP, Longview, Texas: “I enjoy utilizing QAA Version 2.0 for several reasons. First, it allows the user the option to input notes regarding an area of interest or to enter a plan on what the facility is going to do to reach a goal in a certain area such as pressure ulcers or falls. Second, it is a much more organized system than the traditional paper version of QAA documentation. I can’t tell you how much I love the fact that a QAA member or I can input the necessary information for our departments and generate a report.”</li></ul></div> <div><ul><li>Aisha Salaam, RN, MSN, MPH, senior vice president, professional services at Skilled Healthcare, says, “Developing and implementing a user-friendly online QAA program has provided a vehicle that offers an opportunity for heightened system monitoring and action plan follow-up accountability, all with an eye to continuing to improve clinical care, quality of life, safety, customer satisfaction, and care transitions.” </li></ul></div> <div><em>Karen Schindler, PT, is vice president, quality initiatives, and Anthony Ramirez, RN, is director of clinical information technology, for Skilled Healthcare. Schindler can be reached at: <a href="mailto:kschindler@skilledhc.com">kschindler@skilledhc.com.</a></em></div>In 2009, Skilled Healthcare, LLC, created a task force to tackle these issues and to further its goal to enhance the value of the facility QAA committee. Task force participants included a wide range of stakeholders—administrators, clinical, and operational consultants. Along the way, further input came from facility medical directors and interdisciplinary team members. 2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1211/Mgmt1_thumb.jpg" style="BORDER:0px solid;" />Management;Survey and Certification;Quality;Quality ImprovementColumn12
Quality Report Shows Improvements In Nine Of 10 Measures since 2009https://www.providermagazine.com/Issues/2011/Pages/1211/Quality-Report-Shows-Improvements.aspxQuality Report Shows Improvements In Nine Of 10 Measures since 2009<p>​Skilled nursing and post-acute care facilities have improved in nine out of 10 quality measures since 2009, but there is concern these successes will be threatened by reimbursement reductions in the Medicare and Medicaid programs, according to the latest quality report issued by the American Health Care Association (AHCA) and the Alliance for Quality Nursing Home Care. <br><img width="186" height="566" class="ms-rteImage-2 ms-rtePosition-2" src="/Issues/2011/PublishingImages/1211/QualityReport_cover.jpg" alt="" style="margin:10px 5px;height:232px;" /><br>Nursing facilities have improved in all short-stay measures, which include patient delirium, pain, and pressure ulcers and a vast majority of long-stay measures, including improvements in activities of daily living, high-risk pressure ulcers, resident mobility, and pain. “This report is one way we demonstrate our commitment to quality improvement and increased transparency in the facility assessment process,” said Gov. Mark Parkinson, AHCA president and chief executive officer. </p> <p>“This report also calls attention to key issues that our provider community sees as priorities in ensuring we can continue to build upon the improvements we have made.”<br><br>The third annual report from  AHCA and the Alliance used data from the Centers for Medicare & Medicaid Services (CMS) to generate its findings. <br><br>Alan Rosenbloom, president of the alliance, noted that progress on the quality front is at risk from the continuing pressure on Medicaid reimbursement at the state level and even more notably the sharp reductions CMS approved for fiscal year 2012 that kicked in Oct. 1.<br><br>“There is good reason for concern that a lot of progress on quality is in jeopardy,” he said,  noting that when all is said and done, the Medicare reductions could amount to 15 percent for fiscal 2012, reminding him of the situation the industry faced in 1997 when the Balanced Budget Act was passed.<br>“Patients were most affected” by the cuts then, Rosenbloom said, with facilities having to trim staff in order to make ends meet.<br><br>As for the report, there were calls to alter CMS quality measures to better reflect the modern-day nursing facility role.<br><br>“Nursing facilities have seen a dramatic shift in patients requiring short-term therapy services intended to restore function so that patients can ultimately return to an independent living situation,” the report said. <br><br>Expert contributors to the report said current quality measures do not reflect this shift and do not allow for proper measurement of rehabilitation services for short-stay Medicare patients.<br><br>“Post-acute care has gravitated to a system of multiple transfers to different levels of care,” said Andrew Kramer, MD, of Paradigm Health and professor of medicine at the University of Colorado. “With this evolution, it is critical that measures of rehabilitation quality follow patients across these transitions over fixed time intervals rather than during individual stays.” </p>Nursing facilities have improved in all short-stay measures, which include patient delirium, pain, and pressure ulcers and a vast majority of long-stay measures, including improvements in activities of daily living, high-risk pressure ulcers, resident mobility, and pain. “This report is one way we demonstrate our commitment to quality improvement and increased transparency in the facility assessment process,” said Gov. Mark Parkinson, AHCA president and chief executive officer. 2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1211/QualityReport_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality ImprovementColumn12
Tuning In To Telehealthhttps://www.providermagazine.com/Issues/2011/Pages/1211/Tuning-In-To-Telehealth.aspxTuning In To Telehealth<div>Patient care and wellness have always been defining attributes of Ethica Health & Retirement Communities. When Ethica’s medical director advisory board met in 2009 with key clinical leadership to discuss the need for appropriate specialty care for their patients, a solution was immediately forthcoming. <br><br></div> <div>“One of our directors mentioned a telemedicine program, in which technology and medicine converge to provide state-of-the-art specialty care to patients outside the central coverage area,” says Lucy Rogers, senior vice president of compliance and quality advancement for Ethica. </div> <div> </div> <div>“Discussing the parameters and benefits of such a program, we believed this technology could positively impact the care of our patients in skilled nursing centers.” </div> <div> </div> <div>Pursuing the program in conjunction with the <a href="/Issues/2011/Pages/1211/Program-Aims-To-Spread-Telehealth-Throughout-State--.aspx">Georgia Partnership for Telehealth</a>, Ethica’s directors identified five centers that could benefit from a telemedicine pilot program. </div> <div> <span><img class="ms-rtePosition-2 ms-rteImage-2" src="/Issues/2011/PublishingImages/1211/Tech1.jpg" alt="" style="margin:20px 10px;width:369px;height:246px;" /></span></div> <div>A grant obtained from the partnership combined with a matching grant from Community Health Foundation allowed Ethica to install telemedicine units in five of its clients’ centers in rural areas of Georgia, where doctors in certain specialties are rare. </div> <h3 class="ms-rteElement-H3">How It Works</h3> <div>Telemedicine units negate the need for patients to be transferred to specialists’ offices for routine appointments and checkups. Instead, with the aid of a qualified clinical staff member, patients enter an onsite exam room where the unit is located to begin a virtual consultation with an attending physician. </div> <div> </div> <div>A computer screen and a dedicated, secure telephone line allow the physician and patient to easily and confidentially interact as if they were in the room together. </div> <div> </div> <div>“The units are really quite savvy,” Rogers says. “With tremendous magnification capabilities, they allow the doctor to thoroughly examine the patient—from listening to their heartbeat and checking their pulse, to examining wounds and looking for infections,” he adds.</div> <h3 class="ms-rteElement-H3">The Benefits</h3> <div>In skilled nursing facilities, especially those in remote areas, patient transfers out of the facility can be problematic. Oftentimes, reliable transportation to shuttle patients to specialist appointments is not available. </div> <div> </div> <div>“One of the reasons we are participating in this pilot program is to enhance the care of our patients, giving them access to a wide array of specialists across the state,” Rogers says. </div> <div> </div> <div>“We also wanted to limit patient transfers out of the skilled nursing center because the patient’s health may be compromised.” </div> <div> </div> <div>The telemedicine program, which has been in place since early 2009, has had a positive impact not only on patients in Ethica Client Centers, but also on citizens in the surrounding communities. Realizing these units are a health benefit to skilled nursing patients, the five facilities in the pilot program have made the units and their specialist-care capabilities available to community patients seeking advanced care. </div> <div> </div> <div>“Although this program is in its infancy, it’s the only one in the state of Georgia,” Rogers says. </div> <div> </div> <div>“We’ve already observed several positive changes, including improved appointment scheduling, enhanced diagnosis and treatment, improved rural health delivery and care, and decreased admittance to the emergency room for skilled nursing patients. </div> <div> </div> <div>“Overall, these units have provided a benefit to our community and transformed the face of our health care.” </div> <div> </div> <div><em>Lynne Palmer King is vice president, community relations, for the Community Health Foundation, an extension of the Georgia Partnership for TeleHealth. She can be reached at (770) 475-6540 ext. 2405.</em></div>Patient care and wellness have always been defining attributes of Ethica Health & Retirement Communities. When Ethica’s medical director advisory board met in 2009 with key clinical leadership to discuss the need for appropriate specialty care for their patients, a solution was immediately forthcoming. 2011-12-01T05:00:00Z<img alt="" src="/Issues/2011/PublishingImages/1211/Tech1_thumb.jpg" style="BORDER:0px solid;" />TechnologyColumn12