| Assisted Living Spaces: Fostering Social Engagement | https://www.providermagazine.com/Issues/2012/Pages/0412/Assisted Living Spaces Fostering Social Engagement.aspx | Assisted Living Spaces: Fostering Social Engagement | <div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div>
<div><img class="ms-rteImage-2 ms-rtePosition-2" alt="Dining arrangements can be altered to invite varied table mates." src="/Issues/2012/PublishingImages/0412/0412Design1.jpg" style="margin:5px 15px;width:399px;height:282px;" />This senior generation is not coasting to the end. They are still on the journey, seeking new experiences and an expanded awareness. At this stage of life, today’s seniors have more time to indulge in areas of interest that they may have had to set aside in favor of work and family obligations. </div>
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<div>Notwithstanding age in years, the senior today has a more youthful self-identity and aspires to a more engaged and active lifestyle. </div>
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<div>Compared with the tastes of the emerging baby boomer population versus their predecessors, it is clear the design assumptions that were employed in the 1990s no longer work. In the ’90s, designers and residents favored traditional style, dark wood, and “vanilla” colors and textures. </div>
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<div>These created exterior and interior impressions that look old, sedentary, and tired. </div>
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<div>In contrast, baby boomers favor an environment that is lively and energetic. It needn’t be edgy, but it must be bright, with a measured degree of lightheartedness. </div>
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<div>There is no single design aesthetic employed; instead, it should be an activating expression appropriate to the local community’s local design vernacular and population. When strong regional or local community identities exist, the environment should reflect these.</div>
<h2 class="ms-rteElement-H2">Landscaping Important To Feelings Of Contentment</h2>
<div>A vibrant natural world brings energy. Rooms with great views, whether of nourished gardens or expansive vistas, engage the resident with the living world. Landscape, indoor and out, brings a healthy and enriching spirit to the community. Natural building materials and finishes offer a harmonious interface between space and place, advancing a fresh and integrated feel to the environment.</div>
<div><br>Such spaces bring brightness and pleasure to the individual, which is reflected in the quality of spirit they share while in spaces that elevate their mood. Remember, a well-cared-for landscape is a very powerful communicator of overall “caring.” </div>
<div><br>Plants don’t die: With proper care, they flourish. When residents and their families see well-tended grounds, they receive the message that staff care for residents as well.</div>
<div><br>Furnishing comfort determines the length of stay, and the posture in it determines the level of relaxation versus engagement. The ergonomics of the furniture need not only respect the mobility limitations that may exist but should also strive to position the user to lean into the activity of the common area and not withdraw by virtue of a sedentary posture. </div>
<div><br>Over-soft, reclining positions will advance fatigue and result in a drowsy manner, if not a tendency to sleep sitting. The more upright the seat (without sacrificing comfort), the more engaged and prolonged the interaction between individuals. Color and materials also communicate quality and cleanliness. Dusty and darker tones often create an impression that materials and finishes are soiled. Lighter, softer tones offer a more youthful feel even when applied to traditional interior décors. </div>
<h2 class="ms-rteElement-H2">Lighting Choices Critical</h2>
<div>Lighting is often seen as a utility and not as a theatrical tool. However, with creative applications of lighting, the character of rooms can be made energetic or relaxing, comfortable for large groups or comfortable for just two, socially engaging or transient. </div>
<div><br>Lower levels of illumination are often used in large rooms to encourage small independent zones where a few might visit. The brighter the overall illumination, the more it is appropriate for a larger assembly of people who are interacting.</div>
<div><br>Often, lighting is measured on brightness and not on clarity. Lights that are too bright or lamps that are exposed can cause glare. The glare produces early eye fatigue and limits the ability to see beyond the intrusive illumination. Indirect lighting, more softly and uniformly cast, produces a better level of visual acuity and invites visual connection with others. </div>
<div><br>The avoidance of eye fatigue also invites a longer duration in areas where social interaction is encouraged.</div>
<div><br>Composing the décor with the ingredients of indoor planting, proper furniture, brightened colors, and creative lighting will result in residents feeling more lively and interactive and acting accordingly.<br><span id="__publishingReusableFragment"></span></div>
<h2 class="ms-rteElement-H2">Activate Outdoor Living</h2>
<div>If viewing the outdoors inspires the resident with beauty of the living world, then being outdoors ensures that outcome. Much depends on the area’s climate, but even in the northern and southern reaches of the United States, there are times of the year that are temperate, providing a welcome opportunity to get outside the four walls of home. </div>
<div><img class="ms-rteImage-2 ms-rtePosition-1" alt="A gazebo lends an additional neighborly feel to the property." src="/Issues/2012/PublishingImages/0412/0412Design3.jpg" style="margin:15px 25px;" /><br>Yet, all too often, outdoor living spaces are designed for passive viewing, not active experience. This does little to further the goals of social interaction. Consider the following reflections.</div>
<div><ul><li>The most successful outdoor living areas are freely accessible. That begins with transparency. The more the indoor environment presents the outdoors as an extension of the same domain, the more the outside invites engagement. The more the outside is furnished and shaded to feel like a living space, the more it becomes an enhanced and expanded community living area. The more it is appointed with groupings and common features such as fire pits or TV, the more people will enjoy the space for extended periods of time.</li></ul></div>
<div><ul><li>Even in urban environments where open space is often at a premium, outdoor space in the form of a rooftop terrace can become extremely popular with residents. </li></ul></div>
<div><ul><li>An outdoor experience can also be fostered by selecting certain indoor areas to be all-season rooms that advance greater engagement with the outdoors. Sunrooms, solariums, and conservatories are but a few examples of indoor spaces that allow for outdoor experience even in inclement conditions. </li></ul></div>
<div>Artificial daylighting, as well, will project a sunny day even with gray and overcast conditions.</div>
<div><ul><li>Gardening is the most popular outdoor activity in the country, regardless of age. Every senior living community should offer opportunities for residents to engage in the creative, spiritually fulfilling process of nurturing plants. </li></ul></div>
<div>Raised planters provide easy access to gardening for people who cannot get down and up readily. A community garden can even provide food for the common kitchen, flowers for the table, and, most importantly, a common interest to share with others. </div>
<div><ul><li>A pool with a “roll-in” edge, especially if the pool is partially shaded with a canopy, invites use by people with a wide range of physical abilities and use of the amenity for greater periods of time throughout the day. The longer they enjoy the feature, the more social interaction results.</li></ul></div>
<div><ul><li>A pet park where residents can walk and play with their dogs provides regular physical activity and a chance to get to meet other animal lovers. </li></ul></div>
<div><ul><li>Multipurpose outdoor pavilions that can be used for cooking and dining expand the dining venues and change the character and spirit of the occasion.</li></ul></div>
<div><ul><li>Indoor areas suitable for crafts, hobbies, and learning venues bring together individuals who share a common interest. A common interest or purpose is the core of a lasting acquaintance.</li></ul></div>
<div><ul><li>Finally, consider landscaping. Avoid just considering the planter and shrub border. An investment in trees creates communities that age with dignity and ever-increasing value. As trees mature, they provide seasonal interest and form a canopy that offers shelter and charm. Well-shaded outdoor spaces become destinations—rooms without walls—which encourage prolonged interaction and sociable encounters. <br></li></ul></div>
<h2 class="ms-rteElement-H2"><img class="ms-rteImage-2 ms-rtePosition-2" alt="Small common areas provide communal living spaces where residents can gather." src="/Issues/2012/PublishingImages/0412/0412Design2.jpg" style="margin:5px 10px;width:395px;height:277px;" />Integrate Safety, Security</h2>
<div>For social interaction to flow freely, the resident must feel safe and secure. They generally are, when housed in a proper environment, but that reality may still not be perceived. <br></div>
<div><br>The challenge in any planned community is to create an environment that feels protected without expressing it with hardened expressions like bars, gates, and obtrusive surveillance devices—an environment that suggests a home rather than a prison.</div>
<div><br>A community planning theory that grew out of New Urbanism (see <a href="http://www.newurbanism.org/" target="_blank">www.newurbanism.org</a>) integrates safety and security measures that both function effectively and minimize the implication that a threat may prevail. </div>
<div><br>In part, it focuses on visibility, avoidance of blind corners, translucent rather than solid outdoor enclosures, and lighting that avoids bright sources or “hot spots” in favor of uniform and often indirect lighting sources.</div>
<div>At the front desk, use of a lower counter that provides for a fuller view of the attendant—better yet, a segmented desk that allows that attendant to move around the desk and greet a resident or visitor—projects a strong, friendly first impression.</div>
<div><br>Corridors can be intimidating environments. The addition of windows and natural lighting, the appointment of each unit door as if it were the “front stoop” of a private dwelling, and the occasional use of art and furniture that convey an impression of permanence rather than transience are features that bring a safe, secure feeling to the community space.</div>
<h2 class="ms-rteElement-H2">Return On Investment</h2>
<div>For optimal benefit to residents and preferred return on investment to providers, designers must prioritize their focus on common areas that draw residents together in ways that cultivate connectivity. <br><br></div>
<div>Even within existing facilities, many of the principles of social engagement can be advanced with attention to detail and awareness of the objective.</div>
<div><br>As residents become active, engaged, and communicative, they invest in the place they call home. That investment generates durability in both their efforts to delay decline and their respective occupancy within the facility.</div>
<div><br>Thoughtful planning and design and the encouraged use of amenities not only attract residents and their families to a senior-living community, they enable providers to weave a social fabric that activates and engages residents in their community life. </div>
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<div><em><img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2012/PublishingImages/0412/0412Design_Koch.jpg" alt="" style="margin:5px;width:127px;height:171px;" /><br><br>Robert Koch, AIA, is a principal of Fugleberg Koch, an architecture, planning, urban design, and development consulting firm located in Winter Park, Fla. The firm’s residential portfolio includes mixed-use, urban infill, mid-rise, high-rise, direct-entry, senior living, workforce housing, and affordable-housing projects. Koch can be contacted at (800) 393-0595 or online at <a target="_blank">www.fugleberg koch.com/contact.php.</a></em></div>
| This senior generation is not coasting to the end. They are still on the journey, seeking new experiences and an expanded awareness. At this stage of life, today’s seniors have more time to indulge in areas of interest that they may have had to set aside in favor of work and family obligations. | 2012-04-01T04:00:00Z | <img alt="" src="/Issues/2012/PublishingImages/0412/0412Design_thumb.jpg" style="BORDER:0px solid;" /> | Management;Design | Column | 4 |
| A Look At MDS 3.0 Psychosocial Changes | https://www.providermagazine.com/Issues/2012/Pages/0412/A-Look-At-MDS-3-0-Psychosocial-Changes.aspx | A Look At MDS 3.0 Psychosocial Changes | <div> </div>
<div>In October 2010, the minimum data set (MDS) 3.0 changed the way in which nursing home residents’ needs were assessed. It created new psychosocial requirements, including direct resident interviews for cognition, mood, customary routine and preferences, pain, and return to the community. </div>
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<div>It also requires nursing home interdisciplinary staff to use standardized tools, including the Brief Interview for Mental Status (BIMS) and the Confusion Assessment Method (CAM) in Section C, the Patient Health Questionnaire (PHQ) 9 in Section D, a new Preference Assessment Tool (PAT) in Section F, and a Numeric Rating Scale (0-10) or a Verbal Descriptor Scale pain assessment tool in Section H. </div>
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<div>In Section Q, residents are asked about their desire to return to the community. If the answer is yes, there are procedures to follow with local contact agencies and support through Money Follows the Person or local contact agencies.</div>
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<div>This article is a follow-up to a <em>Provider</em> October 2010 focus group article that found MDS 3.0 psychosocial training was needed because social workers and interdisciplinary staff were not prepared for the new requirements. </div>
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<div>There were concerns about inconsistent levels of social work staff, qualifications, and caseloads. Given these results, a second set of focus groups was conducted in 2011 with social workers and nurses to learn how the implementation was going from the perspective of staff in the field. </div>
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<div>This article presents the results from these group sessions, which aimed to understand the impact of MDS 3.0 implementation on psychosocial assessment and care planning in nursing homes. </div>
<h2 class="ms-rteElement-H2">Focus Group Findings</h2>
<div>The second set of focus groups was conducted in two phases, each held with nursing home nurses and with both licensed and unlicensed social workers/social work designees. Twenty-four participants represented a range of for-profit and not-for-profit facilities, small and large facilities, and rural and urban areas. <br><br>During the teleconference, they responded to questions sent in advance regarding the positive and negative impacts of MDS 3.0 on both residents and staff, as well as on the care area assessments (CAAs). </div>
<div><img class="ms-rtePosition-2 ms-rteImage-2" src="/Issues/2012/PublishingImages/0412/0412Caregiving.gif" alt="" style="margin:5px 15px;width:426px;height:604px;" /><br>The results of the focus groups revealed consistency in responses to questions and concerns identified from nurses and social workers. MDS 3.0 positive findings included the insightful nature of resident interviews, which often resulted in new information for staff, and the identification of suicidal residents with the PHQ 9. </div>
<div><br>Importantly, interdisciplinary roles were found to be better defined as different team members are now required to fill out different sections of the MDS 3.0. </div>
<div><br>A stronger role for social work has now been created in terms of acting as interdisciplinary facilitator and leader. The most common MDS 3.0 role configuration involved social workers completing cognition, mood, and return-to-community items; nurses completing the pain and delirium items; and the activities therapist completing preferences.</div>
<h2 class="ms-rteElement-H2">Redundancy, Time Management </h2>
<div>The focus group participants identified the requirement to repeat multiple clinical interviews for the five-, 14-, 30-, 60-, and 90-day Medicare assessments; discharge assessments; and OBRA (Omibus Budget Reconciliation Act) assessments as their most significant concerns about MDS version 3.0. </div>
<div><br>The redundant interviews were reported to be frustrating for residents and resulted in reduced quality time staff can spend with residents. The negative impact on overall quality of care as the result of more time being spent on documentation, repeated interviews, and CAAs was noted to be most concerning to both disciplines. </div>
<div><br>The participants also noted the importance of interdisciplinary work, while also acknowledging a lack of formal training in how to function as a team. Those who believed their teams functioned well prior to MDS 3.0 expressed less role conflict and ambiguity. </div>
<div><br>Several participants emphasized that the greater demands of the new system placed more stress on the teams and therefore more conflict.</div>
<div><br>Ideally, staff members need to be trained to work as a unit, where members feel comfortable expressing themselves and decision making is shared. There needs to be role clarity where staff understand what is expected of them by the organization as it relates to MDS 3.0 completion, care plan development, and implementation. </div>
<div><br>This is a problematic area in facilities, where staff have no training in teamwork and the training and credentials of staff vary.</div>
<div><br>Interdisciplinary teamwork with appropriate understanding of each other’s roles is the gold standard; teams that do not have this seem to struggle more with the MDS 3.0. </div>
<div><br>Both social workers and nurses were concerned because there was limited CAA training, especially around psychosocial issues.</div>
<h2 class="ms-rteElement-H2">CAA Processes ‘Hard To Follow’</h2>
<div>All focus group staff reported using CAAs developed by the Centers for Medicare & Medicaid Services (CMS), and none were using their own evidence method, as described in the “MDS 3.0 Manual” (Appendix C–84). Yet, they had major concerns: CAAs were described as “not easy to follow” and not providing step-by-step evidence-based approaches that would be suitable for staff with varying educational backgrounds, such as those from a social service designee with a high school education versus masters-trained social workers or nurses. </div>
<div><br>In addition, multiple CAAs are triggered and keep staff so busy with documentation that there is less time for continued assessment, interventions, and interdisciplinary coordination of care. Documentation requirements must be understood in terms of the number of CAAs and total caseload. </div>
<div><br>Finally, completion of Section Q creates problems because of inconsistencies across states regarding procedures, expectations, referral response times, and lack of clarity as to how this section should be completed.</div>
<div><br>Engaging residents in the interview process is a positive step toward a person-centered approach, the focus groups agreed. If the MDS 3.0 is to be an effective tool, there need to be consistent standards of training done for an interdisciplinary group of qualified practitioners, participants concluded.</div>
<div><br>This study confirmed the 2010 focus group findings that “clinical training beyond MDS 3.0 coding is required and should be offered by national nursing facility organizations and their affiliates.”</div>
<div>The types of training needed include: team cohesion, using and interpreting scores on standardized scales, and testing issues.</div>
<div><br>In addition, staff need more guidance on developing procedures for addressing differences in self-reporting versus clinical observations and guidelines for developing treatment responses, the focus group observed. </div>
<div>Residents’ voices are critical to person-centered care; however, the frequency of the interviews needs to be addressed as it creates frustration for elders and staff. </div>
<div><br>These focus groups provided critical feedback for improving both processes and practice.</div>
<div>Go to: www.providermagazine.com for a case study example of how the MDS 3.0 has impacted a resident.</div>
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<em></em><div><em>Robert P. Connolly, LCSW-C, a consultant and retired from the Centers for Medicare & Medicaid Services, is based in Ellicott City, Md., Deirdre Downes, LCSW, is director of social work for Jewish Home Lifecare, New York, N.Y., and Jake Reuter, LSW, is director of the North Dakota Money Follows the Person program, Bismarck, N.D.</em></div> | In October 2010, the minimum data set (MDS) 3.0 changed the way in which nursing home residents’ needs were assessed. It created new psychosocial requirements, including direct resident interviews for cognition, mood, customary routine and preferences, pain, and return to the community. | 2012-04-01T04:00:00Z | <img alt="" src="/Issues/2012/PublishingImages/0412/0412Caregiving_thumb.jpg" style="BORDER:0px solid;" /> | Caregiving | Column | 4 |
| Meehan Says He Understands Challenges For LTC Sector | https://www.providermagazine.com/Issues/2012/Pages/0412/Meehan-Says-He-Understands-Challenges-For-LTC-Sector.aspx | Meehan Says He Understands Challenges For LTC Sector | <img src="/Issues/2012/PublishingImages/0412/PatrickMeehan.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:15px 10px;" /><br>First-termer Rep. Patrick Meehan (R-Pa.) wants changes to the Medicare and Medicaid programs to give nursing home providers more certainty in their expectations for reimbursement levels, noting he gets the challenges facing the long term and post-acute care sectors at a time of restrained federal and state spending. <br><br>Meehan, in an interview with Provider, says he keeps long term care as a priority issue not only because of its importance to the nation, but also because his 7th congressional district outside of Philadelphia is home to many seniors. In fact, he says, Pennsylvania ranks third in the country for population of seniors and fourth for the number of residents 85 and older.<br><br>“Ensuring the best care for our seniors is a top priority of mine,” Meehan says.<br><br>To give providers some assistance in their business planning, he wants to start solving the quandary of how to maintain the Medicare and Medicaid programs by ending the way reimbursement is calculated.<br><br>“Medicare and Medicaid providers have been facing high uncertainty in providing care, often not knowing what level of reimbursement they may receive. I believe one way to better manage these programs is to provide certainty. We see the need for certainty with the need to permanently repeal the Sustainable Growth Rate formula that is used to calculate physician reimbursements for Medicare. Congress has no intention of allowing a 30 percent or 40 percent cut in reimbursement for services, and we should not continue to kick the can down the road with short-term patches, pretending that this may actually be the case,” Meehan says.<br><br>Moving forward, he thinks it is important to recognize that nursing facilities, hospitals, and other providers are sharing a significant burden in the effort to curb deficit spending. Meehan wants to pursue savings and reforms, but not at the cost of care.<br><br>“Congress needs to better understand the shoestring on which many hospitals and nursing facilities operate to ensure we are not putting seniors’ health care and quality of life in jeopardy. This is an issue I’ve been working closely on since coming to Congress last year, and I will remain committed to it,” Meehan says. <br><br>For Medicaid, Meehan echoes what many Republicans in Congress want, which is to give the states a larger role in administering and providing access for their beneficiaries. “I believe each state should have the ability to reform their Medicaid program to better serve their patient population,” he says.<br><br>Also in line with most from his party, Meehan does not agree with the part of President Obama’s health care plan that created the Independent Payment Advisory Board (IPAB), which will be charged with finding savings in Medicaid. He said it is actually a bipartisan issue concerning lawmakers from both parties on how much control the IPAB will have.<br><br>“Composed of unaccountable bureaucrats, it will make arbitrary decisions about what is covered and not based on the bottom line and not what contributes to quality of care for seniors, either in hospitals, doctors’ offices, or nursing facilities,” Meehan says.<br><br>Meehan said he supported HR 674, which repealed the 3 percent withholding requirement that would have allowed Medicare to withhold 3 percent of all payments to federal government contractors. <br><br>“While 3 percent may not sound like a significant amount, without repeal, this delayed reimbursement could have jeopardized vital services for seniors and people with disabilities at long term care facilities,” he says.<br><br>His broader view of the health care system reflects his feeling Obama’s health care law missed a chance to help lower skyrocketing costs, noting the reforms will actually boost costs by $311 billion over the next decade. “Instead, we need to take costs out of the system. One way to do that is through small business health plans, which will help bring down health care costs. Many individual small businesses want to provide health benefits to their employees, but find them too expensive to purchase on their own,” Meehan says.<br><br>“By passing a law to allow small business health plans to form, many individual businesses can join together and pool their risk, allowing them to get the same good deals that big corporations get.” <br><br>His duties on Capitol Hill include membership on the House Oversight and Government Reform, Transportation and Infrastructure, and Homeland Security committees. He is also chairman of the Homeland Security Subcommittee on Counterterrorism and Intelligence. <br><br>“In this role, I’ve had the opportunity to examine the changing nature of the threat to the homeland. On the Oversight Committee, I work on a wide range of issues including how we can make our government leaner, more efficient, and more accountable,” Meehan says.<br><br>For the near term, he is focused not only on health care, but on job creation and economic growth and the intersection of these two issues. “With one in six jobs in southeastern Pennsylvania related to the life sciences industry and a high population of seniors, I am making it a priority to work with my colleagues to ensure doctors do not continue to face devastating cuts over and over again.” | First-termer Rep. Patrick Meehan (R-Pa.) wants changes to the Medicare and Medicaid programs to give nursing home providers more certainty in their expectations for reimbursement levels, noting he gets the challenges facing the long term and post-acute care sectors at a time of restrained federal and state spending. | 2012-05-01T04:00:00Z | <img alt="" src="/Issues/2012/PublishingImages/0412/PatrickMeehan.jpg" style="BORDER:0px solid;" /> | Policy | Column | 4 |
| Staff Age Irrelevant When It Comes To Heart | https://www.providermagazine.com/Issues/2012/Pages/0412/Age-Irrelevant-When-It-Comes-To-Heart.aspx | Staff Age Irrelevant When It Comes To Heart | <div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div><div style="text-align:center;"><img class="ms-rtePosition-4 ms-rteImage-3" src="/Issues/2012/PublishingImages/0412/0412CoverStory.jpg" alt="" style="margin:5px;width:497px;height:318px;" /></div>
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<div>The graying of America is in full force, and the long term care facility workforce is not exempt. Instead of seeking a fountain of youth for staff, facilities are finding innovative ways to employ the experience and knowledge of older staff while keeping them safe and healthy, and they are encouraging intergenerational relationships that enhance quality care and teamwork. And in the process, they are finding that caring is ageless.</div></div>
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<div>As the country ages, it isn’t surprising that the health care workforce is getting older as well. A study published in a 2000 issue of the Journal of the American Medical Association projected that between 2010 and 2020, over 40 percent of the registered nurse (RN) workforce alone will be over age 50, according to researchers P. Buerhaus, D. Staiger, and D. Auerbach. Between 1994 and 2001, RNs 50 years old and over grew at an annual rate of 4.7 percent, said the same researchers in a study published in Health Affairs in 2004. Between 2002 and 2003, the rate shot up to 15.8 percent, the researchers said. </div>
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<div>At the same time, the number of RNs under age 35 is going down as part of a 20-year trend, they said.</div>
<h2 class="ms-rteElement-H2">Ageism A Factor?</h2>
<div>While the workforce in general is aging, it hasn’t stopped the influx of ageism in the workplace. According to one study published in the Journal of Gerontology: Psychological Sciences in 2011, there is evidence of bias against older workers. Older workers were thought to be “moderately less apt” in areas such as interpersonal skills and suitability to be selected for any given job, although they were rated higher in reliability, said authors A. Bal, A. Reiss, C. Rudolph, and B. Baltes.</div>
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<div>Nonetheless, in long term care, a profession that centers around aging, most facility leaders value older staff and work to keep them <a href="/Issues/2012/Pages/0412/At-Any-Age,-Motivation-Makes-For-Happy-Staff.aspx">healthy and happy.</a> As J. Kenneth Brubaker, MD, CMD, a medical director in central Pennsylvania, says, “I have never seen an instance of ageism in long term care staffing. I’ve worked with some nurses who have been at their facility for 40 years.” He adds, “If you perform well, age isn’t an issue. I suspect that the lower the turnover, the higher the average age of staff.”</div>
<div><br>Anne Marie Barnett, RN, president of Maryland NADONA/LTC, agrees that ageism isn’t an issue in a profession many workers have entered because “they had an older relative who inspired them to pursue this career. They have a passion for it.”</div>
<div><br>A greater challenge for Barnett is blending cultures. “A large percentage of my nursing and caregiving staff are from different countries. Language barriers and other issues can impact their relationships with residents and other staff. We have to deal with that,” she says. However, she stresses, “It’s all about leadership and creating good staff relationships. You need to be fair across the board and treat all staff with respect.”</div>
<div><br>Susan Persch, MBA, senior director of business systems at Brookdale Senior Living in Milwaukee, Wis., adds that “there is no ageism because there is so much important work to be done. We are always looking for good people who share our passion, and we are welcoming to all who share our mission and compassion for caring.”</div>
<h2 class="ms-rteElement-H2">A Generation Gap?</h2>
<div>It is important for facilities to address the needs and concerns of both younger and veteran staff members. </div>
<div>To do this effectively, they need to understand their common concerns and different needs. “Most of the literature says that there are generational differences in the way people approach and value work, and there are generational differences between older and younger nurses,” says Linda Norman, DSN, RN, FAAN, senior associate dean for academics, Vanderbilt University School of Nursing in Nashville, Tenn.</div>
<div>It is crucial to acknowledge and address these differences, says Henri Carlton, RN, BSN, director of nursing for Charlestown retirement community in Catonsville, Md.</div>
<div><br><img class="ms-rteImage-2 ms-rtePosition-1" alt="Brookdale walkers for Alzheimer’s Association" src="/Issues/2012/PublishingImages/0412/0412CoverStory2.jpg" style="margin:0px 15px;width:365px;height:253px;" />“As we are working alongside younger folks, it becomes difficult to relate sometimes. It can be hard to find common ground, but when we don’t, it can lead to conflict on the floor,” Carlton says. “We have nursing assistants who have been here for 20-plus years, and when a new nurse comes in, they tend to see things differently.”</div>
<div><br>To understand the generational differences between nursing staff, it is useful to look at history. In the 1960s and 1970s, women had fewer career choices, and nursing was a popular traditional option. <br><br>However, as career opportunities for women opened up, Norman says, “We went through a period where it was considered ‘old school’ to be a nurse or teacher—as if you were settling for less if you went into these professions.” In recent years, she adds, there has been a resurgence of interest in nursing as a career choice. Part of this may be because of the nursing shortage and the perception that nursing offers job security, decent pay, and job flexibility. </div>
<div><br>However, Norman stresses, “Much of the renewed interest in nursing has to do with the younger generation’s desire for altruistic work. These young people want to do something meaningful and see nursing as an opportunity to help people improve their health.”<br><span id="__publishingReusableFragment"></span></div>
<h2 class="ms-rteElement-H2">Meeting Staff Expectations</h2>
<div>Norman and her colleagues studied generational differences and found that “the biggest thing was the amount of physical work and hours. Older nurses didn’t like the longer [12-hour] shifts as much as the younger nurses did.” In fact, she says, in facilities where only longer shifts were available, veteran nurses were more likely to retire or look for jobs where they could have 9:00 to 5:00 schedules. </div>
<div><br>Norman suggests, “If you want to retain nurses, issues related to shift lengths become important to consider. That was borne out in our research.”</div>
<div><br><img class="ms-rteImage-2 ms-rtePosition-2" alt="Brookdale resident, Innovative Senior Care therapist" src="/Issues/2012/PublishingImages/0412/0412CoverStory4.jpg" style="margin:5px 15px;width:310px;height:465px;" />Younger staff are more likely to have been weaned on culture change and teamwork. As a result, they expect to be a valued and respected part of the health care team. “One reason a facility may have high turnover is that they have staff who don’t feel valued by practitioners,” says Brubaker. “Good interpersonal relationships between physicians and staff are more likely to create a happy work experience for everyone. It affects the quality of care when staff are afraid to talk to the physicians or feel that the doctors don’t listen to their suggestions.”</div>
<div><br>However, just as younger staff have different learning experiences and expectations, he suggests that younger physicians are being taught teamwork and person-centered care as well.</div>
<h2 class="ms-rteElement-H2">A Common Denominator</h2>
<div>While younger and veteran nurses are different in many ways, they also share many values. For example, Norman says, “Younger and older nurses share an overwhelming desire to help people. They want to be able to feel that they can make a meaningful contribution. Both generations look at nursing as a stable field.” At the same time, younger nurses may come into the profession with a more tangible intention, Norman suggests, because they had many options and chose nursing.</div>
<div><br>To identify and promote the common ground that nurses of all generations share, “you have to change the question,” Carlton says. She suggests that instead of asking nurses why they went into the field, it is more useful to ask them what nursing means to them.</div>
<div><br>“When we asked this, we pretty much heard the same thing across the board—they wanted to make a difference in people’s lives. When we don’t get caught up in the holier-than-thou rhetoric, we find that we all are in this profession for the same reasons. The core of what we do and why we do it is the same,” Carlton says. “Once we talked to staff this way, everyone could relate, and you could see the passion coming out all over the place.”</div>
<h2 class="ms-rteElement-H2">Tossing Out Stereotypes</h2>
<div>Disposing of stereotypes about age is important to the success and satisfaction of older staff and good relationships between staff of all ages. For example, while some older workers may not be as adept at using technology as their younger counterparts, techno-phobia and age don’t necessarily go hand in hand.</div>
<div><br>As 67-year-old Melanie Scalese, coordinator for performance improvement, risk management, safety, and infection control at Charlestown, says, “I do well with computers. Nowadays, most older people are comfortable with technology. Even a lot of our residents use computers easily.” The key is to have strong training programs for younger and older staff that ensure they are comfortable with all the job skills they need, she says.</div>
<div><br>Brubaker adds, “For the most part, nurses’ interest in lifelong learning will make them want to work at a new skill.” </div>
<div><br>Carlton agrees that many older nurses welcome the opportunity to learn something new. “The younger generation challenges us to do better and be more knowledgeable,” she says. “We need to encourage older nurses to take this opportunity to be even better at what they do.” She adds that older nurses need to realize that questioning decisions and seeking multiple opinions is common in the younger generation of nurses.</div>
<div><br>“You can’t take this personally. This is how they have learned to seek and process information. It’s not an attack on your judgment,” she says.</div>
<div><br>Persch agrees that such generational differences don’t have to mean a generation gap: The key is to understand younger people’s frame of reference. </div>
<div><br>“People between the ages of 18 and 25 often are referred to as ‘generation digital.’ They grew up with the computer as a primary language. Rather than have to learn it, they are bilingual. It is a given that they know computers and technology,” she says. </div>
<div><br>One way to get away from stereotypes is to get away from words and language that promote them. As Carlton says, “Words like ‘old’ become very inflammatory. We stopped using those kinds of words, and we were able to get down to the essence of what we do and find common ground. We have to constantly remind ourselves not to get sucked back into earlier ways of thinking.”</div>
<h2 class="ms-rteElement-H2">Two-Way Learning</h2>
<div>Bringing together younger and veteran nurses and nurse assistants can help make the most of the skills and strengths both bring to the table. </div>
<div><br>For example, as Norman says, “You need to look at what contribution older staff can make in mentoring new staff. That is where decision-making experience and clinical expertise can really come into play.” </div>
<div>She urges managers not to be short-sighted in their quest to lure younger nurses with a few years of experience versus new graduates. “It often is harder to recruit new nurses to come into long term care, and sometimes facilities are skeptical of nurses with no experience,” she says. “Matching up veterans with novices can help the newer nurses learn from the older nurses and really begin to appreciate the value of long term care.”</div>
<div><br>This can help facilities attract and keep good young nurses, Norman says. As she explains, “Those who are interested in the field may get turned off when they are told that they need more experience. If they go into acute care to gain that experience, chances are that you won’t get them back.”</div>
<div><br>By partnering newer nurses with more experienced nurses, the pool of practitioners from which to draw grows, and it can help older nurses handle the physical demands of the job. <br><span id="__publishingReusableFragment"></span></div>
<h2 class="ms-rteElement-H2">Growing Awareness Of LTC</h2>
<div>Younger nurses increasingly are seeing long term care as an appealing option, says Norman, partly because of a growing emphasis on geriatrics in the nursing school curriculum. </div>
<div><br>“There has been a push within health care itself to increase the content and emphasis on geriatrics in professional education,” Norman says. “As a result, nursing students are seeing the attributes of the elderly and value of helping them.</div>
<div><br>“When I went to school, the attitude was that you couldn’t do much for elders—just keep them comfortable. Now we know that we can do much more. That helps people see geriatrics and long term care as a more viable place for care delivery,” she says.</div>
<div><br>The growing emphasis on geriatrics in educational curricula presents an opportunity for facilities to attract the best and brightest nursing staff. As Norman says, “Nursing homes can reach out and partner with schools of nursing to identify opportunities such as summer programs where students can come and work in the facility.”</div>
<div><br>She also applauds the idea of facilities providing scholarships with a catch. “Nothing stimulates someone’s interest in a place like a scholarship with a work requirement,” Norman says. </div>
<h2 class="ms-rteElement-H2">Safekeeping Treasures</h2>
<div>As important as it is to attract young nurses, it is equally valuable to retain veteran nurses. One way to do this is to implement procedures and innovations to keep them physically healthy. </div>
<div><br><img class="ms-rteImage-2 ms-rtePosition-1" alt="Brookdale staff at fundraising event." src="/Issues/2012/PublishingImages/0412/0412CoverStory3.jpg" style="margin:5px 10px;width:373px;height:262px;" />“When I went into nursing, I heard seasoned practitioners complain about back pain. They worked through the pain proudly,” recalls Carlton. “When I came to my current facility, there was lots of talk about injuries. They no longer were a badge of honor. In fact, they were unacceptable.”</div>
<div><br>The facility developed a campaign to encourage safe lifting and implemented the use of mechanical lifts. It purchased high-low beds that enable ergonomic-ally correct care, and they utilize simple solutions such as proper desk height, back-friendly chairs, and good lighting. </div>
<div><br>Carlton says, “We constantly look at ways to better preserve the bodies of both residents and staff. We have a very comprehensive wellness program that includes prevention as well as reactionary components.”</div>
<div><br>The results show. As Carlton says, “We have nurses in their 70s who are very effective bedside because we have provided things that assist them.”</div>
<div><br>Maxine Roby, MS, NHA, administrator of Rowan Community, a senior care community in Denver, says that it is important to make older staff feel empowered about their health. “Someone in their 20s goes to the doctor for a knee problem and gets it fixed. But an older person might think he or she is stuck with the problem. We need to encourage people to get help for illnesses or injuries at any age,” she says.</div>
<div><br>When older staff members feel good, the positive energy is reflected in their work. As Roby says, “We have a nurse who is in his 70s. He is standing all day long, bending, moving. In some ways, it keeps him young.”</div>
<h2 class="ms-rteElement-H2">Saying Goodbye</h2>
<div>While facilities may decide to implement initiatives to <a href="/Issues/2012/Pages/0412/Helping-Hands.aspx">retain</a> older nurses, some aging practitioners simply will be unable or unwilling to handle the challenges of working on the floor in this setting. As Barnett says, “When staff get older, they may tend to slow down and look for less physically demanding challenges.” </div>
<div> </div>
<div>Even older nurses who love their jobs and can still perform them effectively may choose another path. For example, Scalese is retiring soon. While she hopes to continue working on an as-needed basis, she is ready for the next phase of her life.<br></div>
<div>“I’m looking forward to retirement. I have goals for my life after retirement. I wouldn’t be comfortable sitting at home.”</div>
<div><br>In the meantime, she loves her work. Some of her younger colleagues call her “mom” and are happy to answer call bells so that she doesn’t have to rush up and down the halls. She will miss her familial relationships with residents and staff, but—like many older nurses—she has left a legacy that she hopes will inspire younger practitioners to follow her example. </div>
<div> </div>
<div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div> | The graying of America is in full force, and the long term care facility workforce is not exempt. Instead of seeking a fountain of youth for staff, facilities are finding innovative ways to employ the experience and knowledge of older staff while keeping them safe and healthy, and they are encouraging intergenerational relationships that enhance quality care and teamwork. And in the process, they are finding that caring is ageless. | 2012-04-01T04:00:00Z | <img alt="" src="/Issues/2012/PublishingImages/0412/0412CoverStory_thumb.jpg" style="BORDER:0px solid;" /> | Caregiving;Management;Workforce | Cover Story | 4 |
| CMS Modifies MDS 3.0 To Ease Burdens | https://www.providermagazine.com/Issues/2012/Pages/0412/CMS Modifies MDS To Ease Burdens.aspx | CMS Modifies MDS 3.0 To Ease Burdens | <p>Nearly 18 months after implementation of the minimum data set (MDS) 3.0, changes and clarifications are being made to the assessment tool in an effort to ease concerns about the burden it has placed on providers and residents. The changes, which were announced March 7 by the Centers for Medicare & Medicaid Services (CMS) during a training conference in St. Louis, will take effect April 1, 2012. <br><br>The modifications include:<br>■ Section Q will now require fewer questions about a resident’s preference to avoid being asked repeatedly about return to the community, among other changes.<br>■ An unplanned discharge has been defined as an “acute-care transfer of the resident to a hospital or an emergency department in order to either stabilize a condition or determine if an acute-care admission is required, based on emergency department evaluation.” Unplanned discharges can also be defined as a resident who unexpectedly leaves the facility against medical advice.<br>■ Providers may now carry forward patient interview coding from scheduled PPS assessments to stand-alone unscheduled assessments (COT, SOT, and EOT), provided that the most recent scheduled assessment interviews were performed no more than 14 days prior.<br>■ The RAI manual and MDS changes will take place less frequently. CMS plans to release errata documents on only those pages where changes and modifications are made, making it easier for providers to maintain the manual. After the next release in October 2012, future updates will occur only once per year. <br><br>“We are pleased that CMS has taken these steps to reduce the burden of MDS on patients and care providers,” said David Gifford, MD, senior vice president of quality, regulatory affairs, and research at the American Health Care Association. <br><br>According to an MDS expert who attended the conference, “Providers are happy about some of the changes,” says Rena Shephard, MHA, RN, RAC-MT, C-NE, executive editor of the American Association of Nurse Assessment Coordination. She notes that among the most significant changes were those made to discharge assessments. <br><br>CMS has determined that if it is an unplanned discharge, then there is an abbreviated discharge assessment required, and it does not include the direct resident interview. “That’s the big thing,” Shephard says. <br><br>“They really did try to hear what providers were saying to them,” she says. <br><br>Changes related to the frequency of resident interviews were applauded, says Shephard. “The way it is now, any time you do an assessment, you have to redo the resident interview,” Shephard says.<br><br>To alleviate this burden, CMS said that as of April 1 when coding an unscheduled prospective payment system (PPS) assessment, the interview items can be coded using responses provided by the resident on a previous scheduled assessment, but only if those interview responses from the scheduled assessment were obtained no more than 14 days before the completion date of unscheduled assessment, Shephard says.<br><br>“That’s a really big deal, that’s a really big change,” she says.<br></p> | Nearly 18 months after implementation of the minimum data set (MDS) 3.0, changes and clarifications are being made to the assessment tool in an effort to ease concerns about the burden it has placed on providers and residents. | 2012-04-01T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/staff_laptop_1.jpg" style="BORDER:0px solid;" /> | Policy | Column | 4 |
| Four States Make Major Changes To Assisted Living Regs In 2011 | https://www.providermagazine.com/Issues/2012/Pages/0412/Four-States-Make-Major-Changes-To-Assisted-living-regs.aspx | Four States Make Major Changes To Assisted Living Regs In 2011 | The National Center for Assisted Living (NCAL) recently released its 2012 edition of “Assisted Living State Regulatory Review,” finding that 16 states made changes to assisted living regulations, statutes, and policies during 2011.<br><br>Four states—Georgia, Nevada, North Carolina, and South Dakota—made major changes. Georgia created a second level of licensure for assisted living communities alongside the state’s existing licensure of personal care homes. “While the categories share many common requirements, assisted living community standards are more stringent or vary in a number of areas,” the report says. <br><br><span><img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2012/PublishingImages/0412/iStock_000016730895Medium.jpg" alt="" style="margin:5px;width:272px;height:184px;" /></span>Facilities with 25 or more beds can opt for either type of licensure.<br><br>In South Dakota, assisted living centers are now regulated under new rules that further define restrictions on accepting and retaining residents, as well as conditions under which hospice care may be provided.<br><br>New regulations for assisted living residences adopted last year in Nevada centered mainly on medication administration, including increased medication administration training for caregivers, from eight initial hours to 16 initial hours, and new refresher training requirements, from three hours every three years to eight hours annually.<br><br>In addition, Nevada administrators must take the same initial medication administration training and the same refresher training as their caregivers, regardless of whether or not the administrator is a licensed medical professional. <br><br>In North Carolina, the legislature approved changes that impact adult and family care home licensure, including penalties and remedies for violations, discharge of adult care home residents, frequency of inspections based on quality ratings, infection control standards, and training and competency evaluation of medication aides.<br><br>“Florida and several other states are considering major changes for 2012,” says Karl Polzer, NCAL’s senior policy director and the report’s author. “As in previous years, this year’s report found many states actively refining and developing regulations.”<br><br>The report is published every March. It is the only annual resource that summarizes state assisted living regulations across 21 categories, which include life safety, physical plan requirements, medication management, and move-in/move-out criteria.<br><br>The report also found that six states added or revised education and training requirements. For instance, Washington began requiring most new direct-care workers to take 75 hours of training within 120 days of being hired and then become certified as home care aides within 150 days. <br><br>Other focal points of state regulatory changes include disclosure of information to consumers, infection control, discharge/transfer between sites, and move-in and move-out criteria, as well as medication management. | The National Center for Assisted Living (NCAL) recently released its 2012 edition of “Assisted Living State Regulatory Review,” finding that 16 states made changes to assisted living regulations, statutes, and policies during 2011.
| 2012-04-01T04:00:00Z | <img alt="" height="150" src="/Issues/2012/PublishingImages/0412/iStock_000016730895Medium.jpg" width="225" style="BORDER:0px solid;" /> | Policy | Column | 4 |
| GAO Wants Upgrades To QIS Monitoring Process | https://www.providermagazine.com/Issues/2012/Pages/0412/GAO-Wants-Upgrades-To-QIS-Monitoring-Process.aspx | GAO Wants Upgrades To QIS Monitoring Process | In a new report, the General Accountability Office (GAO) advised the Centers for Medicare & Medicaid Services (CMS) to improve the way it monitors implementation of the Quality Indication Survey (QIS) process for nursing homes.<br><br>The QIS is a revised long term care survey process that was developed under CMS oversight. It represents an effort to standardize how the survey process measures nursing home compliance with federal standards and the interpretive guidelines that define those standards.<br><br>The new review, GAO-12-214, follows earlier studies of the QIS-based survey process and builds on suggestions for changes that CMS has agreed need to be made. <br><br>“In 2009, CMS commissioned a third study that was completed in 2011 and identified aspects of the QIS process that could affect the consistency with which surveyors identify quality problems,” GAO said.<br>For example, the study found that during resident interviews, surveyors did not consistently probe for further information when provided with incomplete responses to interview questions. <br><br>“However, CMS does not have the means to routinely monitor the extent to which the QIS is helping improve the survey process as intended. Such routine, ongoing monitoring would be consistent with federal internal control standards and could include the use of performance goals and measures,” GAO said.<br><br>GAO said that CMS officials reported taking steps to address the study’s findings and recommendations and noted the agency does have access to some data, such as the amount of time surveyors have spent inspecting facilities, which could be used to help develop performance goals and measures.<br><br>“CMS has taken some steps to monitor and facilitate states’ implementation of the QIS-based routine survey, but CMS’ efforts are not systematic,” GAO said.<br><br>As part of the CMS effort to monitor states’ implementation, it primarily uses quarterly teleconferences with state survey agency officials to obtain information on the extent to which each state has completed training all its surveyors to use the QIS. However, states may not always participate in the teleconferences, and those that do may not provide complete information on their progress.<br><br>“As a result, the information CMS obtains through its monitoring of states’ progress may be incomplete,” GAO said. <br><br>To help facilitate states’ implementation of the QIS, CMS provides states with guidance, gives presentations, and offers states opportunities to share their implementation experiences through quarterly teleconferences. <br><br>However, CMS does not have a systematic method for obtaining, compiling, and sharing information on state experiences, especially information on approaches states have taken to help facilitate implementation of the QIS. Systematically sharing such information—for example, through CMS’ annual conference in which all state survey agencies participate—could help the agency facilitate implementation in states that have not begun QIS implementation, GAO said. | In a new report, the General Accountability Office (GAO) advised the Centers for Medicare & Medicaid Services (CMS) to improve the way it monitors implementation of the Quality Indication Survey (QIS) process for nursing homes. | 2012-04-01T04:00:00Z | <img alt="" height="150" src="/Issues/2012/PublishingImages/0412/Inspect%20QIS%20thumb.jpg" width="150" style="BORDER:0px solid;" /> | Quality | Column | 4 |
| High Court Upholds Pre-Dispute Arbitration Agreements | https://www.providermagazine.com/Issues/2012/Pages/0412/High-Court-Upholds-Pre-Dispute-Arbitration-Agreements.aspx | High Court Upholds Pre-Dispute Arbitration Agreements | A Feb. 21 opinion from the U.S. Supreme Court unanimously upheld the validity and enforceability of pre-dispute arbitration agreements between nursing facilities and their residents.<br><br>The American Health Care Association (AHCA), which supports the use of voluntary pre-dispute arbitration agreements, applauded the decision in the case of Clarksburg Nursing & Rehabilitation Care v. Marchio.<br><br>“The Supreme Court of the U.S. has made clear that it is both legal and appropriate for nursing homes and patients to use pre-dispute arbitration agreements,” said Gov. Mark Parkinson, AHCA president and chief executive officer, in a statement.<br><br>“It is affirming to us that the Supreme Court understands and enforces arbitration agreements to provide more timely and less adversarial conclusions, thus allowing facility staff to focus their time and effort on what is really important—quality patient care,” he said.<br><br>AHCA and the West Virginia Health Care Association have both been involved with the case, whose central issue is whether the Federal Arbitration Act (FAA) protects pre-dispute arbitration when there are claims of personal injury or wrongful death.<br><br>AHCA submitted an amicus brief to the West Virginia Supreme Court, which decided last June that Congress “did not intend for the FAA to protect these types of arbitration agreements from state interference,” making them unenforceable, AHCA said in a statement on the Supreme Court opinion. | A Feb. 21 opinion from the U.S. Supreme Court unanimously upheld the validity and enforceability of pre-dispute arbitration agreements between nursing facilities and their residents. | 2012-04-01T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/legal_2.jpg" style="BORDER:0px solid;" /> | Policy;Legal | Column | 4 |
| LTC Jobs Critical To Economic Recovery, Labor Report Shows | https://www.providermagazine.com/Issues/2012/Pages/0412/LTC-Jobs-Critical.aspx | LTC Jobs Critical To Economic Recovery, Labor Report Shows | Long term and post-acute care jobs will rank among the nation’s top employment groups in the coming decade, according to an American Health Care Association (AHCA) analysis.<br><br>The report from the Bureau of Labor Statistics (BLS) projects that the health care and social assistance sector will gain the most new jobs—5.6 million, or more than a quarter of the total 20.5 million jobs that are expected to be created between 2010 and 2020. <br><br>The top four groups predicted to grow the most in that time are all in the health care field, according to an analysis of BLS data by AHCA’s Research Department. Furthermore, the eight occupational categories identified by BLS as either the largest or fastest growing are at the core of providing long term and post-acute care services: registered nurses; personal care aides; home health aides; nurse assistants, orderlies, and attendants; physical and occupational therapy assistants and aides; and physical therapists.<br><br>The Labor Department report shows “our sector is growing in both projected numbers and importance,” said Gov. Mark Parkinson, president and chief executive officer of AHCA. | Long term and post-acute care jobs will rank among the nation’s top employment groups in the coming decade, according to an American Health Care Association (AHCA) analysis. | 2012-04-01T04:00:00Z | | Workforce | Column | 4 |
| N.Y. Law A Slippery Slope For Nursing Home Liability | https://www.providermagazine.com/Issues/2012/Pages/0412/NY-Law-A-Slippery-Slope-Nursing-Home-Liability.aspx | N.Y. Law A Slippery Slope For Nursing Home Liability | <div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div>
<div><img class="ms-rteImage-2 ms-rtePosition-2" alt="legal" src="/Issues/2012/PublishingImages/0412/0412Legal.jpg" style="margin:5px 15px;width:237px;height:361px;" />In a move that could be a harbinger for similar legislative changes across the country, the bellwether state of New York recently amended portions of its Public Health Law (PHL) in a way that seems to invite more litigation against nursing home providers. </div>
<div> </div>
<div>The statute governs the rights of patients to bring private actions against residential health care facilities when allegedly injured as a result of being deprived of any right or benefit established by contract or by state or federal statute, code, rule, or regulation. </div>
<div> </div>
<div>Subdivision 1 of the statute was amended to define injury to include emotional and physical harm, financial loss, and death, while subdivision 4 was modified to ensure that the statutory remedies available are in addition to, among other things, the ability to bring tort causes of action against nursing home providers. </div>
<div> </div>
<div>In addition, the statute was amended so that a violation of the specific rights set forth in PHL section 2803-c(3) is not a prerequisite for a statutory claim. </div>
<div> </div>
<div>At a time when there is more interest in looking to alternative dispute resolution than lawsuits as a way of resolving disputes, these amendments unfortunately lead the way for more liability claims against nursing homes.</div>
<h2 class="ms-rteElement-H2">Remedies Are Cumulative </h2>
<div>PHL section 2801-d(1) provides that a “residential health care facility that deprives any patient of any right or benefit…shall be liable to said patient for injuries suffered as a result of said deprivation.” The statute provides that “[a] ‘right or benefit’…[is]…created or established for the well-being of the patient by the terms of any contract; by any state statute, code, rule, or regulation; or by any…federal statute, code, rule, or regulation.” </div>
<div><br>The statute also allows for all remedies to be “in addition to and cumulative with any other remedies available to a patient” that may exist in the courts or in any other state agency. “Rights,” according to section 2803-c of the PHL, include, but are not limited to, the following: not to have one’s civil and religious liberties infringed, to manage one’s own financial affairs, and to be fully informed of one’s medical condition and treatment. </div>
<div><br>Before the statute was amended, courts were divided as to whether claims were limited only to those rights set forth in PHL section 2803-c. For example, in Begandy v. Richardson, the trial court held that a patient could not bring suit based on a violation of the statute. In this case, the plaintiff alleged that the defendant’s failure to lock, label, or prevent access to a cellar stairway and to light the stairway violated the relevant building codes and portions of her admission agreement by failing to provide adequate care to prevent her from wandering. </div>
<div><br>But the appellate court disagreed with the plaintiff’s claim, having found that a statutory claim was limited to a deprivation of a “personal right or benefit contemplated by section 2803-c.” </div>
<div><br>Prior to the amendment, the courts had ruled in a variety of ways that had left the issue unresolved as to whether a plaintiff could assert both a PHL section 2801-d claim and a common law tort claim using the same set of facts. </div>
<div><br>The practical distinction between a common law tort claim and a claim under PHL section 2801-d is an important one. Among other things, as the burdens of proof vary, a plaintiff may succeed in one cause of action and not the other, as the common law and statutory claims are not duplicative. A patient’s attorney can thus win a tort claim but lose a statutory claim even though they arise out of the same facts.</div>
<div>In other words, a plaintiff can win on one cause of action and lose on the other cause of action, based on the same facts, because the burden of proof differs. </div>
<h2 class="ms-rteElement-H2">Definitions Broadened </h2>
<div>The law was amended for the purpose of “clarify[ing] the grounds for liability claims against nursing homes.” Thus, subdivision 1 of section 2801-d was amended to clarify that “‘injury’ shall include…physical harm to a patient; emotional harm to a patient; death of a patient; and financial loss to a patient.” </div>
<div><br>Subdivision 4, section 2801-d, which provided that statutory remedies were “in addition to and cumulative with” other remedies, also states that a violation of subdivision 3 of 2803-c “is not a prerequisite for a claim under this section.” Rather than merely “clarify” the statute, the legislature broadened access so that advocates can now assert: 1.) both personal injury claims and a PHL section 2801-c claim; 2.) a PHL section 2801-d claim that is not limited to the rights set forth in PHL section 2803-c; and 3.) claims under a broad definition of what constitutes a statutory injury. </div>
<div><br>Using the facts in the Begandy case as an example, the landscape has clearly changed. In Begandy, the court denied the plaintiff’s motion to amend his personal injury complaint based on violations of both the building code and certain provisions of the defendant’s admissions agreement, as it found that PHL section 2801-d claims were limited to the violation of PHL section 2803-c rights. </div>
<div>Post-amendment, however, such a plaintiff can now assert a claim that a facility violated the statute by failing to comply with the building code—the theory being that the plaintiff was deprived of a statutory “right or benefit” accorded to him. </div>
<div>A provider may now face a whole new category of claims that do not implicate the rights set forth in PHL section 2803-c. What’s more, there is no limitation on the type of injury that may be asserted by the plaintiff.<br><span id="__publishingReusableFragment"></span></div>
<h2 class="ms-rteElement-H2">Defense Strategies</h2>
<div>A provider has an absolute affirmative defense if it can prove that it “exercised all care reasonably necessary to prevent and limit the deprivation and injury.”</div>
<div><br>Does this mean that even if a provider violated a regulation that benefited a patient but thereafter exercised reasonable care to prevent injury to a patient, that the provider is not liable? What does the term “reasonably necessary” mean?</div>
<div><br>A facility has a general duty to exercise reasonable care and diligence in safeguarding a patient, and that duty is based, in part, on the patient’s capacity to provide for his or her own safety. </div>
<div><br>However, there is a clear analogy between the affirmative defense raised under PHL section 2801-d and the defenses a provider raises when facing an ordinary negligence or a medical malpractice claim. </div>
<div><br>Accordingly, a provider should prepare a defense based on whether the statutory claim is based on a legal theory of medical malpractice or ordinary negligence. The distinction between the two turns on whether the acts and/or omissions at issue involve a medical matter that can only be assessed by medical professionals or whether the conduct and/or omission at issue can instead be assessed by using common knowledge and experience. </div>
<div><br>In other words, is the provider liable because it failed to exercise proper medical care and supervision (medical malpractice) or because it failed to exercise the care or supervision that a nonprofessional would use in the situation at issue (ordinary negligence)? </div>
<h2 class="ms-rteElement-H2">Recent Cases</h2>
<div>Recent appellate cases have upheld dismissals of post-amendment PHL section 2801-d claims. </div>
<div>The Gold v. Park Avenue Extended Care Center Corp. case provides a good illustration of a claim dismissed at the trial level. A provider may also examine Butler v. Shorefront Jewish Geriatric Center for guidance. </div>
<div><br>In Gold, the plaintiff asserted both a section 2801-d violation and common law negligence. </div>
<div><br>The plaintiff alleged that, as a result of the defendant’s failure to install side rails on the decedent’s bed, and because of its failure to provide her with proper supervision, she sustained numerous falls that led her to suffer a stroke, dementia, and eventually death.</div>
<div><br>The provider, in support of its motion for summary judgment, submitted a doctor’s opinion establishing that: 1.) there were no supervision deficiencies given regarding the decedent’s health and status; 2.) the use of a restraint would have been inappropriate; and 3.) the absence of a restraint did not proximately cause any injury to the decedent because none of the falls were from the decedent’s bed. </div>
<div><br>The plaintiff, in opposition, only relied on a registered nurse’s affidavit. The court found no merit to her assertion that the federal regulation providing that each resident must receive care to maintain his highest physical, mental, and psychosocial well-being was violated and that the decedent was injured thereby. </div>
<div> </div>
<div><em>Andrew I. Bart is an attorney with Tenzer and Lunin, a New York City law firm. He may be reached at (212) 262-6699 or at <a href="mailto:andrewibart@gmail.com">andrewibart@gmail.com</a>.</em></div> | In a move that could be a harbinger for similar legislative changes across the country, the bellwether state of New York recently amended portions of its Public Health Law (PHL) in a way that seems to invite more litigation against nursing home providers. | 2012-04-01T04:00:00Z | <img alt="" src="/Issues/2012/PublishingImages/0412/0412Legal_thumb.jpg" style="BORDER:0px solid;" /> | Policy;Legal | Column | 4 |
| OIG: More Documentation Cuts Payment Error Rate | https://www.providermagazine.com/Issues/2012/Pages/0412/OIG-More-Documentation-Cuts-Payment-Error-Rate.aspx | OIG: More Documentation Cuts Payment Error Rate | A new report by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) says a more vigorous effort by contractors working for the Comprehensive Error Rate Testing (CERT) program to find missing documentation could have cut the payment error rate in the Medicare program by $956 million in 2010.<br><br>OIG conducted a pilot project to obtain missing documentation identified in the fiscal year (FY) 2010 CERT program and published the report recently. It is available at <a href="http://oig.hhs.gov/">http://oig.hhs.gov</a>. <br><br>“Based on our results, the CERT statistical contractor estimated that additional documentation to overturn claim payment denials would have reduced the FY 2010 error rate estimate from 10.5 percent to 10.2 percent, which would have reduced the estimate of improper payments by approximately $956 million,” the report said.<br><br>OIG obtained additional documentation in its survey project that enabled the CERT review contractor to overturn, or partially overturn, its claim payment denials for 46 of 136 claims, amounting to around 34 percent. <br><br>The CERT review contractor overturned its claim payment denials for 46 claims because it determined that the additional medical records OIG obtained were proof enough to show that the health services or items billed to the Medicare program were medically necessary. <br><br>The CERT contractor did not initially get the added documentation because it did not always contact referring providers directly to obtain missing information, did not always redirect follow-up documentation requests to compliance or reimbursement personnel, or did not always seek proper signatures on clinicians’ notes when the signatures were illegible, the report said.<br><br>To improve the program, OIG recommended that the Centers for Medicare & Medicaid Services (CMS) continue to educate providers on the issue. It also said CMS should assess the improper payments identified by the CERT review contractor and the overturned denials of claim payments to explore which claims may benefit from a deeper review.<br><br>Lastly, the report said, CMS should ensure that the CERT documentation contractor follow established rules in seeking signature attestations.<br><br>CMS disagreed with the final two recommendations, noting it has intensified efforts throughout 2011 to improve the claims documentation process and that contractors have been following procedures on signatures. | A new report by HHS OIG says a more vigorous effort by contractors working for the Comprehensive Error Rate Testing program to find missing documentation could have cut the payment error rate in the Medicare program by $956 million in 2010. | 2012-04-01T04:00:00Z | | | Column | 4 |
| Quality Symposium: CMS Pleased With Industry Initiative | https://www.providermagazine.com/Issues/2012/Pages/0412/Quality-Symposium-CMS-Pleased-With-Industry-Initiative-.aspx | Quality Symposium: CMS Pleased With Industry Initiative | <div><img class="ms-rtePosition-1" alt="Jonathan Blum" src="/news/PublishingImages/blum_jon2.gif" style="margin:5px 15px;" />The long term and post-acute care industry needs to hold the Centers for Medicare & Medicaid Services (CMS) accountable for its inconsistencies, Jonathan Blum, deputy administrator of the agency, told the 425 attendees at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) Quality Symposium in February. </div>
<div> </div>
<div>“Where we need your help, and where you need to come to us, is when you see one part of CMS not operating consistently with the others,” he said. </div>
<div> </div>
<div>“We are a large bureaucracy, so if you feel at any time the payment policies we are promoting are not consistent with what we’re trying to achieve on the quality side, on the survey and cert side, those are opportunities to come to us and say, ‘Hey guys, get this right.’”</div>
<div> </div>
<div>Blum addressed the two-day conference during its opening session, just after Gov. Mark Parkinson, AHCA/NCAL president and chief executive officer, and Neill Pruitt Jr., AHCA chair, had outlined its new Quality Initiative (see Provider’s March issue, page 38, for details) and its four measurable goals.</div>
<div> </div>
<div><div class="ms-rteElement-Callout3"><strong>Initiative Goals</strong><span><strong> AHCA/NCAL Quality</strong></span></div>
<div class="ms-rteElement-Callout3">Safely Reduce Hospital Readmissions. By March 2, 2015, at 12:00 p.m., reduce the number of hospital readmissions within 30 days of a skilled nursing stay by 15 percent.</div>
<div class="ms-rteElement-Callout3">Increase Staff Stability. By March 2, 2015, at 12:00 p.m., reduce turnover among clinical staff (registered nurse, licensed vocational nurse, licensed practical nurse, certified nurse assistant) by 15 percent.</div>
<div class="ms-rteElement-Callout3">Safely Reduce the Off-Label Use of Antipsychotics. By Dec. 31, 2012, at 12:00 p.m., reduce the off-label use of antipsychotics by 15 percent.<span></span> <br></div>
<div class="ms-rteElement-Callout3"><span>Increase Resident Satisfaction. By March 2, 2015, at 12:00 p.m., increase the number of customers who would recommend the facility to others up to 90 percent.<span></span></span></div></div>
<div>As Blum took to the podium, he commended Parkinson and Pruitt for their leadership in recognizing CMS as a partner and “not an adversary,” as Parkinson noted in his opening statement. “It is inspiring at CMS that you see us as a trusted partner,” Blum said to attendees. “I’d like to thank you, to commend you. From our perspective, we couldn’t be more pleased and more proud of you. There will be no disagreement regarding the overall quality goals.”<br><br></div>
<div>With that, Blum described the three-part aim that is guiding CMS’ work, as follows: better care, better health, and lower cost through improvement. In addition, he highlighted six “tangible, overarching goals” the agency hopes to achieve inside of the three-part aim, which he noted fit “very well” with <br><br><strong>AHCA/NCAL’s goals: </strong></div>
<div>1. Reduce health care-acquired conditions. “We are trying to focus on reducing harm to patients while they are in facilities,” Blum said. “We also want to reduce the number of adverse medication events and reduce inappropriate antipsychotic use, which is why we are so pleased to see that this is one of your quality goals,” he said.</div>
<div><br>2. Reduce fragmentation in the health care delivery system. Blum noted that the current health care delivery system has silos of care. “And sometimes that care is not very coordinated,” he said. “One of our key goals is to reduce fragmentation, which led to CMS focusing on reducing hospital readmissions.” In addition, CMS is focusing on bundled payments to create stronger incentives for providers to take a much more integrated approach to care. </div>
<div><br>3. Create a health care system that has the capacity to capture and act on patient-reported information. “It is a fair observation that CMS tends to think of its world as payment, dollars, and survey information,” Blum said. </div>
<div><br>“We’re trying to change that to what the patient needs. We are building payment structures and care structures that focus on what patients need, what patients want, and how they navigate through the health care system.” Blum noted that the goal is to change care structures to encourage a health care delivery system that focuses on “patient-centered, best-quality outcomes at the lowest possible cost.” </div>
<div><br>4. Prevent and reduce harm to patients who have cardiovascular disease. This includes increasing blood pressure control, reducing high cholesterol, keeping patients healthier, and focusing on preventing chronic conditions, Blum said.</div>
<div><br>5. Encourage and promote innovation in local communities. CMS is supporting and nurturing local initiatives and systems throughout the country, Blum said, noting that one policy example the agency is focused on is supporting sites that want to integrate dual-eligible populations. </div>
<div>CMS’ new Center for Medicare and Medicaid Innovation is providing opportunities to spur local innovation, Blum added. </div>
<div><br>6. Identify and define measures that can serve as indicators of cost reduction. “Part of the reason care is not coordinated is because of the financial payment system we have in place,” Blum said. </div>
<div><br>“So, part of our goal, our mission, is also to focus on reducing costs, to lower costs through improvement.” <br><br>He noted that CMS would like “to prove to the world that lower cost, more trust fund solvency, if you will, will come not from just cutting market basket rates or cutting payments, but through better-managed care, better-coordinated care, and providing better transitions for our beneficiaries.” </div>
<div><br>In conclusion, Blum noted that the six goals he outlined are “very consistent” with the goals that Parkinson had outlined in the organization’s Quality Initiative. “This is where our partnership can work really well together,” he said.</div>
<div><br>The Quality Initiative goals that Blum commended were hashed out by board members and AHCA/NCAL staff during a two-day retreat, Pruitt told attendees during the opening session. </div>
<div><br>“We spent the first two days of our meeting—we didn’t talk about policy, Washington politics, or elections—we sat down and discussed quality and how it can make a difference in the buildings and patients we serve,” Pruitt said. </div>
<div><br>“We wanted quality to be an expectation, not just something we talk about. We wanted to think differently; we wanted to embrace the spectrum of services. We wanted to talk about technology and dashboards as a quality improvement tool. And we wanted it for all members regardless of size or profit or nonprofit status.” <br></div> | The long term and post-acute care industry needs to hold the Centers for Medicare & Medicaid Services (CMS) accountable for its inconsistencies, Jonathan Blum, deputy administrator of the agency, told the 425 attendees at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) Quality Symposium in February. | 2012-04-01T04:00:00Z | <img alt="" height="150" src="/Issues/2012/PublishingImages/0412/blum_jon2.gif" width="150" style="BORDER:0px solid;" /> | Quality | Column | 4 |
| Case Study: Minimum Data Set 3.0 Pyschosocial Changes | https://www.providermagazine.com/Issues/2012/Pages/0412/Case-Study-MDS-3-0-Pyschosocial-Changes-.aspx | Case Study: Minimum Data Set 3.0 Pyschosocial Changes | <p>The following case example may help illustrate some of the complex and important issues identified regarding the use of the new minimum data set (MDS) 3.0 assessment tool, particularly around the psychosocial sections.<br><br>Mr. S, age 80, was admitted as a Medicare skilled nursing facility (SNF) resident after hip surgery because of a fall at his group home. Prior to his SNF admission, he lived in an adult home—he never managed to maintain an apartment as he went from job to job. <br><br>His rehabilitation therapy progress was good, and yet his discharge was determined not to be feasible because his group home would not accept him due to his inability to manage the stairs independently. His nursing home social worker and community case manager were unable to find alternative housing. After a 15-day SNF stay, he was transferred from the SNF directly to the nursing facility. <br><br>His OBRA annual assessment was completed on day 14. In the Mood Section of the MDS, Mr. S accurately indicates that he is not experiencing difficulty with eating, fatigue, sleep, concentration, or interest in extra-curricular activities. He scored a total severity of 5 on the PHQ 9 in contrast with the team’s assessment identifying depression. He expresses that he feels bad about himself and perseverates on thoughts that his medical condition is “evidence that God is punishing him” and his feelings of hopelessness. <br><br>He was raised in foster care and has two siblings—one is deceased, and the other has Alzheimer’s disease and is in a facility. Extended family is caring toward him but overwhelmed by caring for the family member with dementia. He indicates in Section Q that he wants to return to the group home. He has a long history of psychiatric illness and has a case manager as his main contact. While he is able to walk around the facility independently, he becomes frustrated due to expressive aphasia, and his Brief Interview for Mental Status (BIMS) score was 14, which shows strong cognitive abilities. The nursing home team is addressing his depression through psychotropic medications, including visits by a psychologist, a social worker, and pastor.<br><br>In the case example, Mr. S is being interviewed for his 14-day OBRA admissions assessment. He has a history within the facility of becoming frustrated when attempting to communicate his needs due to expressive aphasia. Facility staff are now attempting to complete the BIMS, PHQ 9, and preference interviews with Mr. S for at least the third time in the past 30 days. It is highly likely that he will experience feelings of anger and frustration when being interviewed and further compromise his overall well-being. The validity of the interview may also be decreased as the result of Mr. S responding negatively to the interviewer. </p>
<div>Social Workers and nurses indicated that the repeated interviews, especially for BIMS and PHQ 9, required for SNF and significant change assessments, result in residents refusing to answer the questions or elicit feelings of frustration that compromise the data being captured. </div>
<div> </div>
<div>In addition, the staff assessment has to be completed when a resident refuses to answer resulting in additional time spent on paperwork instead of providing clinical support to residents. [In this case, the self-report and staff report are likely to differ since he presents differently to clinical staff compared with his self-report.]</div>
<h2 class="ms-rteElement-H2">Care Area Assessment</h2>
<div>The following table illustrates Mr. S’s MDS 3.0 interdisciplinary CAA and care planning needs:</div>
<p> </p>
<table class="MsoNormalTable ms-rteTable-default" border="1" cellspacing="0" cellpadding="0" style="border-bottom:medium none;border-left:medium none;margin:auto auto auto -5.3pt;width:617px;border-collapse:collapse;height:261px;border-top:medium none;border-right:medium none;"><tbody><tr class="ms-rteTableHeaderRow-default"><th class="ms-rteTableHeaderFirstCol-default" colspan="7" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:6.65in;padding-right:5.4pt;border-top:windowtext 1pt solid;border-right:windowtext 1pt solid;padding-top:0in;"><div style="text-align:center;"><font face="Calibri">SNF Stay Issues</font></div></th></tr>
<tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Problem</span></div></th>
<td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Care Area Assessment Triggered</span></div></td>
<td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">SW</span></div></td>
<td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">RN</span></div>
<div><span style="font-family:'times new roman', 'serif';font-size:10pt;">LPN</span></div></td>
<td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">MD</span></div>
<div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Psychiatrist</span></div></td>
<td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">CNA</span></div></td>
<td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Activities</span></div>
<div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Other</span></div></td></tr>
<tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Requests Discharge</span></div></th>
<td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">#20 Return to Community Referral</span></div></td>
<td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td>
<td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr>
<tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" colspan="7" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:6.65in;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">NF Admission Assessment Issues</span></div></th></tr>
<tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"><span> </span>High BIMS Score</span></div></th>
<td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"># 2 Cognition Loss/Dementia</span></div></td>
<td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td>
<td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr>
<tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Aphasia/Making self understood</span></div></th>
<td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">#4 Communication</span></div></td>
<td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td>
<td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td></tr>
<tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Normal PHQ 9 score & yet need for further depression<span> </span>assessment</span></div></th>
<td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">NONE</span></div></td>
<td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td></tr>
<tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Use of antipsychotic and antidepressant medications</span></div></th>
<td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"># 17 Psychotropic Drug Use</span></div></td>
<td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"><span> </span></span></div></td>
<td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td>
<td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr>
<tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Requests Discharge</span></div></th>
<td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">#20 Return to Community Referral</span></div></td>
<td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td>
<td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td>
<td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr></tbody></table>
<p> </p>
<p>Mr. S' case exemplifies many important care planning and CAA issues. First, the interdisciplinary care planning needs generated by his problems require clinical skills since his behavior is not consistent with his PHQ 9 score. Further, it is clear that his needs require the full complement of interdisciplinary staff, yet staff may be stretched by new MDS 3.0 documentation requirements or by lack of adequately trained mental health staff to assist Mr. S.<br><br>The social worker is a key team member to bring the care plan team together to address his needs and yet her/his priority is split between the SNF and the nursing facility (NF), with the NF often being the priority. It is estimated that it would take Mr. S’ social worker approximately three hours to complete the three CAAs, document depression needs in the medical record, and to coordinate with Mr. S’ case manager and the local contact agency regarding his desire to return to the community when it is unlikely that resources exist to support him. </p>
<p>This case study is relevant to Provider's April 2012 Caregiving column on the MDS 3.0 Pyschosoical changes: <a href="/Issues/2012/Pages/0412/A-Look-At-MDS-3-0-Psychosocial-Changes.aspx">http://dev19.providermagazine.com/Monthly-Issue/2012/Pages/0412/A-Look-At-MDS-3-0-Psychosocial-Changes.aspx</a>. </p>
<p> </p> | This case study helps to illustrate some of the complex and important issues identified regarding the use of the MDS 3.0 assessment tool, particularly around the psychosocial sections. In this case study, Mr. S, age 80, was admitted as a Medicare SNF-stay resident after hip surgery because of a fall at his group home. | 2012-04-06T04:00:00Z | <img alt="" height="150" src="/Issues/2012/PublishingImages/0412/April%2011%20case%20study%2016445232_thb.jpg" width="150" style="BORDER:0px solid;" /> | Caregiving;Clinical;Management | Column | 4 |