Healthy Skinhttps://www.providermagazine.com/Issues/2014/Pages/0114/Healthy-Skin.aspxHealthy Skin<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>Pressure ulcers are among the most common soft tissue injuries that occur in nursing homes and hospitals. They also cause pain and increase the risk of infection. The treatment of pressure ulcers often requires the person to be in bed on a special surface for long periods daily, which may result in feelings of social isolation and depression. In 2008, the Centers for Medicare & Medicaid Services (CMS) deemed pressure ulcers a “never event,” which meant they were considered preventable. The designation prompted CMS to exclude hospital-acquired pressure ulcers from reimbursement.</p> <div> </div> <p></p> <div> </div> <div> </div> <div> </div> <div>These events also spurred the creation of the Pennsylvania Restraint Reduction Initiative (PARRI). Under the auspices of Kendal Outreach, PARRI has been collaborating with nursing homes in Pennsylvania since August of 2008 on pressure ulcer prevention, mainly focusing on process and prevention. </div> <div> </div> <h2 class="ms-rteElement-H2">Boosting Best Practices</h2> <div> </div> <div>Having compiled a collection of best practices from nursing homes that demonstrated success with pressure ulcer prevention, PARRI created in 2010 “A Practical Guide to Pressure Ulcer Prevention,” which includes process components, data collection tools, assessment tools, and prevention techniques. </div> <div> </div> <div><br>In 2011, the concept of the Pennsylvania (PA) MAP-IT for Healthy Skin emerged after a year of planning and working with other entities in the state. MAP-IT stands for Manage, Assess, Plan, Implement, and Teach. An expert panel discussion led to identification of potential barriers as well as some key discoveries, which helped launch a successful program. There already existed an abundance of resource materials, evidence-based interventions, standards, and guidelines that were collected and made available for all MAP-IT participants and as a repository for the general public. </div> <div> </div> <h2 class="ms-rteElement-H2">Education Key To Success</h2> <div> </div> <div>The cornerstone of the program has been, and continues to be, educational opportunities for staff providing all levels of care, with a particular focus on the education of frontline and direct care staff and their roles in preventing pressure ulcers. <br></div> <div> </div> <div><br>A website (<a href="http://www.pamap-it.org/" target="_blank">www.pamap-it.org/</a>) has helped disseminate information, keep communication open, and accord additional educational opportunities for staff.</div> <div> </div> <div><br>In April 2012, the MAP-IT initiative was officially launched. From this auspicious beginning, partnerships among health care organizations were established. Hospital, long term care, personal care, and home health care organizations with established associations were assembled into a continuum of care. Two continuums of care were recruited, with each consisting of one acute-care agency, skilled nursing homes, personal care homes, and home health care agencies. </div> <div> </div> <div><br>The organizations in each continuum were identified by the discharge planners working in the acute setting, based on the post-acute referrals for care. </div> <h2 class="ms-rteElement-H2"> Identifying Process Weaknesses </h2> <div>The first step in the development of each continuum was to have the participating agencies complete an organizational needs assessment to help identify gaps and/or weaknesses in the current pressure ulcer prevention and treatment process in each participating organization.</div> <div> </div> <div><br>Included was a checklist of pressure ulcer-related topics, which included screening for pressure ulcer risk, developing a pressure ulcer care plan, assessing and reassessing pressure ulcers, monitoring prevention of pressure ulcers, monitoring treatment of pressure ulcers, and assessing staff education and training </div> <div> </div> <div>needs. </div> <div> </div> <div><br>Pennsylvania’s MAP-IT for Healthy Skin adopted the Institute for Healthcare Improvement’s model of collaboration across the health care continuum, a process that gathers a group of health care workers, along with experts in the field, to enable better learning from each other. This system employs evidenced-based practices throughout the continuum and encourages consistent use of such practices in all care settings. </div> <div> </div> <div><br>The PARRI team has provided in-services and individual consultation to participating organizations to fill gaps identified by the needs assessment. The PARRI education modules have been used by the MAP-IT organizations to educate their own staff, their clients, and family members. </div> <div> </div> <div><br>Many of the modules have activities that help revitalize staff enthusiasm for pressure ulcer prevention. </div> <div> </div> <div>Additional proficiency has continued to be gleaned through best practices that are shared among participating organization members.</div> <div> </div> <div><br>Education has been a large part of this collaboration, using both experts and practitioners to emphasize best practices. The first topic of prevention to be targeted was the appropriate response for all direct care staff and nursing staff when a change in the skin color, texture, or temperature is discovered, aptly named the Red Alert Program. </div> <div> </div> <div><br><img alt="The Skincare In-Service" class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/0114/caregiving1.gif" style="margin:5px 15px;" />Prior to the Red Alert Program, staff completed a survey to help determine future educational needs. Based on these survey results, PARRI staff developed a second in-service, known as the SKINCARE Bundle, based on the SKINCARE bundle from Penn Presbyterian Hospital (see sidebar, left). </div> <div> </div> <div><br>Organizations were asked to incorporate this material into training for new staff and annual training or as needed. </div> <div> </div> <div><br>Another level of education was added by offering continuum participants the Wound, Ostomy, and Continence Nurses Society’s new program for Wound Trained Associate (WTA). The WTA program is an online class that focuses on wound physiology, prevention, treatment, and care. </div> <div> </div> <div><br>Abington Memorial Hospital (AMH) sponsored the program, which provides certified training to all levels of nursing staff, including certified nurse assistants, licensed practial nurses, and registered nurses.</div> <div> </div> <div>The 40-hour training modules have been offered periodically to all MAP-IT members.</div> <div> </div> <h2 class="ms-rteElement-H2">Dialogue, Communication Prioritized</h2> <div> </div> <div>Data collection began in July 2012, prior to the Red Alert program, and continues. Thus far, most organizations have benefited from the ongoing education, collaboration, and communication afforded by MAP-IT. A few organizations that have seen an increase in prevalence have been involved with additional training and education from the PARRI staff, with positive results. </div> <div> </div> <div><br>Another measured outcome was increased satisfaction regarding communication across the continuum. Communication was initially identified as a barrier for both continua, since it is common to attribute pressure ulcers to care settings other than staff’s own. </div> <div> </div> <div><br>Establishing relationships and allowing open, honest dialogue among continuum members has brought effective communication to the forefront, making it a priority for the first year. </div> <div> </div> <div><br>Along those lines, communication guidelines were developed by both continua to stipulate information that moves among health care settings concerning the skin of patients. The combined recommended information was published as “Guidelines for Communicating Skin Condition Across the Continuum” and is available on the MAP-IT website (<span><a href="http://www.pamap-it.org/" target="_blank">www.pamap-it.org</a><a href="http://www.pamap-it.org/" target="_blank"><span></span></a></span>). </div> <div> </div> <div><br>A consequence of the guidelines being developed was building relationships of trust, mutual respect, and cooperation among the various organization representatives. For example, in the western continuum a wound, ostomy, and continence nurse from one organization offered to become the wound expert for a small nursing home that could not financially afford its own wound nurse.</div> <div> </div> <div><br>This typifies the exchange of expertise and knowledge among members being established through this program. Mentoring on an unofficial level has also occurred among members. One member has retired but agreed to continue to attend the meetings and share her expertise and experiences with other members. </div> <div> </div> <div>Relationships and network building have become common side effects of the continua.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Best Practices Identified</h2> <div> </div> <div>MAP-IT participants have identified some best practices of member organizations for pressure ulcer prevention and treatment. For example, PARRI staff recently interviewed an eastern continuum member, who shared his facility’s process for maintaining a pressure-ulcer-acquired incidence rate of less than 0.2 percent (see <a href="http://www.pamap-it.org/" target="_blank">www.pamap-it.org</a>). </div> <div> </div> <div><br>PARRI staff also identified a MAP-IT organization that has decreased its incidence rate by 50 percent over five months.<br><br><span><img width="372" height="434" class="ms-rtePosition-2" src="/Issues/2014/PublishingImages/0114/resources_caregiving.gif" alt="" style="margin:5px;" /></span>In the eastern continuum, members are developing information about the skin for consumers that will be posted on YouTube to educate the general public about skin care and pressure ulcer prevention. In the western continuum, members are concerned that insufficient lighting was preventing them from visualizing the earliest manifestation of pressure ulcers. A proposed pilot study will explore ideal lighting across the various settings of the continuum of care. </div> <div> </div> <div><br>Also, both continua are interested in additional education for nursing staff on the correct use of the Braden Risk Assessment for Predicting Pressure Ulcers.</div> <div> </div> <div><br>The long-term goals for PA MAP-IT include identifying new continua of care interested in pressure ulcer prevention. To serve the needs of the underserved urban population, a third continuum has been identified and initiated in Philadelphia. </div> <div> </div> <div><br>Another goal is to use the PA MAP-IT process to improve other quality measures that participants across the current continua choose. For example, PA MAP-IT for Safe Environments would encompass both fall management and restraint elimination and would be a good fit for both continua using the expertise the PARRI team can provide. </div> <div> </div> <div><br>PA MAP-IT for Palliative Care would involve quality of care and a holistic approach to care at all levels of care and would enhance serious illness and end-of-life experiences for patients and their families, as well as staff involved in the care. As PA MAP-IT moves forward, the group anticipates that the relationships will continue to grow and contribute to seamless movement of patients within the health care continuum. </div> <div> </div> <div>Education will continue to be at the forefront for participants. These processes, in turn, will improve care and efficiency in the participating systems, which will enhance the patients’ outcomes. </div> <div> </div> <div><br>The MAP-IT process can be used as a model for other continua to develop an enhanced experience for patient and staff alike. <br><br></div> <div> </div> <em>Linda Hnatow, RN, a regional director of the Pennsylvania Restraint Reduction Initiative, can be reached at lhnatow@kendaloutreach.org or (610) 742-6416. Karen Russell, RN, a regional director of the Pennsylvania Restraint Reduction Initiative, can be reached at krussell@kendaloutreach.org or (724) 864-3767.</em><br>In 2011, the concept of the Pennsylvania (PA) MAP-IT for Healthy Skin emerged after a year of planning and working with other entities in the state. MAP-IT stands for Manage, Assess, Plan, Implement, and Teach. An expert panel discussion led to identification of potential barriers as well as some key discoveries, which helped launch a successful program2014-01-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0114/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn1
Study Reveals Varying Characteristics Of Assisted Living Residentshttps://www.providermagazine.com/Issues/2014/Pages/0114/Study-Reveals-Varying-Characteristics-Of-Assisted-Living-Residents.aspxStudy Reveals Varying Characteristics Of Assisted Living Residents<p>An analysis of the 2010 National Survey of Residential Care Facilities data, completed by George Mason University (GMU) researchers, helped establish some important distinctions among the populations and care needs of residents in small and large assisted living communities nationwide. </p> <p>“It’s important to recognize we are not drawing conclusions on the quality of care between communities of different sizes,” says Andrew Carle, executive-in-residence/director of the program in Senior Housing Administration at GMU. “The care required by an older adult with chronic conditions and those who are younger, dealing with severe mental illness or a developmental disability, or those afflicted with Alzheimer’s, is simply different. What we now know is these specialty populations are being more frequently served within the nation’s smaller communities.” <br></p> <p>The researchers analyzed data gathered for the National Center for Health Statistics’ report. Data on almost 8,100 residents from 2,302 assisted living communities were analyzed. <br></p> <p>The data were then compared for residents in communities categorized as small (four to 10 beds), medium (11 to 26 beds), and large/extra-large (more than 26 beds). The data in this report excluded communities exclusively for individuals with developmental disabilities or mental illness, but did not exclude assisted living communities that co-housed seniors and individuals with severe mental illness or developmental disabilities.<br></p> <p>Following are some highlights of the study:<br></p> <p>■ Small Community Characteristics: Small assisted living communities are nearly three times more likely to house “non-senior” residents under 65 years, with more than 21 percent of residents falling within this group, compared to slightly more than 7 percent in larger communities. Small communities housed more than twice as many residents with severe mental illness (13 percent versus 6 percent) and five times as many residents with a developmental disability (10 percent versus 2 percent). In addition, small communities were also more likely to house residents with Alzheimer’s or other forms of dementia (53 percent versus 41 percent), conditions typically associated with seniors 85 years and older. <br></p> <p>The researchers noted that the data do not provide a clear picture of whether an individual with Alzheimer’s or dementia is in a setting designed for dementia care or co-housed with younger residents, or a combination both. <br></p> <p>■ Larger Community Resident Characteristics: Larger assisted living communities typically had residents who were older than smaller communities. Nearly 85 percent of residents in large communities were older than 75 years, with 56 percent older than 85 years. Residents in larger communities had more chronic conditions than residents in small communities, such as congestive heart failure (36 percent versus 25 percent), hypertension (58 percent versus 50 percent), and osteoporosis (21 percent versus 14 percent). <br></p> <p>GMU researchers want to pursue a second phase of the study that would compare specific quality-of-life indicators of an average assisted living resident to a peer-acuity senior who chooses to stay at home. <br></p> <p>Carle added that such a study would be the first to compare at-home seniors to those in assisted living. It would also help “in separating what is thought of as a ‘typical’ assisted living resident from the specialized groups, versus viewing all assisted living communities as the same.”<br><br></p>The researchers analyzed data gathered for the National Center for Health Statistics’ report. Data on almost 8,100 residents from 2,302 assisted living communities were analyzed. 2014-01-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0114/mgmt2_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn1
Rep. Renacci: A Centrist With LTC Experiencehttps://www.providermagazine.com/Issues/2014/Pages/0114/Rep-Renacci-A-Centrist-With-LTC-Experience.aspxRep. Renacci: A Centrist With LTC Experience<p>U.S. Rep. Jim Renacci won his first election by a wide margin. A former long term care executive and a Republican, he ran in 2010, when public anger over Obamacare was at its fiercest. <br></p> <p>But, despite that background, Renacci is no fire eater. He has spent his time in Congress talking openly about the need for a “safety net”—words that otherwise would act like a dog whistle to some of his colleagues.<br></p> <p><img width="152" height="407" class="ms-rtePosition-1" alt="Jim Renacci" src="/Issues/2014/PublishingImages/0114/Renacci.jpg" style="margin:5px 10px;" /><br>As Renacci tells it, he simply sees government problems as a business manager ought to do. <br></p> <p>“We need to look at the drivers of the debt,” he told an Ohio television station during last fall’s government shutdowns. “Entitlement programs are drivers of the debt. Now that doesn’t mean we should eliminate entitlement programs. Quite frankly, we need to make sure they’re around for our children and our grandchildren. If we do nothing, which is one of the problems, we’ve let this government just allow some of these programs to continue without change, and if we don’t change them, they’re not going to be around in the future.”<br></p> <p>It’s that kind of centrist, business-minded approach that has made him a welcome, and constructive, partner for long term care advocates. <br></p> <p>“As a former skilled nursing care owner and operator, Rep. Renacci is able to bring a unique perspective to Congress,” says Mark Parkinson, president and chief executive officer of the American Health Care Association. “He knows how important it is to protect access to skilled nursing care.”<br></p> <p>Renacci, an accountant by training, formed LTC Management Services in 1985. It brought him into long term care centers across Ohio. <br></p> <p>He’s proud of his background and familiarity with the profession, and he says that advocates have to do more to make his colleagues familiar with their businesses. “They should be inviting their congressperson into their facilities,” he told Provider in a recent interview in his office on Capitol Hill. “If you’re going to ever be able to show somebody what you’re doing, you need to be able to bring them in and show them how you do it and why you need certain things. I think there are many members of Congress here who’ve never been in a nursing home. And yet it’s a big expenditure. I think officials, legislators, need to get into these facilities, understand how they operate.”<br></p> <p>Renacci won plaudits from long term care advocates recently when he introduced what he calls the CARES Act, which would eliminate requirements that Medicare patients spend three days in a hospital before their skilled nursing care can be reimbursed. <br></p> <p>“Clearly for those that qualify and need to be in a nursing home … they should have the ability to go straight to the nursing home,” he says. “This comes down to what care is needed.”<br></p> <p>For Renacci, this isn’t ideology; it’s just good business. “My career has been based on making sure that the elderly have the opportunity to get the proper care that they need,” he says.<br></p> <p>This makes it all the more important for providers to bring their congressional representatives into their centers.<br></p> <p>“There just has to be a connection,” Renacci says. “It’s one of the things we should make sure the system is there, that it’s working … and ultimately we need to make sure that we’re paying for what we’re requiring nursing homes to do.” <br></p>Renacci won plaudits from long term care advocates recently when he introduced what he calls the CARES Act, which would eliminate requirements that Medicare patients spend three days in a hospital before their skilled nursing care can be reimbursed. 2014-01-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/headshots/Renacci-thumb.jpg" style="BORDER:0px solid;" />Management;QualityColumn1
In The Spotlight: Rising Stars In Long Term And Post-Acute Carehttps://www.providermagazine.com/Issues/2014/Pages/0114/Rising-Stars-In-Long-Term-And-Post-Acute-Care.aspxIn The Spotlight: Rising Stars In Long Term And Post-Acute Care<div>Effective and caring leaders come in all shapes and sizes. And this year’s class of 20 To Watch demonstrates now more than ever that passionate leaders lead from every position. </div> <div> </div> <div>The best leaders lead in the moment they are in and from the place they are in that moment, with vision, authenticity, transparency, and a steadfastness; all of these are key when their calling and work is the health, wellness, and safety of another person.</div> <div> </div> <div>One of the effective leadership attributes shared by all of the outstanding professionals chronicled on these pages is a sense of calling, and each of this year’s 20 To Watch is driven to be the part of the solution that ensures quality care for people in need and thoughtful support and empowerment to the families of the people receiving care.</div> <div> </div> <div>Among this year’s honorees, you will also read of leaders—among them nurses, physicians, administrators, and chief executive officers—who are not only helping residents and patients to be their best, healthiest, and most engaged selves, but who are dedicated to doing it for their colleagues, 360 degrees in their organizations.</div> <div> </div> <div>By honoring these leaders, we are planting a flag dedicated to what could and must be in meeting the health and care needs of an aging America; the best of our best don’t aim for the lowest bar, they reach and stretch over the  highest one.</div> <div> </div> <div>Their stories are uplifting and inspirational, and that’s important because in this age, and with the challenges and opportunities we and the people in long term and post-acute care face, we live in a time when we need as many great leaders as we can get. I encourage you to read, discuss, and share these brief profiles of <em>Provider’s</em> 2014 Class of 20 To Watch with colleagues, friends, families, and people inside and outside the industry. </div> <div> </div> <div>And if you are a passionate leader yourself, I ask you to join me in asking the following questions:</div> <ul><li>What vision do I do I have for a better tomorrow?</li> <li>Who can, and must, I ask to join me, lead me, or follow me in this vision?</li> <li>What action can I take today to make this vision for a better tomorrow a reality?      <em>   </em>          </li></ul> <div> </div> <div style="text-align:right;">–Joseph DeMattos Jr.</div> <div> </div> <div><em>Joseph DeMattos Jr. is president and chief executive officer of the Health Facilities Association of Maryland, an adjunct professor at the University of Maryland Baltimore County’s Management of Aging Services master’s program, and a leadership consultant.</em> <br></div> <div></div> <div> </div> <h2 class="ms-rteElement-H2B"><img class="ms-rtePosition-1" alt="Michelle Gifford" src="/Issues/2014/PublishingImages/0114/MichelleGifford.jpg" width="123" height="179" style="margin:5px 15px;" />Michelle Gifford, RN</h2> <div><strong>Director of Nursing</strong></div> <div><strong>Atlantic Nursing and Rehab Center</strong></div> <div><strong>Atlantic, Iowa</strong></div> <div> </div> <div>Being a caregiver is in Michelle Gifford’s roots. Both her mother and grandmother were nurses, and Gifford herself was a certified nurse assistant (CNA) for 12 years, working in both hospitals and long term care, before becoming a nurse. She was motivated to get a nursing degree after tiring of “wanting to do more but not having credentials and education to do it,” she says.</div> <div><br>Today she is “a teacher, a mentor, and a leader,” says Kim Jimerson, RN, Atlantic’s administrator. “She seldom hesitates to offer to help out at our buildings or help another director of nursing [DON] figure something out. She does this because she loves to teach and share and work with others.”</div> <div> <br>Gifford, who worked as a charge nurse before becoming a DON, has adopted a motto that illustrates her leadership style: “You never want to tell someone to do something that you wouldn’t want to do yourself,” she says with conviction.</div> <div> </div> <div>Among Gifford’s accomplishments, says Jimerson, are her efforts to reduce turnover among staff at Atlantic, as well as working with local hospitals to reduce rehospitalizations. </div> <div> <br>Says Jimerson: “Michelle has worked very hard to reduce staff turnover within our building. With the support of our corporation she has been able to offer such things as anniversary bonus programs. Michelle works directly with our employees in the nursing department, trying to make sure that our employees are able to earn their bonus check. She listens to what her employees need, and she advocates for that.”</div> <div> </div> <div>The result of Gifford’s work has paid off. Jimerson reports that Atlantic’s turnover within the building has plummeted from “more than 120 percent … to less than 50 percent at last review; we are working on a 34 percent turnover rate currently year-to-date.”</div> <div><img class="ms-rtePosition-2" src="/Issues/2014/PublishingImages/0114/Top20-1.jpg" width="182" height="635" alt="" style="margin:10px 15px;width:217px;height:857px;" /><br>Gifford’s mentoring of staff has earned her additional accolades, while many of her staff have gone on to obtain their registere nurse or licensed practical nurse degrees and returned to Atlantic to work. </div> <div><br>“Michelle meets with her staff to discuss such things as hours and what will work for them. She assists them with the ability to juggle their schedules and find replacements, as necessary,” Jimerson says.</div> <div><br>“When an employee looks to leave our employment, Michelle will try to find out the real reason for their leaving, and then she will try to find a way to work within their limitations so that the residents have stable staff in our building.”</div> <div><br>Gifford’s efforts to reduce unnecessary hospitalizations have brought her additional praise, as well. She utilizes a program known as LTC Trend Tracker—an American Health Care Association (AHCA) software tool that enables users to access reports to track, organize, identify, benchmark, examine, and compare the profession’s data online—to augment her efforts and learn about how other providers are doing.</div> <div><br>Jimerson notes that Gifford also takes advantage of multiple educational opportunities available to her. She takes classes through the Iowa Health Care Association and recently became certified as a Resident Assessment Coordinator and as a Nurse Executive, “to get that extra little bit of education,” Gifford says.</div> <div><br>“I always say that I’m lucky for working with my peers, I always say it’s not me it’s them,” Gifford says. “I love talking to elders and learning their stories.”</div> <div> </div> <h2 class="ms-rteElement-H2B"><img class="ms-rtePosition-1" alt="Andrea Rathbone" src="/Issues/2014/PublishingImages/0114/AndreaRathbone.jpg" style="margin:5px 15px;width:123px;height:143px;" />Andrea Rathbone</h2> <div><strong>Administrator </strong></div> <div><strong>D’Youville Senior Care</strong></div> <div><div><strong>Lowell, Mass.</strong></div> <div> </div> <div>As administrator of a 208-bed skilled nursing facility, Rathbone’s first priority is helping both residents and staff to achieve their full potential, says Ann Marie Antolini, vice president of administration for the Massachusetts Senior Care Association (MSCA).</div> <div> </div> <div>“Each employee and resident is supported in their endeavors with respect, dignity, and compassion. Whether encouraging an employee to apply for a scholarship to support their educational goals or interacting with a resident in the facility’s Learning Center as they expand their knowledge, Andrea provides an unrivaled level of enthusiasm, passion, and energy in her support of employees and residents,” says Antolini.</div> <div> </div> <div>Rathbone’s take on her recognition as one of this year’s 20 To Watch is much humbler, indeed. She admits that she doesn’t understand why she was chosen for the honor, but those familiar with her work have nothing but praise for her accomplishments. From being instrumental in the development of a Dedicated Education Unit at D’Youville to her prominent roles in achieving AHCA’s Bronze and Silver Quality Awards, as well as being responsible for the construction, development, and implementation of an orthopedic recovery unit within a skilled nursing center, Rathbone’s modest response speaks volumes about her dedication and compassion.</div> <div> </div> <div>For the past two years, under Rathbone’s leadership, D’Youville Senior Care has participated in MSCA’s Statewide Initiative to Safely Reduce the Off-Label Use of Antipsychotic Medications. </div> <div> </div> <div>What’s more, according to Antolini, “staff have successfully adopted and implemented a unique, person-centered approach that helps staff understand and respond to the individual needs of each resident in order to develop and refine strategies that will improve the resident’s quality of life and job satisfaction for staff.” </div> <div> </div> <div>As a result these efforts, D’Youville achieved a 15 percent reduction in atypical antipsychotic drug use for long-stay residents over the past two years, Antolini reports.</div> <div> </div> <div>Of her center’s accomplishments, Rathbone notes that “at the end of the day we’re here for one reason and that’s [to be here] for residents and staff, and I try to make that part of my day,” every day, she says.</div> <div> </div> <div>What motivates Rathbone is knowing that every day she can make a small difference in someone’s life. “I think in life it’s all about the small differences we make. And in life all those small differences build, and you realize you’ve done a good thing for a family member or a resident,” she says.</div> <div> </div> <div>Rathbone’s experience with long term care reaches back to her elementary school days. Her mother was a scheduler for a large nursing home. Rathbone would go to the home after school and wait in the lobby until her mother was finished with her day. Once in high school, Rathbone worked at the home answering phones in the evenings. “It was all that I knew,” she says. “I went to college knowing that I would major in health care administration, although I wasn’t sure about long term care. But midway through college, I knew I wanted to be in long term care, and I shifted my work and studies to elders.”</div> <div> </div> <div>Rathbone is emphatic about serving elders and remembering that they come first. “Something I say to staff every day is you have to remember we’re not the ones going through the transition, it’s the residents who are going through transitions. They may have just lost a spouse or just moved in or just recovered from surgery; they have a whole lot of transition, and we can’t forget that,” she says.<br><br></div> <div><img class="ms-rtePosition-1" alt="Wendell Anderson" src="/Issues/2014/PublishingImages/0114/WendellAnderson.jpg" width="160" height="161" style="margin:5px 10px;" /></div> <h2 class="ms-rteElement-H2B">Wendell Anderson </h2> <div><strong>Certified Nurse Assistant</strong></div> <div><strong>Maravilla Care Center</strong></div> <div><div><strong>Phoenix, Ariz.</strong></div> <div> </div> <div>Having worked in long term care as a CNA for nearly three decades, Wendell Anderson is highly regarded at Maravilla Care Center, where he has worked for the past 11 years. Anderson’s supervisor, Virginia Krueggel, extols his virtues without hesitation: “He is amazing with the residents—and we deal with some of the most difficult people in the psychiatric population—and he can walk into a room and bring this calmness and deescalate a potential situation,” she says. “He’s awesome, great, amazing—the way he’s grown and taken opportunities that he’s run with, and he’s amplified it to the nth degree.”</div> <div> </div> <div>Anderson was inspired to become a CNA after seeing how well his grandfather, who suffered from cancer, was cared for in a Veteran’s home. Working as a caregiver was his way of giving back, he says.</div> <div> </div> <div>“I love taking care of the neighbors [his term for elders]; I love being there to help with my neighbors’ quality of life and being a part of their family. Every morning I get up and look forward to being with my family,” he says. </div> <div> </div> <div>His love for elders is reflected in Krueggel’s testimony: “Residents feel safe and secure with Anderson, and he works well with almost everybody—a huge asset to our team here,” she says, adding that Anderson has “grown beyond leaps and bounds for the past 11 years that I’ve been working with him.”</div> <div> </div> <div>Krueggel notes that Anderson started on the floor and showed great leadership skills. So much so that he moved up to a lead CNA position and “has been my right and sometimes my left hand,” she says. </div> <div> </div> <div>Anderson’s leadership skills have been on display in his work with the National Association of Health Care Assistants (NAHCA). Having served on NAHCA’s National Steering Commission for three years and currently holding the position of vice chair, Anderson helps plan and execute activities within the association, such as the annual CNA conference, and is active in the group’s advocacy efforts in Washington, D.C. </div> <div> </div> <div>“He has spearheaded NAHCA programs and activities at Maravilla Care Center that bring recognition, education, and leadership to his fellow team members, resulting in enhanced teamwork, reduced turnover, and enhanced morale—all of which ultimately positively impact the neighbors being served,” says Kathleen Collins Pagel, executive director of the Arizona Health Care Association in her nomination letter.</div> <div>He even played the superhero “NAHCA Man,” complete with costume, in a YouTube video encouraging positivity and teamwork. </div> <div> </div> <div>“With Wendell’s leadership, Maravilla Care Center’s NAHCA Leadership Team received the NAHCA Leadership Team of the Year Award in 2011, a national honor,” Collins Pagel wrote. Anderson’s efforts at Miravilla and with NAHCA also earned him the 2013 NAHCA Member of the Year award.</div> <div> </div> <div>“Wendell Anderson is a shining example of a leader from the frontline with compassion, capability, and unlimited potential. He is an outstanding and articulate advocate, with a proven track record on Capitol Hill. But it is Wendell’s passion and fierce devotion to those he cares for, along with his belief in the power of CNAs, that make him a ‘person to watch.’ He truly represents the very best of our profession in every way. It is an honor to be his colleague.”<br></div> <h2 class="ms-rteElement-H2B"><img class="ms-rtePosition-1" alt="Bernadette Ledesma" src="/Issues/2014/PublishingImages/0114/BernieLedesma.jpg" style="margin:5px 10px;width:123px;height:153px;" />Bernadette Ledesma, MPH</h2> <div><strong>Administrator</strong></div> <div><strong>Pearl City Nursing Home</strong></div> <div><div><strong>Pearl City, Hawaii</strong></div> <div> </div> <div>Bernadette Ledesma is a hands-on administrator, involved in the day-to-day activities of Pearl City Nursing Home, policy development and education, and communication with residents and their families.</div> <div> </div> <div>Ledesma is often seen making rounds through the building and stopping to encourage residents to participate in their plans of care, talking to families to resolve issues, and observing staff to ensure that the facility is meeting the needs of residents.</div> <div> </div> <div>Through her professional work and service, Ledesma exemplifies what it means to be a champion for the aging. She does so as a provider of care, a leader in improving policy, and an active community member who helps others achieve their goals. She is acknowledged throughout the health care and broader community as a leader.<img class="ms-rtePosition-2" src="/Issues/2014/PublishingImages/0114/Top20-2.jpg" width="173" height="635" alt="" style="margin:10px 15px;width:228px;height:905px;" /></div> <div> <br>Ledesma provides excellent care for older persons, advocates for improving Hawaii’s capacity to care for residents across settings, and shares her experience and expertise throughout the community. Ledesma is always generous with her time and knowledge, and she is patient and calming even during times of duress. As one Healthcare Association of Hawaii staff member who has worked with her for years shares, “[She] has a wonderful personality; is always supportive, creative, and fun to work with; and gets along with everyone she meets.” </div> <div> </div> <div>Ledesma has been a tireless champion for long term care in Hawaii for over 30 years, and she has done so with grace, humor, and a generosity of spirit that is contagious.</div> <div> </div> <div>Her supporters note that Ledesma has contributed to the welfare of the elderly throughout her 30+ years in geriatric health care in Hawaii. She is very involved in statewide and nationwide initiatives related to long term care, including legislation, regulations, and guidelines that affect the long term care community in general and nursing homes in particular.</div> <div> </div> <div>Ledesma incorporates her wealth of knowledge, providing direction for the operation of Pearl City Nursing Home, and openly shares her knowledge with other nursing home administrators and people interested in geriatric health care. She effectively educates national and local elected officials on policy and regulatory issues and continually mentors new members and colleagues. She makes connections along the continuum of care, across the health care delivery system and community health.</div> <div> </div> <div>Colleagues say that Ledesma exemplifies the spirit of aloha. Here are three recent examples:</div> <ul><li>At Pearl City Nursing Home, Ledesma is an advocate for Culture Change and the Namaste philosophy of looking beyond the surface into the true nature of every resident. The culture change movement in long term care strives to change the way frail people interact with their surroundings. Namaste programs also are focused on individualized engagement and the embrace of each resident’s needs and preferences.</li> <li>Under Ledesma’s leadership, Pearl City Nursing Home joined a nationwide CMA Partnership to Improve Dementia Care in Nursing Homes, which included training staff and emphasizing nonmedical interventions for behavioral health issues faced by long term care residents.<br></li></ul> <div>Keith Ridley, chief of the Hawaii Department of Health’s Office of Health Care Assurance and head of the Dementia Care Improvement task force, called the results “remarkable.” Already a leader in the nation for utilization, Hawaii has reduced its rate of antipsychotic medication for dementia residents from 19 percent last year to 11 percent this year.</div> <ul><li>To address the ongoing challenge of transitions of care, Ledesma has spearheaded communication between transferring facilities in her region to promote sharing a list of federally-required and facility-specific documents.</li></ul> <h2 class="ms-rteElement-H2B"><img class="ms-rtePosition-1" alt="Alicia Seaver" src="/Issues/2014/PublishingImages/0114/AliciaSeaver.jpg" style="margin:5px 10px;width:123px;height:174px;" />Alicia Seaver</h2> <div><strong>Executive Director</strong></div> <div><strong>Bridges by EPOCH at Hingham</strong></div> <div><div><strong>Hingham, Mass.</strong></div> <div> </div> <div>On the job at Bridges by EPOCH at Hingham for two years, Executive Director Alicia Seaver says she sought the assisted living facility out, knowing that it was moving into the area of memory enhancement, which is a field she has been heavily involved in for 25 years. </div> <div> </div> <div>As a CNA in a nursing home, Seaver met her first person with memory impairments at 18 and “fell in love,” she says. “It’s something that I have a passion for.</div> <div> </div> <div>“When I get into my car in the morning, I know where I’m going. And when I get into my car every night, I know that I’ve made a difference.” </div> <div> </div> <div>Seaver is arguably the foremost expert in memory care in all of new England. Co-workers say her dedication and passion are beyond anything they have seen, that she sets the bar high for herself and encourages other staff to do the same. </div> <div> </div> <div>Seaver is a memory-impairment specialist certified by the National Institute on Aging. In addition to running the memory care program at Bridges by EPOCH at Hingham, Seaver regularly leads educational presentations about memory impairment for caregivers, nurses, social workers, and family members.</div> <div> </div> <div>She presents about the different types of dementia, coping tips for caregivers, understanding dementia from multiple perspectives, and more. She offers these presentations in part because of a personal passion to educate, support, and help people who are affected by memory loss. By regularly sharing her knowledge of and experience with memory impairment and caregiving, Seaver continuously supports her residents and staff, as well as members of the larger community. </div> <div> </div> <div>For example, Seaver leads a monthly support group for her residents with early-stage memory impairment. These residents have a working memory and can articulate how frustrating it is to deal with their memory loss on a daily basis. The support group offers a safe environment where residents can articulate their frustration and receive support and encouragement from their peers. Ever sensitive to the needs and emotions of her residents, Seaver encourages them to drive the group. Sometimes, that means they ask her to discuss common types of dementia; other times, it’s a simple check in. Seaver has said that the most important thing is that people have a venue to talk openly about their feelings, because talking leads to healing.</div> <div> </div> <div>Seaver and her staff hold resident council meetings every month, encouraging residents to offer any suggestions or ideas they have. These meetings have helped residents thrive, inspiring them to participate in a number of volunteer projects, including car wash fundraisers and bake sales for the Alzheimer’s Walk and a carnival to benefit the Hope for Caroline foundation. </div> <div> </div> <div>An ardent believer in the power of support groups, Seaver also hosts a group for spouses of individuals with memory impairment. What’s really special about this program is that she invites and welcomes spouses to bring their loved ones with memory impairments along. While caregivers attend the support group, their spouses participate in activities taking place in the community. This has allowed many family caregivers to receive the support and encouragement they need from people who have walked in their shoes—often, spousal caregivers are hesitant to attend such support groups, not wanting to leave their loved one home alone. Seaver has eliminated this worry. <br></div> <h2 class="ms-rteElement-H2B"><img class="ms-rtePosition-1" alt="Melanie Lite Matthews" src="/Issues/2014/PublishingImages/0114/MelanieLiteMatthews.jpg" style="margin:5px 10px;width:123px;height:154px;" />Melanie Lite Matthews</h2> <div><strong>Vice President of Operations</strong></div> <div><strong>Prestige Care</strong></div> <div><strong>Vancouver, Wash.</strong><br><br>Quality care is in the spotlight in the long term care community, and Melanie Lite Matthews is doing her part to promote, implement, and practice quality throughout her organization and in Washington state’s long term care community.<br><br>Taking the lead by motivating her colleagues to apply for and achieve Bronze and Silver Awards through the AHCA/National Center for Assisted Living National Quality Awards Program; participating on the Quality Improvement Committee for the Washington Health Care Association (WHCA); and promoting quality care through projects, initiatives, and efforts of the association through her board position are just a few of the ways that Matthews is helping Washington move the dial on quality. <br><br>Matthews is a rising star in long term care. Large organizations have sought to employ her because of her energy, drive, understanding of long term care, and her sincere passion to improve outcomes for residents. <br>Currently the WHCA Board vice chair, Matthews believes in working together with legislative, regulatory, and other state entities to achieve common goals.<br><br>Matthew’s enthusiasm for a focus on quality is contagious, and her efforts are having an impact. She has helped put quality at the center of WHCA’s legislative priorities and worked with the Department of Social and Health Services and other policy-making entities in Washington in an effort to connect providers with oversight agents to achieve quality outcomes together. <br><br>Matthews works tirelessly with the Washington state Quality Improvement Organization on the Collaborative Project, designed to help providers learn from one another. She spends time with the Medical Directors Association in an effort to work on the goal to safely reduce unnecessary readmissions to the hospital. <br><br>It is under Matthews’ supervision, training, and example that many of the communities she oversees have earned national recognition for AHCA/NCAL Quality Initiative goals achievement. Her efforts and those of her communities made had a direct impact on the reduction of the off-label use of antipsychotic medications, the reduction in staff turnover, the improvements in resident satisfaction levels, and the safe reduction of unnecessary readmissions to the hospital. <br><br>Matthews is continuously looking for ways to improve. She spends time with administrators, DONs, caregivers, residents, legislators, and others who can help to improve the quality of care for seniors in Washington. She motivates her own organization to have legislators in for facility tours and she encourages other organizations to do the same.<br><br>While busy in her public role, Matthews does not diminish the time she spends or the attention she gives to making quality the center of her everyday operations. <br><br><strong>Sponsored by:</strong><br><img class="ms-rtePosition-1" alt="Tena logo" src="/Issues/2014/PublishingImages/0114/Tena.jpg" style="margin:20px 10px;" /><br>SCA is a leading global hygiene and forest products company that develops and produces personal care products, tissue and forest products. With sales in 100 countries, SCA has 37,000 employees and had revenue in 2012 of $13 billion.  With nine manufacturing facilities across North America, the company’s Americas headquarters is in Philadelphia, Pennsylvania.<br><br>In North America SCA produces the Tork line of napkin, towel, tissue and wiper products used in commercial settings such as office buildings, restaurants, schools and health care facilities and the TENA® line of incontinence care products used by consumers at home and in health care facilities. TENA and Tork the global leading brands in their categories.<br><br>More information at <a href="http://www.sca.com/us" target="_blank">www.sca.com/us</a>.<br></div></div></div></div></div>The best leaders lead in the moment they are in and from the place they are in that moment, with vision, authenticity, transparency, and a steadfastness; all of these are key when their calling and work is the health, wellness, and safety of another person.2014-01-01T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/dr_staff.jpg" style="BORDER:0px solid;" />20 to Watch;Caregiving;Management;QualityCover Story1
Survey: Docs Slow To Adopt Mobile Devices For Drug Carehttps://www.providermagazine.com/Issues/2014/Pages/0114/Survey-Docs-Slow-To-Adopt-Mobile-Devices-For-Drug-Care.aspxSurvey: Docs Slow To Adopt Mobile Devices For Drug Care<p>Nursing home doctors appear reluctant to use mobile gadgets for help in prescribing drugs, researchers at the University of Pittsburgh are saying. <br></p> <p>Researchers surveyed hundreds of long term care doctors at an annual convention and asked them about whether, and how often, they used iPhones or other mobile devices for help in writing prescriptions for residents. “Fewer than half (42 percent) of the respondents indicated that they owned and used a mobile device for assisting with prescribing” in the nursing home. <br></p> <p>Experts argue that smartphones and other hi-tech gadgets can help doctors in their rounds, particularly in looking up drug interactions and potential bad reactions to medicine. Those adverse drug events (ADEs) are associated with some 93,000 nursing home deaths and another $4 billion in excess health care costs per year. <br></p> <p>“Mobile devices, such as personal digital assistants (PDAs), hand-held computers, table PCs, and smartphones, represent a potentially attractive alternative solution to prevent or mitigate ADEs without requiring extensive investment in software and hardware infrastructure,” lead researcher Steven Handler, MD, wrote for the team. <br></p> <p>The research findings were reported in the December issue of the Journal of the American Medical Directors Association. <br></p> <p>Earlier surveys had found that up to 86 percent of doctors in other clinical settings used mobile devices for help in their rounds. But long term care doctors appeared to be behind their colleagues, Handler and his colleagues found. <br></p> <p>In fact, the more veteran the long term care doctors were, the less likely they were to seek cellular help, the researchers found. <br></p> <p>“Specifically, those with 15 or fewer years of clinical experience were 67 percent more likely to be mobile device users, compared with those with more than 15 years of clinical experience,” Handler wrote. <br></p> <p>And the more time doctors spent in the nursing homes, the less likely they were to use mobile devices. Doctors who reported spending less than half of their time in long term care centers were 64 percent more likely to use the gadgets, compared with those who spent more than half of their time in the centers, Handler said. <br></p> <p>For those doctors who are using the devices, though, they appear to be helpful: The doctors reported that they looked up one to two medicines per day, with 43 percent saying they looked up about six different medicines per day, Handler said. <br></p> <p>The three most common mobile brands were Palm (31 percent), iPhone (30 percent) and Blackberry (25 percent), Handler wrote. <br><br></p>Researchers surveyed hundreds of long term care doctors at an annual convention and asked them about whether, and how often, they used iPhones or other mobile devices for help in writing prescriptions for residents.2014-01-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0114/caregiving2_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn1
Providers Grapple With Managed Care Inevitabilitieshttps://www.providermagazine.com/Issues/2014/Pages/0114/LTC-Execs-Managed-care-Inevitable.aspxProviders Grapple With Managed Care Inevitabilities<p><em>This is the first of a two-part series covering a recent </em>Provider<em> roundtable held in conjunction with the AHCA/NCAL convention in Phoenix, Ariz., in October. The purpose of the forum was to convene long term and post-acute care providers from a variety of states and markets around the country to shed light on how they are tackling the many issues that accompany the ever-growing cadre of managed care and Accountable Care Organizations around the country. The roundtable was sponsored by American HealthTech, at <a href="http://www.healthtech.net/" target="_blank">www.HealthTech.net</a>.</em><br><br><img class="ms-rtePosition-1" alt="Provider Roundtable, Phoenix, Arizona" src="/Issues/2014/PublishingImages/0114/Phoenix-Roundtable_0347.jpg" width="283" height="185" style="margin:5px 15px;" /><br>Lengths of stay, hospital readmission rates, and five-star ratings remain buzzwords for long term and post-acute care providers as managed care works its way into markets around the country, according to a recent gathering of roundtable participants. </p> <p>Be it a managed care organization (MCO) or an Accountable Care Organization (ACO), the consensus of the gathering was that it’s not a matter of whether it’s coming but a matter of when it’s coming. And the corollary to that is: Providers must know their quality measures, and they must know them very well. <br><br>In Kansas, where Medicaid managed care is just nine months old, all beneficiaries have been assigned to one of three MCOs, reports Fred Benjamin, chief operating officer of Medicalodges in Coffeyville, Kan. In fact, his company has embraced the roll-out of managed care in the state. “It’s been interesting so far,” he says. “I’m excited about it because we have an opportunity to rebuild the health care system the way we want to rebuild it. It’s not being dictated to us by the hospitals, and it’s not being dictated to us by somebody else. We have a fairly good relationship with a couple of MCOs. We have an opportunity to partner with them, and they seem very receptive to it.”  <br><br>On the West Coast, California is currently enduring the “throes of managed care,” says Jim Gomez, chief executive officer of the California Association of Health Facilities. He notes that California now has 13 MCOs within the state’s eight largest counties, representing about 25 million people. “For about the last two-and-a-half years, I’ve been preaching to my members that it’s coming,” he says. <br><br><img class="ms-rtePosition-2" alt="/archives/2014_Archives/PublishingImages/0114/roundtable_thumb.jpg" src="/Issues/2014/PublishingImages/0114/Phoenix-Roundtable_0373.jpg" width="279" height="192" style="margin:5px 10px;" />“I meet with the head of the [health maintenance organization] association on a monthly basis to make sure those relationships are connecting and we’re saying the same thing. My biggest fear is the loss of independent providers in the state. The bigger companies, I believe, can integrate vertically and horizontally, and they are going to present a different picture to MCOs than an independent owner/operator who does only skilled nursing.”<br><br>In an effort to stave off this fear, Gomez has been educating independent operators in the state “so they’re in front of the curve,” he says. “I would say this at every workshop: All administrators should know their rehospitalization rates and their lengths of stay. And any administrator who doesn’t know these data should be fired.” Regarding length of stay, Gomez believes that it will drop from an average of 28 days to 21 days as a result of managed care. He points to Kaiser Health System, the largest player in the Sacramento area, as evidence: “Their average length of stay is 12 days,” he says. “They put their own nurse practitioners and docs in the nursing homes.” <br><br>In Massachusetts, ACOs are the main focus, as opposed to MCOs, says Naomi Prendergast, chief executive officer of D’Youville Life and Wellness Community in Lowell, who has been working with the state association to create a model ACO contract for other providers in the state. <br><br>“Forty percent of all fee-for-service Medicare beneficiaries are going through an ACO,” she says, adding that they are also creating educational programs for providers in order to get ACOs and skilled nursing facilities on the same page with regard to expectations on both sides.  <br><img class="ms-rtePosition-1" alt="/archives/2014_Archives/PublishingImages/0114/roundtable_thumb.jpg" src="/Issues/2014/PublishingImages/0114/Phoenix-Roundtable_9103.jpg" width="308" height="170" style="margin:15px 10px;" /><br>“One ACO is in the process of going from 500 down to 50 [skilled nursing facilities] in its network,” says Prendergast. <br><br>“The sands around us are shifting constantly. We need to be aware of who now is affiliating with whom. It’s changing almost daily.” <br></p>This is the first of a two-part series covering a recent Provider roundtable held in conjunction with the AHCA/NCAL convention in Phoenix, Ariz.2014-01-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0114/roundtable_thumb.jpg" style="BORDER:0px solid;" />Management;Reimbursement;Quality ImprovementManagement1
Match Makinghttps://www.providermagazine.com/Issues/2014/Pages/0114/Match-Making.aspxMatch Making<div> </div> <div>When a resident is in a skilled nursing facility for Medicare-based rehabilitative services (physical therapy, occupational therapy, and/or speech therapy), who is responsible for the plan of care? Is it the nursing or therapy department? </div> <div> </div> <div>According to the “Semiannual Report to Congress” submitted by the Office of Inspector General (OIG), 37 percent of Medicare stays in 2009 did not have the appropriate care plan in place to meet the needs of the resident. </div> <div> </div> <div>In addition, the study found that services either did not match the care plan or the facility provided too much care, resulting in harm to the resident. OIG reported an estimated $5.1 billion in overpayments for the reporting period. Getting the care plan right is essential to avoiding OIG scrutiny and payment loss.</div> <h2 class="ms-rteElement-H2">Department Coordination Improves Care</h2> <div>When care coordination does not occur, not only does the chart lack proof of necessary care, but residents suffer. In an OIG podcast, Judy Kellis, an OIG team leader, described a situation found during an audit where a resident received intensive therapy five times a week for five weeks, even though he had terminal lung cancer and did not want the therapy. </div> <div><br>In another situation, a resident received hours of therapy even though she had a dislocated hip. Treatment plans that are detrimental to the resident can be avoided when therapy and nursing staff work together holistically to assist the resident in achieving his or her rehabilitative goals, to provide pain control, and to support disease management. </div> <div><br>As part of the required Resident Assessment Instrument (RAI) process, it is critical to link the Minimum Data Set (MDS) process to the care plan in a way that accurately reflects the needs of the resident. The purpose of the RAI process is to conduct an interdisciplinary review of the resident’s care needs that is holistic in scope. </div> <div><br>In order to do this effectively, therapists and nursing staff must closely align their work in caring for the Medicare resident. Dialogue between therapy and nursing staff should clearly identify the resident’s baseline status, as well as his or her progress toward goals. Wasteful spending to the tune of $1.5 billion was blamed on the use of incorrect Resource Utilization Groups (RUGs) in establishing payment, the result of inaccurate MDS coding. </div> <div><br>The OIG-identified culprit was inaccurate charting for therapy services and activities of daily living (ADLs), which OIG auditors reported was the result of upcoding. </div> <div><br>Therefore, it is critical that nursing and therapy department staff coordinate appropriate Medicare services so that care is cohesively and accurately captured by the medical record, care plan, MDS, and billing claim.       </div> <h2 class="ms-rteElement-H2">Pay Attention To The RAI Process</h2> <div>Tying the RAI process to care that is delivered in the therapy department can greatly enhance the coordination of care that needs to occur. The critical thinking involved in the RAI process helps facility staff determine appropriate interventions, address critical elements of the resident’s preferences and needs, and avoid providing too much care. </div> <div><br>The nurse involved in completing the ADL Functional/Rehabilitation Potential Care Area Assessment should work closely with the treating therapist to enhance the integrity of the critical thinking process. This will enhance the likelihood of a comprehensive care plan that results in appropriate treatment provided by all staff involved in caring for the resident. </div> <div><br>In addition to the RAI process, teamwork is essential when therapy starts and ends, when residents refuse treatment, and in between these times. Another way to put it: Teamwork and coordination should occur during the entire Medicare stay. </div> <div><br>At the start of therapy, teamwork is essential to communicate the baseline and the goals. Nursing involvement in the resident’s ADLs contributes to supporting the need for therapy services by reflecting the resident’s deficits as well as showing the progress a resident is making as a result of the therapy services. </div> <div>For example, nursing can show how a resident’s mobility has gone from non-weight-bearing, to weight-bearing with two assists, to weight-bearing with one assist, to guided maneuvering. This type of coordination of service paints a powerful picture of the benefit the resident is receiving from therapy services.</div> <h2 class="ms-rteElement-H2">Don’t Forget To Review Residents’ Needs</h2> <div>When a resident refuses therapy, the best practice is for nursing and therapy staff to work together to assess the reason for the refusal and coordinate mitigating interventions. This coordination includes assessment of, and interventions for, pain, sleep needs, scheduling of daily activities, potential illness, mood status, and so on. </div> <div><br>If the end of therapy always spells the end of the Medicare stay, then coordination of care may be lacking. Some residents require skilled nursing services after therapy ends. </div> <div><br>A thorough review of the resident’s needs is necessary to ensure that residents aren’t precipitously dropped from Medicare when continued coverage is reasonable and necessary. On rare occasions, residents may need observation and assessment, teaching and training, management and evaluation of the care plan, or direct skilled nursing care.</div> <div><br>For a resident on Medicare for rehabilitative services, an appropriate care plan is the responsibility of both the nursing and therapy departments and should include involvement by other interdisciplinary team members. Appropriate, well-documented care is essential to protecting the facility from adverse OIG audits. To achieve this, it is critical to dialogue openly about how well the nursing and therapy departments coordinate care services. </div> <div><br>There should be no territorial overtones or departmental silos that prevent honest dialogue and thorough teamwork. Managers should take time to evaluate the communication and coordination that occurs between the nursing and therapy departments. </div> <div><br>This action can make the difference between accurately providing each resident with the appropriate level of care and coming under scrutiny from OIG auditors. </div> <div> </div> <div><em>Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.<br><img src="/Issues/2014/PublishingImages/0114/AANAC.jpg" alt="" style="margin:5px;" /><br><br></em></div>According to the “Semiannual Report to Congress” submitted by the Office of Inspector General (OIG), 37 percent of Medicare stays in 2009 did not have the appropriate care plan in place to meet the needs of the resident. 2014-01-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0114/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn1
Parkinson’s Disease: A Brain Tune-Uphttps://www.providermagazine.com/Issues/2014/Pages/0114/Parkinsons-Disease-A-Brain-Tune-Up.aspxParkinson’s Disease: A Brain Tune-Up <div>Parkinson’s disease (PD) has dragged me through hellfire; it has wrecked my body and tested my soul. This ordeal has taught me much about life in general, and about matters both great and trivial. Following are some highlights of my life with PD, and of what this mean teacher taught me about modern medicine, its marvels and pitfalls. </div> <h2 class="ms-rteElement-H2">A New Tack</h2> <div>It happened 10 days before Christmas 2009. I was somewhere over the rainbow, in deep slumber—when I felt a hand pressing my shoulder and heard a voice, “Dr. Tellis-Nayak! I want you to be awake!” <br></div> <div><br>Reality dawned ray by ray—I couldn’t budge; I was belted down, my skull was in a vise inside a steel trap bolted down to the metal bed. Around me stood six men and women, all oozing smarts. I saw, on my left, a compact figure wearing a white gown and a triumphant smile. “How do you feel?” Dr. V asked. Suddenly, reality crashed in, and everything came into focus.</div> <div><br>I was at the hospital getting a brain tune-up from Dr. V. I was under “conscious sedation” and told to stay awake, but trusting my brain in Dr. V’s hands, I had slid into a midday siesta on my personal “Fantasy Island.”</div> <div><br>PD had sneaked up on me; my left-hand tremors started in 1995. PD turned my world upside down, and it directed its unmitigated fury toward my professional life; it took aim at areas where I felt particularly proud and would hurt the most.</div> <div><br>Worse, PD made me watch in slow motion my descent into a personal hell. The professor, the researcher, and the public speaker in me suffered exquisite mortification. My strut gone, now I shuffled my way to the podium; I stood there unstable and ungainly, my left hand shaking against my will, my voice barely louder than a squeak, my speech reduced to a mumble, my words slurring; I could not read my scrawl on the blackboard. </div> <div><br>My medical regimen had blunted PD’s attack but did not halt its advance. My intellectual and spiritual defenses did not match its resolve to drag me toward the black hole of helplessness, meaninglessness, self-pity, and despair.</div> <div><br>On the verge of surrender, I reached out to Dr. V for a brain tune-up. He recommended DBS (Deep Brain Stimulation). I signed on immediately.</div> <h2 class="ms-rteElement-H2">Resetting Brain Circuits</h2> <div>DBS is based on the evidence that each human action (motor, memory, or cognition) is modulated by a specific brain circuit located in a specific brain area. DBS works as a radio works. You turn one dial to locate the station and another to turn the volume up or down. Similarly, you locate the brain area whose circuit is linked to a specific human activity. You implant a pace setter to stabilize, accelerate, or slow that circuit and so to regulate the activity associated with it. </div> <div><br>Two professors at Grenoble, France, introduced DBS to the world in 1987 as an effective treatment for PD. It is now used to treat other movement disorders and neurological and psychiatric conditions. About 100,000 DBS implants have been done worldwide.</div> <div><br>I was at the hospital the night before my early morning date with DBS. Dr. V planned the event to unfold in two steps. First, they wrapped a metal trap around my skull, calling it a “halo.” </div> <div><br>The halo bolted down my head immovably as the medical cognoscenti mapped my brain; the coordinates set and traced the optimal route to my subthalamic region. They numbed my scalp, cut a five-inch gash, and, with a press-drill a bit fancier than my TrueValue version, they bore a hole the size of a quarter into my skull. </div> <div><br>Human brains have no pain feelers. So, under “conscious sedation,” I was supposed to stay awake and enjoy the sight and sounds of my own demolition. I chose to snore away in dreamland. </div> <h2 class="ms-rteElement-H2">High Drama</h2> <div>The next part was high drama. The docs held an electrode (metal rod) at the hole in my head (front-right and due north from the eye), angled it about 45 degrees, and drove it through the center of the brain toward a pea-sized target in the subthalamus basement of the brain.</div> <div><br>The mindless invader decimated my brain cells in its path and sent them into oblivion, each emitting a digital dying wail. I mourned the IQ points I lost in Operation DBS.</div> <div><br>With the rod lodged close to its destination, Dr. V pulled me back from my dreamy escape. His smiley-like smile told me the train had arrived, and now he needed my help to pick the right platform where it should be stationed. </div> <div><br>For the next 15 minutes he twisted and turned my left hand in every direction, while Dr. O, his partner in this invasion, jabbed, stabbed, and poked around my brain till they found the optimal spot to park the hot rod. </div> <div><br>To spare me the gruesome sight of the last scene, the medicine men tripped my main fuse and blanked me out. They cut open a pouch below my right collar bone, nested in it a thick credit-card-sized battery with a trailing cable, which they buried under the skin along a path from my chest, winding up behind the ear and joining it to the electrode under the skull. </div> <div><br>My traumatized brain protested, swelled, and delayed the turning on of the switch buried in my chest. They gave me a remote control that turns the stimulator in my brain on or off. </div> <div><br>I take care to keep out of reach of my grandkids, lest they should get ideas and use it as a joystick. </div> <h2 class="ms-rteElement-H2">Belles and Cherubs</h2> <div>The gurney brought me to the recovery room looking like Lazarus swaddled in bandages staggering out of the sepulcher.</div> <div><br>I was relieved that I survived the eight-hour storming of my defenseless brain, and was buoyed by the company of Mary, my long-suffering personal nurse and bride of over four decades. </div> <div><br>Back in my room a bevy of belles—bright-faced, freshly minted young nurses—greeted the return of their most compliant patient who since last evening had let them poke needles into me; draw blood from me; and thrust thermometers, meds, and other foreign objects into my orifices. </div> <div><br>I felt blessed among these women. </div> <div><br>My son had dropped in the night before and had fortified my soul for the ordeal. This evening, he came with his consort and their two bouncy cherubs in tow. The next two hours were pure chaos—laughter, son, and horse play as the cherubs revived Grandpa Lazarus.</div> <div><br>Jocelyn, RN, had recorded my runaway blood pressure a little before the kids came. She dropped by to track it again, as they were about to depart. Her jaw dropped to the floor: My blood pressue had plummeted down to normal!</div> <div><br>Do kids have a role to play in brain surgery? Why do hospital visiting rules for kids vary so widely? Some hospitals encourage families to visit, when some others cannot seem to bear the sight of them. I wondered which of these policies and practices were rooted in firm evidence and which in common sense? </div> <div> </div> <div>Next month: Anomalies of Bionic Medicine<br><br><em>Vivian Tellis-Nayak, PhD, is senior research advisor at National Research Corp., Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He has conducted research in the United States and abroad, and his major findings have reached a wider public through his writings in trade magazines. Tellis-Nyak can be contacted at <a target="_blank" href="mailto:vtellisn@gmail.com">vtellisn@gmail.com</a>. </em><br></div> Parkinson’s disease (PD) has dragged me through hellfire; it has wrecked my body and tested my soul. This ordeal has taught me much about life in general, and about matters both great and trivial. 2014-01-01T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_hands.jpg" style="BORDER:0px solid;" />Quality;CaregivingColumn1
Demystifying QA Record Disclosure Ruleshttps://www.providermagazine.com/Issues/2014/Pages/0114/Demystifying-QA-Record--Disclosure-Rules.aspxDemystifying QA Record Disclosure Rules<div>During annual certification surveys, nursing homes are routinely faced with surveyor requests for incident reports, audits, tracking logs, and other records analyzed by the provider’s quality assurance (QA) committee, as part of the <a target="_blank" href="/Issues/2014/Pages/0114/QA-What-You-Need-To-Know.aspx">QA</a> process.</div> <h2 class="ms-rteElement-H2">‘Privileged’ COmmunications</h2> <div>Historically, these documents have been considered privileged communications. <br></div> <div><br>An ever-present concern has been that if a nursing home discloses such QA records to surveyors, the privilege will be destroyed and they may become discoverable in future litigation, or worse, form the basis for additional survey deficiencies.</div> <div><br>In short, the ability of facility staff to engage in frank, meaningful QA discussion and analysis, and even to conduct thorough investigations, is at risk when QA records are disclosed. </div> <div><br>Recent interpretations of F-Tag 520, Quality Assessment and Assurance (QAA), by state and federal courts, as well as the Departmental Appeals Board (the independent review for the Department of Health and Human Services), warrant revisiting this often-sticky issue. </div> <h2 class="ms-rteElement-H2">Basic Law</h2> <div>F-Tag 520, which contains the requirements for nursing facility QAA committees, defines not only the composition and meeting requirements of the QAA committee, but also its function. </div> <div><br>Specifically, a QAA committee “meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary, and it must develop and implement appropriate plans of action to correct identified quality deficiencies.”</div> <div><br>The QAA privilege plainly states: “The State or the Secretary [of Health and Human Services] may not require disclosure of the records of the committee except insofar as such disclosure is related to the compliance of [the quality assessment and assurance] committee with the regulatory requirements.”</div> <div><br>That is, is the QAA committee comprised of the appropriate individuals, meeting quarterly as required, and is it identifying issues and developing plans to address problematic areas? The CMS investigative protocol for F-Tag 520 further clarifies that “the facility is not required to release the records of the QA committee to the surveyors for review, and the facility is not required to disclose records of the QA committee beyond those that demonstrate compliance with the regulation.”  </div> <h2 class="ms-rteElement-H2">QAA Committee Record Reporting Requirements</h2> <div>The critical question is then, what constitutes the “records of the QAA committee” that are not required to be released or disclosed? While a broad definition has often been used, the Centers for Medicare & Medicaid Services (CMS) and the federal courts have narrowed the definition over the past several years. </div> <div>In fact, CMS recognizes that nursing home providers collect and analyze data about their performance in various forms and from various sources that may help them to identify quality deficiencies. </div> <div><br>The agency’s interpretive guidelines for F-Tag 520 specifically reference “facility logs and tracking forms, incident reports, and consultant reports” as part of the data collection process. </div> <div><br>But the F-Tag 520 interpretive guidance, labeled “Identification of Quality Deficiencies,” goes on to clarify that while records of the QAA committee meetings that identify quality deficiencies “may not be reviewed by surveyor,” unless the facility chooses to provide them, “the documents the committee uses to determine quality deficiencies are subject to review by the surveyors.”  </div> <div><br>Therefore, logs, tracking forms, and incident reports may be reviewed by surveyors, at least according to CMS’ interpretation. <br></div> <h2 class="ms-rteElement-H2">Can QA Records Form The Basis For Survey Deficiencies?</h2> <div>As existing case law makes clear, CMS takes the position that incident reports authored contemporaneously with an accident or incident are subject to review by surveyors, and these reports are not privileged under the statute. </div> <div><br>Incident reports, according to CMS, are simply fact-gathering documents and are separate and distinct from the QA process.    </div> <div><br>With regard to QA committee minutes, internal deliberations, analyses, and good faith attempts by the QA committee to identify and correct quality deficiencies “will not be used as a basis for sanctions.” </div> <div>Furthermore, as found in F-Tag 520, the facility is “not required to release the records of the [quality assurance] committee to the surveyors to review, and the facility is not required to disclose the records of the QA committee beyond those that demonstrate compliance with the regulation.” </div> <h2 class="ms-rteElement-H2">Guidelines Advise Finding Alternative Measures</h2> <div>The interpretive guidelines at F-Tag 520 suggest that viewing QA records is appropriate “if it is the facility’s only means of showing the composition and functioning of the QA committee.” </div> <div><br>In other words, surveyors should exhaust alternative investigative measures to assess compliance with the F-Tag before the surveyors request that the facility disclose QA records. Alternative investigative measures may include interviews with QA committee members and review of QA policies, meeting schedules, and blank or redacted QA committee forms. </div> <div><br>Under no circumstances should copies be required to be turned over to surveyors.</div> <h2 class="ms-rteElement-H2">What Is Allowable</h2> <div>What seems most problematic is when surveyors demand disclosure of QA records when investigating a resident fall or another accident. Incident reports and their corresponding investigatory information can demonstrate that an appropriate investigation has occurred and may be requested by, and reviewed by, the survey team. </div> <div><br>But a subsequent request to review additional analytical materials prepared by or at the request of the QA committee should be resisted. Where data compilations such as monthly fall logs, weight-tracking reports, or other similar analyses are compiled at the request of and distributed to the QA committee for review and analysis, the best approach is to avoid disclosure.  </div> <div><br>Based on the above Medicare requirements, surveyor requests to review QA records for the purpose of investigating a particular incident are inappropriate. </div> <div><br>Instead of reviewing QA records to investigate resident falls and accidents, surveyors should review resident medical records and other records kept as a part of the resident’s medical record in the ordinary course of treatment. And if a facility feels compelled to allow surveyor review based on a particular situation, the reviewed documents cannot be used as a basis for sanctions. </div> <div><br>Any attempt by CMS to do so should be challenged. <br><br><em>Jeannie Adams, director at Hancock, Daniel, Johnson & Nagle, Richmond, Va., advises long term care providers on state and federal reporting requirements and Medicare certification and survey requirements. Adams is a frequent speaker and contributor to written publications involving the long term care industry. She can be reached at (804) 967-9604 or at <a target="_blank" href="mailto:jadams@hdjn.com">jadams@hdjn.com</a>.</em></div>During annual certification surveys, nursing homes are routinely faced with surveyor requests for incident reports, audits, tracking logs, and other records analyzed by the provider’s quality assurance (QA) committee, as part of the QA process.2014-01-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0114/legal_thumb.jpg" style="BORDER:0px solid;" />LegalLegal Advisor1




Travel Activity Spurs Reminiscencehttps://www.providermagazine.com/Issues/2014/Pages/0214/Travel-Activity-Spurs-Reminiscence.aspxTravel Activity Spurs Reminiscence<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p> </p> <div><br><img width="182" height="287" class="ms-rteImage-0 ms-rtePosition-1" src="/Issues/2014/PublishingImages/0214/caregiving/caregiving1.jpg" alt="" style="margin:5px 10px;" /><br>Although a hectic day-to-day work schedule rarely allows one to take a minute to enjoy the beauty of the surrounding world, it is important to stop and soak it in—explore. In a health care environment, there is a tendency to overlook the fact that residents still strive to broaden their personal worlds, reminisce, discuss, and learn.<br><br></div> <div>Addressing this issue by promoting new ideas and engaging residents in a vast array of activities creates a better quality of life throughout care centers.</div> <h2 class="ms-rteElement-H2">Engaging The Senses</h2> <div>Last year, the Extendicare Foundation received a grant request from Elder and Adult Day Services to fund an innovative program aimed at stimulating cognitive function, increasing physical activity, and engaging the five senses of elderly individuals or those with limited function or disabilities. <br><br></div> <div>Dubbed Destinations Travelogue, the program enables residents and staff to travel to different nations and experience different cultures across the world without leaving their current residence. <br></div> <div><br>“The Destinations program was on the drawing board for years, but we could never free up the resources to get it done,” says Jeff Bradt, chief executive officer of Elder and Adult Day Services. “We were delighted when we learned that the foundation saw the potential in the project and was willing to invest in it. We’d done travelogues in the past and thought that, done right, a travelogue could engage the intellect and all of the senses to create an authentic travel experience.”</div> <div><br>To create this experience, Destinations Travelogue transforms each center through the materials it provides every month. Each center receives a packet that includes a DVD presentation highlighting the different aspects of a specific country; mock passports; online references; and discussion notes intended to present a historical, cultural, and interactive overview to residents. </div> <div><br>The partnership between Elder and Adult Day Services and Extendicare has enabled many residents to experience ethnic recipes and activities unique to a variety of countries. </div> <div><br>Director of quality life services, Janet Krahn, has helped implement the program throughout the Extendicare centers. “The Destinations Travelogue program allows our residents opportunities to learn about new countries as well as reminisce about all the traveling they have done in their lifetime,” says Krahn. “These travelogues are often the start of a conversation or program that lasts all month long. It has been extremely successful in our centers, and the life enrichment directors and residents are very appreciative of the materials provided. It is continually growing and a great program for all involved.”</div> <h2 class="ms-rteElement-H2">Centers Tailor Experiences </h2> <div>With the implementation of this program in 120 Extendicare centers across the country, residents have already been able to “travel” to unique places around the world, including China, Ireland, India, the southwestern United States, the Caribbean, Kenya, Australia, Germany, Hawaii, and New Orleans. </div> <div><br>Throughout these adventures, the centers have been personalizing the way they present the information to their residents in a variety of ways. </div> <div><br><img width="225" height="433" class="ms-rtePosition-2 ms-rteImage-0" src="/Issues/2014/PublishingImages/0214/caregiving/caregiving4.jpg" alt="" style="margin:5px 10px;" />For example, utilizing the 110th Harley-Davidson anniversary in late August, Lake Country Landing in Oconomowoc, Wis., merged the Harley celebration and the Destinations Travelogue journey throughout the southern United States via motorcycle. </div> <div><br>They used this road trip as an opportunity to present their residents with a one-of-a-kind experience. After watching the presentation, residents could feel the atmosphere change as loud noises emerged and the ground started to shake. Moments later, 20 bikers came whizzing through the town of Oconomowoc waving their USA flags as they pulled into Lake Country Landing. </div> <div><br>Residents were able to reminisce with the bikers, telling them about their biking adventures of the past. In return, the bikers revealed stories of their own from road trips taken throughout different areas around the country. As stories dwindled, bikers led residents outside to take photographs on their bikes, creating new memories to carry with them. </div> <div><br>“It was so exciting, and they talked about it for days,” says Lori Lutz, executive director at Lake Country Landing. </div> <div><br>Valley Manor Nursing and Rehab Center in Coopersburg, Pa., personalized its trip to India by contacting local Lehigh Valley India natives. After residents viewed the presentation and were well versed on the country, a traditional performance was planned by the Lehigh Valley India natives. </div> <div><br>Participants were able to experience first-hand some of the Indian traditions they had learned. Dressed from head to toe in stunning traditional attire, the native women, men, and children took the stage to demonstrate musical customs through dance, drumming, and piano. Afterwards, they spent time speaking about the different areas of India and details specific to each region.</div> <div><br>Nanci Bain, life enrichment director at Valley Manor, says residents “were really excited to hear the group mention some of the places and foods they had learned about in the DVD. The natives really spent time with the residents, answering any questions they had. It was a great night for everyone!”  <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Luaus and Leis</h2> <div>An “aloha” at Statesman Health and Rehabilitation in Levittown, Pa., kicked off its Hawaii Destinations Travelogue and was a night of fun in the sun. Under the direction of Danielle Quindlen, life enrichment director at Statesman, the team utilized beautiful decorations ranging from leis, posters, and palm trees to transform the center into a festive luau. </div> <div><br>Statesman took advantage of the additional recipes provided in the packets and created a traditional tropical drink in coconuts and an authentic pineapple upside-down cake. </div> <div><br>While the presentation was given, residents were able to simultaneously listen to the show and enjoy their treats, complete with a small tiki umbrella. Residents reminisced about their travels over the Pacific and the authentic food they had eaten years ago. Ranging from whole roasted pigs to fresh fruit, residents and staff shared their culinary journeys with one another. </div> <div><br>Destinations Travelogue has not only livened up the routine in Extendicare’s health centers, it has allowed residents and staff to bond on a deeper level. </div> <div><br>“We feel so fortunate to be able to integrate this program into the lives of our residents. This monthly activity is something that they look forward to with great anticipation; it is appropriate for all ages and all types of people who love to learn about new places or have traveled themselves,” says Angela Szewczyk, life enrichment director at Tendercare Kalamazoo (Michigan). “I am so encouraged to see a spark of recognition on my residents’ faces when they see a picture of a place they have been to and meaningful conversation follows reminiscing with staff or family members.”</div> <h2 class="ms-rteElement-H2">Expanding Horizons</h2> <div>As the program’s exploration throughout the world continues, the nontraditional passports of residents are becoming increasingly full. From road tripping across the United States on the back of a motorcycle to visiting the Taj Mahal in India, Destinations Travelogue has allowed residents to gather information about the people around them, in addition to the world around them. </div> <div><br>Elder and Adult Day Services has provided the base materials for the program, and the centers have truly personalized the way they are incorporating the program into the lives of their residents. These hands-on, interactive approaches promote new ideas for the centers, allowing residents and staff members alike to actively get involved. </div> <div><br>As centers look to the future, many anticipate utilizing the additional resources more frequently and to a greater extent. Recipes, crafts, and games transform the ordinary into the extraordinary and allow residents to travel to places they may have never thought possible. </div> <div><br>As the saying goes, “the world is your oyster.” Where to next? </div> <div> </div> <div><div><span style="font-family:'calibri', 'sans-serif';font-size:11pt;"><strong>To find out more information about the Extendicare Foundation and Elder and Adult Day Services, visit </strong><a href="http://www.extendicarefoundation.org/"><font color="#0000ff"><strong>www.extendicarefoundation.org</strong></font></a><strong> and </strong><a href="http://www.eads-cares.org/"><font color="#0000ff"><strong>www.eads-cares.org</strong></font></a><strong>.</strong></span></div> <div><span style="font-family:'calibri', 'sans-serif';font-size:11pt;"> </span></div></div> <p><em>Alyssa Evans is communications assistant for Extendicare Health Services, Milwaukee, Wis. She can be reached at <a href="mailto:%20AEvans3@extendicare.com" target="_blank">AEvans3@extendicare.com</a>.</em> <br></p>The Destinations Travelogue program enables residents and staff to travel to different nations and experience different cultures across the world without leaving their current residence. 2014-02-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0214/caregiving/caregiving_thumb.jpg" style="BORDER:0px solid;" />Caregiving;QualityColumn2
Guardianship And Medicaid: The Ins And Outs https://www.providermagazine.com/Issues/2014/Pages/0214/Guardianship-And-Medicaid.aspxGuardianship And Medicaid: The Ins And Outs <p></p> <div><br>As the long term and post-acute care profession braces for fallout from implementation of the Affordable Care Act and multiple statewide initiatives aimed at curbing the cost of providing care to the elderly, it has become increasingly important for providers to maximize every possible receivable dollar. </div> <div><br>Coupled with the changing scenery in the profession is the growing trend for residents and their families to maximize strategies to attempt to limit their personal exposure to contributing to the cost of their own care. Many facilities struggle to develop a sound policy with respect to the level and extent to which assistance is provided to residents and their families in applying for Medicaid.</div> <h2 class="ms-rteElement-H2">Statutes Differ By State</h2> <div>While private-pay rates are typically higher than Medicaid reimbursement rates, the Medicaid reimbursement is a (relatively) secure and consistent source of payment and does not usually require any collection activity.<br><br></div> <div>Nursing homes utilize a range of resources in assisting with Medicaid applications. Some have dedicated staff members who assist applicants with the cumbersome task of assembling the records, while some outsource the responsibility to independent contractors paid for either by the resident or the provider. </div> <div><br>An increasing problem under these scenarios is residents with little to no family, or family members who refuse to provide any assistance. </div> <div><br>In these cases the facility is left struggling to make an application for a resident who cannot communicate the information required to successfully obtain Medicaid coverage, usually because of a diagnosis of dementia or Alzheimer’s disease. The question becomes: What does the facility do in this scenario? There is a range of answers, but the one many providers find most practical is to make an application for guardianship on behalf of the resident.</div> <div><br>The guardianship statutes differ widely state by state, and although most states have enacted the Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act, which seeks to provide a mechanism for resolving multi-state jurisdictional disputes when people subject to guardianships migrate, the complicated fabric of substantive guardianship statutes still varies.</div> <h2 class="ms-rteElement-H2">Resources A Knotty Issue</h2> <div>The federal law governing the state-by-state management of Medicaid programs, 42 U.S.C. §1396a(a)(17), and the section that controls the extent of resources that a Medicaid applicant or recipient can retain says that the Medicaid program should take into account “only such income and resources as are…available to the applicant or recipient…” </div> <div><br>In most states, once an application for guardianship is filed, the person with the alleged incapacities is deemed to no longer have access to his or her resources and income. </div> <div><br>The practical implication is that for a resident who is in the throes of applying for Medicaid, a pending guardianship application will force the Medicaid department to review that application as though the resident has no income and resources. </div> <div><br>As long as the rest of the Medicaid application is complete, this could be a relatively quick path to Medicaid qualification. The rub, so to speak, occurs once the guardianship application has been resolved. <br>At that point, the Medicaid department would return to the application and determine from the resources and income of the applicant whether they are indeed eligible for Medicaid coverage under the traditional means-tested approach.</div> <div><br>This strategy works well when the nursing home has a good indication that the resident’s resources are in line with the levels required by Medicaid. In other cases, available resources may be difficult to determine, especially when a resident has diminished or no capacity and/or an uncooperative family. <br><br></div> <h2 class="ms-rteElement-H2">Guardianship Ups And Downs</h2> <div>The guardianship application may go a long way toward resolving this issue. If the nursing home is appointed as guardian, which is allowed in most states, it will have wide-ranging authority to investigate the resident’s income and resources. This authority usually allows the facility to obtain the information necessary to complete the Medicaid application.</div> <div><br>Although near-immediate Medicaid qualification with a pending guardianship application may be a great approach for some residents with nominal personal resources, this could serve as a trap when a resident has excess resources that will eventually disqualify him or her for Medicaid coverage. </div> <div><br>Assume the facility files for guardianship for a resident with advanced Alzheimer’s and then files a Medicaid application. Medicaid approves the application and begins reimbursing the facility. Once the guardianship is resolved, a few months later, it is discovered that the resident has sufficient resources and cannot qualify for Medicaid. In this case, the facility will be forced to disgorge the payments received by Medicaid. </div> <div><br>Theoretically, this would not be the worst problem in the world, because the facility then would have discovered the resident’s resources, which would, again in theory, be available for privately paying the facility. </div> <div><br>However, as Yogi Berra once said, “In theory, there is no difference between theory and practice. But in practice, there is.” It is not always that cut-and-dried once the facility discovers the resident has resources. If the guardianship application is unsuccessful for some reason, the facility may know about the resource but need to employ additional strategies to collect it. </div> <h2 class="ms-rteElement-H2">Example Offers Insight</h2> <div>An example may be helpful: Recently Dolly was admitted to a nursing home from the hospital where she was sent by the local adult protective unit because she was found to be living in an unsafe condition in her home. The nursing center knew she owned her home, but had no idea whether she had any other assets.</div> <div><br>Dolly’s only child was living in a group home himself and was unable to assist Dolly in any way and could not help with a Medicaid application. Since there did not appear to be anyone to manage Dolly’s affairs and because it was clear she would not be able to return to her home, the nursing home applied for and was granted guardianship over Dolly, which gave them the authorization to go through her house and try to assemble a list of her assets. </div> <div><br>In the meantime, the nursing home had applied for Medicaid coverage while the guardianship application was pending, and Dolly was approved for Medicaid coverage, which allowed the nursing home to be reimbursed for her care. </div> <div><br>After the guardianship was approved, it was discovered that Dolly owned her home (where the taxes were three years delinquent) and had a small bank account. As her resources were well within the limits for Medicaid, her Medicaid application was approved and there was an adjustment made based on her income for her contribution to the cost of her care. </div> <div><br>Although the nursing home absorbed the expense of the guardianship proceeding, in the face of a family and a resident who could not assist in the process, it was the only way to ensure that the home could find a way to pay for Dolly’s care.</div> <div><br>Using the guardianship application is not a panacea when a facility needs to get a resident on Medicaid, especially if his/her level of functioning does not make the resident an appropriate candidate to have a guardian appointed. However, using the guardianship application in tandem with a Medicaid application is one method nursing homes are using to secure a guaranteed source of payment for many residents. <br><br><em>Josephine Yang-Patyi and Anthony Marrone II, are attorneys with Menter, Rudin & Trivelpiece, in Syracuse and Watertown, N.Y. Reach them at (315) 474-7541, <a target="_blank" href="mailto:jyangpat@menterlaw.com">jyangpat@menterlaw.com</a> or <a target="_blank" href="mailto:amarrone@menterlaw.com">amarrone@menterlaw.com</a>.</em><br></div> <p></p>While private-pay rates are typically higher than Medicaid reimbursement rates, the Medicaid reimbursement is a (relatively) secure and consistent source of payment and does not usually require any collection activity. 2014-02-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0214/legal_thumb.jpg" style="BORDER:0px solid;" />Legal;CaregivingLegal Advisor2
Inventive Solutions Boost Managed Care Relationshipshttps://www.providermagazine.com/Issues/2014/Pages/0214/Inventive-Solutions-Boost-Managed-Care-Relationships-.aspxInventive Solutions Boost Managed Care Relationships<p>Offering innovative solutions for quality care across the spectrum of settings, even when it means creating partnerships with unorthodox entities, will result in more successful managed care relationships, participants at <em>Provider’s</em> Executive Roundtable in October concluded. The roundtable was sponsored by American HealthTech. </p> <p><img class="ms-rteImage-0 ms-rtePosition-1" alt="Provider Executive Roundtable" src="/Issues/2014/PublishingImages/ProviderRoundtable.jpg" style="margin:10px 5px;" /><br>In California, for example, two nursing home providers are considering the addition of adult day health care services and a geriatric care practice to their buildings. “You have to look at repurposing the building,” says Jim Gomez, president and chief executive officer (CEO) of the California Association of Health Facilities. “Two of my members are coming together and repurposing their space. I’m talking about taking part of their building and putting a geriatric practice into it for adult day health care. So they will have a better link to the community, provide a wide range of services, and it will bring flow to them.” <br></p> <p>The benefit of this, says Gomez, is so that when providers are working with health maintenance, managed care, or accountable care organizations, they can they have a doctor’s office, long term care services, and adult day health care all in one building.<br></p> <p>“You can say, ‘I can take care of the patient throughout this,’” says Gomez, who negotiated for an HMO for many years and notes that “they will look to you for solutions, and when you come up with a solution you may be able to capture a significant amount of the marketplace because you are doing more than just the typical long term care provider.”<br></p> <p>Building on the concept of innovation and serving the community, Medicalodges Chief Operating Officer Fred Benjamin sees a “great opportunity” for providers with regard to Medicaid programs.<br></p> <p>“In Kansas, the program serves many kinds of subpopulations, including frail elderly and women and children. And it goes to creating different kinds of programs—dialysis, for example, home health, and if you have extra land, creating a low-cost senior apartment building on the campus,” he says. “It’s all about serving the managed care company as your customer. They have issues they want to take care of with these subpopulations … and we can create a series of programs that solve their problems and their issues.”<br></p> <p><img class="ms-rtePosition-2" src="/Issues/2014/PublishingImages/0214/roundtable1.jpg" alt="" style="margin:10px;" />Summing up the consensus was Ken Lund, president and CEO of Kennon S. Shea and Associates: “Ultimately, [MCOs] are like any other customer. They want you to create the solution, they want it to be affordable, and probably equally important, they want it to be easy and convenient.”<br></p> <p>Lund described an innovation that he says has been very successful for his company. “The model we’ve built is to deliver a continuum with a single point of entry so that whoever is the trusted advisor of the patient, when they come to us, we don’t have to say ‘we’ve got these skilled beds for you.’ Instead, we can say, ‘where do you want to go in the continuum?’” he says. <br></p> <p>“We’ve literally tried to abolish the word discharge in our vernacular, because what we really see as our opportunity is being able to follow that patient through a lifetime rather than just through an episode. We’re finding that very effective because we bought a home health care company, and in 10 months it’s our single largest operation without doing any external marketing.”<br></p> <p>Garen Cox, president and CEO of Medicalodges, explained that a majority of his companies’ buildings are in rural areas where the hospitals are struggling. <br></p> <p>“So we’ve spent a lot of time building a backbone to our infrastructure … and we’ve found ourselves becoming the health center for the community. <br></p> <p><img class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/0214/roundtable2.jpg" alt="" style="margin:10px;" /><br>“We are not only the largest employer in some of these areas, but we’re the place where folks go for health care,” he says. “So, in some of our facilities we’ve looked at bringing in physicians to operate a clinic out of the centers. We’re also partnering with other entities to offer other services.”<br></p> <p>Gomez took this concept a step further with the suggestion that providers consider partnering with federally qualified health centers. “If there’s a center out there that wants to expand, some of our members are considering housing the community center in an empty wing,” he says. “You then get people coming into the facility and developing that community relationship.”<br></p> <p>Visit our <a href="http://www.youtube.com/playlist?list=PLdaXQI95Z7j8-7u4mrjdbwPjb7X4oZ69Q">YouTube </a>channel to see interviews with roundtable participants.<br></p>Offering innovative solutions for quality care across the spectrum of settings, even when it means creating partnerships with unorthodox entities, will result in more successful managed care relationships, participants at Provider’s Executive Roundtable in October concluded. 2014-02-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/Roundtable_thumb.jpg" style="BORDER:0px solid;" />Management;Quality;Quality Improvement;ReimbursementColumn2
On Food And Food For Thoughthttps://www.providermagazine.com/Issues/2014/Pages/0214/On-Food-And-Food-For-Thought.aspxOn Food And Food For Thought<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>An 86-year-old woman enthused to her daughter, “I don’t mind being in the rehab center—the food here is great!” This comment might serve as the standard to which long term and post-acute care facilities aspire: to create delicious, nutritious meals that ensure living there is a highly palatable experience. <img width="345" height="258" src="/Issues/2014/PublishingImages/0214/mgmt/mgmt1.jpg" class="ms-rtePosition-2" alt="" style="margin:10px;" /></p> <p>Nutrition is the bedrock of both health recovery and continued well-being, especially among elders and those with compromised immunity. Yet health care providers can face significant challenges designing menus to meet patient needs. Some of the factors providers must address include the following:<br></p> <p>■ <strong>Emotional factors.</strong> Loneliness and depression can affect appetite. For some, feeling depressed leads to not eating; in others it may trigger overeating. </p> <p>■ <strong>Metabolism.</strong> For every year over the age of 40, metabolism slows down. This means if someone continues to eat the same amount and kinds of food as when they were younger, they are likely to gain weight because they are burning fewer calories. In addition, seniors in assisted living or post-acute care settings are generally less physically active than previously. </p> <p>■ <strong>Taste and appetite.</strong> Taste and smell diminish with age, and salt must often be restricted or omitted due to health conditions. Medications can also negatively influence <a target="_blank" href="/Issues/2014/Pages/0214/Appetite-Enhancers.aspx" title="Appetite Enhancers">appetite</a>. </p> <div>■<strong> Digestion.</strong> Due to changes in the digestive system, older adults generate less saliva and stomach acid, making it more difficult for their bodies to process certain vitamins and minerals, such as B12, B6, and folic acid, which are necessary to maintain mental alertness, memory, and good circulation.  </div> <div> </div> <h2 class="ms-rteElement-H2">Conventional Vs. Organic</h2> <div>One of the biggest ongoing food debates concerns conventional versus organic foods. For older people, especially those with chronic health conditions, organic (or unsprayed) is far better and may not cost more when purchased in large quantities, or directly from the organic farmers. </div> <div><br>What’s the distinction? The terms “conventional” and “organic” refer to the ways in which food is grown, handled, and processed. Conventional farmers use synthetic or chemical means to fertilize soil, control weeds and insects, and prevent livestock disease. Organic farmers opt for less-invasive methods such as manure or compost fertilizer, crop rotation, and giving animals room to roam; hence, the term “grass-fed” for beef and “pasture-raised” for eggs.</div> <div><br>One important caveat: The term “natural” does not equal organic. Natural is an unregulated term that can be applied by anyone and is therefore potentially misleading. </div> <div><br>While commonly seen food labels such as “all natural,” “free-range,” or “hormone-free” signify that the food has been raised or grown humanely, only the “USDA Organic” label indicates that a food is certified <br>organic.</div> <div><br>However, unsprayed foods, as mentioned above, can often be considered “as good as” organic. Local farmers may not have the financial resources to undergo the lengthy, expensive USDA (United States Department of Agriculture) certification process. </div> <div><br>The main consideration is how the food is grown or raised, not whether it has a specific sticker on the package. </div> <div><br>If assisted living, nursing center, and post-acute care providers can develop business relationships with local farmers who practice pesticide-free farming methods, this is an excellent way to ensure residents receive high-quality, safe, nutritious food.</div> <h2 class="ms-rteElement-H2">What’s Really In Organic And Nonorganic Foods</h2> <div>The Environmental Working Group (www.ewg.org), a nonprofit organization that specializes in research and advocacy in the areas of toxic chemicals, agricultural subsidies, public lands, and corporate accountability, compiled two lists using USDA data on the amount of pesticide residue found in nonorganic produce after it had been washed. </div> <div><br>The “Dirty Dozen” foods tested positive for a minimum of 47 different chemicals when conventionally grown, while the “Clean 15” are safer to buy as conventional, as they contain little to no trace of pesticide once harvested (see sidebar).</div> <div><br>Genetically modified organisms (GMOs) are life forms that have been genetically engineered. Genetic engineering (GE) is the process of taking genes from one strain of a plant, animal, or virus and inserting them into another, with the goal of reproducing characteristics of the original species in the receiving species. </div> <div><br>The U.S. government first sanctioned pharmaceutical gene splicing in 1982. However, GE and GM foods didn’t make their way onto supermarket shelves until 1994.</div> <div><br>Although three government agencies are involved in the GMO approval process (the USDA, Environmental Protection Agency, and Food and Drug Administration), there are no mandated pre-market safety studies. As with pesticides and drugs, safety testing for GMOs is done by the companies that produce them, raising concern about ethics and conflict of interest.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Side Effects</h2> <div>Unintended health impacts from GMOs can include:</div> <div><br>■ <strong>Allergens.</strong> Because the addition of new genetic material changes protein sequences, GMO could produce known or unknown allergens—especially in people with weakened immune systems. </div> <div><br>■ <strong>Nutritional deficiency.</strong> Altered DNA could decrease levels of important nutrients in the </div> <div>GE crop.</div> <div><br>■ <strong>Increased toxins.</strong> Genetic engineering could inadvertently increase naturally occurring plant toxins—or introduce a new toxic strain created by the marriage of genes.</div> <div><br>■ <strong>Antibiotic resistance.</strong> An antibiotic resistant gene inserted into most GM crops may pose the most serious health hazard, since there is the possibility that these genes might transfer to pathogenic bacteria in human bodies and create new, antibiotic-resistant super-diseases.</div> <h2 class="ms-rteElement-H2">The Organic Advantage</h2> <div>In addition to eliminating the potential health and environmental hazards posed by pesticides, GMOs, irradiation, and additives, organically grown produce actually confers health benefits, according to new research. Organic foods are better for a senior’s body because they have more nutritional value, contain more antioxidants, and promote biodiversity. </div> <div><br>Organic foods contain higher levels of vitamin C, calcium, magnesium, and iron, while also containing more antioxidants.</div> <div><br>Food scientists at the University of California, Davis, found that organically grown fruits and vegetables show significantly higher levels of cancer-fighting antioxidants than conventionally grown foods. </div> <div><br>In addition, pesticides and herbicides reduce the production of phenolics—chemicals that act as a plant’s natural defense and are also good for human health. Organic fertilizers, however, appear to boost the levels of these anti-cancer compounds. </div> <div><br>Another benefit of organic foods is that they promote biodiversity. According to a study, “The Biodiversity Benefits of Organic Farming,” organic farms had five times as many wild plants and 57 percent more species. The organic farms also had more birds, spiders, and non-pest butterflies than nonorganic farms.</div> <div> </div> <div><img width="671" height="486" src="/Issues/2014/PublishingImages/0214/mgmt/mgmt_toxic.jpg" alt="" style="margin:5px;width:679px;" /><br><br><em>Amara Rose is a personal and business coach with a broad background in health and positive aging. She is a contributing columnist to seniors housing publications. Rose can be reached at <a target="_blank" href="mailto:amara@liveyourlight.com">amara@liveyourlight.com</a> or <span class="baec5a81-e4d6-4674-97f3-e9220f0136c1" style="white-space:nowrap;">(800) 862-0157<a href="#" title="Call: (800) 862-0157" style="border-width:medium;border-style:none;border-color:-moz-use-text-color;margin:0px;width:16px;bottom:0px;display:inline;white-space:nowrap;float:none;height:16px;vertical-align:middle;overflow:hidden;right:0px;top:0px;left:0px;"><img title="Call: (800) 862-0157" alt="" style="border-width:medium;border-style:none;border-color:-moz-use-text-color;margin:0px;width:16px;bottom:0px;display:inline;white-space:nowrap;float:none;height:16px;vertical-align:middle;overflow:hidden;right:0px;top:0px;left:0px;" /></a></span>. </em> </div>Nutrition is the bedrock of both health recovery and continued well-being, especially among elders and those with compromised immunity. Yet health care providers can face significant challenges designing menus to meet patient needs.2014-02-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0214/mgmt/mgmt_thumb.jpg" style="BORDER:0px solid;" />Management;CaregivingColumn2
Quality Through The Ageshttps://www.providermagazine.com/Issues/2014/Pages/0214/Quality-Through-The-Ages.aspxQuality Through The Ages<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p><br></p> <p><img src="/Issues/2014/PublishingImages/0214/anniversary/4ologo.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:5px 10px;" /><br>The quality evolution in long term care has paralleled the transformation of the profession itself. Over time, shifting regulatory, marketplace, and consumer expectations, as well as a growing understanding of best practices and the application of continuous quality improvement to long term care settings, has altered the very concept of quality.</p> <p>For 40 years, the quality journey has been at the core of <em>Provider’s</em> editorial content. As the flagship magazine of the American Health Care Association (AHCA) and the long term and post-acute care industry, <em>Provider</em> has delivered articles on quality trends, initiatives, and clinical best practices, chronicling the emergence of a culture of quality. </p> <p>That journey continues, and as <em>Provider</em> enters its fifth decade of publishing, the magazine celebrates with a look at quality through the ages.</p> <p></p> <h2 class="ms-rteElement-H2">In The Beginning…</h2> <div>The definition, measurement, and reporting of long term care quality was forged in the regulatory fires of the Omnibus Budget Reconciliation Act (OBRA).<br><br></div> <div>“That’s when there was not just an expectation for change, but a mandate for change,” says Mary Ousley, a registered nurse and president of Ousley and Associates. That’s when nursing centers were required to provide the “highest practicable level” of physical, mental, and psycho-social well-being, she adds.<br><br></div> <div>By establishing a threshold of “optimal” care, standards became “patient-centered, resident-centered, person-centered,” says Ousley, a past chairman of AHCA whose leadership in long term care quality is so extensive that AHCA renamed an award in her honor: The Mary K. Ousley Champion of Quality Award.<br><br></div> <div>Enacted in 1987, OBRA regulations weren’t published in final form until 1990, with controversial enforcement rules released much later, in 1995. While battles over the substance and implementation of OBRA raged, the reforms ushered in an era that would reshape nursing centers and the long term care marketplace. </div> <div><br>“Clearly, OBRA 87 was a huge transition point,” says David Gifford, MD, senior vice president of AHCA quality and regulatory affairs. “A lot has flowed from that.”</div> <h2 class="ms-rteElement-H2">Key Turning Points</h2> <div>Several quality milestones cascaded directly from OBRA, while others were set in motion as regulatory and marketplace forces converged, introducing new models and measurement for systemic quality. Gifford points to several key turning points and influences, including: <br></div> <div><br>■ The Medicare Minimum Data Set (MDS), which Ousley describes as “the largest database that exists anywhere in health care.” The MDS, a component of the OBRA Resident Assessment Instrument, was automated in 1998. </div> <div><br>“Once we had standardized digitized information, collected in a standardized way with standardized frequency, it quickly became evident that we could use it to assess quality” and establish payment levels, Gifford says. </div> <div><br>■ Medicare prospective payment system for skilled nursing facilities, which led to the advancement of rehabilitation and post-acute care and gave rise to a significant and growing population of short-stay nursing facility residents who are discharged from the hospital for these services, then return home or to a community-based setting;</div> <div><br>■ Publicly reported quality data through Nursing Home Compare, the Centers for Medicare & Medicaid Services (CMS) website established in 2002, and later the Five-Star Rating System for quality; </div> <div><br>■ The culture change movement, which spurred new person-centered models and philosophies of care; and</div> <div><br>■ The national campaign to reduce the use of physical restraints, which emanated from OBRA’s right for individuals to be free from physical or chemical restraints that were “not required to treat the resident’s medical symptoms,” Gifford says.</div> <div><br>The multifaceted effort, which CMS attributed to the work of “thousands of individuals in both nursing homes and in government,” has led to the steady reduction in the percent of residents who are physically restrained, from 21.1 percent in 1991 to 1.5 percent currently, according to CMS. </div> <div><br>The success of the initiative set the stage for subsequent targeted quality improvement campaigns.</div> <h2 class="ms-rteElement-H2"><span id="__publishingReusableFragment"></span><br></h2> <h2 class="ms-rteElement-H2">Seeds Of Market-Based Quality Reform</h2> <div>For several years in the post-OBRA marketplace, “quality was couched in a regulatory environment,” says Lane Bowen, executive vice president of Kindred Healthcare and president of its nursing division. “A good survey meant a quality operation,” says Bowen, who also serves as AHCA’s vice chair.<br><br></div> <div>But in the 1990s, while OBRA dictated nursing facilities’ regulatory obligations, private-sector approaches to quality, such as total quality management and continuous quality improvement, which had been used for decades in manufacturing and other industries, began migrating to long term care.<br><br></div> <div>This early movement was bolstered by the emergence of health information technology, which facilitated outcomes and performance measurement. A booming assisted living sector, built on the concepts of hospitality and customer satisfaction, also had an effect on providers’ acceptance of new ideas about quality.<br><br></div> <div>“The influence that seniors housing and hospitality had on us through their involvement [in AHCA] is a notable feature of the quality journey for nursing homes,” says Dale Thompson, the recently retired president/chief executive officer of Benedictine Health Systems who served as president of AHCA in 1996 and 1997.<br><br></div> <div>Under Thompson’s leadership, AHCA created the National Quality Award, a cutting edge program modeled after the rigorous Baldrige Award, which requires applicants to demonstrate systemic quality improvement.<br><br></div> <div>The AHCA award program was created as a three-step process, allowing providers to grow their quality improvement efforts over time.<br><br></div> <div>In 1996, 15 facilities received “Step 1” awards. Last year, there were 361 awards at that level, now designated as the Bronze, with 60 facilities taking home a Silver award, and five receiving the Gold. Over the lifetime of the program, there have been 3,215 Bronze, 317 Silver, and 18 Gold award recipients.</div> <h2 class="ms-rteElement-H2">Leading Effort</h2> <div>AHCA’s long-standing leadership in quality improvement includes the 1994 formation of the Quality Assessment Task Force, chaired by Thompson, which developed guiding principles for change. <br><br></div> <div>Significant quality programs sponsored by AHCA have included Facilitator, a 1997 quality management software system and precursor to today’s LTC Trend Tracker, which enabled AHCA members to track and compare their performance on key quality indicators.<br><br></div> <div>In February 2012, the organization launched the Quality Initiative, which took leadership a step further by establishing voluntary but defined quality targets for members to work toward and achieve by March 2015. </div> <div>Specifically, the initiative called for a 15 percent reduction in preventable hospital readmissions that occur within 30 days of admission to a nursing center; an increase in the portion of customers who would recommend the facility to others to 90 percent; and a reduction in nursing staff turnover by 15 percent. The initiative also called for a 15 percent reduction in the off-label use of antipsychotic medications by December 2013.<br><br></div> <div>In its first 18 months, the Quality Initiative had a significant impact, says Gifford, with 6,206 skilled nursing centers having achieved one or more of the four goals, and 68 facilities having accomplished all of them.</div> <h2 class="ms-rteElement-H2">Market-Driven Quality</h2> <div>Today, nursing centers operate in a marketplace where the expectation of regulatory compliance and good results on state surveys is compounded by the expectations of private-sector partners and payers, Bowen says.<br><br></div> <div>Accountable care organizations (ACOs) and managed care organizations (MCOs) “are becoming more of a driver than government,” he says. MCOs and ACOs “manage lives,” and as a result they may dictate staffing levels, length of stay, even clinical pathways when a complication or change in a resident’s condition occurs, Bowen says.<br><br></div> <div>To operate in this environment, Kindred has created “integrated markets,” consolidating all lines of business in a particular category and geographic area under a single manager to ensure consistency and efficiency. <br><br></div> <div>“We can’t have clinical protocols change from one setting to another,” Bowen says.<br><br></div> <div>“Today we have new expectations for financial performance and quality performance,” says Ousley. “Every financing model is now predicated on quality outcomes and metrics that determine the value of what you’re providing on a daily basis.”<br><br></div> <div>While providers should always be striving to achieve excellence and compliance in the survey process, Ousley says, efforts cannot stop there “when you are looking to be part of an ACO or network of care” that expects quality performance on a daily basis.<br><br></div> <div>“Only through robust quality improvement processes can you achieve that,” she says. ■</div> <div> </div> <p><em>Lynn Wagner is a freelance writer based in Shepherstown, W.Va.</em></p>The quality evolution in long term care has paralleled the transformation of the profession itself. Over time, shifting regulatory, marketplace, and consumer expectations, as well as a growing understanding of best practices and the application of continuous quality improvement to long term care settings, has altered the very concept of quality.2014-02-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0214/anniversary/4ologo.jpg" style="BORDER:0px solid;" />QualityCover Story2
Parkinson’s Disease: Anomalies Of Bionic Medicinehttps://www.providermagazine.com/Issues/2014/Pages/0214/Anomalies-Of-Bionic-Medicine.aspxParkinson’s Disease: Anomalies Of Bionic Medicine<p><em>This is the final installment of our blog series, “ProviderNation In Print.” We were so taken by Tellis-Nayak’s gripping, poignant, and candid descriptions of his struggle with Parkinson’s disease (PD), we feel these posts are worth every drop of ink.</em></p> <p>My introduction to <a href="/Issues/2014/Pages/0214/All-About-Deep-Brain-Stimulation-For-Parkinson’s-Disease.aspx" target="_blank">Deep Brain Stimulation</a> (DBS) also introduced me to a wide difference among hospital policies and safety protocols. In a tertiary care hospital, the sanctuary of modern medicine, I witnessed homage being paid to the false gods of irrationality.</p> <p></p> <div>I was at the center of a scary incongruity, only hours before surgery. I was at the hospital late Wednesday evening, sporting a confident smile that masked my diffident heart. To combat PD, the docs were to plant a sentinel inside my skull—and I had no clue how my brain would accept its new roommate. </div> <h2 class="ms-rteElement-H2">Fiasco Avoided</h2> <div>I perked up when they brought in, as a compromise, not the bed we requested, but a reclining chair, so my wife, Mary, could be with me the pre-surgery night. A parade of clinicians drifted in and out. They checked my vitals, told us what I could eat and drink (a strict fast beginning at midnight), and what meds to take (strictly no PD drugs tuntil after surgery—they seriously hinder the optimal positioning of the deep brain device).<br><br></div> <div>The parade continued through the night; new faces materialized by my bed at unpredictable intervals. Each time they nudged me awake, introduced themselves, and checked my vitals for the hundredth time. </div> <div>Mary, a reputed expert in person-centered care, was aghast; none of the well-meaning clinicians were aware that they were complying with a misguided protocol that disrupted her husband’s rest on the night before major surgery. <br><br></div> <div>Her conclusion: “This system is thoughtless and ill-planned. Could it be they have not heard of patient-centeredness and of customer service?”<br><br></div> <div>It’s 5:00 a.m. I am up again, this time fully awake to be prepped for surgery.<br><br></div> <div><img alt="Vivian and wife, Mary" class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2014/PublishingImages/0214/V-Tellis-Nayak-and-wife-Mary.jpg" width="320" height="182" style="margin:10px;" />At the tail end of the parade, friendly Nicole, RN, shows up, chit chats, and graciously asks, “Are you ready for your first dose of medicine?”<br><br></div> <div>Ever vigilant, Mary is up instantly, sitting bolt upright. The nurse in her wants to know: “And what medicine is that?” Nicole reads out, word after deliberate word, the prescription. In effect, she detonates a bomb: “It is his first dose of Parkinson’s drugs.”<br><br></div> <div>The verbal cat fight that followed was great theatrics, but it should not have been a part of my prep. Mary puts her foot down and will not let me take the medicine, and Nicole invokes the protocol that includes no “hold” on the pre-surgical administration of the medicine. An accord is reached, and Mary is declared the hero. She had forestalled a disaster. An expensive eight-hour surgical event presided over by the high priests of medicine, backed up by state-of-the-art support system—all this would have come to naught and would have triggered a cascade of financial, legal, and ethical consequences. <br><br></div> <div>Mary had spared me the clinical fallout from a tragic medical fiasco.</div> <h2 class="ms-rteElement-H2">Weak Links and Pitfalls</h2> <div>It unnerved me to see up close how one weak link can unfasten a fine-tuned intricate procedure. My spirits sank further when I discovered there might be other kinks in the system. <br><br></div> <div>Everything was a go. I am at ground zero waiting for a stranger I have never met to come and drill a hole in my head.<br><br></div> <div>The surgeon arrives on time. He coasts in with an unexpectedly jolly demeanor; he greets the assembled acolytes and cheerfully lobs a question somewhere in my direction, “So, which side do I drill today?”<br><br></div> <div>The casual question hit me like a ton of bricks. “Which side? He doesn’t know?”—an inaudible scream welled from my depths and my mind conjured up an image of a scalper who does his routine on one nameless head and moves to the next. <br><br></div> <div>His question probably was part of a best practice among clinicians to avoid identity errors. Still, his demeanor, words, and tone did little to reassure the befuddled and unnerved patient at his mercy.</div> <div>A credentialed brain surgeon who flouts elementary rules of psychology and courtesy—how does a hospital monitor such behavior and measure its effects? <br><br></div> <div>Earlier that morning I watched in living color another misalignment: a technical compliance to protocol out of synch with the needs of the patient and of the moment.<br><br></div> <div>On the way to surgery, my gurney made stops; nurses, interns, and other unknowns took their turn with me. They asked me questions. Again and again I told them my name and date of birth, wondering why at this stage they were not convinced that I was really me. I took note. Most questioners showed concern, but were not focused. For sure, they were not hanging on my answers.</div> <h2 class="ms-rteElement-H2">Anxiety-Inducing Incongruities</h2> <div>They kept asking their scripted questions, I mumbled inaudible or incorrect answers. A lower-rung functionary sensed my playfulness and winked me his approval. None of the others caught on; they had followed protocol and that was that. I witnessed other incongruous encounters at every turn. <br><br></div> <div>When medics meet patients and their families in a hospital setting, they are usually not aware that their demeanor, even a single word or gesture, may have an unintended blighting effect.<br><br></div> <div>The anxious and sometimes traumatized patient looks for a meaning in every nod, shrug, or smile. A casual observation, a hint of impatience, interrupting the patient’s narrative—the silent vocabulary of our everyday body language—may carry a dire message or may seem to trivialize the patient’s concern. <br><br>Hi-tech medicine should not be incompatible with the caring touch.<br><br></div> <div>My surgery complete, I run smack into yet another glitch. A considerate, muscled orderly wheeled me to the recovery room. Mary was waiting for me, looking her happiest; the doc had told her the surgery was an A-plus success. The orderly aligned the gurney with the recovery room bed. He gingerly stepped aside and politely asked me to scoot over from the gurney to the bed.<br><br></div> <div>Instantly Mary’s spine went ramrod straight—her Irish was up. “What are you saying?” she demanded. “My husband has just had brain surgery; he cannot transfer to the bed by himself!” <br><br></div> <div>The orderly visibly shrank. Timidly, he whispered, “Nobody told me that!”</div> <h2 class="ms-rteElement-H2">Untapped Resources </h2> <div>Back to home life, the surprises continue. The hospital that offered me a course (call it: hi-tech success and low-tech failure) on the promise and perils of modern medicine makes the honors list of the top safest hospitals in the country. <br><br></div> <div>A national magazine hails the technical and behavioral innovations in these hospitals to combat hospital-based infection and human error that harm one in three patients and kill 180,000 every year. <br><br>Sadly, I find it does not refer to a single hospital that has partnered with staff, patients, and families and has viewed safety from their unique vantage point. <br><br></div> <div>The glitches I encountered all occurred below the radar of the hospital’s state-of-the-art, risk-alert system. </div> <div>My DBS surgery, by any standard, was a modern medical miracle. That feat was accomplished despite the pitfalls that lurked around every corner—that was no less a miracle. <br><br><em>Vivian Tellis-Nayak, PhD, is senior research advisor at National Research Corp., Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He has conducted research in the United States and abroad, and his major findings have reached a wider public through his writings in trade magazines. Tellis-Nyak can be contacted at <a target="_blank" href="mailto:vtellisn@gmail.com">vtellisn@gmail.com</a>. </em><br></div> <p></p>I was at the center of a scary incongruity, only hours before surgery. I was at the hospital late Wednesday evening, sporting a confident smile that masked my diffident heart. 2014-02-01T05:00:00ZCaregiving;ClinicalSpecial Feature2




In The Spotlight: Rising Stars In Long Term And Post-Acute Care Part 3https://www.providermagazine.com/Issues/2014/Pages/0314/In-The-Spotlight-Part-3.aspxIn The Spotlight: Rising Stars In Long Term And Post-Acute Care Part 3This month’s crop of eight 20 To Watch honorees exemplify the leadership qualities of humility, initiative, and perseverance. Among the profiles in this issue are several administrators, two directors of nursing, an administrative assistant, a dietary aide, and a chief medical officer. <br><br>As we close the 2014 list in print, please note that further details about the honorees will be posted online on our 20 To Watch page throughout the year. Please stay tuned.<br><br><strong class="ms-rteForeColor-10 ms-rteFontSize-3"><img src="/Issues/2014/PublishingImages/0314/KathleenPajor.jpg" alt="Kathleen Pajor" class="ms-rtePosition-1" style="margin:5px 15px;" />Kathleen Pajor MS, LNHA</strong><br><strong>President/Executive Director</strong><br><strong>Beechwood Post-Acute and Transitional Care</strong><br><strong>New London, Conn. </strong><br><br>Kathleen Pajor is very passionate about long term and post-acute care, and she wants others to feel just as passionate about it as she does. “We really do care about the people we take care of,” she says. As executive director of Beachwood Post-Acute and Transitional Care for nine years, Pajor says she loves interacting with the patients and staff every day, as well as mentoring new administrators. Among Pajor’s accomplishments are numerous leadership positions at the state and national level within the profession, including past president of the Connecticut chapter of the Healthcare Financial Management Association, president of the American College of Health Care Administrators, and a board member of the Connecticut Association of Health Care Facilities.<br><br>Pajor also teaches health care management at the undergraduate and graduate levels at the University of New Haven and at Quinnipiac University.<br><br>“Kathy encourages her staff to strive to attain their goals, to be the very best they can be,” says Sandy Swider, director of marketing and admissions at Beechwood. “She is a cheerleader for her staff and sees potential in every staff member, whether it is a nurse assistant going back to school to get a nurse license, a licensed practical nurse going back to school to get a registered nurse degree, a dietary aide being groomed as a cook, or staff being promoted to an administrative position.”<br><br>Among the many initiatives implemented by Pajor is the BEST program, which spotlights employees for a job well done, says colleague William White, chief executive officer (CEO) of Health Care Visions.<br><br>“The criteria are based on the Nursing Home Patient Bill of Rights. Any patient or resident can submit a form indicating the employee and the reason he or she is the BEST. The more BEST nominations, the more chances an employee has to win one of four $250 cash prizes at the end of the year,” says White.<br><br>“Not only has this program improved employee relations, but the patient/resident/family survey results jumped from 85 percent to 91 percent in the ‘recommending Beechwood’ and ‘overall satisfaction’ categories.”<br><br>Pajor’s advice for up-and-coming administrators in the field: “You really have to understand the operations of all departments, and that may mean working with them side by side in order to understand.” <br><br>If you do that, your staff will respect you more, she adds.<br><br><br><strong class="ms-rteForeColor-10 ms-rteFontSize-3"><img src="/Issues/2014/PublishingImages/0314/DeborahSaccone.jpg" alt="Deborah Saccone" class="ms-rtePosition-1" style="margin:5px 10px;" />Deborah Saccone</strong><br><strong>Dietary Aide</strong><br><strong>Aspen House Memory Care Assisted Living</strong><br><strong>Loveland, Colo.</strong><br><br>Modest is an appropriate term to describe Deborah Saccone’s response to being selected as one of this year’s 20 To Watch recipients. On the job for just over two years, Saccone works the evening shift as a dietary aide. Her job is to prepare meals and ensure that each resident gets meals tailored to their needs and desires. <br><br>She humbly suggests that she does not belong among the 20 To Watch. But her boss and fellow staff members eagerly disagree. To wit: “Every care partner will consult with Deborah regarding anything diet-related,” says Jean Cannon, executive director of Aspen House. “Every care partner looks up to Deborah as the expert regarding the evening meal. Deborah attends every dementia-related training opportunity to enable her to better understand the population she serves. She willingly shares her knowledge and experiences with her co-workers.”<br><br>Saccone says she happened upon long term care and has fallen head over heels in love with it (a now-familiar tale of many 20 To Watch honorees). But as soon as she interviewed for the position she knew she wanted to be part of it. <br><br>Saccone is quick to point out that each care partner (staff member) is part of a larger team that is not boxed in by limited roles. <br><br>“During and after serving the evening meal, Deborah makes note of what a person likes or dislikes, has difficulty or ease in eating, or how much the person eats. Then she makes immediate adjustments,” Cannon says. “For example, she will make a different food item for a resident, will sit down and join the resident to make sure he/she gets proper nourishment, and will notify the nurse if she sees that a resident is having difficulty swallowing so that a diet can be adjusted.”<br><br>Saccone says she is not afraid to try new things to help make residenys feel comfortable in their surroundings.<br><br>“Don’t be afraid to experiment, and don’t lock yourself in a box with things,” she says. “At Aspen House we know that food is important—that it’s part of the social aspect of life, and that’s a big part of living.”<br><br><br><strong class="ms-rteForeColor-10 ms-rteFontSize-3"><img src="/Issues/2014/PublishingImages/0314/RobertBreeden.jpg" alt="Robert Breeden" class="ms-rtePosition-1" style="margin:5px 10px;" />Robert Breeden, MS, NHA</strong><br><strong>Executive Director</strong><br><strong>The Heritage Center of Morristown/Life Care Centers of America</strong><br><strong>Morristown, Tenn.</strong><br><br>As with nearly all 20 To Watch honorees, Robert Breeden has tremendous passion and commitment for the long term and post-acute care profession. “He loves his residents and his staff and shows them true compassion each and every day,” says Jesse Samples, president and CEO of the Tennessee Health Care Association. <br><br>Breeden, whose long term care career spans nearly two decades, “has remained passionate about the development of leaders. A fan of author John Maxwell, Breeden shares Maxwell’s leadership principles with his management team,” says Samples. <br><br>Before his seven years as executive director with The Heritage Center, Breeden worked his way up at another nursing home in the state. Before that, his work was in hospitals. But long term care is where he feels best. <br><br>“It took me by surprise, how much I liked long term care,” says Breeden. “At hospitals, it was more difficult to keep touch with the patients themselves, while long term care has a blend of administrative work, and it’s easier to have direct contact with those you serve,” he says.<br><br>Humble and grateful are two leadership qualities that Breeden displays. Quick to thank his colleagues and staff for their excellent work, he says he cannot do what he does without them. “They are the reason for my success and the reason why I am getting this recognition,” he says. “I want them to know how much I appreciate and admire them. They are my heroes. They make my job easy.” <br><br>His advice for other leaders in the profession: “I think the greatest gift as a leader you can give to anyone is helping them learn how to step into your role. The folks that you surround yourself with will be the key to your success or failure.” <br><br>Showing his gratitude again, Breeden wanted to thank his wife for supporting him and their family and for enabling him to follow his passion. <br><br>Finally, he gave a shout out to his company, Life Care Centers of America, for “allowing me to be a servant leader and for the opportunities they have given me over the years.” <br><br><strong class="ms-rteForeColor-10 ms-rteFontSize-3"><img src="/Issues/2014/PublishingImages/0314/JessicaJohnston.jpg" alt="Jessica Johnston" class="ms-rtePosition-1" style="margin:5px 10px;" />Jessica Johnston</strong><br><strong>Administrative Assistant</strong><br><strong>Riverview Retirement Community</strong><br><strong>Spokane, Wash.</strong><br><br>Jessica Johnston’s hard work, tenacity, and inner drive are good reasons for her selection as one of this year’s 20 To Watch, according to Melissa Goetz, RN, administrator at Riverview. “Jessica has worked at Riverview for approximately six years in a variety of roles, mastering each, and moving forward to find new challenges for her own professional growth,” she says. <br><br>Goetz has nothing but praise for Johnston’s initiative and smarts. “She successfully implemented PointClickCare [an electronic medical record system] for our care center, as well as for the assisted living side. This is a monumental accomplishment given the stark differences between regulatory requirements of a skilled nursing setting versus an assisted living setting,” Goetz says. <br><br>Johnston notes that she is very excited to have been able to get in on the ground level of the electronic medical record program.<br><br>“I’m grateful to have the opportunity to do this because I’ve learned so much. My experience has taught me to not sweat the big stuff in the end,” Johnston says.<br><br>Geotz reports that because of Johnston’s hard work, Riverview has reduced charting time, improved safety during medication administration, and gained tremendous efficiency in the admission and discharge process, “which ultimately improves the quality of life for our residents and staff.,” she says. <br><br>While Johnston was modest about her selection, Goetz was lavish in praise. “Jessica is amazing,” she says. “She is our jack of all trades—one of the brightest women I know. She has a creative mind that is always working, always coming up with better ways of doing things. She also has a wicked sense of humor. It doesn’t matter what task we throw her way, she just tackles it, puts it in a choke hold, and makes it happen. She is phenomenal.”<br><br><strong class="ms-rteForeColor-10 ms-rteFontSize-3"><img src="/Issues/2014/PublishingImages/0314/MarkRotham.jpg" alt="Marc Rotham, MD" class="ms-rtePosition-1" style="margin:5px 10px;" />Marc Rothman, MD </strong><br><strong>Chief Medical Officer, Nursing Center Division</strong><br><strong>Kindred Healthcare</strong><br><strong>Louisville, Ky.</strong><br><br>With significant experience as a practicing long term and post-acute care physician with Kaiser Permanente, Marc Rothman knows whereof he speaks when it comes to the role of the medical director and attending physician in skilled nursing centers. <br><br>And as chief medical officer at Kindred’s nursing home division for the past two years, he has played a significant role in the company’s efforts to enhance care coordination for patients and residents within nursing and rehabilitation centers, says Susan Feeney, Kindred’s senior director of communications and public policy. <br><br>Among his achievements, Feeney says, are reducing rehospitalizations within 30 days of admission and improved patient outcomes. “These efforts have facilitated better clinical outcomes along with shorter lengths of stay—meaning that patients are able to more quickly recover and return home,” says Feeney.<br>She also credits Rothman with the implementation of the Interventions to Reduce Avoidable Care Transfers (INTERACT), activation of electronic health records that are accessible to physicians off-site, engagement of physicians practicing within the company’s centers, and coordination with referring hospital partners.<br> <br>What’s more, Feeney notes, Rothman “understands the day-to-day reality of the best approach to deliver quality care and make recovery possible for patients and residents. For these reasons he is increasingly turned to as a national subject area expert.” Rothman says one of his goals is to inspire the several hundred physicians who care for Kindred patients to become excellent stewards of care in their centers and to work with all of them to create a community of physicians who, among other things, are well-equipped to reduce the off-label use of antipsychotic meds as well as hospitalizations. <br><br>The physicians at Kindred’s centers “are viewed as the leaders within their buildings, and it’s our job to keep them informed via communication tools, data, and best practices, so that they deliver the best care to our patients,” says Rothman.<br><br><strong class="ms-rteForeColor-10 ms-rteFontSize-3"><img src="/Issues/2014/PublishingImages/0314/TomWatts.jpg" alt="Tom Watts" class="ms-rtePosition-1" style="margin:5px 10px;" />Tom Watts</strong><br><strong>President and Chief Executive Officer</strong><br><strong>Exceptional Living Centers</strong><br><strong>Lexington, Ky.</strong><br><br>After a decade of being with Exceptional Living Centers (ELC), Tom Watts still feels duty-bound by his role as CEO of the company. <br><br>“I feel an awesome responsibility to care for our employees and residents,” he says. “That means making this company an enjoyable and fulfilling place to work and making our senior living properties enjoyable places for our residents to live.” <br><br>Watts’ path to long term care was not a straight shot, but he seems to have found his home at ELC. <br><br>“I was working for an accounting and consulting firm [PricewaterhouseCoopers], and one of my clients was ELC. The owners were longtime operators of senior living properties. They were true gentlemen who everyone loved to work with,” says Watts. <br><br>“When their business grew they invited me to join them. It was the easiest decision I have ever made.”<br>Named one of the “Best Places to Work in Kentucky” by The Best Companies Group, for the second consecutive year, ELC continues its drive to be a leader in long term and post-acute care, says Kate Vaulter, director of public affairs for the Indiana Health Care Association.  <br><br>“Watts has put his extensive experience in accounting, finance, and management, as well as his leadership skills, to work at ELC. He has helped to improve quality of care for residents and create a positive work environment for employees,” she says. <br><br>“At quarterly meetings, administrators and nurse staff sit down with staff from referring hospitals, discharge planners, and medical directors to discuss recent survey results, trends in hospital readmissions, and resident referrals and diagnoses, along with other important topics. These regular dialogues lead to better communication and, by extension, better resident care.”<br><br>Among Watts’ additional accomplishments, says Vaulter, is the renovation of Randolph Nursing Home in Winchester, Ind., that included new landscaping, a remodeled dining area, and a new common area for residents in the dementia unit. <br><br>Watts, who says he enjoys taking care of people, is honored to be chosen as one of Provider’s 20 To Watch, “but none of this would be possible without the hard work of the employees of ELC.”<br><br><strong class="ms-rteFontSize-3 ms-rteForeColor-10"><img src="/Issues/2014/PublishingImages/0314/PatrickLampard.jpg" alt="Patrick Lampard" class="ms-rtePosition-1" style="margin:5px 10px;" />Patrick Lampard, RN</strong><br><strong>Director of Nursing</strong><br><strong>Heritage Manor of Slidell </strong><br><strong>Slidell, La.</strong><br><br>According to Jim Collins, author of “Good To Great,” the hallmark of a great leader is someone who recognizes the importance of his team. And Patrick Lampard is someone who personifies this characteristic. <br><br>“I’d like to say something about my team,” he tells Provider. “I am being recognized in this way because of the people who work with me; a good director of nursing [DON] is nothing without their team. I’d like to thank them and give gratitude to them.” <br><br>One of those team members, Andy Hughes, RN, outlined Lampard’s accomplishments in his nomination for 20 To Watch. “Mr. Lampard helped Heritage Manor earn a tier-one recognition level as part of the American Health Care Association Quality Improvement Recognition Program for safely reducing the off-label use of antipsychotics last year, and the center also had a deficiency-free survey during Patrick’s first year as DON,” Hughes said.<br><br>Although Lampard has been a DON for just a few years, he began his long term care career nearly two decades ago as a nursing home volunteer. Eventually, he was hired as a CNA, and just one year later he became a licensed practical nurse. He worked his way up through different departments until he earned a registered nurse degree in 2012, which spurred his move to a quality improvement nurse position before becoming DON.<br><br>“I love being able to make a difference in people’s lives, for everyone—staff, residents, and family,” says Lampard, who adds that he loves the geriatric setting because he likes seeing the day-to-day of people’s lives. “I like seeing them on good days and helping them get through bad days.”<br><br><strong class="ms-rteForeColor-10 ms-rteFontSize-3"><img src="/Issues/2014/PublishingImages/0314/CynthiaFrancia.jpg" alt="Cynthia Francia" class="ms-rtePosition-1" style="margin:5px 10px;" />Cynthia Francia</strong><br><strong>Director of Nursing</strong><br><strong>Carmel Mountain Rehabilitation & Healthcare </strong><br><strong>San Diego, Calif.</strong><br><br>“As Cynthia’s supervisor, I view her as the No. 1 asset to this facility,” says Administrator Glenn Matthews. “She is my partner, my confidant, and the person I rely on to manage not only the clinical side of the facility, but all departments that provide patient care. Words cannot express how much Cynthia contributes to the success of our facility.”<br><br>With three decades of nursing service under her belt, Francia continues to make significant contributions to quality of care at her nursing center, Matthews notes. “Throughout the facility, Cynthia has provided training on oral care, elder abuse, dementia care, tracheotomy care, and CPR for all staff. Beyond clinical, Cynthia continues to train her staff on bedside manner, team building, and culture.” In addition to setting high expectations for herself and her staff to deliver excellent results and an esteemed reputation, Francia had a hand in helping Carmel Mountain become the only five-star facility with a subacute unit in California.<br><br>In 2013 alone, Francia was bestowed a number of awards. Among them are the California Achiever Award and the California Leader Award, both from the Health Services Advisory Group, for reducing falls and restraint use within the facility. <br><br>Francia also helped reduce staff turnover from 41 percent in 2011 to 19 percent in 2012, and she initiated a weekly culture day for residents, where specific holidays are celebrated, along with expanding the residents’ exposure to other cultures around the world. <br><br>As if these accomplishments are not enough, Francia also was instrumental in implementing a number of tools to help communicate with non-English-speaking residents, Matthews says, including dial-up phone services and translation applications on iPads within the facility. <br><br>“Cynthia pushes her fellow department heads to excel,” says Matthews. “Thanks to Cynthia, our leaders went from a working group—individuals that managed their own department with little cross over into other departments—to a team. <br><br><span>SCA is a leading global hygiene and forest products company that develops and produces personal care products, ti<span>ssue and forest products. With sales in 100 countries, SCA has 37,000 employees and had revenue in 2012 of $13 billion. With nine manufacturing facilities across North America, the company’s Americas headquarters is in Philadelphia, Pennsylvania.</span></span><br><br><span>In North America SCA produces the Tork line of napkin, towel, tissue and wiper products used in commercial settings such as office buildings, restaurants, schools and health care facilities and the TENA® line of incontinence care products used by consumers at home and in health care facilities. TENA and Tork the global leading brands in their categories.</span><br><br><span>More information at </span><a target="_blank" href="http://www.sca.com/us"><span>www.sca.com/us</span></a><span>.</span>This month’s crop of eight 20 To Watch honorees exemplify the leadership qualities of humility, initiative, and perseverance. Among the profiles in this issue are several administrators, two directors of nursing, an administrative assistant, a dietary aide, and a chief medical officer. 2014-03-01T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/nurse_2.jpg" style="BORDER:0px solid;" />20 to WatchColumn3
PEPPER Gives Corporate Compliance Guidancehttps://www.providermagazine.com/Issues/2014/Pages/0314/PEPPER-Gives-Corporate-Compliance-Guidance.aspxPEPPER Gives Corporate Compliance Guidance<div> </div> <div>An East Coast skilled nursing facility (SNF) administrator had a very efficient secretary. She sorted his mail and threw away everything that looked like junk. This worked well until a nondescript white envelope from TMF Health Quality Institute arrived in the mail. The efficient secretary threw it in the circular file.</div> <div> </div> <div>The envelope contained sensitive data about the facility’s Medicare performance via an initiative known as Program for Evaluating Payment Patterns Electronic Report (PEPPER).</div> <h2 class="ms-rteElement-H2">It’s Not Junk Mail</h2> <div>TMF is the contractor for the Centers for Medicare & Medicaid Services (CMS) PEPPER program. It is tasked with preparing a report for each SNF that identifies areas of potential improper payments. </div> <div><br><a href="http://pepperresources.org/" target="_blank"><img src="/Issues/2014/PublishingImages/0314/PEPPER.jpg" alt="PEPPER Access Update" class="ms-rteImage-1 ms-rtePosition-1" style="margin:5px 10px;" /></a>Using UB-04 billing claim data provided by the facility’s Medicare Administrative Contractor (MAC), the report contains tables, graphs, and details about specific target areas known to be at high risk for billing errors. </div> <div><br>While SNFs that are part of a hospital system have access to PEPPER through the acute care hospital’s QualityNET electronic system, other SNFs will receive their PEPPER report in the mail, addressed to the facility’s chief executive officer/administrator. </div> <div><br>According to TMF, the next official SNF PEPPER reports will be available in May 2014. The next round of reports will cover claims data for Medicare “episodes of care” that ended during the federal fiscal years (Oct. 31 through Sept. 30)of 2011, 2012, and 2013.</div> <h2 class="ms-rteElement-H2">Areas Of Concern</h2> <div>The episode of care is determined by pulling a series of claims for a Medicare A beneficiary, from the earliest to the latest submitted claim. If the last submitted claim indicates that the resident was discharged from Medicare and did not return for continued care for at least 30 days, that episode of care will be included in the report year in which the last claim “through” date falls.</div> <div><br>The PEPPER report focuses on six CMS-targeted areas that use the Resource Utilization Groups (RUGs), which classify patients into case-mix-driven payment categories and have a high likelihood for improper payments. </div> <div><br>These target areas include the following: </div> <div><br>■ Therapy RUGs with a high score for activities of daily living (ADLs), indicating that a facility may be reporting more assistance than was actually needed (up-coding), resulting in overpayment.</div> <div><br>■ Non-therapy RUGs with high ADLs, indicating a potential for up-coding, resulting in overpayment.</div> <div><br>■ Change-of-therapy (COT) assessments, which are required when the amount of therapy provided no longer reflects the RUG level. </div> <div><br>According to the TMF Skilled Nursing Facility PEPPER Training, Session 1, “SNFs that have a high proportion of change-of-therapy assessments may want to investigate whether there are barriers preventing the provision of anticipated services for beneficiaries, care planning, or other issues” (PEPPER, 2014b). Conversely, a facility that has a low proportion of COTs, or none at all, may be targeted by MACs or RACs (Recovery Audit Contractors) for review.</div> <div><br>■ Ultra therapy RUGs. This item calculates the proportion of days billed for all therapy RUGs that fell into the Ultra High levels. Facilities with a high percentile ranking of Ultra therapy RUGs, such as RUX, RUL, RUC, RUB, and RUA, are at increased risk for MAC and RAC payment reviews. Facility leaders should ask themselves whether the therapy provided at these levels was “reasonable and necessary.” Using a triple-check process, they should review whether the Minimum Data Set coding is supported by the medical record documentation.</div> <div><br>■ Therapy RUGs. This item calculates the proportion of days billed for all therapy RUGs. High levels of therapy RUGs may indicate inappropriate therapy programming. Review coverage decisions by facility nursing and therapy staff to ensure that the care was “reasonable and necessary.”</div> <div><br>■ Episodes of care of 90+ days. This target area identifies the proportion of all episodes of care that had a length of stay of 90 or more days. TMF explains that “SNFs that have a high proportion of episodes of care with 90 or more days should ensure that beneficiaries are receiving services that are necessary, and the SNF should also ensure that beneficiaries received skilled care the entire duration of their SNF stay” (PEPPER, 2014b). </div> <h2 class="ms-rteElement-H2">Percentages Determine Risk</h2> <div>Each of the six target areas is reported as a percentage ratio of the defined numerator divided by the denominator, multiplied by 100. The SNF’s percentages are then ranked against those of other facilities in the state, within the MAC jurisdiction, and nationally. <br><br></div> <div>Nursing home managers should review their facility rankings as calculated in each of the three comparison <br>groups. </div> <div><br>PEPPER scores above the 80th percentile indicate a potential risk in payment error and should be the focus of internal audit and review activities. </div> <div><br>Falling below the 20th percentile ranking for low ADLs or COTs is also an indication for internal quality review.</div> <div><br>TMF emphasizes that the PEPPER report is not intended to identify the actual or confirmed presence of improper payments. </div> <div><br>“Those can only be confirmed through a review of the medical record, but PEPPER can help give you clues as to where your billing patterns differ from others so that you can take the first step in determining whether issues exist.”</div> <div><br>Providers can utilize PEPPER as a resource and launching pad to comply with the 2010 Affordable Care Act requirements for a corporate compliance program. The report results can direct the facility staff audit and quality improvement activities and lead to detecting errors and system problems. </div> <div><br>For more information on PEPPER, see TMF Health Quality Institute, 2013.</div> <div><br>Be on the lookout for the facility’s PEPPER report this May. And don’t let it end up in the waste basket. <br><br><em>Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em></div> While SNFs that are part of a hospital system have access to PEPPER through the acute care hospital’s QualityNET electronic system, other SNFs will receive their PEPPER report in the mail, addressed to the facility’s chief executive officer/administrator. 2014-03-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0314/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn3
Personal Tech One Key To Better Healthhttps://www.providermagazine.com/Issues/2014/Pages/0314/Personal-Tech-One-Key-To-Better-Health.aspxPersonal Tech One Key To Better Health<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div>Imagine if pills had sensors that transmitted information about when they were taken and what affect they were having soon after they were swallowed. Consider the benefits of a system that could enable residents to attend family birthday parties via live video, get instant medication and appointment reminders, transmit information about vital signs to their clinicians, communicate with caregivers, and call for help when they have a problem—all within their televisions or computer tablets.</div> <div> </div> <div>Or think of how many falls might be prevented if a resident’s gait and movements could be tracked virtually.</div> <h2 class="ms-rteElement-H2">The Future Is Now</h2> <div>If this sounds like futuristic or unattainable technology, it actually is within reach for many senior care communities and long term care facilities. In fact, some organizations already using such technology believe that the senior care industry won’t be able to succeed without it in 10 or 20 years.<br><br></div> <div>“We’ll begin to see more of these kinds of things being integrated into daily life, and more people will expect it,” says Lynne Giacobbe, executive director of Kendal at Home in Westlake, Ohio.<br><br></div> <div>She adds, “We want to be on the cutting edge of this. This way, we will be able to have input into revisions and developments as the technology evolves. It will allow us to help shape what the future will look like.”</div> <div>Laura Mitchell, vice president of business development for GrandCare Systems in West Bend, Wis., predicts, “In the future, it will be unheard of for aging parents to go to a facility where they don’t have access to video chats, sharing of videos/photos, and devices that can keep them safe and comfortable in their homes.” </div> <div><a title="Technology that helps people move, live, engage" target="_blank" href="/Issues/2014/Pages/0314/Technology-That-Helps-People-Move,-Live,-Engage.aspx"><br>Cutting-edge eldercare technology</a> is here, and it is accessible and increasingly affordable. A growing number of communities and care settings are using these products, systems, and programs to solve some of the most pressing challenges eldercare providers face. Technology is helping to prevent resident isolation and promote social engagement and mental stimulation, delay moves from lower to higher levels of care, and avoid emergency room (ER) visits and rehospitalizations. </div> <h2 class="ms-rteElement-H2">Edible Data: Pills That Talk</h2> <div>Ingestible sensors from California-based Proteus Digital Health are made entirely from ingredients found in food and are activated on ingestion. Patients swallow one of these along with their regular medication, and it captures the exact time of ingestion. The sensor links to a patch the person wears—much like a Band-Aid—which captures and relays the body’s physiological responses and behaviors. </div> <div><br>The system receives information from the ingestible sensor; detects heart rate, activity, and rest; and sends information to a mobile device. Using a Bluetooth-enabled device, such as a cellphone or tablet, caregivers or clinicians can customize and access data and use them to monitor medications’ impact and adjust or stop prescriptions as necessary.</div> <div><br>This product can help improve communication about medications between settings and practitioners, says Proteus co-founder and Chief Medical Officer George Savage, MD. It will help identify patient noncompliance with medication regimens before it causes problems such as acute condition changes.</div> <div>“Fewer than one-half of patients take medications as directed, often because they feel it isn’t working with them,” he says. </div> <div><br>Nonetheless, he suggests that patients won’t admit this to the doctor or confess that they aren’t taking their medications. The ingestible sensor will communicate information to the clinician that the patient can’t or won’t.</div> <div><br>The ingestible sensor “closes the feedback loop and enables the physician and others to see what is happening,” says Savage. “The data will show exactly how a patient is taking or not taking medications correctly, and you will see measurements of how well the body is responding to the medications. Then, you will be able to make specific changes that are necessary,” he adds.</div> <h2 class="ms-rteElement-H2">Data Reporting Selective</h2> <div>Savage stresses that users will not be bombarded with data. He says, “The point is to provide specific information that provides touchpoints to help maximize the effectiveness of medication management. You also have the ability to decide who gets to see what information.”</div> <div><br>For example, family members can get the basics—just enough information to let them know if Mom is taking her medications and how she is doing in general. </div> <div><br>The physician, on the other hand, gets information that enables him or her to watch for adverse effects or other problems. The physician can choose to get data every day, for example, when a heart failure patient is discharged from the hospital and is at risk of problems that could result in readmission, or he or she can just call up the data during a monthly office visit to assess what, if any, changes are needed in a patient’s medication regimen.</div> <div><br>Savage says that this technology is increasingly affordable. He also anticipates that payers will be interested in including it as a covered service once its value in terms of improving outcomes and preventing drug errors becomes apparent. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Care And Connections: Wireless And Worriless</h2> <div><a title="Keys to tip top tech" target="_blank" href="/Issues/2014/Pages/0314/Keys-To-Tip-Top-Tech.aspx">Technology that connects</a> patients, families, caregivers, and clinicians virtually and seamlessly is gaining fans nationwide. At the center of this are user-friendly, highly adaptable, flexible, practical, and cost-effective systems that bring residents, families, caregivers, and clinicians into a constructive and efficient communication loop. Facilities using them claim they are changing the way their residents live, how their families think and feel, and how staff work to improve outcomes. </div> <div><br>GrandCare Systems is one company producing this technology. The GrandCare System is connected to any dedicated Internet connection and communicates with wireless sensors throughout the resident’s home. </div> <div><br>These sensors are designed to accurately monitor the daily activities, vitals, and wellness of a resident, without intruding on the person’s lifestyle or privacy. </div> <div><br>Designated caregivers log into the GrandCare website to send communications to the resident, view activity graphs, access <a href="/Issues/2014/Pages/0314/Long-Term-Care-EHRs.aspx" target="_blank" title="Long term care EHRs">digital health</a> and medication information, and customize automated rules and alerts. Caregivers may choose to receive a call, email, or text message if specified conditions—such as there is no motion dedicated for several hours—are noted. The caregiver has full control over the actions the system will take when a designated event occurs, such as a phone call to a neighbor if the person’s front door opens during the night.</div> <h2 class="ms-rteElement-H2">Engagement Features</h2> <div>However, the system isn’t just about medical care and safety. It also includes a calendar feature to post appointments and events in monthly and daily views. Additionally, from an online portal, designated caregivers can add personalized photos, messages, reminders, videos, favorite music, and more right to the touchscreen inside the loved one’s home.</div> <div><br>For example, family members can set up a Facebook feed so that their loved one can automatically see specified photo albums. One-button video chats via Skype also can be set up to enable virtual visits and participation in family events.</div> <div><br>Each system also comes preloaded with optional stock photos, card and board games, trivia, brain exercises, spiritual programming/content, weather reports, news headlines, word definitions, and music. Family members can add content such as video and music links, specific news and websites, and more.</div> <div><br>“We are tethered to our cell phones all day. It seems unfair that we would cut off others from the technology we enjoy and benefit from on a daily basis,” says Mitchell. She adds that this technology keeps family members involved and in tune with their elderly loved ones.</div> <div><br>For example, she recalls one client who loved the TV show, “Little House on the Prairie,” and her family adds videos for her to watch. “You can personalize the system, and people can engage with it as much or as little as possible. I have people with late-stage dementia who don’t really interact with it, but their families provide things like photos, videos, and music that they know will bring their loved ones pleasure. <br>And it makes them feel like they are doing something positive,” says Mitchell.</div> <div><br>“We call our systems proactive, predictive, and preventive,” Mitchell says. She explains that it can help identify problems and get them addressed before residents require a trip to the hospital. “A caregiver or family member may notice something—such as slurred speech or changes in skin color—during a video chat. It turns caregivers into super caregivers.”</div> <div><br>Mitchell notes that while prospective residents and family members aren’t requiring such systems yet, she expects the demand to grow. Hospitals’ interest in this technology will grow as facilities demonstrate that they can be used to prevent ER visits and rehospitalizations, she says.</div> <h2 class="ms-rteElement-H2">Blending Care And Life</h2> <div>Technology designed to improve quality of care while maximizing quality of life can help facilities collect, analyze, and use data more efficiently while enhancing patient and family satisfaction. For example, Chicago-based Caremerge has a quality measures program that enables real-time capture and reporting of clinical data and shares it at the touch of a finger. </div> <div><br>At the same time, the program enables organizations to save and organize all communication and conversations with families, send instant and automated family notifications, communicate easily with family members, and see all outstanding family questions in one place. </div> <div><br>There also are features to allow facilities to capture, track, and organize activities of daily living (ADLs) and other observations and clinical notes from any mobile device; send instant notifications to staff members; and have immediate access to notes and observations.</div> <div><br>At the same time, residents can receive instant reminders about activities and upcoming events, and family members can get notifications about a loved one’s activities. “Systems such as this bring information onto everyone’s radar screen,” says Asif Khan, Caremerge chief executive officer (CEO). </div> <div>This technology can help keep patients out of the hospital. “It will prompt nurses to ask questions and learn how much a patient understands about how to care for themselves. They will know who needs more education and coaching and what topics to address,” says Khan.</div> <div><br>He stresses that Caremerge designed its technology to fit in with caregivers’ workflow. “No one takes the time to walk around with the CNA [certified nurse assistant] and see how many times people hand her a sticky note or how many times she has to find a pen and paper to record something,” Khan says. The key, he suggests, is to give staff something that will enhance their workflow and simplify their lives.</div> <div><br>“If people can press one button instead to accomplish something that used to take 10 or even five minutes, they are more likely to embrace and use technology.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Innovations Encourage Independent Living</h2> <div>Enabling seniors to stay at the lowest possible level of care is a growing priority as facilities seek to keep apartments and beds filled and adult children seek to control care costs. Toward that end, many technological innovations are designed to keep elders safe and secure, as well as socially and mentally engaged.</div> <div><br>For example, California-based Independa has a holistic telecare and social engagement program that uses a suite of wireless health devices and home sensors for remote, passive health and activity monitoring. The program requires no computer skills or knowledge by the resident, and it is user-friendly for professional and family caregivers as well.</div> <div><br>The foundation of Independa’s platform is a Web-based application that caregivers can access via standard browser from electronic devices, including a smartphone. This application provides caregivers with access to a dashboard of information, reminders about medications and appointments, health measures, life stories, alerts, reports, and more.</div> <div><br>Elsewhere, the Independa Angela program, run on a touchscreen tablet or LT television, is designed to prevent social isolation and keep the resident in touch with friends and family and engaged in the activities and interests they enjoy. Residents can use this system for activities such as video chats, emailing, games, reminders about events and medications, photo sharing, and more.</div> <div><br>“Social interaction is a critical part of care that has been overlooked in the past. The value of social engagement isn’t a soft benefit but a real and primary one,” says Kian Saneii, Independa CEO. </div> <div><br>“What could be a better platform for this technology than the TV, which is the Holy Grail for many people?”</div> <div>Information also can be communicated via tablet, so people can take it with them wherever they go. For example, they can take it to the hospital, use it to communicate to staff there what medications they are taking, and the nurse can check it at discharge to make sure it is current and that the patient has “all the information he or she needs to return home safely,” Saneii says.</div> <h2 class="ms-rteElement-H2">All About Wellness</h2> <div>“We are all about wellness, and this technology fits right in with that,” says Mike Perry, chief operating officer of The WellBridge Group in Michigan, which offers post-acute rehabilitation and nursing care.</div> <div>“We believe that connecting our guests with family and friends really helps in that overall wellness process.” </div> <div><br>For example, one woman came from a distance for rehab, and she was able to Skype with friends and family back home. “This visual contact is important. Everyone feels better about the whole situation. It keeps people from getting anxious, and they can focus on care planning,” says Perry. He adds, “Often, when the family or guest feels anxious, they try to rush progress. And their anxiety can make staff tense and uncomfortable. When the guest and family feel more involved, they relax more, and the whole environment is better.”</div> <div><br>Perry says that this technology has great potential to help manage acute condition changes more effectively. </div> <div><br>“We had one guest who was Skyping with her daughter, and the younger woman noticed that her mother wasn’t quite herself,” he says. The daughter called and asked the nurse to check on her, and after a quick assessment and some testing, some changes were made to the woman’s medication regimen.</div> <div><br>“We don’t know if this prevented a hospitalization, but we definitely were able to catch something early and put a family member’s mind at ease. We expect to see more of this as we continue to use such technology,” Perry says.</div> <div><br>Sensors that capture changes in health care also are increasingly popular. “Technology that keeps people in their homes because it tracks early changes has tremendous potential. If we can identify these changes early and correct health problems while they are small, we can prevent catastrophic situations that result in hospitalizations and ER visits. This has been borne out in our research,” says Marjorie Skubic, professor in the Electrical and Computer Engineering and Computer Sciences departments at the University of Missouri.</div> <div><br>“We’ve conducted a series of studies over the years that have shown we can use environmental sensors to predict health events weeks before they happen,” she says. “We then can alert health care providers and caregivers so that they can assess for problems.”</div> <div><br>Much of this technology is affordable, says Andy Carle, executive-in-residence, assistant professor, and director of senior housing administration at the George Mason University College of Health and Human Services. He stresses that the return on investment more than pays for their costs.</div> <div><br>“There is zero reason for facilities not to be able to enable things such as Skyping and other ways for families to interact,” he says. When they implement systems that enable broader interaction and communication, the results are significant.</div> <div><br>For example, he says, “It breaks down the domains—physical, cognitive, social—and the activities director becomes a wellness director. And we are seeing positive outcomes.”</div> <h2 class="ms-rteElement-H2">Time To Get On Board</h2> <div>“We are getting more requests from adult children who want to buy the system to use in home care or asking how they can get it in Mom or Dad’s community,” says Khan. He adds, “Moving Mom or Dad into a long term care facility creates a great deal of guilt for adult children, and this helps them feel better about it.” They can know when Mom is happy and active. Conversely, they can see when Dad is just sitting around or sleeping all the time, and they can do something about it promptly. </div> <div><br>The impact of technology on the lives of elders, particularly those with illnesses or impairments, can’t be underestimated, says Giacobbe. For example, she says, “Skype may not seem like a big deal, but when someone has visual or cognitive impairments, the ability to communicate with family members and friends on a high-definition big screen has a tremendous impact. Technology will be key for us to monitor residents and enable them to stay in their homes,” she says. “It increasingly will enable us to serve people effectively and to ensure that they can have meaningful interaction with their loved ones.” ■</div> <br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em>Imagine if pills had sensors that transmitted information about when they were taken and what affect they were having soon after they were swallowed. Consider the benefits of a system that could enable residents to attend family birthday parties via live video, get instant medication and appointment reminders, transmit information about vital signs to their clinicians, communicate with caregivers, and call for help when they have a problem—all within their televisions or computer tablets.2014-03-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0314/cover_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality ImprovementCover Story3
Rehab Validation Takes Shape In IMPACT Acthttps://www.providermagazine.com/Issues/2014/Pages/0314/Rehab-Validation-Takes-Shape-In-IMPACT-Act.aspxRehab Validation Takes Shape In IMPACT Act <div> </div> <div> </div> <div> </div> <div>The IMPACT Act of 2014 won’t generate dramatic headlines. With an acronym that stands for Improving Medicare Post-Acute Care Transformation, the act is focused on enhancing and standardizing clinical data and assessments across post-acute care (PAC) settings, developing new quality and resource measures for PAC providers, and facilitating the comparison of outcomes among providers and settings—all in the service of creating an infrastructure for site-neutral payment reforms in a not-too-distant future.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Introduced in late June by Rep. Dave Camp (R-Mich.), the IMPACT Act might have broken laws of physics and entrenched partisanship on Capitol Hill as it sped through the House of Representatives on a voice vote last September, passed the Senate two days later by unanimous consent, and was signed into law on Oct. 6 by President Obama.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Act Will Have Impact</h2> <div> </div> <div> </div> <div> </div> <div>Though it took just 40 days to go from introduction to public law, the act was the culmination of months of bipartisan work among lawmakers and their staff, according to Rep. Sander Levin (D-Mich.), who spoke on the House floor just before the bill’s passage. </div> <div> </div> <div> </div> <div> </div> <div><br>Despite a rare smooth sailing and the absence of controversy, and despite being described by one lawmaker as “innocuous,” the IMPACT Act is far from a trifle. </div> <div> </div> <div> </div> <div> </div> <div><br>It has in fact been heralded as a post-acute care milestone, one that lays the groundwork for significant payment reforms. </div> <div> </div> <div> </div> <div> </div> <div><br>Even before broader reforms materialize, the act is expected to boost skilled nursing facilities’ (SNFs’) ability to demonstrate their value as high-quality, cost-effective therapy providers through the creation of standardized assessments and quality measures, says Daniel Ciolek, senior director of therapy advocacy for the American Health Care Association (AHCA).</div> <div> </div> <div> </div> <div> </div> <div><br>This is particularly important as providers reach out to policymakers—whose perception of nursing facilities may still be rooted in the 1970s—in an effort to convey (often through a facility tour) the sophisticated level of care that’s provided in today’s SNFs.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Under A Microscope </h2> <div> </div> <div> </div> <div> </div> <div>SNFs have been scrutinized and sometimes criticized for the rising volume and intensity of the therapy they provide, Ciolek says. </div> <div> </div> <div> </div> <div> </div> <div><br>Correlating therapy utilization to resident acuity and outcomes has been an uphill battle, primarily due to a data gap that the IMPACT Act has the potential to close, he adds. </div> <div> </div> <div> </div> <div> </div> <div><br>“The current clinical and functional data gathered through the MDS [minimum data set] patient assessments are inadequate to reflect true patient complexity and degree of positive functional and other care-related outcomes obtained from SNF rehabilitation services,” he says.</div> <div> </div> <div> </div> <div> </div> <div><br>By refining and standardizing post-acute care assessments and implementing quality measures across settings, the IMPACT Act mandates filling data gaps and creating a more accurate view of resident needs and outcomes.</div> <div> </div> <div> </div> <div> </div> <div><br>As an agent of change and transformation, the IMPACT Act is “the most important thing to happen to therapy” since Medicare began covering services, Ciolek says. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Breaking Ground</h2> <div> </div> <div> </div> <div> </div> <div>Drawing on broad support from provider and beneficiary groups, as well as quality organizations, the statute breaks new ground by requiring standardized patient assessment data to be reported at admission and discharge across SNFs, inpatient rehabilitation facilities, long term care hospitals, and home health agencies (HHAs). All but home health agencies must report uniform assessment data by Oct. 1, 2018, with HHAs following on Jan. 1, 2019.</div> <div> </div> <div> </div> <div> </div> <div><br>The statute also calls for new quality measures to be created in five domains: functional status, which includes mobility and self-care; skin integrity; medication reconciliation; major falls; and patient preference regarding treatment and discharge.</div> <div> </div> <div> </div> <div> </div> <div><br>Reporting on the measures will be phased in beginning Oct. 1, 2016, for all but HHAs, which will start in 2017.</div> <div> </div> <div> </div> <div> </div> <div><br>Therapy touches nearly all of those measures, Ciolek says, as therapists are engaged in boosting mobility, preventing falls and skin breakdowns, and making community discharge possible. </div> <div> </div> <div> </div> <div> </div> <div><br>By Oct. 1, 2016, providers will be required to report new measures of resource use, including Medicare spending per beneficiary, rates of discharge to the community, and rates of potentially preventable hospital readmissions.</div> <div> </div> <h2 class="ms-rteElement-H2"> A Tale Of Two SNFs </h2> <div> </div> <div>At any given time, a typical 100-bed skilled nursing facility has 86 long-term residents, whose average length of stay is more than a year, and 14 short-term residents receiving post-acute care for an average stay of 27 days, according to AHCA. Over the course of a year, the same facility will serve 189 short-stay residents, comprising nearly 69 percent of its annual population, and 86 individuals requiring extended long term care services. </div> <div> </div> <div> </div> <div> </div> <div><br>“Today’s SNFs care for two distinct populations,” AHCA said in its August 2013 PAC reform response to the Senate Finance and House Ways and Means committees (<em><a title="Caring for two populations" target="_blank" href="/archives/2015_Archives/Pages/0315/Caring-For-Two-Distinct-Populations.aspx">see box</a></em>). </div> <div> </div> <div> </div> <div> </div> <div><br></div><div>In 2009, only 854,000, or 23 percent of the 3.7 million individuals who received care in a nursing facility, stayed for at least a year, AHCA reported.</div> <div> </div> <div> </div> <div> </div> <div><br>Short-stay residents are also driving a growing rate of discharge to the community. Among AHCA members, for example, 61 percent of residents are currently returning to their communities, up from 58 percent last year, according to data from LTC Trend Tracker, a Web-based tool available to AHCA members. Trend Track allows users to track a wide range of metrics and compare their performance to that of other providers. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Rehab A Major Factor In Restored Health</h2> <div> </div> <div> </div> <div> </div> <div>The majority of people served in SNFs today “need rehabilitation or skilled nursing care to complete their course of care following an acute illness,” AHCA said. As a result, “both the range of services provided in SNFs and the acuity of illness of persons served have significantly increased over time.”</div> <div> </div> <div> </div> <div> </div> <div><br>The ability of providers to convey this trend, however, has been hampered by data-gathering and -reporting processes that are out of step with the evolving role of SNFs, their demographics, and the clinical needs of residents, says AHCA’s Ciolek. </div> <div> </div> <div> </div> <div> </div> <div><br>The IMPACT Act’s requirement for the assessment of functional status at the time of admission and discharge is critical to gaining a more accurate view of SNF residents’ initial abilities and changes that occur after receiving therapy, he adds.</div> <div> </div> <div> </div> <div> </div> <div><br>“The current MDS items related to function were designed for the needs of long-term residents, and are neither specific nor sensitive enough to adequately address the functional needs of the resident at admission or reflect functional improvement through a therapy episode,” Ciolek says.</div> <div> </div> <div> </div> <div> </div> <div><br>Furthermore, the timing of the initial MDS assessment, which is completed within five to eight days of admission, is not responsive to short-stay residents who, by the time the assessment is done, may be a third of the way through their stay and have already made significant functional gains that will be missed on the MDS, Ciolek says. </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Data Matter </h2> <div> </div> <div> </div> <div>Data on acute-care hospital trends suggest that patients are leaving sooner and, presumably, with more intensive needs at discharge. According to the Centers for Medicare & Medicaid Services 2014 Statistics, the average length of a Medicare hospital stay has decreased significantly over time, from 9.0 days in 1990 to 5.0 days in 2012, a 44 percent decline. </div> <div> </div> <div> </div> <div> </div> <div><br>In its annual data book released last June, the Medicare Payment Advisory Commission (MedPAC) reported that from 2006 through 2012, the average length of an inpatient stay for Medicare beneficiaries fell nearly 7 percent, from 4.93 days to 4.59 days. </div> <div> </div> <div> </div> <div> </div> <div><br>“Medicare length of stay declined at an average annual rate of approximately 1.2 percent during this period,” MedPAC reported, while the length of stay for non-Medicare inpatients remained “nearly unchanged” for the period, at 3.9 days.</div> <div> </div> <div> </div> <div> </div> <div><br>Despite such findings, policymakers remain skeptical that acuity among residents entering a SNF has changed significantly, or that increased frailty and acuity justified therapy utilization increases over the past decade, Ciolek says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Numbers Controversial</h2> <div> </div> <div> </div> <div> </div> <div>Last March, MedPAC reported that between 2002 and 2012, the share of SNF days that were classified into “rehabilitation case-mix groups increased from 78 percent to 93 percent,” while the share of “intensive therapy days as a share of total rose from 29 percent to 77 percent.”</div> <div> </div> <div> </div> <div> </div> <div><br>The panel conceded that “shorter hospital stays could have shifted some therapy provision from the hospital to the SNF sector,” pointing out that between 2008 and 2012, “hospital lengths of stay decreased 9 percent on average for the five highest-volume diagnosis-related groups discharged to SNFs.”</div> <div> </div> <div> </div> <div> </div> <div><br>Nevertheless, MedPAC maintained that during the same period, “the increase in the most intensive therapy days (18 percent) far outpaces the changes in patient characteristics,” the commission said.</div> <div> </div> <div> </div> <div> </div> <div>The conundrum underscores the need for SNFs to gather and report “standardized, meaningful data on patients’ condition, function, and outcomes,” Ciolek says.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Getting Proactive On PAC Reform</h2> <div> </div> <div> </div> <div> </div> <div>AHCA has not been waiting in the wings for post-acute reform to arrive. </div> <div> </div> <div> </div> <div> </div> <div><br>The organization has been active in developing a payment reform proposal based on two key elements: a SNF-stay bundle of care, which would cover all Part A services from admission to discharge, and the reduction of some administrative and regulatory burdens, including a partial phase-out of the three-day prior hospital stay required for Medicare SNF coverage.</div> <div> </div> <div> </div> <div> </div> <div><br>The organization is embracing reform, and Ciolek expresses confidence in its members’ ability to meet a new era of post-acute care. “The bottom line is that we’re improving residents’ function and demonstrating that we are meeting the goals we’ve set,” he says. </div> <div> </div> <div> </div> <div> </div> <div><br>“We are sending people home and, ultimately, saving the system a lot of money.” </div> <div> </div> <div> </div> <div> </div> <div><br>Ciolek says he looks forward to the transformation that will result from the IMPACT Act and payment reforms that “incentivize and validate the great outcomes we achieve,” while spurring less successful providers to improve. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><em>Lynn Wagner is a freelance writer based in Shepherdstown, W.Va.</em></div> The IMPACT Act of 2014 won’t generate dramatic headlines. 2014-03-01T05:00:00ZCaregiving;ClinicalSpecial Feature3
2014 Long Term Care Software Suppliers Guidehttps://www.providermagazine.com/Issues/2014/Pages/0314/2014-Long-Term-Care-Software-Suppliers-Guide.aspx2014 Long Term Care Software Suppliers Guide<p>Download the <a href="/reports/Documents/2014/2014Software_R.pdf">2014 Long Term Care Software Suppliers Guide.</a><br></p>Download a PDF of the 2014 Software Suppliers Guide.2014-03-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0314/software_thumb.jpg" style="BORDER:0px solid;" />TechnologyColumn3




QAPI: A Foundation For Successful Caregivinghttps://www.providermagazine.com/Issues/2014/Pages/0414/QAPI-A-Foundation-For-Successful-Caregiving.aspxQAPI: A Foundation For Successful Caregiving<div> </div> <div><img class="ms-rteImage-2 ms-rtePosition-1" src="/Issues/2014/PublishingImages/0414/caregiving.jpg" alt="" style="margin:10px;" /><br>Nursing, rehabilitation, and post-acute care providers today are more focused than ever on tracking and improving every aspect of their businesses—from the quality of individualized care to cost management—especially as the Quality Assurance and Performance Improvement (QAPI) initiative continues to develop. </div> <div> </div> <div>QAPI aims to make nursing homes more accountable by penalizing those that do not meet federal standards. In order to set in place the building blocks to ensure QAPI compliance, providers should take the following first two steps: Build a governing body, and develop a strong team.</div> <h2 class="ms-rteElement-H2">Move From Reactive To Proactive </h2> <div>It is of the highest importance to select not only a strong facility-level team that can generate proactive solutions for care, but to have a dedicated governing body that embraces a culture change within a community to bring QAPI to the forefront of care.<br><br></div> <div>This companywide support will help shift the culture of health care from reactive to proactive, bringing the right expertise of each care staff member to the table for the best outcomes and avoiding a key problem that many face: quality communications across every aspect of the</div> <div>business. </div> <div><br>Despite continued improvements in communication in the health care world, specifically with the advancement of electronic medical records (EMRs), care staff often focus solely on their respective disciplines, holding back vital information that could lead to better outcomes and care. If they were to share their data and care plans with one another, each staff member could help support the individual goals created for every resident in order to achieve the highest level of function. </div> <div><br>This is where QAPI could be a successful tool for bringing the best of each care provider to the table, with the focus always on individualized care for the resident.</div> <h2 class="ms-rteElement-H2">Team Building</h2> <div>QAPI’s Performance Improvement Projects (PIPs), which implement proactive care initiatives, are only as good as the teams that work on them (<em>see box</em>). When developing a successful PIP, providers first must start with a strong root-cause analysis.<br><br></div> <div><img class="ms-rtePosition-2" alt="What Is A Performance Improvement Project?" src="/Issues/2014/PublishingImages/0414/care_perm_imp.jpg" style="margin:10px 5px;" />The key here is to bring the team together to discuss the insights and data collection they do on a daily basis. The governing body can design the framework of the PIP and have the necessary tools available to facilitate a productive, objective conversation on improving outcomes while decreasing overall health care costs.</div> <div><br>The next step is to bring the experienced caregivers and their objective data to the table. It is important to select the right variety of team members for each specific PIP, and this can include consultants and representatives from outside agencies that support the residents and community. </div> <h2 class="ms-rteElement-H2">A Case In Point</h2> <div>Take the discussion of continence care and incontinence product selection for a resident as an example: These topics are extremely important, as they have a direct impact on a resident’s dignity and a potential for risk for slips and falls, infections, and rehospitalizations. <br><br></div> <div>However, they can also bring many challenges, such as the difficulty of discussing the associated cost. In fact, incontinence care as a whole can account for up to 15 percent of a facility’s total costs. <br><br></div> <div>This is where having experienced health care professionals—such as nurses and physical and occupational therapists—present can be incredibly helpful. </div> <div><br>Those professionals can help break down stigmas and focus on the data that will lead to better resident outcomes, making the conversation as productive as possible.</div> <div><br>Additionally, including consultants and representatives from outside agencies that support the overall community can improve the focus on the resident by explaining all aspects of incontinence products and care practices, possibly uncovering areas of data collection and input from nonclinical staff. </div> <div><br>Such areas could include housekeeping, maintenance, central supply, and laundry, all of which are related to incontinence product selection. </div> <div><br>Together, the community staff and external representatives can define a proactive care plan for each resident, areas of data collection, and team collaboration to keep the focus on improving outcomes, while decreasing resident and community costs.</div> <div><br>The most valuable part of objective data and measures is that they are objective. Developing a strategic plan for data collection and analysis will support the proactive care plan by eliminating the subjective review of each resident. </div> <h2 class="ms-rteElement-H2">Track Measures </h2> <div>It is always important to have resident and family feedback on how the PIP is improving the resident’s quality of life. <br></div> <div><br>It is equally important to consistently track objective measures and quality indicators that are put in place, so there are triggers that warn the staff if a specific plan is not working for a resident. For example, Functional Outcome Measures (FOMs) for physical and occupational therapists are evidence-based tests that allow therapists to track the functional and cognitive status of a resident. </div> <div><br>These tests are standardized, with clearly defined thresholds, allowing for easy access to baseline scoring and the ability to replicate, so each resident’s progress toward their goals can be closely monitored.</div> <div><br>By effectively sharing resident outcome data with the team, an updated care plan can be created to avoid risk of decline or injury to the resident, while keeping their goals and dignity at the forefront of the conversation. Additionally, data collection from both internal and external team members will break down the barriers that may have limited communication in the past, allowing the focus to remain on the well-being of the resident, while lowering the overall cost of care.</div> <h2 class="ms-rteElement-H2">The Next Step</h2> <div>Whether a facility is new to QAPI or looking for areas of improvement, the first area to examine is the PIP team. In order to be an effective team and achieve the culture shift of proactive care, members require the proper training, tools, and leadership. <br><br></div> <div>With the support of the governing body, a clear direction can be defined that, in turn, makes everyone accountable for the dignity and well-being of all residents. </div> <div> </div> <div><em>Bill Lampe, PT, DPT, MS, is clinical director, United States, Personal Care - North America, at SCA Americas. He can be reached at <a href="mailto:Bill.Lampe@sca.com" target="_blank">Bill.Lampe@sca.com</a> or <span class="baec5a81-e4d6-4674-97f3-e9220f0136c1" style="white-space:nowrap;">(215) 809-9672<a title="Call: (215) 809-9672" href="#" style="border-bottom:medium none;position:static !important;border-left:medium none;margin:0px;width:16px;bottom:0px;display:inline;white-space:nowrap;float:none;height:16px;vertical-align:middle;overflow:hidden;border-top:medium none;cursor:hand;right:0px;border-right:medium none;top:0px;left:0px;"><img title="Call: (215) 809-9672" alt="" style="border-bottom:medium none;position:static !important;border-left:medium none;margin:0px;width:16px;bottom:0px;display:inline;white-space:nowrap;float:none;height:16px;vertical-align:middle;overflow:hidden;border-top:medium none;cursor:hand;right:0px;border-right:medium none;top:0px;left:0px;" /></a></span>.</em></div> QAPI aims to make nursing homes more accountable by penalizing those that do not meet federal standards. In order to set in place the building blocks to ensure QAPI compliance, providers should take the following first two steps: Build a governing body, and develop a strong team.2014-04-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0414/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn4
All The Stars Have Aligned For Lincoln Squarehttps://www.providermagazine.com/Issues/2014/Pages/0414/All-The-Stars-Have-Aligned-For-Lincoln-Square.aspxAll The Stars Have Aligned For Lincoln Square<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p><br></p> <p><img width="362" height="241" src="/Issues/2014/PublishingImages/0414/Lincoln_096.jpg" class="ms-rtePosition-1" alt="Lincoln Square" style="margin:5px 15px;" />Delta Valley Convalescent Home in Stockton, Calif., was not exactly known for the high quality of its care. A few years ago, in fact, it racked up more than 600 points in its annual survey. Employees at the hospital across the street remarked that when walking past the convalescent home on warm days, when its windows were open, the stench of urine was overwhelming even from the sidewalk. Within the local medical community, Delta Valley was referred to as “Death Valley.” </p> <p>But then in 2009, Delta Valley was sold. The new owners contracted with a consulting firm that had stated its goal was to help all of its client facilities achieve a five-star rating from the Centers for Medicare & Medicaid Services (CMS).</p> <p>The owners embarked on a multimillion dollar remodel, instituted a radical change in culture that empowered employees to improve the lives of those they care for, and incorporated technology to enable easy tracking of quality indicators. The owners also increased the number of caregivers per patient and rebranded the facility Lincoln Square Post-Acute Care. </p> <p>Last year, Lincoln Square was ranked the No. 1 provider of post-acute services in its county, based on hospital discharge data. Its surveys had improved so much that it received a five-star rating on the CMS Nursing Home Compare website. And its 2013 annual survey turned up not a single deficiency. Not one.<br>Last September, after that survey was complete, 50 or more Lincoln Square employees gathered to hear from the surveyors how they’d fared, says Ben Pyper, Lincoln Square’s administrator.</p> <p></p> <div>“Our state surveyors—because they knew how bad Delta Valley had been—the two surveyors couldn’t even get out the words ‘zero deficiencies’ without crying,” he says. They weren’t alone. “Half of our staff was crying,” he says. “It was a tremendously emotional experience.”</div> <h2 class="ms-rteElement-H2">How They Did It</h2> <div>The 68-bed facility’s new owners focused a lot of attention on staff, says Pyper.<br><br></div> <div>Although the change in the facility's culture resulted in the departure of some of the employees who had worked there when it was named Delta Valley, many more remained and embraced the changes, Pyper says.<br><br></div> <div>“There were people here craving a better experience for their patients, and they’re still here now,” says Pyper, saying these individuals were at all levels and included dietary personnel, certified nurse assistants (CNAs), nurses, and Activities Director Michelle Adams and Social Services Director Lorena Mora.<br><br></div> <div>“They’ll tell you they were just craving a change like this. They were doing everything they could to give the best care, but because of limitations of ownership and management” weren’t able to do as much as they would have liked, he says.<br><br></div> <div>In addition, the overall number of staff was increased. “A lot of good care is just giving patients the [amount of] time they need for good care,” Pyper says. “Our philosophy is to give outstanding patient care, and everything else will fall in line behind that. We staffed up and hired great nurses that we had to recruit from other facilities, hospitals, and right out of school,” and then they provided a lot of training, he says.</div> <h2 class="ms-rteElement-H2">Involving All Staff In Quality Assurance</h2> <div>Beyond that, most components of providing care and services seem to be looped through a pervasive quality assurance (QA) process.<br><br></div> <div>“Having a solid QA process allows us to make changes quickly and effectively and follow up on them,” says Pyper. “That’s how you develop a culture where people actually care about who their patients are and who they’re working with. Say I’m a CNA and I noticed that the macaroni salad we’re serving, nobody’s eating that. So I’m going to make a suggestion to my supervisor” that a different salad be served, Pyper says.<br><br></div> <div>“We take that suggestion to our QA meeting, and we actually make a change; we replace the macaroni salad with a nice broccoli salad. So that CNA feels empowered and thinks, ‘I made a difference in my patient’s life.’” So having a QA process where suggestions turn into change results in staff who personally feel invested in the process, Pyper says.<br><span><img src="/Issues/2014/PublishingImages/0414/Lincoln_185.jpg" class="ms-rtePosition-2" alt="Lincoln Square" style="margin:5px;" /><span id="__publishingReusableFragment"></span></span></div> <div></div> <h2 class="ms-rteElement-H2">Aggressive Feedback Solicitation, Technology Support</h2> <div>But perhaps the most important group whose feedback is solicited weekly is made up of residents and their families. It’s called the Guardian Angel Program.<br><br></div> <div>Pyper and his team found that paper customer service surveys given to families or residents don’t generate enough of a response to be optimally useful.<br><br></div> <div>Instead, Pyper and all of the department heads at Lincoln Square interview residents every Tuesday and call a family member of each resident every Friday (or else catch them while they’re at the facility for an in-person interview). <br><br></div> <div>The interviews are conducted using a set of questions developed in the QA meeting, which are designed to elicit any concern, no matter how small, the individual may have had over the past week.<br><br></div> <div>The information gathered through the interviews is brought back to the monthly QA meeting, where changes are proposed and considered and, if appropriate, their implementation is designed.<br><br></div> <div>“I can’t think of a better QA process than that—straight from the front lines we hear about food, care, lighting, or whatever feedback they may have,” says Pyper. “It’s working well. For us, it’s wonderful. If you don’t know what your customer is thinking, then you’re at a disadvantage. You have to know what they’re thinking, wanting, and expecting for their loved one’s care, and we have to try to meet that—especially if you want to be the best in the county.”<br><br></div> <div>Lincoln Square also put technology to work in its QA efforts, using a tool called SNF QAPI. Staff throughout the facility put data into the system, and it automates everything from reminders to perform specific tasks to tracking and measuring the results of a clinical program more closely.<br><br></div> <div>“We’re able to all get on it and check in and measure data,” says Pyper, “and that really helps, because it’s so complex trying to turn around the culture and go from terrible care to great care.”</div> <h2 class="ms-rteElement-H2">The Essential Role Of North American Health Care</h2> <div>Pyper gives a lot of the credit for the facility’s phenomenal success to North American Health Care (NAHC).<br><br></div> <div>The relationship between NAHC and its 35 “client facilities,” of which Lincoln Square is one, is complicated. While the client facilities are all standalone entities, they benefit from many NAHC services, which range from managing payroll to providing consultant services on everything from physical plant maintenance to clinical care. Individual client facilities (including Lincoln Square) may even have a board of directors composed of the same individuals that are on the NAHC board. In fact, some of the owners of Lincoln Square also have ownership interests in NAHC.<span></span><br><br></div> <div>In 2008, NAHC announced a new goal: helping all of its client facilities achieve five-star ratings on Nursing Home Compare.<span><span><img width="382" height="254" src="/Issues/2014/PublishingImages/0414/Lincoln_154.jpg" class="ms-rtePosition-2" alt="Lincoln Square" style="margin:15px 10px;" /></span></span><br><br></div> <div>It was a lofty goal, but it only took NAHC five years to do it. Last year, every single one of NAHC’s 35 client facilities received the coveted five-star rating.<br><br></div> <div>“I think we would not be able to [achieve a five-star rating] without them,” says Pyper. “I know that for a fact. NAHC has given me as the administrator what it takes to take care of my patients. I need people who are experts on medical records and best practices, and they’re always there to support us with that. We always have best practices at our fingertips.”<br><br></div> <div>One of the NAHC services that directly impacts a facility’s rating on Nursing Home Compare is the mock surveys conducted a couple times a year at each facility. The mock surveys occur without notice so the facility’s actual practices can be examined.<br><br></div> <div>NAHC sends teams composed of former state surveyors to inspect the facilities from top to bottom, exactly as the state surveyors do. Any issues noted by the mock surveyors are pointed out to the facility, which then must develop and submit a written plan on how it will correct the issue. How well the plan worked is checked during a second survey.<br><br></div> <div>The process is highly beneficial, says Pyper. “It calms our nerves” about the real state survey, he says. “Our staff know the regulations better because we’re having to address them. The same team spends a day or two with our nursing team, following the nurses around the building, coaching them and giving them constructive criticism.”<br><br></div> <div>Pyper says the process is invaluable. “People like to learn and be challenged,” he says. “It’s when you get bored that you get complacent and don’t care anymore about what you’re doing.” </div> <p></p> <p><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em><br></p>Last year, Lincoln Square was ranked the No. 1 provider of post-acute services in its county, based on hospital discharge data. 2014-04-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0414/feature_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Quality;Quality ImprovementColumn4
Companionship Exemption: Know The Ruleshttps://www.providermagazine.com/Issues/2014/Pages/0414/Companionship-Exemption-Know-The-Rules.aspxCompanionship Exemption: Know The Rules<div> </div> <div>Months after its April 2013 target date, the U.S. Labor Department issued its final rule restating the requirements for and limitations upon the “companionship exemption” in the federal Fair Labor Standards Act’s (FLSA’s) Section 13(a)(15). The changes are significant. </div> <h2 class="ms-rteElement-H2">The Current Rule</h2> <div>Since 1974, individuals who are employed in “domestic service employment” to provide “companionship services” to the elderly or people with infirmities have been exempt from the minimum wage and overtime requirements of the FLSA.<br><br></div> <div>“Domestic service employment” refers to services of a household nature the worker performs in or about the private home of the person by whom he or she is employed.<br><br></div> <div>“Companionship services” are currently defined as follows: “Those services which provide fellowship, care, and protection for a person who, because of advanced age or physical or mental infirmity, cannot care for his or her own needs. Such services may include household work related to the care of the aged or infirm person such as meal preparation, bed making, washing of clothes, and other similar services.”<br><br></div> <div>Companionship services do not include services relating to the care of the aged and infirm that “require and are performed by trained personnel, such as a registered or practical nurse.” However, the exemption does permit the performance of general household work, such as bed making, so long as this work is incidental to the “fellowship, care, and protection” of the aged or infirm person and does not exceed 20 percent of the total weekly hours worked by the employee. Thus, the incidental household work is permissible, but is subject to the 20 percent cap.</div> <h2 class="ms-rteElement-H2">The Changes</h2> <div>Under the final rule, which becomes effective January 2015, third-party employers, such as home-care staffing agencies, will no longer be able to assert the exemption. According to the Department of Labor (DOL), this will be true even when the employee is jointly employed by both the third-party provider and the family or individual receiving the employee’s services. <br><br></div> <div>Beginning January 2015, only the individual, household, or family employing a companionship worker will be able to utilize the exemption.<br><br></div> <div>Another change is that the scope of the phrase “companionship services” is narrowed considerably, and companions are now limited in the amount of incidental “care” services that they can perform each work week. This reflects DOL’s view that “care” services should be secondary to the “fellowship and protection” services that should be the companion worker’s primary focus.<br><br></div> <div>These “care” services include meal preparation, driving, grooming, bathing, and similar activities. Under the final rule, if the companion spends more than 20 percent of his or her total hours performing such incidental “care” services in a given work week, the exemption will be lost for that work week. </div> <h2 class="ms-rteElement-H2">Household Work Restricted</h2> <div>Another change relates to a companionship worker’s performance of “domestic services” that benefit other members of the household. Under the final rule, the exemption will be lost in any work week in which the companionship worker performs domestic services that are “primarily for the benefit of other members of the household.” <br><br></div> <div>Examples provided by DOL include a companionship worker washing the laundry of other members of the household or cooking meals for the entire household (as opposed to just for the aged or infirmed individual). According to DOL, the exemption would be lost in any work week under either of these scenarios.<br><br></div> <div>Similarly, if the companionship worker spends Monday through Thursday providing fellowship and care to the aged or infirmed individual, but spends Friday exclusively performing housework for the household as a whole, the exemption would be lost for the work week. Determining whether the housework “primarily” (as opposed to “tangentially”) benefits other members of the household is bound to be a difficult, fact-intensive inquiry. </div> <h2 class="ms-rteElement-H2">The Bottom Line</h2> <div>In DOL’s view, the individuals who provide in-home care today are not the type of workers that Congress intended to exempt when it passed the “companionship exemption” in the 1970s. According to DOL, Congress intended to exempt “neighbors performing elder sitting” from the FLSA requirements—not the “professional direct care workers” in today’s world.<br><br></div> <div>The final rule reduces the “companionship” exemption to the point of nonexistence in any practical sense. The vast majority of employers that currently utilize the exemption (third-party employers) are now required to begin paying the minimum wage and overtime.<br><br></div> <div>According to DOL’s estimate, nearly 1.9 million companionship workers will be affected by the changes in the final rule.<br><br></div> <div>Moreover, even for families and individuals that will still be able to utilize the exemption, it is more likely that the exemption will be lost in a significant number of work weeks due to companions’ performing services that fall into the expanded incidental “care” services category that is subject to the 20 percent cap, or due to a companion performing work that is deemed “primarily for the benefit of other members of the household.”<br><br></div> <div>In order to properly treat companionship workers as nonexempt under the FLSA, home care staffing agencies and other third-party employers will need new compensation plans, timekeeping systems, and other related policies. Employers will also need to ensure that companionship workers and their managers are properly trained on the new policies. </div> <div> </div> <div><em>Ted Boehm is a labor and employment attorney with Fisher & Phillips in Atlanta. For questions about this or other labor and employment issues, please contact Boehm at </em><a target="_blank" href="mailto:tboehm@laborlawyers.com"><em>tboehm@laborlawyers.com</em></a><em> or (404) 231-1400.</em></div> Since 1974, individuals who are employed in “domestic service employment” to provide “companionship services” to the elderly or people with infirmities have been exempt from the minimum wage and overtime requirements of the FLSA.2014-04-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0414/legal_thumb.jpg" style="BORDER:0px solid;" />LegalLegal Advisor4
Volunteer Programs Take A Quantum Leaphttps://www.providermagazine.com/Issues/2014/Pages/0414/Volunteer-Programs-Take-A-Quantum-Leap.aspxVolunteer Programs Take A Quantum Leap<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><br><img width="226" height="302" src="/Issues/2014/PublishingImages/0414/mgmt1.jpg" alt="student volunteer" class="ms-rtePosition-1" style="margin:15px;" /><br>Volunteering has changed. Until recently, the only way to recruit volunteers was to plaster flyers in libraries, churches, and schools, with the hope of attracting a few people to come read the Bible to residents or call numbers at the weekly Bingo game. </div> <div> </div> <div>While this outdated concept of volunteer recruitment and management may be familiar, the benefits of a modern and well-run volunteer program may not be. Here is the new reality: There are hundreds of people in the immediate community eager to get involved, and these volunteers can not only improve the quality of life and satisfaction with stays for residents and patients, but they can also lower building expenses, increase job satisfaction for staff, and become the best marketing tool a facility has. </div> <h2 class="ms-rteElement-H2">Nontraditional Paybacks</h2> <div>The best part: The ability to connect with potential volunteers is literally right at one’s fingertips.<br></div> <div>Littleton Care and Rehabilitation in Littleton, Colo., launched its volunteer program in December 2012, under the direction of a volunteer coordinator working 18 hours per week. <br><br></div> <div>Before the program began, Littleton was much like any other care center, with only several longtime volunteers helping in the activities area. In the span of just 10 months, this new program has welcomed more than 350 individual volunteers into the building and now consistently provides more than 100 hours of volunteer time each month.<br><br></div> <div>Many activities are now exclusively run by volunteers, freeing staff to focus on other tasks, and in the past few months, more and more patients have chosen Littleton Care and Rehabilitation after a referral by a volunteer.<br><br></div> <div>Furthermore, by recruiting volunteer musicians and performers, and by designing volunteer positions to assist with nontraditional areas like reception, dining, and landscape maintenance, the volunteer program at Littleton has benefitted the center financially as well.<br><br></div> <div>For a building with only 34 residents, this influx of community members has absolutely transformed Littleton Care and Rehabilitation and set it apart from other nursing centers offering similar services. </div> <div>Given the success in Littleton, the program has quickly expanded to three more Ensign Group buildings around Denver. All four are experiencing the benefits of thriving volunteer programs, and each is pioneering new and exciting ways to utilize volunteers for the betterment of the entire facility. </div> <h2 class="ms-rteElement-H2">Areas Of Service Branch Out</h2> <div>Whereas the old model of volunteering focused almost exclusively on resident-centered activities of service, such as assisting with scheduled group activities and visiting with residents one-to-one, a more modern approach also understands that volunteering can be a means to acquire valuable skills and experience in the growing fields of health care, business, and nutrition. <br><br></div> <div>While volunteers have always been recognized as a valuable resource for a facility, it is equally important to recognize that a nursing home can be a valuable resource for the volunteer.<br><br></div> <div>For example, one of the most popular areas of volunteering is the dietary volunteer position. These are volunteers who assist in the dining room during mealtimes with the goal of ensuring a more attentive and friendly environment for the residents and patients.<br><br></div> <div>This position is appealing for volunteers who want to get to know seniors without the pressure that can come from individual interaction, but it is especially appealing for people heading into any branch of culinary arts, hospitality, food service, or nutrition and dietetics.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Opportunities For Volunteer Skill Building</h2> <div>These new volunteers are not only interested in helping out the seniors in their community, but they are also eager to gain experience that could give them an edge in securing competitive internships or improve their career marketability. <br><br></div> <div><img width="208" height="278" src="/Issues/2014/PublishingImages/0414/mgmt2.jpg" alt="volunteer" class="ms-rtePosition-2" style="margin:5px 10px;" />For the dietary departments at the facilities, the advantages of the dietary volunteer program are clear: increased resident and patient satisfaction with meal service, shorter clean-up time for the dietary staff, and the relief of knowing that there is a group of people on hand that can keep the dining room running smoothly if the dietary department is unexpectedly short-staffed due to illness or absence.<br><br></div> <div>The dietary volunteer position is just one example of the many nontraditional volunteer opportunities that exist alongside the more traditional volunteer routes in the Denver Ensign buildings.<br><br></div> <div>These nontraditional opportunities not only provide experience to the volunteer and help to the staff, but they also increase the diversity of a building’s volunteer base.</div> <h2 class="ms-rteElement-H2">Matching Tasks To Volunteers For Overall Satisfaction</h2> <div>Generally, older adults tend to be interested in the more traditional volunteer roles of one-to-one conversation and group games and crafts, and younger people (teenagers, college students, young professionals, and parents with small children) tend to be interested in volunteer areas that provide an opportunity to learn or practice a new skill. <br><br></div> <div>If a building limits its view of volunteering to the outdated one presented at the beginning of this article, then it inherently limits the number and diversity of potential volunteers. When a wide variety of innovative volunteer positions are designed and offered, a wide variety of people will respond, bringing community members from all walks of life into the building and enriching the overall culture of the institution.</div> <h2 class="ms-rteElement-H2">Coordinator Important</h2> <div>To illustrate how a volunteer coordinator can benefit on a larger scale, all four of the Ensign Group buildings in the Denver area share one volunteer coordinator, who works a total of 20 hours per week, meaning that each building essentially pays for five hours of volunteer coordination per week. <br><br></div> <div>With this small investment, these buildings have seen their volunteer numbers grow exponentially, with no end to their growth in sight (<em>see box</em>). <img class="ms-rtePosition-2" alt="Tips for a successful volunteer program" src="/Issues/2014/PublishingImages/0414/mgmt_tips.jpg" style="margin:15px 10px;" /><br><br>As a specific example of this growth, another Ensign Group building in Denver, Sloan’s Lake Rehabilitation, saw its monthly volunteer hours top 100 after only five months of working with the same volunteer coordinator.<br><br></div> <div>All centers in the field of long term care, skilled nursing, and assisted living face the same challenge of meeting growing responsibilities with limited resources. Very often, the response to this challenge has been to focus almost exclusively on cutting expenses.<br><br></div> <div>However, when a facility begins to view the surrounding community as an untapped resource, it can add value to an institution by providing both immediate and long-term benefits, and it soon becomes clear that a modern volunteer program can itself provide the solutions to some of the problems that cost-cutting efforts have sought to address.<br><br></div> <div>Under the direction of a volunteer coordinator who has a vision for what the new world of volunteering can be and an understanding of all the valuable experiences a nursing home or assisted living community can offer, the modern volunteer program is one in which everyone wins: residents, volunteers, and the entire community. </div> <div> </div> <div><em>Kristina Moritz is volunteer coordinator for the Ensign Group buildings of Denver: Littleton Care and Rehabilitation, Sloan’s Lake Rehabilitation, The Julia Temple Healthcare Center, and Arvada Care and Rehabilitation. Moritz can be reached at <a target="_blank" href="mailto:KMoritz@EnsignGroup.net">KMoritz@EnsignGroup.net</a> or (720) 400-0978.</em></div> There are hundreds of people in the immediate community eager to get involved, and these volunteers can not only improve the quality of life and satisfaction with stays for residents and patients, but they can also lower building expenses, increase job satisfaction for staff, and become the best marketing tool a facility has. 2014-04-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0414/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn4
Five Tips For Successful Tech Adoptionhttps://www.providermagazine.com/Issues/2014/Pages/0414/Five-Tips-For-Successful-Tech-Adoption-.aspxFive Tips For Successful Tech Adoption<div> </div> <div><img width="149" height="149" class="ms-rtePosition-1" alt="Jim Rubadue" src="/Issues/2014/PublishingImages/0414/Rubadue.jpg" style="margin:5px 15px;" /></div> <div>Senior care providers have traditionally been late to the game when it comes to adopting new technologies. But it’s a new year, and with it comes a surge in new technology implementations. In fact, health care information technology (HIT) spending is expected to top $34.5 billion in North America this year. </div> <div> </div> <div>Mobile devices, smartphone apps, Web-based software, and cloud-based solutions have changed the playing field when it comes to using new technologies. Implementing these solutions has been dramatically simplified, with little or no technology resources required.</div> <div> </div> <div>But while clinical, operational, financial, and other systems promise everything from better care and time savings to lower costs, the products themselves, of any kind, don’t actually do all the work. That’s because all successful technology implementations require a foundation of people, processes, management commitment, and best practices to deliver the benefits that they promise to deliver.</div> <h2 class="ms-rteElement-H2">Mind The Change</h2> <div>Commonly, the most overlooked piece of implementation is the organizational change that may be required to get the most value out of the technology. The keys to successful adoption involve a range of roles within a community, a willingness to change and adapt, and a commitment to success. <br><br></div> <div>The technology suppliers who have been selected play an important role as well. Those suppliers who are focused on customer success and offer the resources, services, and proven practices to support it can help pave the way to a successful adoption, realizing the full value of the new solutions.<br><br></div> <div>The following best practices have been developed based on thousands of experiences in senior care communities. Managers should consider these best practices when introducing new technology products into the organization to get up and running quickly, optimize the technology investment, and experience maximum success. </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0"><img class="ms-rteImage-0 ms-rtePosition-1" alt="Supplier Support Implementation Checklist" src="/Issues/2014/PublishingImages/0414/tech_checklist.jpg" style="margin:5px 10px;" />1. Get Involved And Stay Involved.</h3> <div>Management support for introducing a new technology product and promoting adoption among users is critical. In fact, lack of management support is often the primary reason an implementation fails in a senior care organization. The most successful implementations are typically driven by a champion who takes ownership for communications, issue resolution, and risk avoidance. This person needs to have authority within the organization, be empowered to make decisions, and be accountable over the success of the initiative. </div> <div><br>In addition, key management stakeholders need to stay on top of the new program. Administrators and managers with cross-organizational responsibilities, like regional vice presidents and heads of operations, finance, clinical, and human resources, for example, should be involved with the rollout of the new technology. Email updates to these important roles are not enough. Champions should look for ways to give key management positions some skin in the game. Administrators, executive directors, and other stakeholders should be familiar enough with the technology to have insight into the value to be gained and be accountable for it.</div> <div><br>For example, if key data are important to the success of the deployment, managers need to review the information on a consistent basis. If employees and other users sense that the data are not being reviewed or used, it could lead to lack of adoption. </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0"><span></span>2. Communicate Change.</h3> <div>Managers should make sure that stakeholders, technology users, and anyone affected by the new products understand what’s coming before it gets there. Managers should set expectations for how the technology will affect each and every person involved.<br><br></div> <div>Get the team prepared for the new products, make sure they understand the value, and discuss the changes that may occur. How will their jobs change? What new responsibilities are involved? How soon can they expect to see the benefits?<br><br></div> <div>Managers should hold a kick-off meeting with key stakeholders to define the upcoming changes, reinforce the reasons the technology is being introduced, and clearly outline the roles and responsibilities for all involved. Managers need to scope the impact for every role that will be affected and communicate it, right out of the gate. </div> <h3 class="ms-rteElement-H3"><span class="ms-rteThemeForeColor-5-0">3. Tac</span><span class="ms-rteThemeForeColor-5-0">kle Training. </span></h3> <div>Continue with the important messages about value, objectives, and change during employee in-servicing and training sessions. When the time comes to train users on the new technology, the technology supplier should offer services that are tailored to positions, learning styles, and even generations.</div> <div>For example, a 54-year-old director of nursing and a 22-year-old nurse assistant may both need to be trained on a new clinical product that’s delivered on tablets and smartphones. Their learning styles and the time required to adequately train each may be at the opposite ends of the spectrum. Training plans and services need to be flexible enough, both virtual and onsite, to accommodate the range of users within each community. </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0"><div>4. Create A Turnover Action Plan.</div></h3> <div>Employee turnover has and continues to be a major obstacle in senior care. Average certified nurse assistant (CNA) turnover in long term care is a staggering 55.3 percent, which can have a big impact on the success of technology adoption. Managers should create a contingency plan to address employee turnover. <br><br></div> <div>Education and re-education are critical in minimizing disruption. Virtual and on-demand training options offered by technology suppliers can help get new users up to speed quickly. Also, managers should consider appointing some key longer-term employees to assist with knowledge transfer when new CNAs or others join the organization and need to pick up new products as part of their everyday tasks. Employee turnover is going to happen, so managers should leverage services, training, and guidelines from their technology partners and have a contingency plan for employee turnover to ensure ongoing success.</div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">5. Manage, Monitor, And Measure.</h3> <div>It is critical to work with the technology supplier at the very beginning of the partnership to identify and agree upon expected value. Be sure to determine value that fits with the organization’s terms and environment.<br><br></div> <div>Managers should be realistic in expectations. Also, managers should continually monitor progress toward the goals of the technology initiative and understand where adjustments need to be made. What kind of measurable impact has the technology delivered? Is it living up to expectations? If not, understand why. <br><br></div> <div>In addition, managers should work with their technology partners in tracking to important milestones. For example, the end of training and beginning of the “go-live” is a critical event. Managers should try to accelerate the time between training and go-live, avoiding any prolonged gaps that could put adoption at risk. Check the temperature of all users at this point and then two weeks into the implementation. If adoption isn’t going as well as hoped, work with the technology partner to find out why and identify what can be improved.<br><br></div> <div>In the early stages of a rollout, managers should demand a quarterly business review with the technology partner to check progress toward deployment milestones and the value achieved. This can provide for short-term course corrections and good visibility into the success of the project. Continuous improvement is a core part of every successful technology adoption. <br><br></div> <div>Get a head start over the competition with these five essential practices when introducing new technologies into the organization.<br><br></div> <div>And remember, ongoing support, best practices, and successful services from the technology partner along with internal teams and processes are just as important as the new products themselves. <br><br><em>Jim Rubadue is vice president of customer success at OnShift, a provider of Web-based staff scheduling and labor management software for long term care and senior living. He can be reached at <a href="mailto:jrubadue@onshift.com" target="_blank">jrubadue@onshift.com.</a> </em></div>The keys to successful adoption involve a range of roles within a community, a willingness to change and adapt, and a commitment to success. The technology suppliers who have been selected play an important role as well.2014-04-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0414/tech_thumb.jpg" style="BORDER:0px solid;" />TechnologyColumn4
New Training For Alzheimer’s Caregivers Puts The Emphasis On Routine Taskshttps://www.providermagazine.com/Issues/2014/Pages/0414/New-Training-For-Alzheimer’s-Caregivers.aspxNew Training For Alzheimer’s Caregivers Puts The Emphasis On Routine TasksHealthCare Interactive (HCI), a Minneapolis-based national provider of online dementia care training programs, launched its latest training program—CARES Activities of Daily Living (ADLs)—last month at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) sixth annual Quality Symposium. HCI’s training programs have been recommended by the Centers for Medicare & Medicaid Services and are the basis of the Alzheimer’s Association dementia care certifications.<br><br>CARES ADLs is meant to help caregivers make routine tasks, such as getting ready for the day, more pleasurable for people living with dementia.<br><br>HCI’s award-winning, self-paced programs—delivered either online or via DVDs or CD-ROMs—are videos that feature interactive activities, interviews with nationally known dementia experts, and simulations of real-life situations facing caregivers. The programs require only basic computer or DVD skills. <br><br>“With one of our national Quality Initiative goals being the reduction of antipsychotic medications in long term care centers, the CARES ADLs program is an essential tool to find innovative ways to care for those living with dementia,” said David Gifford, MD, AHCA’s senior vice president of quality and regulatory affairs and a geriatrician. <br><br>“AHCA/NCAL is honored to partner with the Alzheimer’s Association and HealthCare Interactive to bring this exciting new program to nursing and assisted living professionals around the country at our quality event of the year.” <br><br>To develop the programs, HCI collaborated with nationally known Alzheimer’s and dementia researchers at organizations such as the Alzheimer’s Association, the U.S. Department of Veterans Affairs, National Institutes of Health, and numerous universities such as Duke and Emory. <br><br>John Hobday, HCI chief executive officer and founder, says, “This is not a one-stage-fits-all disease, and approaches change depending upon the person living with the illness. What I like the best about this program is that it allows staff members to actually see the progression of the disease, from normal thinking to complete dependence.”<br>HCI’s award-winning, self-paced programs are videos that feature interactive activities, interviews with nationally known dementia experts, and simulations of real-life situations facing caregivers. 2014-04-01T04:00:00ZClinical;CaregivingFocus on Caregiving4
The Strange Case Of Betty Whitehttps://www.providermagazine.com/Issues/2014/Pages/0414/The-Strange-Case-Of-Betty-White.aspxThe Strange Case Of Betty White<br> <p><img width="175" height="256" src="/Issues/2014/PublishingImages/0414/BettyWhite_20359992Medium.jpg" alt="Betty White" class="ms-rtePosition-1" style="margin:5px 15px;" /><br>Those who care about stereotypes of aging will always have Snickers with them. <br></p> <p>The candy bar company—and its advertising agency, BBDO—climbed the summit of marketing in 2010, when a Super Bowl ad featured a then-88-year-old Betty White, representing what it was like for a young man to play hungry.<br></p> <p>For those involved, the spot was a knockout: It went viral (hundreds of thousands of views and counting), got good buzz during the game, and revived White’s career. <br></p> <p>But, four years after the fact, it still rankles senior advocates.<br></p> <p>“I don’t single out the U.S. particularly,” Cornell University Assistant Professor Corinna Loeckenhoff says. “But there are just horrible ads, where, if you ran them about a culture or racial background, they would be out of business.”<br></p> <p></p> <div>The Snickers ad, of course, is Exhibit A in Loeckenhoff’s brief. “It says when you’re hungry, you’re not you—you’re an old woman. How bad does it get? This view is still accepted. And it shouldn’t be,” Loeckenhoff says. </div> <h2 class="ms-rteElement-H2">It Got Their Attention</h2> <div>Still there are complexities (if not ironies) around the Snickers spot. First, of course, was White herself—most famous among post-baby boomers for her role in “The Golden Girls,” an ’80s sitcom that reveled in the varieties and richness of life for Women of a Certain Age. <br><br></div> <div>After the Snickers spot, the children of baby boomers (collectively known in adspeak as “millennials”) took to social media and launched a campaign to get White to host "Saturday Night Live." It worked, and White’s boffo performance drew a bigger audience than the show had had in years.<br><br></div> <div>Nor has White been relegated to the rubbish bin since the rekindling. She remains a fixture on television. </div> <div>“She is darling,” Ohio University media Professor Karen Riggs says. “She is still kind of a Hollywood matron, and she was married to Mr. Password. She’s got those dimples, and she’s just precious, really.”</div> <div>Riggs says that White is an outlier. Broadly, Riggs thinks, “the joke is still, really, on the elderly.” <br><br></div> <div>“We see this extremely cute old lady with this salty tongue and a kind of in-your-face humor that appeals to the young,” Riggs says.<br><br></div> <div>In other words, White is playing her age for laughs. </div> <h2 class="ms-rteElement-H2">Media And The Elderly</h2> <div>And don’t expect that to change soon, Riggs says. Media has always had “a tenuous relationship” with the elderly. But millennials are well into adulthood now, and they’ve brought with them new media technology that is unraveling business models and panicking ad executives, Riggs says. <br><br></div> <div><img width="198" height="198" src="/Issues/2014/PublishingImages/0414/KarenRiggs.jpg" alt="Karen Riggs" class="ms-rtePosition-1" style="margin:5px 10px;" /><br>“Television is hemorrhaging audience. And, therefore, advertising dollars are really in danger for these traditional broadcast media,” she says. Meanwhile, millennials have some disposable income (not nearly as much as the baby boomers did), and social media “is a difficult game to play.”<br><br></div> <div>That means that media companies and advertisers can more or less take the older generation for granted while they desperately pitch and woo the young ’uns.<br><br></div> <div>“Representation across the medium spectrum is increasingly less enamored of aging,” Riggs says. “And it never was very good. Because now we know that the people who are consuming online information are millennials, or at least Gen-Xers.”<br><br></div> <div>It’s true that baby boomers are the fastest-growing segment of social media customers (and even Betty White has more than 1 million followers on Twitter). But that’s only because the market is “saturated” with the young, Riggs says. <br><br></div> <div>Not all is lost, though. The structure of modern media means that baby boomers and the elderly don’t have to have their culture dictated to them.<br><br></div> <div>“These social networks aren’t the production of content, but they’re enabling the production of content that is much more in the hands of consumers themselves,” she says. “The good news is that older people are able to participate more in their own message. They’re able to be producers as well as consumers of Web 2.0 media.”<br></div> <div>So a new slogan for the elderly as they march in front of the Web cams might be: You have nothing to lose but your stereotypes.</div> <p></p>2014-04-01T04:00:00ZColumn4
The QIS Expert: What Is The Right Hospital Readmission Rate?https://www.providermagazine.com/Issues/2014/Pages/0414/What-Is-The-Right-Hospital-Readmission-Rate.aspxThe QIS Expert: What Is The Right Hospital Readmission Rate?<div> </div> <h3 class="ms-rteElement-H3"><span class="ms-rteFontSize-5">Q: </span>We get a different readmission rate for our nursing center from several sources, so how do I tell which rate is right?</h3> <div> </div> <div><strong class="ms-rteFontSize-5">A:</strong> Currently, there is no standard method that is used by the Centers for Medicare & Medicaid Services (CMS) to calculate a publicly reported readmission rate for skilled nursing facilities (SNFs). However, CMS does calculate a readmission rate during the QIS survey that I discussed in some detail in my <a href="/archives/archives-2011/Pages/0611/The-QIS-Expert.aspx" target="_blank">June 2011 column.</a> This 30-day readmission rate, based on a random sample of 30 admissions, is valid for surveyors to use in Stage 1 to determine whether to conduct a Stage 2 investigation. </div> <div> </div> <div>In Stage 2, surveyors review individual readmissions to determine when they were elective or appropriate, and also when care was inadequate given the individual resident’s risk for readmission. For calculating a raw (or unadjusted) readmission rate, the QIS methodology is the best. </div> <div> </div> <div>While your unadjusted rate is important so that you know the percentage of your admissions that are readmitted to hospital in 30 days, this is not the “right rate” to determine if you are improving when conducting QAPI, or when comparing with other facilities. When readmission rates are used for comparing facilities (such as in public reporting) or over time, then adjusting for readmission risk is essential. </div> <div> </div> <div>A “risk-adjusted rate” is necessary for these purposes. Our research team has been calculating risk-adjusted rates that are used by the Medicare Payment Advisory Commission (MedPAC) in its annual reports on SNF quality since 2004 (see March 2014 “MedPAC Report to the Congress”). The challenges in calculating these risk-adjusted rates can result in different methods and different rates, some of which are flawed. </div> <div> </div> <div>Risk adjustment requires predicting the likelihood that each resident will be readmitted to determine an “expected rate” of readmission. The selection of resident characteristics for making this prediction is where the science comes in. We use a combination of comorbid diseases; functional measures; and measures of cognition, mental health, and selected conditions. We do not use services such as therapy, which are under the discretion of the facility to provide, or prior hospitalization, which would give facilities that hospitalized residents multiple times a distinct advantage. Inclusion of these for risk adjustment is not appropriate.</div> <div> </div> <div>Depending on what is included in the model and how they are weighted, one can have very different risk-adjusted rates, even though the raw rate is the same. Using the risk models that CMS uses for the 30-day readmission measures for hospitals has serious limitations, because these were developed for hospital discharges with selected diagnoses that go to any setting, including home with no further care. These models do not fit discharges of frail SNF residents well, because discharges to SNFs represent only a small portion of all hospital discharges.</div> <div> </div> <div><span></span>In summary, the raw rate is the right rate when you want to know the proportion of your admissions that get readmitted. However, a correctly calculated risk-adjusted rate is necessary for tracking your rates over time; comparing with other facilities; or in discussions with hospitals, physicians, or integrated care systems such as managed care or accountable care organizations.</div> <div> </div> <div><em>Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).</em></div> <div> </div>2014-04-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/headshots/AndyKramer.jpg" style="BORDER:0px solid;" />Quality;ManagementColumn4
Cultural Obstacles to Aging With Gracehttps://www.providermagazine.com/Issues/2014/Pages/0414/Cultural-Obstacles.aspxCultural Obstacles to Aging With Grace<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p><br></p> <p>“Perhaps being old,” Philip Larkin has it, “is having lighted rooms...<br><br>Inside your head, and people in them, acting<br>People you know, yet can’t quite name; each looms<br>Like a deep loss restored, from known doors turning,<br>Setting down a lamp, smiling from a stair, extracting<br>A known book from the shelves; or sometimes only<br>The rooms themselves, chairs and a fire burning,<br>The blown bush at the window, or the sun’s<br>Faint friendliness on the wall some lonely<br>Rain-ceased midsummer evening. That is where they live:<br>Not here and now, but where all happened once.<br><br>Larkin was a nasty fellow in so many ways. But he became one of the most celebrated English-language poets of the 20th century because of this kind of frigid empathy. Indeed, in the next stanza of “The Old Fools,” he moves that cold eye of his from the old folks to the young, watching them. He wonders if, given all of the foregoing, that’s why old people give...<br><br>An air of baffled absence, trying to be there <br>Yet being here. For the rooms grow farther, leaving<br>Incompetent cold, the constant wear and tear<br>Of taken breath, and them crouching below<br>Extinction’s alp, the old fools, never perceiving<br>How near it is…<br><br>What Larkin confronted is what so few seem to want to confront: Getting old and, eventually, dying—is hard work. </p> <p></p> <div> </div> <div>The thing is, it’s only going to get harder. </div> <h2 class="ms-rteElement-H2">Talkin’ ’Bout Their Generation</h2> <div>It is by now notorious that the baby boomers—the echt generation, the generation, for better or worse, that gave Americans most of their modern concepts of generation (right down to the ad man’s most sinister science, demographics)—are getting on in years. A body can’t read a mainstream news story about Alzheimer’s (say) without reading a graf that begins, “As America ages…” <br><br></div> <div>“If you watch TV for even a second, you’ll see this pill helps you revive your sex life, burn that fat, take off that wrinkle,” says Chris Perna, chief executive officer of The Eden Alternative. (Television is, of course, the Rosetta Stone of boomer culture.)<br><br></div> <div><img width="198" height="198" class="ms-rtePosition-1" alt="Chris Perna" src="/Issues/2014/PublishingImages/0414/ChrisPerna.jpg" style="margin:5px 10px;" />So the baby boomers are growing old. The question is, are they growing up? Because the generation that more or less invented youth culture (or, had youth culture invented for it) is now more or less in charge of the money, the politics, and even the means of cultural production that will shape the future of how people care for, and think about, all of their elders. </div> <div><br>“It’s always difficult for America when the post-war generation moves from one life stage to the next,” says Bill Thomas, the doctor who has spent his career trying to get long term care to rethink the way it does business.</div> <div><br>“In the 1960s and 1970s, they left childhood and entered adulthood. And now, quite reluctantly and quite disjointedly, they’re going to leave adulthood and go into elder-hood. </div> <div><br>"And they have no idea what’s going to happen.”</div> <div><br>Thomas has just released his new book, “Second Wind.” He says that eldercare can’t simply be contested in a few paragraphs of legislation or regulation: What’s needed is a thorough-going “deconstruction” of cultural paradigms, he says (<em><a title="Veteran Reformer Sees" target="_blank" href="/Issues/2014/Pages/0414/Veteran-Reformer-Sees-Aging-Boomers’-Chance-To-Catch-‘Second-Wind’.aspx">see sidebar</a></em>).</div> <div><br>From the view of those who work hard to improve quality of care (and of life) for elders, the situation can feel every bit as bleak as Larkin sees it.</div> <div><br>“I think the general prevailing view is that is that it sucks to get old,” Perna says, encapsulating Larkin in a more demotic idiom. </div> <div><br>“The view is that illness is a curse and that dying should be put off as long as possible and you should spend whatever it takes. People want to live and be well forever and take whatever heroic measures it takes to preserve it.</div> <div><br>“We’re a society of doers,” Perna adds. “As a society of doers, as we age, when we get sick, we’re able to do less. I think there’s a latent fear in everybody—and not just latent in many—that, God, the less I can do, the less valuable I am. I think aging is met with fear and dread.” <br></div> <h2 class="ms-rteElement-H2">Stereotypes: Unsafe At Any Speed?</h2> <div>This isn’t an extended kvetch about commercials. The research is piling up, and it’s pointing to an overwhelming conclusion: Stereotypes about the elderly aren’t just nasty, they’re dangerous:<br><br></div> <div>■ A 2013 study led by Yale psychologist Becca Levy found that older folks with positive views of aging were 44 percent more likely to recover fully from severe injuries or disabilities than those who held negative age stereotypes.<br><br></div> <div>■ A 2012 survey of public health majors and graduate students by University of Northern Iowa gerontologist Elaine Eshbaugh found that the biggest obstacle for students pursuing a career in long term or post-acute care was their fears of aging, death, and dying. (“It’s a tough sell to 18- to 24-year-olds,” Eshbaugh told Provider at the time.)<br><br></div> <div>■ A study published in the March edition of the <em>Journal of the American Medical Directors Association </em>(JAMDA) found that frontline workers—nurse assistants, volunteers, and the rest, were most likely to struggle with guilt and anxiety over their residents’ deaths. (Overall, only 30 percent of long term care professionals reported having trouble with death—but that’s precisely the turnover benchmark set by quality advocates at the American Health Care Association.)<br><br></div> <div>“Death is a taboo subject in our society,” the JAMDA researchers wrote. “Workers need to demonstrate empathy with their residents, be compassionate, and be willing to take the risk of personal involvement. Dealing with residents and their families can be very emotionally demanding. Facing it every day requires a degree of distancing for providers.”<br><br></div> <div>For most providers, of course, this is perfectly obvious. But the JAMDA study notes that the more advanced a worker’s education, the better he or she was at dealing with death and dying. Could it be that the emotional rigors of climbing extinction’s alp might explain why so many frontline workers drop off so often?<br><br></div> <div>Or, as Larkin has it (and he might as well be speaking directly to frontline workers): </div> <div> </div> <div>At death you break up: the bits that were you</div> <div>Start speeding away from each other for ever</div> <div>With no one to see. It’s only oblivion, true:</div> <div>We had it before, but then it was going to end,</div> <div>And was all the time merging with a unique endeavour</div> <div>To bring to bloom the million-petalled flower</div> <div>Of being here. Next time you can’t pretend</div> <div>There’ll be anything else. And these are the first signs:</div> <div>Not knowing how, not hearing who, the power</div> <div>Of choosing gone. Their looks show that they’re for it:</div> <div>Ash hair, toad hands, prune face dried into lines—</div> <div>How can they ignore it?<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Stereotypes Of Stereotypes</h2> <div>If long term care professionals themselves struggle with questions of aging and dying, how can they expect their friends and relatives (and regulators and Congress-folk) to have a healthy attitude toward aging and dying? <br><br></div> <div>The work there, in the hearts and minds of business, may not be as hard as one may think. Yes, Americans generally love to think of themselves as perpetually young. And yes, baby boomer Americans in particular love to think of themselves as perpetually young. But the broader culture may have a more tolerant view than one would think. <br><br></div> <div><img width="198" height="198" class="ms-rtePosition-2" alt="Corinna Loeckenhoff" src="/Issues/2014/PublishingImages/0414/Loeckenhoff.jpg" style="margin:5px;" />“I think in some respects the U.S. is getting a bad rap,” says Corinna Loeckenhoff, an assistant professor of human development at Cornell University.<br><br></div> <div>Five years ago, Loeckenhoff and her colleagues looked at cultural attitudes toward aging in 26 cultures. America scored solidly in the middle, with a generally more positive attitude toward the elderly than even supposedly filial-centric Japan. </div> <h2 class="ms-rteElement-H2">Positive Signs</h2> <div>“At the same time, U.S. culture is strongly focused on renewal and innovation—and some may have the impression that older adults can’t really keep up with that,” the German-born Loeckenhoff says. “But the U.S. has done a lot to protect the elderly, with laws against age discrimination, mandatory retirement. <br><br>They’re actually ahead of other countries. In some parts of Europe, it’s expected to give your date of birth on your resume.” Additionally, Americans are much more open to reinvention, Loeckenhoff says. On her own campus in upstate New York, she routinely sees middle-aged (or older) students coming “back” for further education. Such a thing is relatively unheard of in her native Europe, Loeckenhoff says.<br><br></div> <div>That doesn’t mean the United States is the land of milk and honey for seniors: Negative aging stereotypes are perpetuated by the media, she says. Loeckenhoff says her blood still boils every time she thinks of the Snickers commercial where a man who’s hungry morphs into Betty White. “How bad is that?” Loeckenhoff asks (<em><a href="/Issues/2014/Pages/0414/The-Strange-Case-Of-Betty-White.aspx" target="_blank" title="The Strange Case of Betty White">see sidebar</a></em>).</div> <h2 class="ms-rteElement-H2">Mixed Signals</h2> <div>What Loeckenhoff and others have found, though, is a much more complex attitude toward aging and dying than many would have believed. <br><br></div> <div>For instance, people may not view older relatives or friends as “old” until the friend or relative enters what scientists unsentimentally call “the terminal drop”—that last five or so years of a person’s life where, all other things being equal, they go into a relatively rapid decline from disease that swallows them.<br><br></div> <div>“But that’s not healthy aging,” Loeckenhoff says. “In part, it’s a just perceptual mechanism. People may not really think of people as being old until they view people as dying.”<br><br></div> <div>Further, Loeckenhoff and others have found that the higher the percentage of elderly in a population, the more negative views the society will have toward aging and dying.<br><br></div> <div>And—perhaps most surprisingly in results if not in hypothesis—Loeckenhoff and her colleagues have found that aging stereotypes correlate pretty well with economic development. In China, for instance (long and lazily thought to be the country of filial piety par excellence), the more rapidly industrialized or industrializing a region was, the less support the young showed toward the old, Loeckenhoff says.<br><br></div> <div>“As society develops, the means of production spread away from the people,” she says. “That basically takes power away from older people. Potentially, there’s a post-industrial phase, where egalitarian values and a more realistic view of aging kick in.”<br><br></div> <div>Thomas, the veteran firebrand, says he thinks the country has a long way to go. And “you don’t have to look any further than the capital,” he says.<br><br></div> <div>“First off, the No. 1 public policy debate that has obsessed Washington for at least the last three years—and really, longer—is how older people are a plague of locusts that are going to bankrupt us if we don’t do something about it,” Thomas says. “Why is long term care so underfunded? Why are wages in the sector so low? I think it’s evidence of a very conflicted society.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Navigating Complexities (And Ironies) Of Aging</h2> <div>If Loeckenhoff is right that American attitudes toward aging are more complex than all that, it means that providers must rethink their own cultural attitudes first. “As a society, it will mean really valuing people who have experience and wisdom,” Eden’s Perna says. “I’m a class-A doer, and I always have been. One of the reasons I took the job at Eden was because I knew the things I had to work on: to not get caught up in the day-to-day doing, to really reflect on relationships and a deeper knowing.”<br><br></div> <div>A deeper knowing, indeed, and not a deeper marketing slogan. For Perna, it’s an increasingly bitter irony for him and his colleagues—having spent decades pushing providers to rethink everything—now seeing “person-centered care” become the boilerplate language of every brochure, every regulation, and every piece of legislation.<br><br></div> <div>“If you traveled around the country and talked to people and asked them to show what person-centered care looks like, you’ll see a pretty broad spectrum,” he says. “It’s not a word that has been nailed down.”</div> <div>In one way, it’s a great victory that Perna doesn’t see anyone argue against person-centered care, at least in principal. But Perna is worried that “person-centered” is becoming a brand and not a culture.<br><br></div> <div>“For us [at Eden], it translates to, how close to the elder is the decision-making made?” he says. “Where are the decisions made in the organizations? And if the answer you get is the administrator, then they’re not doing person-centered care, I’ll tell you right now.”<br><br></div> <div>For Perna, the matter can’t wait.<br><br></div> <div>“Boy, as a society, what the heck are we going to do with all these baby boomers? We aren’t going to care for all these people in the 16,000 nursing homes that exist today,” he says. “First of all, there isn’t enough capacity. Secondly, the baby boomers don’t want to go there. They just don’t. They see it as a last option.”</div> <div>In any case, as Larkin understood, the question will find people, no matter how long they ignore it. Speculating about extinction’s alp, he wonders if this is what keeps old folks quiet:</div> <div> </div> <div>The peak that stays in view wherever we go</div> <div>For them is rising ground. Can they never tell</div> <div>What is dragging them back, and how it will end? Not at night?</div> <div>Not when the strangers come? Never, throughout</div> <div>The whole hideous inverted childhood? Well,</div> <div>We shall find out. <br></div> <p></p>So the baby boomers are growing old. The question is, are they growing up? Because the generation that more or less invented youth culture is now more or less in charge of the money, the politics, and even the means of cultural production.2014-04-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0414/coverstory_thumb.jpg" style="BORDER:0px solid;" />Culture Change;QualityColumn4




Bringing Closure, Peace When Saying Good-byehttps://www.providermagazine.com/Issues/2014/Pages/0514/Bringing-Closure-Peace-When-Saying-Good-bye.aspxBringing Closure, Peace When Saying Good-bye <p>Jerry Pannell welcomed an elderly couple to the Pittsburgh-based nursing center where he is a registered nurse and administrator. He had known them for years. The husband, a pastor at Pannell’s local church, reminisced with his ill wife and rarely left her bedside during her stay. They laughed; they prayed. But husband and wife didn’t discuss the worst-kept secret in the room. </p> <p>She was dying from a brain tumor. Her body progressively failing, she had weeks to live. The wife asked nurses not to tell her husband, but he noticed her getting weaker. “It was a conversation neither wanted to have,” Pannell says. <br></p> <p>So Pannell and other care team members helped them have the conversation. The team laid out the wife’s prognosis and possible treatment options. They encouraged the couple to confront uncomfortable, yet critical topics. What were the wife’s goals of care? What, at this point, mattered most in the couple’s lives? They decided it was time to go home. <br></p> <p></p> <div>“She spent time with her granddaughter,” Pannell says. “She passed away peacefully, surrounded by family, and her husband and children are in a good place. It was a good death.”</div> <h2 class="ms-rteElement-H2">Program Promotes Planning</h2> <div>Pannell shared his experience as part of Closure, an education, planning, and outreach effort launched by the Jewish Healthcare Foundation (JHF) to raise expectations for end-of-life care. </div> <div><br>Since 2007, Closure has gathered patients, loved ones, health care professionals, clergy, and policymakers to talk about what’s most important at the end of life and provide the information, resources, and support needed to honor patients’ wishes and values. </div> <div><br>“Closure made me look at death straight on,” Pannell says. “It’s a reality of life, and it’s best we prepare for it by making decisions when we are healthy enough to decide what we would like to happen when we approach that time.”</div> <div><br>Such decisions are often deferred until a health crisis arises. Seventy percent of Americans over age 65 will use some form of long term care, according to the U.S. Department of Health and Human Services. </div> <div>Yet, a 2011 National Center for Health Statistics Data Brief found that only 65 percent of nursing home residents have an advanced care directive on record. Without documented treatment preferences, patients may receive painful, unnecessary, and costly treatments that diminish quality of life without extending life.<br><br></div> <div><a href="/Issues/2014/Pages/0514/Closure-Resources-For-Health-Care-Professionals.aspx" target="_blank">End-of-life conversations</a> must become a routine, rather than a taboo, subject to ensure patients receive desired care, says Maureen Saxon-Gioia, RN, BSN, senior quality improvement specialist with the Pittsburgh Regional Health Initiative (PRHI), an operating arm of JHF.</div> <div><br>“Long term care facilities are moving to incorporate this into daily care of residents,” says Saxon-Gioia. “But we need to do more than identify residents’ goals—we also need to train and prepare staff so they’re comfortable having these conversations.” </div> <div><br>Helping patients, families, and providers reach closure requires many things—teamwork, across-the-continuum training, and an appreciation of the spiritual and cultural values that give life meaning. </div> <h2 class="ms-rteElement-H2">Palliative Care Nurses Deployed</h2> <div>Since 2008, the Fine Awards for Teamwork Excellence in Health Care have recognized and rewarded western Pennsylvania health care teams taking a collaborative approach to treating patients. The theme of this year’s Fine Awards, sponsored by the Fine Foundation and JHF, built upon lessons learned in Closure by honoring 10 teams helping patients make informed decisions and easing physical, emotional, and financial burdens at the end of life.</div> <div><br>The University of Pittsburgh Medical Center (UPMC) Palliative and Supportive Institute (PSI) won the Silver Award by creating interdisciplinary palliative care programs across the continuum and helping seriously ill patients navigate a once-fragmented system. </div> <div><br>Previously, hospitalized nursing home residents rarely met with a clinician specially trained in palliative care. </div> <div><br>Providers had no consistent, reliable way to know whether a hospitalized resident had been consulted about palliative care during a previous hospital admission. Upon discharge, nursing home staff often struggled to meet the increasingly complex needs of their residents. </div> <div><br>“Our nurses treat chronically frail patients,” says Denise Stahl, RN, MSN, PSI executive director. “We’re talking acute change in mental status, a fall, an infection—things that if there’s not a higher level of resources, staff often had no option but to send the patient back for possible admission.”</div> <div><br>To reduce resident transfers, PSI deployed nursing practitioners (NPs) trained in a combined palliative care/geriatric curriculum at each facility. The NPs coordinate care for residents, facilitate goals of care meetings, document treatment wishes, and contact hospitals when patients are admitted or discharged. <br></div> <div>The NPs also train other staff in palliative care and lead quarterly educational sessions where all team members explore subjects ranging from comorbid health conditions to symptom management, to pharmacology. Staff now collect the same data on pain management and palliative care conversations, and a revamped information technology system alerts the care team when patients are readmitted. </div> <h2 class="ms-rteElement-H2">Transfers Reduced </h2> <div>PSI’s interventions reduced unplanned transfers from UPMC communities (from 5.9 per 1,000 resident days in 2011 to 2.1 in 2013). Patients who received palliative care and passed away in 2012 were better able to control symptoms (87 percent satisfaction in the first quarter to 94 percent in the third quarter) and felt their input was valued (89 percent to 97 percent).</div> <div><br>“Our staff always want to do the right thing,” says Bob Arnold, MD, PSI medical director and a committee member of the Coalition for Quality at the End of Life, a consortium of stakeholders dedicated to improving end-of-life care across Pennsylvania established and steered by JHF. </div> <div><br>“The goal is to give them the training and resources to do the right thing.”</div> <div><br>Frontline education and teamwork were also crucial for Fine Award finalist Kane Regional Center in Scott Township, part of a four-site skilled nursing and rehabilitation network. </div> <div><br>Nursing, social services, and health care providers rarely discussed advanced care options with residents or relayed those conversations to other staff. Physician Orders for Life-Sustaining Treatment (POLST) forms often documented a resident’s cardiopulmonary resuscitation preferences, but little else.</div> <div><br>To facilitate advanced care discussions, the center trained doctors, nurses, social workers, and dietitians on the POLST paradigm, hospice criteria, enrollment and services, and ways to identify residents with a higher risk of mortality. </div> <div><br>A multidisciplinary team holds regular care conferences with new residents and those with a change in health status and notifies the attending doctor of the consult.</div> <div><br>“When people are working in an isolated fashion, it’s hard to develop a plan and form a consensus on goals of treatment,” says Mario Fatigati, MD, chief medical officer of the Kane centers. “But when you do it in a multidisciplinary fashion, you’re going to have meaningful conversations with patients.”</div> <div><br>The center’s work led to an 80 percent increase in advanced care discussions for high-risk patients and a 23 percent decrease in resident emergency room visits and hospitalizations. Fatigati plans to expand the center’s program to the other three network sites.</div> <div><br>“End of life has to be part of the culture,” Fatigati says. “It defines the complete goals of treatment and provides families and patients with options so they can make informed choices.”</div> <h2 class="ms-rteElement-H2">Acknowledging Grief </h2> <div>Making end-of-life conversations part of the culture requires more than enhanced clinical skills and streamlined care—it also requires providers to understand residents’ world views and process their own losses when a resident passes away. </div> <div><br>Pannell’s center is part of the Jewish Association on Aging (JAA), which has offered social, residential, rehabilitation, and nutrition services in accordance with Jewish values for over a century. Most of the staff participating in Closure were non-Jewish, so Pannell arranged for Rabbi Eli Seidman, JAA’s director of pastoral care, to discuss how spirituality influences views on death. </div> <div><br>“People saw that being religious doesn’t necessarily mean that you pursue every last treatment,” says Jonathan Weinkle, MD, who facilitated JAA’s Closure sessions. “But it does give priority to comfort and dignity—preserving life without being made to suffer more than you can tolerate.”</div> <div><br>Frontline workers at JAA are better able to recognize changes in a resident’s health, Pannell says, thanks to coaching and quality improvement training provided through the Long-Term Care Champions program, a JHF initiative to reduce unplanned transfers in skilled nursing facilities. The talks on spirituality helped staff see the resident as much more than their condition.</div> <div><br>“We’re comfortable broaching these subjects,” Pannell says. “We know where residents and families are coming from.”</div> <h2 class="ms-rteElement-H2">It’s Personal </h2> <div>JAA’s Closure sessions have also encouraged providers to share stories about the bonds formed with residents and the sorrow experienced when a friend moves on. </div> <div><br>“We know these people intimately,” says Nadine Kruman, JAA’s care navigator. “How can you not form an attachment when you care for them daily for months or years? Sometimes you need a shoulder to lean on.”</div> <div><br>Sivitz Jewish Hospice and Palliative Care, part of JAA, is lending a shoulder in a health care environment that rarely acknowledges the effect of a patient’s death on workers. </div> <div><br>“When someone passes away, nurses often suppress their grief and move on to the next patient,” Pannell says. “That’s not healthy. So now, our hospice has volunteered to send over their grief counselor to help our staff come to terms with their loss. Giving both the staff and family support leads to the best outcome for the patient.” </div> <p></p> <p><em>David Golebiewski is communications specialist at Jewish Healthcare Foundation/Pittsburgh Regional Health Initiative/Health Careers Futures, Pittsburgh. He can be reached at (412) 594-2553.</em><br></p>Closure, an education, planning, and outreach effort launched by the Jewish Healthcare Foundation (JHF) raises expectations for end-of-life care. 2014-05-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0514/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn5
Employee Engagementhttps://www.providermagazine.com/Issues/2014/Pages/0514/Employee-Engagement.aspxEmployee Engagement<p>There’s no question that employee turnover in senior care has been, and continues to be, one of the profession’s most challenging issues. With 50 percent turnover in direct care, as reported in the American Health Care Association (AHCA) “2013 Quality Report,” community leaders are continually looking for ways to dismantle the revolving door and increase long-term retention. </p> <p></p> <div>One area that deserves attention is employee engagement, which can not only reduce turnover but also improve quality and the bottom line. In fact, research from Gallup shows that work units with high engagement have “higher productivity, profitability, and customer ratings; less turnover and absenteeism; and fewer safety incidents” than those with less engaged workers. </div> <h2 class="ms-rteElement-H2">Types Of Engagement</h2> <div>Operating with a disengaged workforce can be costly. Gallup estimates that disengagement costs a staggering $450 billion to $550 billion annually in lost productivity.</div> <p></p> <p>To improve employee engagement, leaders must first be aware that it is not the same thing as employee satisfaction. Satisfaction refers to how happy employees are, with no regard to their performance. Employee engagement is the “emotional commitment the employee has to the organization and its goals,” the AHCA report says, and can be measured in part by the amount of effort an employee expends on behalf of the organization. <br></p> <p>The report lists three types of commitment that come into play when examining employee engagement: <br>■ Affective commitment: An emotional attachment to the organization, or “I stay because I want to.” <br>■ Continuance commitment: Fear of loss, or “I might as well stay.” <br>■ Normative commitment: Obligation to stay, or “I need a job.”<br></p> <p>Getting more employees to the level of affective commitment will advance engagement in an organization. Employee engagement should be a key strategy for any senior care employer looking to reduce turnover, lower costs, and improve productivity and the quality of care their residents receive. After all, engaged workers are those who enjoy coming to work. They are productive, feel respected, and go beyond what is expected of them, often without being asked. <br></p> <p></p> <div>While there are many ways to go about driving employee engagement—from interviewing and hiring practices to recognition initiatives and leadership training—the following steps offer practical advice to drive sustainable improvements among the workforce.</div> <h2 class="ms-rteElement-H2B">1. Getting It Right From The Start</h2> <div>Employee turnover is highest during the first 90 days of employment. This is a critical time to get new workers properly trained and oriented so they start their new job on the right foot. Administrators and executive directors play an important role during this time, although it’s very common for their involvement to be limited during employee onboarding. </div> <p></p> <p>A good place to start is during general orientation. Executive directors and administrators should welcome new orients, have coffee with them, and even deliver the resident rights in-service. A community’s open door policy should be explained from day one, inviting new employees to stop in to talk with community leaders whenever they’d like. <br></p> <p></p> <div>Shelly Szarek-Skodny, chief executive offer at Century Oak Care Center in Middleburg Heights, Ohio, reinforces how critical it is for leadership to be present during an employee’s first days. “Administrators need to let new employees know that they care, they’re available, and employees are welcome to talk to them at any time. They need to be present and walk the floors every single day,” she says.</div> <h2 class="ms-rteElement-H2B">2. Embrace Mentoring </h2> <div>Mentor pairing is another practice that facilitates employee engagement from the outset. Assigning a mentor to a new employee helps to fast-track employees becoming self-sufficient. Mentors should come in to the first day of training to meet their new hires with the goal of making them part of the team, right off the bat. </div> <p></p> <p>“The engagement of a peer is much different than management. It’s faster for new hires to become successful taking care of patients and residents because they have someone working right next to them,” says Szarek-Skodny. “Quite often, they become friends, which is a great thing. When friendships form, attendance typically improves because no one wants to call-off and leave their friend hanging.”<br></p> <p>Mentors should be involved with their new hires for the first 90 days. Their involvement should be greatest during the first 30 days, beginning with orientation and shadowing and then reaching out every day once initial assignments begin. <br></p> <p>Weekly touch-base meetings for the rest of the onboarding period are critical in keeping new hires engaged, offering them a peer support system and encouragement when they need it. Mentor feedback is also critical in helping the employee demonstrate the proper technical skills to ensure patients and residents are receiving quality care.<br></p> <p>Once new hires hit their 90-day milestone, it’s party time. “This is a big accomplishment. Celebrate it at a company meeting with a cake and certificate of achievement. These little things can go a long way,” Szarek-Skodny says. <br></p> <p></p> <div>Mentors should also be recognized. Consider a financial bonus or thank-you lunch. This provides additional incentive for the mentor to make each new employee successful and engaged with the organization. </div> <h2 class="ms-rteElement-H2B">3. Give Employees A Voice</h2> <div>Knowledge, power, and information are important aspects of engagement. Providing transparency into key processes within the organization and giving employees some level of control will go a long way toward facilitating engagement. </div> <p></p> <p>A good place to start is with employee schedules. Giving staff a voice in the scheduling process will help them feel better about the results. <br></p> <p>Community schedulers and supervisors should ask employees about their shift and work-availability preferences. Which days work best for them? What times do they prefer? When are they unable to work? Do they feel strongly about working in one unit or department over another? <br></p> <p>While it can be difficult to balance requests, it’s important to give employees some control over their own schedules. When open shifts arise, be sure to communicate them openly and broadly, so extra shifts can be shared equally among staff. <br></p> <p></p> <div>Consider how the use of technology can help balance requests with the organization’s needs to create best-fit schedules, track shift updates, and offer easy schedule access to employees. </div> <h2 class="ms-rteElement-H2B"><div>4. Make It A QAPI Thing</div></h2> <div>Creating an employee task force is another way to increase engagement. When employees have a role in solving an issue, they tend to have greater buy-in. Different people from different roles and departments should make up the group. They should meet monthly for 30 minutes at a time, using information from employee surveys to help identify the specific task or issue to be resolved. </div> <p></p> <p>This approach can also be part of Quality Assurance and Performance Improvement (QAPI) efforts, asking employees for areas of improvement and connecting these back to organizational goals and vision. </p> <p>An open forum for communication is foundational to a successful task force to establish trust and promote engagement. Once action plans have been formed and implementation begins, be sure to credit the employees for their hard work.</p> <p>Consider these practices to increase employee engagement by fostering openness, empowerment, input, and recognition. Incremental improvements in these areas can add up to greater numbers of workers who work for the organization because they genuinely want to stay. <br></p> <p><em><img height="107" width="107" src="/Issues/2014/PublishingImages/0514/markwoodka.jpg" alt="Mark Woodka" class="ms-rtePosition-1" style="margin:5px 15px;" /><br><br>Mark Woodka is chief executive officer of OnShift, a provider of Web-based staff scheduling and labor management software for long term care and senior living. He can be reached at <a href="mailto:mwoodka@onshift.com" target="_blank">mwoodka@onshift.com</a>. </em><br></p>With 50 percent turnover in direct care, as reported in the American Health Care Association (AHCA) “2013 Quality Report,” community leaders are continually looking for ways to dismantle the revolving door and increase long-term retention. 2014-05-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0514/HR_thumb.jpg" style="BORDER:0px solid;" />Management;WorkforceColumn5
Shift Worker Rules Warrant Special Attentionhttps://www.providermagazine.com/Issues/2014/Pages/0514/Shift-Worker-Rules-Warrant-Special-Attention.aspxShift Worker Rules Warrant Special Attention<p></p> <div>The long term care industry depends on shift workers to provide patient care 24 hours per day, seven days per week. Even experienced and sophisticated employers, however, can find the application of state and federal labor and employment laws particularly challenging in a shift-work setting. This column will identify a few common pitfalls and provide strategies for avoiding them.</div> <h2 class="ms-rteElement-H2">Overtime Pay Calculation</h2> <div>Most employers are aware that pursuant to the federal Fair Labor Standards Act (FLSA) and many states’ laws, nonexempt employees who work more than 40 hours in a given week are entitled to overtime pay at a rate of time-and-one-half of their “regular rate of pay.”<br><br></div> <div>A common mistake made by some employers, however, is treating the employee’s hourly rate of pay as the “regular rate of pay” and forgetting to include <a href="/Issues/2014/Pages/0514/Guidance-Through-Example.aspx" target="_blank">shift differentials or certain bonuses</a> in the calculation of the regular rate of pay, resulting in the improper payment of overtime compensation to some shift workers (see sidebar, page 42, for examples that illustrate the problems).</div> <div><br>The only remuneration excluded from the regular rate of pay under the FLSA are certain specified types of payments such as discretionary bonuses, gifts, contributions to certain welfare plans, payments made to certain profit-sharing and savings plans, and pay for foregoing holidays and vacations (not for actual hours worked). </div> <div><br>As such, nondiscretionary bonuses, such as a flat-fee bonus for treating more patients in a given period than the agreed-upon usual case-load or an attendance bonus, must be included in the regular rate of pay. </div> <div>For employees who work various shifts and have more than one shift differential that applies to their weekly hours worked, the same procedure for calculating the proper base rate of pay for overtime pay applies, adding the total remuneration for the week and dividing by the number of hours worked. </div> <h2 class="ms-rteElement-H2">Exceptions Apply</h2> <div>Of course, employees who are exempt from the overtime requirements of the FLSA, such as a registered nurse (RN) who is paid on a salaried basis of at least $455 per week and whose training and job duties satisfy the test for the FLSA’s statutory “Learned Professional Exemption,” need not be paid time-and-one-half for hours worked over 40 in a given week. <br><br></div> <div>That being said, an employer may provide additional compensation to that employee in the form of shift differentials or bonus pay for additional hours worked or patients cared for without risk of converting them to hourly nonexempt employees. </div> <div><br>According to the FLSA regulations, as long as the worker receives “all or part” of his or her weekly compensation on a salaried basis of at least $455 per week, which amount is not subject to reduction because of variations in the quality or quantity of work performed, the worker is considered to be paid on a “salary basis” (the salary provides a floor, not a ceiling, on compensation). </div> <h2 class="ms-rteElement-H2">Reasonable Accommodation To Employees With Disabilities</h2> <div>Another sometimes troublesome issue for employers when dealing with shift workers is determining how to properly handle requests for reasonable accommodation from employees with disabilities. </div> <div><br>Under the Americans with Disabilities Act and under some states’ laws, employees who are “disabled” and present adequate proof of same, such as a doctor’s note validating the limitation even if not the diagnosis, may be entitled to certain changes in their job duties, work environment, or the way things are usually done that allow them an opportunity to continue to perform the essential functions of their job notwithstanding their physical or mental impairment. </div> <div><br>These types of changes are referred to as “reasonable accommodation,” and it is the employer’s duty to provide such accommodation to the employee, absent a showing of undue hardship. </div> <div><br>In some instances, provision of a reasonable accommodation may be accomplished without much, if any, hardship to the employer, as demonstrated by the following hypothetical:</div> <div><br>A billing specialist who prepares patient bills and submissions to insurance companies and Medicare suffers from diabetes and requests to take several brief 15-minute breaks during the day to check her blood sugar and, if necessary, eat a snack to regulate her blood sugar levels. </div> <div><br>Even though company policy provides that billing specialists are only entitled to one 15-minute break in the morning and one 15-minute break in the afternoon, in addition to their lunch hour, it may be considered a “reasonable accommodation” to permit the additional breaks for the disabled employee, even though other employees who are not disabled are not allowed the same privileges. </div> <h2 class="ms-rteElement-H2">Complexities Exist</h2> <div>The provision of reasonable accommodation to shift workers, however, can often raise more complex issues, as demonstrated by the following hypothetical:<br><br></div> <div>An RN who regularly works the night shift (11 p.m. to 7 a.m.) three days per week advises her employer that she suffers from seizure disorder, and her physician has provided a note indicating that it is medically necessary for her to avoid overnight or rotating shifts and to work only the day shift (7 a.m. to 3 p.m.). </div> <div><br>Shift assignments at the facility, however, are governed by a collective bargaining agreement that gives preference in order of seniority, and this RN is the most junior member of the staff.</div> <div><br>Must the employer grant the disabled RN the day shift position as an accommodation to her disability even if it requires displacing a more senior RN?</div> <div><br>The short answer is probably not, as the courts and the U.S. Equal Opportunity Commission have stated that reassigning a disabled employee to a position to which another employee has rights under a seniority system could be considered an “undue hardship” and thus may not be a “reasonable accommodation.”</div> <div><br>If the disabled RN, however, can show that exceptions to the seniority system have been made in other circumstances, the employer’s obligations may not be so clear. Thus, a prudent employer will not apply a blanket rule and will explore the particular circumstances of each situation to determine if a reasonable accommodation can be made.</div> <h2 class="ms-rteElement-H2">Contract Worker Situations</h2> <div>Health care providers should also be aware that even when the employee is a temporary or contract worker supplied by a third-party staffing company, the health care provider will often be considered a joint employer obligated to offer reasonable accommodation in appropriate circumstances. </div> <div><br>The fact that the worker was retained through a staffing company likely will not relieve the health care provider of the duty to comply with state and federal laws concerning provision of reasonable accommodation to disabled employees.</div> <div><br>The management of an organization that operates 24/7 through the use of shift workers presents challenging issues not faced by 9-to-5 businesses. With careful oversight, however, an employer can create rewarding opportunities for its employees while providing valuable and much needed assistance to the patients and clients it serves. </div> <p></p> <p><em>Jeffrey Dretler is a partner in the Boston office of Fisher & Phillips, representing employers in state and federal courts and administrative agencies in cases involving discrimination, harassment, wrongful termination, retaliation, civil rights, and wage-and-hour issues. Dretler can be reached at <a target="_blank" href="mailto:jdretler@laborlawyers.com">jdretler@laborlawyers.com</a>. </em><br> <br></p>Most employers are aware that pursuant to the federal FLSA and many states’ laws, nonexempt employees who work more than 40 hours in a given week are entitled to overtime pay at a rate of time-and-one-half of their “regular rate of pay.”2014-05-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0514/legal_thumb.jpg" style="BORDER:0px solid;" />Policy;LegalLegal Advisor5
Wellness In Assisted Living: Make It Counthttps://www.providermagazine.com/Issues/2014/Pages/0514/Wellness-In-Assisted-Living-Make-It-Count.aspxWellness In Assisted Living: Make It CountRoundtable Sponsored by <img width="92" height="25" class="ms-rtePosition-4" src="/Issues/2014/PublishingImages/logos/Matrixcare_MDI-Achieve.jpg" alt="" style="margin:5px;" /><br><br><br><img class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/Roundtable_thumb.jpg" alt="" style="margin:5px 15px;" /><br><br>In-depth assessments, improved dining and dietary options, and data tracking are just some of the components of creating effective wellness programs for residents in assisted living, according to executives who gathered in Las Vegas for another in a <em>Provider</em> Executive Roundtable series. The event, sponsored by MatrixCare, took place during the National Center for Assisted Living’s Spring Conference in March, where executive and management types from nearly a dozen provider companies exchanged information about what makes their programs successful and how to implement person-centered programs in an effective and efficient manner. <br><br>“You have to honor what the [residents] want. First, you need to figure out why someone wants one thing but not another, and once you take the time to understand the resident, you will be able to give them what they want,” says Michelle DeClemente-Hughes, vice president of operations for Emeritus Senior Living.<br><br>“I realized that it’s about the diversity of what we offer. You have to have enough going on that you meet needs of residents every day.”<br><br>The participants also touched on the seven dimensions of wellness (social, emotional, spiritual, environmental, occupational, intellectual, and physical), while some noted their participation in partnership programs such as <a href="http://www.silversneakers.com/" target="_blank">Silver Sneakers</a> and A Matter of Balance (created at Boston University), which are designed to help residents stay fit longer. <br><br>In addition to covering physical activity, many providers offer brain health and brain-challenging programs, with others focusing on dietary initiatives by offering healthier options, including vegetarian and gluten-free meals, as well as organics foods. Denise German, vice president of operations for Skilled Healthcare Group, noted that some of her buildings are conducting a pilot program on diabetes and obesity. “Believe it or not, as a result of our restaurant-style dining options, we’re now seeing more weight problems,” she said. “So we’re offering more nutrition programs.” <br><br>Chelsea Senior Living President and Chief Executive Officer Roger Bernier said his company is focusing on dietary as well. “People definitely want more healthy options,” he said. “Our residents are savvier. This year was the first time someone asked if our salmon was farm-raised or wild.” <br><br>Underscoring the importance of dietary options, Pat Giorgio, president of Evergreen Estates, noted that her company is making the switch to fewer processed foods and more homemade meals. <br><br>For Midwest Health Management, which has communities in Kansas, Iowa, and Oklahoma, the focus is dementia care, especially with regard to offering residents “normalized activities” related to the things residents used to do, said Regional Manager Carrie Stone. <br><br>Also discussed was the importance of assessments. Several participants noted that they had revamped and improved their assessment process in order to obtain better data and to get a better handle on the “whole person.” Chris Mason, president and chief executive officer of Senior Housing Investments and co-moderator of the roundtable, noted that his assessments now take about an hour and a half to conduct.“They’re longer,” he says, “but we make it more engaging so that we get more information from them.”<br>In-depth assessments, improved dining and dietary options, and data tracking are just some of the components of creating effective wellness programs for residents in assisted living, according to executives who gathered in Las Vegas for another in a Provider Executive Roundtable series.2014-05-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0514/News_roundtable_thumb.jpg" style="BORDER:0px solid;" />Management;CaregivingColumn5
More States Dip Into Managed Care Watershttps://www.providermagazine.com/Issues/2014/Pages/0514/More-States-Dip-Into-Managed-Care-Waters.aspxMore States Dip Into Managed Care Waters<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div>Just as providers have adjusted to the alphabet soup of programs, initiatives, models, and laws impacting long term care, from ACOs and ACA to PQRS and PCMH, a new addition to the mix—MLTSS, or Managed Long Term Services and Supports—is causing heartburn. Fortunately, with planning, support, communication, and information, providers can feel healthy and even happy.</div> <div> </div> <div>MLTSS refers to the delivery of long term care services and support through capitated Medicaid managed care programs. Traditionally, states have provided Medicaid benefits using a fee-for-service system. However, in the past 15 years, a growing number of states have implemented a managed care delivery system for these benefits. </div> <div> </div> <div><img src="/Issues/2014/PublishingImages/0514/coverstory1.gif" class="ms-rtePosition-1" alt="" style="margin:5px 15px;" />Currently, about 50 million people receive Medicaid benefits through some form of managed care, </div> <div>although most are children and adults under 65, and the number is increasing almost daily.</div> <div> </div> <div>Depending on the state, participation in a Medicaid managed care program may be voluntary or mandatory. However, more states are requiring people to enroll in managed care, and more states are using MLTSS to expand home- and community-based services. </div> <h2 class="ms-rteElement-H2">Programs Come In Many Packages</h2> <div>MLTSS may involve managed care organizations (MCOs) that provide most Medicaid benefits to people in exchange for a monthly payment from the state. They also may involve limited benefit plans that look like health maintenance organizations (HMOs) but provide only one or two Medicaid benefits (such as mental health or dental services), or primary care case managers who act as an individual’s primary care provider and receive small monthly payments for coordinating referrals and other medical services. The vast majority of states are using the HMO model to implement MLTSS.<br><br></div> <div>States can implement a MLTSS system through a state plan or waiver authority. A waiver allows the state to waive certain federal rules to offer optional services and/or expand eligibility to a group of individuals that would not otherwise qualify for Medicaid. A state plan is a contract between a state and the federal government describing how that state administers its Medicaid program.<br><br></div> <div>However, states must comply with federal regulations governing managed care delivery systems. These regulations include requirements for a managed care plan to have consumer protections, including a quality program, appeal and grievance rights, reasonable access to providers, and the right to change plans. </div> <h2 class="ms-rteElement-H2"><br></h2> <h2 class="ms-rteElement-H2">Movement Here To Stay</h2> <div>While some states already are waist-deep in Medicaid managed care, others are just dipping their toes in or still contemplating how to take the plunge. <br></div> <div><br>Wherever a provider’s state stands today, Mike Cheek, American Health Care Association (AHCA) vice president of Medicaid and long term care policy, cautions, “You need to understand that Medicaid fee-for-service appears to be quickly going away. Close to 30 states have implemented or are planning to implement managed care for all of their Medicaid populations. If it’s not in your state now, it soon will be. </div> <div><br>“You no longer will be paid by the state Medicaid agency. Instead, you will be paid by HMOs or other entities with whom you have contracts. These entities will drive how you’re paid, how often, how many referrals you receive, and how long residents will stay in your facility,” he says.</div> <div><br>The move into Medicaid managed care is mostly nonpartisan. Although some Republican lawmakers may view it as a way to downsize government, says Cheek, the overarching issue is cost saving and moving patients into the setting with the lowest level of care as quickly as possible. </div> <div><br>Nonetheless, how a state implements its Medicaid managed care program will help determine what challenges providers face as they begin to get involved.<br><br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Most Successful Ventures</h2> <div>The programs that have been most effective to date have employed a phased-in enrollment and implementation plan so that kinks and problems can be worked out before the program is rolled out on a widespread basis. </div> <div><br>Another key to success is the development of quality metrics that involves providers up-front. </div> <div>Whatever approach a state takes to MLTSS, says Cheek, the program must have improving access and quality—not just cost savings—as the primary goals. </div> <div><br>Medicaid managed care won’t impact how facilities care for their residents, but it is likely to affect patient demographics and lengths of stay. Arizona Health Care Association Executive Director Kathleen Collins Pagels says, “Expect seismic shifts to less acute settings, including assisted living and home care. Also expect higher acuity of patients in both assisted living and skilled nursing.”</div> <h2 class="ms-rteElement-H2">Start By Building Relationships </h2> <div>To succeed in the world of Medicaid managed care, Kansas Health Care Association Executive Director Cindy Luxem says, “It’s all about relationship building from the beginning. We’ve found that the providers who have the best relationships with their plans are ultimately successful.” </div> <div><br>Fortunately, says Cheek, facility leaders already know how to do this. “The way you developed good relationships with hospitals, you can establish good relationships with managed care plan personnel," he says. </div> <div><br>“I have regular meetings with managed care plan leadership,” says Pagels. “I bring them to tour facilities, and we have lunch with the team leaders there. This helps them understand what we do and our commitment to care.” </div> <div><br>She adds, “We invite them to our meetings and participate in theirs. We share resources and education.”</div> <div>While it is important to help plan leaders understand what you need from them, she stresses, it also is essential to know what they need and want from you. “Talk about their needs for network development and what services they need assistance with,” she says.</div> <span><h2 class="ms-rteElement-H2"><span><img src="/Issues/2014/PublishingImages/0514/coverstory3.gif" class="ms-rtePosition-2" alt="" style="margin:5px 10px;" /></span></h2></span>To truly understand Medicaid managed care, Pagels suggests, become an expert on the plan. “Understand the plan’s idiosyncrasies, strengths, and weaknesses,” she says. This information is easy to find. <br> <div><br>“Start with your state association,” she suggests. It is a priority for staff there to assist their members in making these important connections, she says. There also is a great deal of information about plans, their history, scope, capitation rates, and more on their websites and on state Medicaid sites.</div> <div><br>“Share this information with your entire team. Teach staff from the bottom up what they need to know to work effectively with the managed care plans,” says Pagels.</div> <h2 class="ms-rteElement-H2">Sign On The Dotted Line?</h2> <div>The contract between the managed care plan and the provider cements the relationship. “You will be paid under the terms of the contract,” says Cheek. “The volume of referrals you get and how long residents stay will be driven by the contract. What you’re paid may be set by the contract.”  Some states, such as Tennessee, have made contracting easier by setting Medicaid rates so that providers don’t have to negotiate them with plans. (<em>For a contract checklist, see box on right.</em>)</div> <div><br>Transparency is key to an effective contract, says Jesse Samples, executive director of the Tennessee Health Care Association. “Almost everything you need to know is in this agreement—including the specific responsibilities of the plan and the provider,” Samples says. </div> <div><br>It is important to have legal counsel review a contract before finalizing it, says Luxem. This can help identify areas where language is unclear and requires clarification. She adds, “This can save you a great deal of heartache and money down the road.”</div> <div><br>Luxem gives the example of a provider that accidentally submitted billing for only $31 per day per resident, and the plan refused to pay more after the mistake was uncovered. “The contract says that the provider would receive the state-approved amount or the amount the provider submits, whichever is less. It took months to straighten this out,” says Luxem. “These are the kinds of problems that can occur with a new contract for a new program.”</div> <div><br>Revisit and review contracts annually, suggests Pagels. “You have to stay on top of this, as the plan doesn’t necessarily have an incentive to do this. Inclusions and exclusions can cost you significant dollars.” She says that the contract must be reasonable for both parties. </div> <div><br>“If you generate a contract that you think is extraordinary, you may get personal satisfaction from that, but you may never get a referral from the plan.”</div> <div><br>Samples cautions that providers shouldn’t expect to do a lot of negotiating on their managed care contracts. “Unlike Medicare Advantage plans where you can decline to sign a contract you’re uncomfortable with, contracts on the Medicaid side are more standard. However, if you have questions or concerns about issues outside of payment—such as issues relating to quality or performance measures, your state association may be able to help.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Managed Care And Culture Change </h2> <div>Long term care facilities have put tremendous resources into culture change in recent years, and Medicaid managed care plans need to understand that the concept of person-centered care is linked inextricably to long term care.</div> <div><br>The good news, says Pagels, is that plans actually understand—and appreciate—culture change and its impact on promoting quality care. </div> <div><br><span><img src="/Issues/2014/PublishingImages/0514/coverstory2.gif" class="ms-rtePosition-1" alt="" style="margin:5px 10px;" /></span>However, she says, “It is helpful to understand what measures plans use to assess quality and make sure there is a common language. Make sure they understand what is being measured.” She adds, “Sometimes it is essential to help plans understand what we do and how we work in our regulatory environment.”<br><br></div> <div>Luxem notes that person-centered care incentives are included in her state’s pay-for-performance initiative. “I believe that more states will demand that plans pay attention to quality measures that focus on person-centered care. This will position AHCA members well, because we already are focused on Baldrige criteria and quality and performance measurement,” she says. </div> <h2 class="ms-rteElement-H2">Show How Culture Change Relates To Outcomes </h2> <div>Samples suggests that there is still a learning curve regarding managed care and culture change. “There is an opportunity to bring plans into the fold and educate them about person-centered care and how it relates to quality, outcomes, and cost-effectiveness.” Samples says. “When you bring them to the table on this, they are more likely to incorporate this information into their contracts and the collaborative process. <br><br></div> <div>“In addition to educating plans about culture change, you should help them understand all aspects of long term care and the challenges you face from an operational standpoint. If you want successful program implementation, all of the players have to be on board with the different components that make up the total package,” he says.</div> <div><br>According to Tony Marshall, senior director of reimbursement at the Florida Health Care Association, Medicaid managed care plans don’t have any incentive to lean toward or away from culture change. <br></div> <div>“They aren’t in the business of managing care. Their job is to help you case-manage and review services to determine if a patient can be moved from the nursing home in a quicker, more efficient manner,” he says. Nonetheless, Medicaid managed care plans do have an interest in quality, although they are more focused on outcomes.</div> <div><br>“In our state, managed care plans monitor survey data but try to avoid duplicating the survey process. They are looking at the underlying survey and quality metrics related to issues such as falls, and they are interested in how your facility ranks in relation to other providers,” Marshall says.</div> <div><br>Florida actually mandated in its state law that Medicaid managed care plans would not duplicate the survey process. This was a lesson state leaders learned from talking to their counterparts from states that had taken the managed care plunge before them. “We heard about one state where providers got surveyed by every single plan they contracted with. We wanted to avoid this excessive burden on our providers,” Marshall says.</div> <h2 class="ms-rteElement-H2">Maintaining Census, Expanding Services </h2> <div>As a goal of Medicaid managed care is to keep patients in nursing center beds for as few days as possible, maintaining census in this environment will present a new challenge for facilities.</div> <div><br>“Providers will have to make sure that plans see them as worthy of referrals. You want to establish yourself with the plans so that you can become a preferred provider and receive more referrals,” says Cheek. </div> <div>This requires documenting low rates of readmission and antipsychotic use, low staff turnover, and “other data points to show you offer stable, quality health care that maximizes functioning.”</div> <div><br>At the same time, Cheek suggests looking to start or grow robust post-acute services and considering ways to diversify. “Think about adding respite services and end-of-life care, offering assisted living, providing adult day care, or delivering in-home services,” he says. He also recommends becoming part of a long term care provider network to secure more referrals.</div> <div><br>“You can’t be just one kind of provider anymore,” Luxem agrees. “You must offer skilled care, as well as other services such as adult day care, assisted living, and respite care if you want to move successfully in the future.” Plans, she says, increasingly will be seeking providers that offer a variety of services and can move patients seamlessly from one care setting to another. </div> <div><br>Diversity is the way of the future, says Samples. “If you are a provider with access to the entire continuum, you not only are attractive to health plans but to potential staff.” He adds that this is the right thing to do for patients as well.</div> <div><br>“If someone can get his or her needs met in a community setting, that is where that person should be. But it is advantageous for patients to be able to stay in the same system when they need skilled care,” Samples says.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Payment Paradox</h2> <div>“‘How do we get paid?’ is a question most providers have when it comes to Medicaid managed care,” says Luxem. That can take a while to sort out. </div> <div><br>“We quickly discovered that some systems we had set up for billing in the state were more progressive than what the plans had. [The managed care] systems were not set up to handle our case-mix system, where rates can change frequently,” she says. </div> <div><br>The newer the state and the plans are to Medicaid managed care, the more likely providers may experience payment delays and glitches. “We have experienced our own history of problems with timely payments over the years, particularly with new plans coming in,” says Pagels. “You need to manage your cash flow with this in mind.”</div> <div><br>Fortunately, facility leaders can do more than cross their fingers and hope for the best. Pagels advises providers: “Invest in your business office. Make sure they have the training and support necessary to work effectively with the Medicaid managed care plans. Take opportunities to get involved with people at the plans who work with payments and understand appeals and grievance processes.”</div> <div><br>Another key to ensuring prompt payment is to establish patients’ Medicaid eligibility as early as possible. “Some providers have run into payment delays because eligibility wasn’t approved in a timely manner. This makes it difficult to move into managed care,” says Luxem.</div> <h2 class="ms-rteElement-H2">Planning Ahead</h2> <div>Providers need to be patient and be prepared to educate plans as necessary. “Some plans have had difficulty understanding how payment works for special services such as ventilator care,” says Luxem. The onus is on providers to watch these issues carefully and alert the plan immediately if they see problems.</div> <div>Planning is key, agrees Marshall. “We anticipated that receiving payments in a timely manner might be a challenge. We had the benefit of putting language in our state statutes to ensure timely payments,” he says. Specifically, they included a provision that plans have to pay claims with sufficient information within 10 days. However, Marshall notes, while the statutes require plans to meet payment standards, there are no penalties for a failure to do so.<br><br></div> <div>“From our perspective, plans aren’t trying to delay payment, but there was inadequate readiness review to test the claims processes," says Marshall, referring to a review process designed to focus on elements that include assessment procedures, care coordination, and staffing.</div> <div><br>"And, unfortunately, most plans are not long term care-oriented, so they are unfamiliar with our payment systems,” Marshall says.</div> <div><br>Marshall suggests some other efforts that may help improve payment in a Medicaid managed care world. </div> <div>For instance, he suggests that states consider development of a uniform claims form process, standards for electronic funds transfer, and provider-plan workgroups to address payment issues on the front end.</div> <div>Marshall also suggests that others learn a lesson from his state: “We included a provision to have a technical advisory workgroup, but we didn’t include a time frame for it, and it disappeared. This really needs to be a continuous process for ongoing dialogue to deal with challenges and situations as they arise.”</div> <div><br>Work on payment issues should begin as soon as the ink is dry on the contract, Marshall stresses. “Have office staff work with their counterparts at the plan immediately. Allow sufficient time for training. Have plans come to the facility and participate in multiple trainings on the front end,” he says. Plans are more than willing to participate in meetings with providers. Take advantage of opportunities to interact, share information, and put processes in place during the transition period, Marshall says.</div> <div><br>Ultimately, plans want to do the right thing for providers, Marshall says. “Our plans have gone above and beyond in their efforts to get payments to providers. They’ve even chosen to provide overpayments just to ensure that providers have the necessary cash flow.”</div> <h2 class="ms-rteElement-H2">Suit Up, Get Ready</h2> <div>Like it or not, Medicaid managed care is here to stay, and, as Cheek observes, the days of traditional fee-for-service are numbered in most states. J. Emmett Reed, CAE, Florida Health Care Association executive director, adds, “Managed care is sweeping the country. It’s not a matter of if it will hit your state, it’s a matter of when.”<br></div> <div><br>For providers in states yet to embrace Medicaid managed care, Reed suggests they reach out to colleagues in states where it already is up and running.</div> <div><br>“One thing our membership did when we heard the managed care drum beating is have a group travel to other states and meet with their association leaders to talk about how managed care is affecting them,” he says.</div> <div><br>By taking this proactive approach, Reed and his members were able to implement safeguards up front to avoid common glitches, have a strong role in developing statutes that protect providers, and enable problems to be solved almost before they happen. </div> <div><br>States like Florida, Kansas, Tennessee, and Arizona are proof that with strong relationship building, providers can make Medicaid managed care plans partners in quality care.</div> <div><br>“This is how we conduct our business,” says Pagels. “We navigate this journey and continue to seek common ground and the best ways to care for our patients.” ■</div> <div> </div>Currently, about 50 million people receive Medicaid benefits through some form of managed care, although most are children and adults under 65, and the number is increasing almost daily. Depending on the state, participation in a Medicaid managed care program may be voluntary or mandatory. 2014-05-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0514/coverstory_thumb.jpg" style="BORDER:0px solid;" />Management;Policy;QualityCover Story5




The Case For Nurses’ Noteshttps://www.providermagazine.com/Issues/2014/Pages/0614/The-Case-For-Nurses’-Notes.aspxThe Case For Nurses’ Notes<div> </div> <div> </div> <div>Implementation of electronic medical records (EMRs) in the nursing home setting is to be celebrated. As an industry, long term and post-acute care is finally catching up with the remainder of the health care industry and providing point-of-service documentation. <br></div> <div><br>This type of documentation, the “check the box” documentation, however, should never take the place of a good narrative note that encompasses clinical assessment and critical thinking. </div> <div><br>So many software programs claim to promote effectiveness and efficiency through streamlined check-the-box documentation styles. Administrators may embrace this, the business office may love it—but nurses should be cautious of it.</div> <h2 class="ms-rteElement-H2">Skills Hard-Earned</h2> <div>Nurses have spent years learning assessment skills, fine-tuning those skills, moving from amateur to novice, novice to expert, and now to just checking a box? The concept of writing a narrative note, documenting clinical assessment, and critical thinking is paramount to providing the complete picture of resident care. </div> <div><br>The act of actually writing or typing a note triggers key points to touch on in the assessment. Many times nurses don’t realize how much assessment they have done until they sit to write the note—checking the box doesn’t allow the nurse to give credit to the expert assessment skills she has developed over the years or the specific care that was given in any given shift. </div> <div><br>As anyone who works as an expert legal case reviewer will attest, there are far too many medical records that have been rendered indefensible due to the inherent limitations of the check-the-box form of documentation.</div> <h2 class="ms-rteElement-H2">A Case In Point: Pressure Ulcer</h2> <div>A family brought a claim against a nursing home for an extensive pressure ulcer located on the left hip of a male resident. It appeared from the wound care notes, and in interviews, that despite the outcome, the nursing home was vigilant in providing appropriate care and treatment to this resident’s pressure ulcer. </div> <div><br>Unfortunately, the facility had moved to a check-the-box software, and its daily documentation did not support the care given. On admission, the facility had generated a standardized care plan for a Stage II pressure ulcer. The nurse was given the options of checking either “actual” or “potential” pressure ulcer, and under interventions was “Reposition as Tolerated.” </div> <div><br>The admitting nurse checked “actual,” signed the bottom, and placed the care plan in the resident’s medical record. As with many nursing centers, the standardized care plans are used for the first 21 days of the stay until the individual care plan is developed. Unfortunately, this resident moved from a Stage II to a Stage IV ulcer in only a couple of weeks, resulting in this standardized care plan being the only documentation of the nursing treatment plan, except for the nurses’ notes.</div> <h2 class="ms-rteElement-H2">What Was Missing</h2> <div>The care plan should have included substantial documentation in the nurses’ notes supporting an individualized repositioning program, such as the standard “Turned q 2 hours, repositioned off left side.” However, what was in the care was a standardized check-the-box software for daily documentation. </div> <div><br>For each shift, the nurse was prompted to answer questions regarding care. In addition, there was an option of writing a nurse’s note, which some nurses did and some did not exercise, but clearly those who did write notes were the exception. The following items were checked by either the nurse or nurse assistant at each shift: pressure ulcer, repositioning program, pressure-relieving mattress, pressure-</div> <div>relieving device in chair, nutritional supplement, and incontinence care.</div> <div><br>This was the extent of the preventative nursing care documented on this pressure ulcer for two weeks. In prior years, the nurse would sit down at the end of her shift and write something like this: “Resident with a Stage II pressure ulcer on left hip. Dressing dry, clean, and intact. No drainage noted. Up in chair for meals only. Consumed 75% of dinner and 240 cc protein shake. Repositioned off left side, position changed q 2 hours. Pressure-relieving mattress in place. Resident without complaints of pain.”</div> <div><br>An examination of this case study would find that the nursing home would have a difficult time preparing a defensible case, as the record lacked any information on how often the resident was repositioned and if he was positioned off his left side, how often incontinence care was done, and how often a nutritional supplement was given and consumed. </div> <h2 class="ms-rteElement-H2">Case Two: Substandard Care</h2> <div>A family had brought a claim against a nursing home for substandard care relating to their mother who had resided in the center for well over a year. The resident had end-stage renal disease and received dialysis three times per week. This resident was completely cognitive and often refused to go to dialysis and follow her recommended diet.</div> <div><br>Those refusals resulted in highly fluctuating weights, significant weeping edema in the legs, and, eventually, leg ulcers. The resident was clear on her wishes and could clearly understand the risks of her refusals. </div> <div><br>The nursing home had not yet moved to the check-the-box documentation, which resulted in nurses writing narrative notes each shift for almost a year. The nurses were able to clearly articulate good assessment skills, the resident’s mood and cognitive status, the resident’s understanding of the risks, and the resident’s consistent refusal of care. </div> <div><br>After the resident’s passing, the family contended that the resident was not of sound mind to understand the risks of her behavior.</div> <div><br>The nurses’ notes were paramount to the facility’s defense. This center had a defensible case for this resident’s care.</div> <h2 class="ms-rteElement-H2">Beware Of EMR Efficiencies</h2> <div>As the industry embraces and celebrates the efficiency of the EMRs, it should not lose sight of the reasoning behind the narrative note and the need to document clinical assessment and critical thinking. </div> <div>The professional health care staff have been trained and educated to assess areas that don’t have a check box. </div> <div><br>Staff should be empowered to document these findings, encouraging the use of narrative notes as a means to get the whole picture and trigger subtle assessment findings.</div> <div><br>This form of documentation provides crucial information when determining defensibility of a medical record; it cannot be replaced by a check box. <br><br><em>Lori Shibinette, RN, MBA, NHA, is the administrator of Merrimack County Nursing Home in Boscawen, N.H. She does expert record reviews as a consultant for facilities that are engaged in liability disputes. She can be reached at <a target="_blank" href="mailto:lshibinette@mcnhome.net">lshibinette@mcnhome.net</a>. </em></div>The “check the box” documentation should never take the place of a good narrative note that encompasses clinical assessment and critical thinking. 2014-06-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0614/caregiving_t.jpg" style="BORDER:0px solid;" />CaregivingColumn6
Feds Revise Key Survey & Cert Provisionshttps://www.providermagazine.com/Issues/2014/Pages/0614/Feds-Revise-Key-Survey--Cert-Provisions.aspxFeds Revise Key Survey & Cert Provisions<br>Under new federal agency rules, all nursing centers will be granted the option to petition for an Independent Informal Dispute Resolution (IIDR) if the agency has imposed Civil Monetary Penalties (CMPs) in the course of a serious deficiency citation.<br><br> <p>The Centers for Medicare & Medicaid Services (CMS) released its revision to Chapter 7 of the State Operations Manual, “Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities,” in March that focuses on the issues of the IIDR process and CMPs. <br></p> <p>The revision says that while CMS will continue to offer facilities an opportunity for an existing Informal Dispute Resolution (IDR) conducted by state agencies, all skilled nursing facilities (SNFs), nursing facilities (NFs), and SNF/NFs will be given an opportunity to request and participate in an IIDR if CMS imposes CMPs. <br></p> <p></p> <div>Each state can have its own IIDR process, but all states must include provisions established by CMS. </div> <div>Decisions by the IIDR will be handled in either of two ways. If the state agency agrees with the recommendations of the IIDR and no changes will be made to the disputed survey findings, the survey agency will send written notice to the facility within 10 calendar days. If the state agency disputes the recommendations of the IIDR, the CMS regional office will review all information and make a final decision. </div> <div>CMS retains the ultimate authority for the survey findings and CMPs.</div> <h2 class="ms-rteElement-H2">IIDR Requirements</h2> <div>To be approved as an IIDR entity or person, specific CMS requirements must be met. To determine “independence,” the entity or person must meet the following requirements: <br><br></div> <div>■ Demonstrate an understanding of Medicare and Medicaid program requirements, including the State Operations Manual Chapter 7, Appendix P, Appendix PP, and Appendix Q;<br><br></div> <div>■ Have no financial or other conflict of interest;<br><br></div> <div>■ May be a component of a state agency, provided that it is organized separately; and<br><br></div> <div>■ May be an independent entity or person selected by the state and approved by CMS.<br><br></div> <div>After a state’s proposed IIDR process is approved by CMS, the state survey agency and the IIDR entity or person can then formalize a written contract or Memorandum of Understanding (MOU). <br><br></div> <div>An IIDR is conducted only upon a timely request by facility staff; they must make their request within 10 calendar days of receipt of the offer from CMS.<br><br></div> <div>If the request is mailed, the postmark on the envelope should confirm that a response was made within the 10-day time period. Once the facility’s request for an IIDR is received, the state agency will notify the involved resident (or resident representative) and the ombudsman and give them an opportunity to comment. </div> <h2 class="ms-rteElement-H2">Process Restrictions</h2> <div>The IIDR process does not delay imposition of remedies, including CMP. The process gives staff the chance to dispute the factual basis of cited deficiencies, but not the scope and severity classifications unless these involve substandard quality of care or immediate jeopardy levels. </div> <div><br>Things facility staff may not dispute include remedies, failure of the survey team to comply with requirements of the survey process, and the survey team’s inconsistencies in citing deficiencies in comparison with other facilities. </div> <div><br>The IIDR may not be used to allege that the IDR or IIDR process was inadequate or inaccurate. Facility staff may not use the process to dispute a previous decision from another survey in which they elected to follow the IDR process. </div> <div><br>The IIDR will be conducted within 60 days of the facility’s request, and findings of the IIDR review will be documented in a written report no later than 10 calendar days after the decision is reached. </div> <div><br>The state agency provides the final decision to the facility no later than 10 calendar days after receiving the IIDR report. </div> <h2 class="ms-rteElement-H2">Where Challenges Go</h2> <div>Deficiencies that are pending an IIDR are entered into both the Automated Survey Processing Environment (ASPEN) software and the ASPEN IDR Manager software, but are not uploaded to the Certification and Survey Provider Enhanced Reporting (CASPER) system until the IIDR is completed. </div> <div>In the event that a facility has undergone a federal survey with the imposition of a CMP, a federal IIDR will be offered. It will be conducted as a paper review performed by a federal IIDR entity under contract with CMS. </div> <div><br>If the facility has a conflict of interest with the federal IIDR entity, or if the federal entity is unavailable, the review will be performed by the CMS central office. Federal reviews are to be completed within 60 days of the facility’s timely request. </div> <div><br>If facility staff do not request the IIDR in the proper time frame, then the process is considered to be completed. </div> <h2 class="ms-rteElement-H2">Agency Actions</h2> <div>When an IIDR is conducted and the final decision is in the facility’s favor, the survey agency will:<br><br></div> <div>■ Change the deficiency citation content findings;<br><br></div> <div>■ Adjust the scope and severity;<br><br></div> <div>■ Annotate the citations as “deleted” or “amended as recommended;”<br><br></div> <div>■ Have a new CMS Form 2567 signed by a survey manager or supervisor;<br><br></div> <div>■ Recommend to CMS the deletion or reduction of enforcement actions; and<br><br></div> <div>■ Provide facility written notice.<br><br></div> <div>Facility staff have the option to request a clean (new) copy of CMS Form 2567. This new copy will only be released when a new plan of correction is provided and signed by a facility representative. The original CMS Form 2567 will be released to the public if the facility does not meet these requirements. </div> <h2 class="ms-rteElement-H2">Penalties May Be Reduced</h2> <div>CMPs are subject to collection and placement in an escrow account pending a final administrative decision of the IIDR. Under the original guidelines of Chapter 7, facility representatives can waive their right to a hearing in writing within 60 days from the date the CMP is imposed. The CMP will then be reduced by 35 percent. Payment is not due until after this time period passes. <br><br></div> <div>Under the IIDR process, if the facility staff have self-reported, promptly corrected the facility’s noncompliance, and waived their right to a hearing, the CMP will be reduced by 50 percent. Facility staff cannot request both the 35 percent and 50 percent reductions.<br><br></div> <div>Noncompliance that is designated immediate jeopardy, a pattern of harm, widespread harm, or that results in a resident’s death is not eligible for CMP reduction.</div> <h2 class="ms-rteElement-H2">CMP Funds Allocated To Benefit Resident Care</h2> <div>The Patient Protection and Affordable Care Act allows 90 percent of CMP funds to be used to support activities that benefit residents. These include assistance to support and protect residents of a facility that closes either voluntarily or involuntarily. If a facility is decertified, funds may be used to offset the cost of relocating the residents. <br><br></div> <div>Other CMS-approved uses for the CMPs include projects that support resident and family councils, other consumer involvement in ensuring quality of care, and facility improvement initiatives.<br><br></div> <div>These initiatives must be approved in advance and may include joint training of facility staff and surveyors, technical assistance for facilities such as implementation of quality assurance programs, and appointment of temporary management firms. All proposed activities must receive approval from CMS prior to initiation. </div> <div>Areas considered inappropriate for CMP use include capital improvements to facilities, payment for services or items already the responsibility of the facility, projects not related to improving quality of life or quality of care for residents, projects in which there is an appearance of a conflict of interest, projects taking longer than three years, temporary manager salaries, and supplementary funding of federally required services. <br><br>Click to obtain <a href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-18.pdf" target="_blank" title="Click here!">Survey and Certification Memorandum S&C-14-18-NH and the revised Chapter 7</a>.<br><br><em>Betty MacLaughlin Frandsen, RN, NHA, MHA, CDONA/LTC, C-NE-MT, is the curriculum development specialist for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em><br></div> <p></p>CMS released its revision to Chapter 7 of the State Operations Manual, “Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities,” in March that focuses on the issues of the IIDR process and CMPs. 2014-06-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0614/feature_t.jpg" style="BORDER:0px solid;" />Management;CaregivingColumn6
Jumping Off The Readmissions Carouselhttps://www.providermagazine.com/Issues/2014/Pages/0614/Jumping-Off-The-Readmissions.aspxJumping Off The Readmissions Carousel<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>Congress has imposed readmissions standards on the profession, but providers that commit to quality have a chance not just to survive the new environment, but to thrive in it. </div> <div> </div> <div>As part of a short-term fix to the perennial question of Medicare’s physician payment formula, Congress tacked on a whole new catalogue of regulations, requirements, and incentives aimed at making providers focus on needless trips back to the hospital. </div> <div> </div> <div>\It’s what some policy wonks call “value-based purchasing.”</div> <h2 class="ms-rteElement-H2"><div>‘I Guess We Were Right’</div></h2> <div>The new regulations weren’t a surprise; lawmakers and policymakers have been focused on cutting Medicare expenses for years, and hospitalizations account for nearly half of the public’s health care spending. In fact, before Congress imposed its first readmissions standards on hospitals, long term and post-acute care activists had been coming up with their own answers to the problem. </div> <div> </div> <div>It wasn’t just a matter of cost, either. </div> <div> <br>“We know that when people go back to the hospital, they often come back in worse condition than when they left,” says David Gifford, a medical doctor and senior vice president of quality at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL). “They’re more debilitated. The acute illness that led them to go to the hospital—the pneumonia, the heart failure—that’s treated, but the person comes back in worse shape.”</div> <div><br>AHCA/NCAL has tasked its members with finding ways to reduce avoidable readmissions by 15 percent no later than March of next year. </div> <div><br>“To us, it was sort of a no-brainer,” Gifford says of the quality goal. “You could have better outcomes, lower costs, and offer a better quality of life. I guess we were right, because now everyone’s focusing on it, too.” </div> <div> </div> <h2 class="ms-rteElement-H2"><div>Reality Bites</div></h2> <div>If providers hadn’t been focusing on readmissions before, the new federal mandates should grab their attention. The new law means that, beginning in fiscal year 2019, officials will hold back 2 percent of providers’ Medicare cut each fiscal year. Up to 70 percent of that money will go into a reward fund, and providers that keep their rates low, or lower their readmission rates significantly, will get a chance to win the money back. <br></div> <div>Provider advocates aren’t thrilled about it, but they say their lobbying efforts helped put a lot of incentives in the bill that may mean extra money for homes and centers that keep their eyes on the prize. </div> <div> </div> <div>“It’s a cut. That is the reality,” says Clif Porter II, the top lobbyist for AHCA/NCAL. “However, what is positive about this is that our providers have some constructive goals before them. If they perform well—and frankly, our members perform better than most—they won’t get cut at all. They also may earn even more.”</div> <div> </div> <div><br>Providers that improve their readmission rates, or maintain low rates from the get-go, will be given cash at the end of the fiscal year. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"><div>The Era Of Austerity</div></h2> <div>If that still seems too bitter a brew to swallow, recall that President Obama’s initial proposal would have cut the sector by 3 percent across the board. For many provider advocates, the sad reality is that they are living through the Era of Austerity. Whatever one’s politics, the fact is Washington doesn’t have a lot of money and isn’t in the mood to shell out much of it. <br><br>And it’s not entirely as if providers are being singled out. Hospitals have been forced to take much harsher readmission medicine since October 2012. (The penalties amount only to 1 percent at worst, but hospitals can’t get any more than 100 percent of their rates even for improving or excelling.) In the first year of the new regime, more than 2,200 hospitals were dinged for more than $280 million in penalties.</div> <div> </div> <div><br>With that in mind, many leading advocates, such as AHCA/NCAL’s Porter, are hoping to build the kind of relationships with lawmakers and policymakers that will help blunt the worst effects of the Era of Austerity, while also banking the kind of favors they can call back on when (if) things improve. Hence, AHCA/NCAL’s advertising slogan, “We Are the Solution.”</div> <div> </div> <h2 class="ms-rteElement-H2"><div>Weighing In On Policy</div></h2> <div>“It’s a differentiator for us,” Porter says, “So policymakers know we’re very committed to working on both sides of the aisle. No one else in this sector is doing that in this town.”</div> <div> </div> <div>In fact, the readmissions standards that were passed by Congress in March were largely shaped by AHCA/NCAL’s efforts. If cuts are inevitable—and they certainly seem to be—providers can say, “At least let us take a look for ourselves at where we can save,” Porter says. </div> <div> </div> <div>Porter says he’s confident that the more constructive approach is paying off. “We’ve established credibility for the sector,” he says. </div> <h2 class="ms-rteElement-H2"><div>Science On Their Side </div></h2> If the new regulations were a long time coming (and still a long way off), providers should at least take comfort that science is on their side. And the solutions can be relatively straightforward. <div> </div> <div>Years of research show, for instance, that having nurse practitioners on staff makes a critical difference in cancelling those ambulance trips (<a href="/Issues/2014/Pages/0614/Beyond-The-Biology-How-Nurse-Practitioners-Lead-The-Way.aspx" target="_blank">see sidebar</a>).</div> <div> </div> <div>Many advocates and caregivers, for instance, sing the praises of the NTERACT system, which stands for Interventions to Reduce Acute Care Transfer.</div> <div> </div> <div><br>INTERACT is a quality improvement program to help providers identify, document, and communicate resident needs and problems. The goal is to improve care and reduce the frequency of avoidable trips to the hospital.</div> <div> </div> <div>INTERACT was first developed by Joseph Ouslander, MD, and a team of researchers at Florida Atlantic University, but it has grown into its own consulting and online resource system supported by private grants. </div> <div> </div> <div>If it sounds complex, it’s really not, AHCA/NCAL’s Gifford says. The real goal of INTERACT and approaches like it, Gifford says, is to get providers talking to their residents—and to one another. </div> <div> </div> <h2 class="ms-rteElement-H2"><div>‘It Makes Total Sense’</div></h2> <div>“It’s less focused on specific disease management, but more on these broader systems of care,” Gifford says. “If you talked about management for each disease, you’d have to talk about hundreds of protocols, and hundreds of systems. The INTERACT system distills it down to its essence.”</div> <div> </div> <div>Decades of research have shown that many hospitalizations could be avoided if residents and their caregivers were not only talking to each other, but making sure they were understanding each other, Gifford says. “Doctors and nurses are smart people,” he says. “But they just aren’t always able to communicate properly.”</div> <div><br>Systems like INTERACT “really go to the root cause,” Gifford adds. “As soon as you read it and look it, it’s like, ‘Oh, yeah. That makes total sense.’”<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2">‘We’ve Been Working … For A Long Time’</h2> <div> </div> <div>Tom Coble is one provider who sings INTERACT’s praises. A former energy company executive, Coble came to Elmbrook Management Co. in his hometown of Ardmore, Okla., knowing little to nothing about health care (<a href="/Issues/2014/Pages/0614/The-Top-Down-Road-To-Quality.aspx" target="_blank">see sidebar</a>). But he did know systems and revenue, and he could see early on that, if his company were going to make any money, it would have to become Medicare-certified.</div> <div> </div> <div><br>To do that, he recognized, it would have to deliver quality care. And a key component of quality care, Coble says he realized early in his education as a provider, was to keep people out of the hospital.</div> <div> </div> <div><br>His company started putting nurse practitioners in its buildings in the early 2000s. It adopted INTERACT in 2005. In the fourth quarter of last year, one of his centers had a 0 percent readmission rate. “We’ve been working on readmissions for a long time,” Coble says. The key, he says, agreeing with Gifford, is open lines of communication—not just in the buildings, but beyond them.</div> <div> </div> <h2 class="ms-rteElement-H2">Emergency Or ‘Stress Of A Family?’</h2> <div> </div> <div>Many hospitalizations, Coble saw quickly, stemmed from anxiety by residents or their families, the common stress of a new environment for an ailing relative. The company now puts “Stop and Watch” guides in admission packets and hands them out to residents, families, and loved ones from day one, Coble says. The cards are an early warning tool, a part of the INTERACT system that gives caregivers a checklist of physical changes in condition to watch for.</div> <div><br>The choice, as Coble sees it, is to send a stricken person to the hospital needlessly, or “just deal with the stress of a family worried about their loved one.” </div> <div><br>Additionally, Coble says, his staff have worked hard to develop “lines of contact” with local emergency rooms. In those nonemergency cases, “We can call [the hospital] and tell them, ‘We can handle this. This family just wanted to be comforted,’” Coble says. “Most often, we can get those residents back to our facilities without the admission.”</div> <div> </div> <h2 class="ms-rteElement-H2">‘They’re Going To Fall Behind’</h2> <div> </div> <div>Gifford is cheered by examples such as Coble’s, but he hopes the rest of his colleagues won’t take too long in following Coble’s lead. The 2019 penalties are coming faster than anyone thinks. <br></div> <div><br>“We’re trying to talk about instilling broader systems of care,” Gifford says. “They take time to implement. If people think it’s off on the horizon, they’re going to fall behind, and their center is going to suffer.”</div> <div> </div> <div><br>AHCA/NCAL has been working on its quality goals since 2012. One of the things Gifford says he’s learned from the experience is that a targeted focus actually can have the broadest possible impact. Those centers that have reduced readmissions, for instance, have also reduced hospitalizations, he says. </div> <div> </div> <div><br>“Clearly, we’re seeing improvement across the board,” he says. “The lesson is, if you focus on the root causes, you can change for the better. If you flit from problem to problem, you do end up doing nothing, and things don’t really change.” <br><br>Also, see <a href="/Issues/2014/Pages/0614/The-Bottom-Up-Road-To-Quality.aspx" target="_blank">The Bottom-Up Road To Quality</a> </div> <div>  </div>As part of a short-term fix to the perennial question of Medicare’s physician payment formula, Congress tacked on a whole new catalogue of regulations, requirements, and incentives aimed at making providers focus on needless trips back to the hospital. 2014-06-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0614/coverstory_t.jpg" style="BORDER:0px solid;" />Caregiving;ManagementCover Story6
The QIS Expert: Is QIS Consistent With Person-centered Care?https://www.providermagazine.com/Issues/2014/Pages/0614/The-QIS-Expert.aspxThe QIS Expert: Is QIS Consistent With Person-centered Care?<p>Person-centered care represents the most essential feature of culture change in national models, such as the Eden Alternative. Advancing Excellence highlights the principle that “person-centered care promotes choice, purpose, and meaning in daily life.” And as nursing homes, as well as assisted living centers, are increasingly caring for elders living with various stages of dementia, the Pioneer Network, among other groups, is focused on person-centered dementia care. <br></p> <p>Regulation is often seen as a barrier to person-centered care in nursing homes; however, it can be argued that regulation offers the most direct avenue for widespread culture change across the industry. Voluntary initiatives provide the critical step of developing and testing culture-change processes and how to implement them among committed organizations. They also provide the tools to articulate and evaluate these processes from a regulatory perspective.<br></p> <p>QIS offers some of these rudimentary tools based on the knowledge base available when person-centered care was designed a decade ago. The resident and family voice became much more central in surveys such that nursing home staff and surveyors began to focus on the resident’s perspective—a first step toward more person-centered care. <br></p> <p>Specific QIS questions are aimed at choices, dignity and respect, and participation in care planning decisions, for example, all of which are central to person-centered care. <br></p> <p>But what about person-centered care for the growing number of nursing home residents with dementia?<br>In its most recent Survey and Certification (S&C) letter 14-22-NH; April 18, 2014, the Centers for Medicare & Medicaid Services (CMS) said that it is “undertaking a pilot to more thoroughly examine the process for prescribing antipsychotic medication, as well as other dementia care practices in nursing homes.” This pilot is intended to build on the CMS National Partnership to Improve Dementia Care in Nursing Homes, an interim report attached to S&C letter 14-19-NH; April 11, 2014. <br></p> <p>The program focuses significantly on reducing antipsychotic use, but more broadly on “implementing person-centered care practices, individualized care plans, and enhanced resident and family engagement.”<br></p> <p>In S&C letter 13-35; May 24, 2013, that provided new surveyor guidance for Quality of Care (F 309) and Unnecessary Drugs (F 329), CMS listed person-centered care as the first principal of dementia care. CMS also recognized the need for considerable training for surveyors to understand this standard and provided training videos to meet this need. Enhancing the QIS process to more fully explicate and assess standards for persons with dementia should be a high priority for CMS.<br></p> <p>Providing person-centered care, however, requires a cultural shift in the care for residents who are able to direct their care and services, and those with dementia who cannot. <br></p> <p>Relationships between staff and residents are critical in order to support residents in preserving what is meaningful in their lives. The physical environment has to be comfortable and manageable, whether it is like the Greenhouse project, in neighborhoods, or some other physical design. All of these are measurable, but require informed development of more explicit regulations that can provide impetus for culture change.<br></p> <p><em>Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).</em><br></p>Relationships between staff and residents are critical in order to support residents in preserving what is meaningful in their lives.2014-06-01T04:00:00Z<img alt="" src="/Articles/PublishingImages/headshots/AndyKramer.jpg" style="BORDER:0px solid;" />QualityColumn6
The Top-Down Road To Qualityhttps://www.providermagazine.com/Issues/2014/Pages/0614/The-Top-Down-Road-To-Quality.aspxThe Top-Down Road To Quality<p><br></p> <p>However providers tackle their readmission rates, all their routes are going to lead through person-centered care, experts say. That phrase has become a bit of a marketing cliché of late, but advocates say it’s really as simple as making sure that care decisions are made either by the resident, or those closest to her. <br></p> <p><img height="211" width="158" class="ms-rtePosition-1" alt="Tom Coble" src="/Issues/2014/PublishingImages/0614/TomCoble.jpg" style="margin:5px 10px;" />It’s a deceptively simple program. It’s a lot harder than anyone thinks. But there are a lot of ways to do it. </p> <p>Tom Coble was an outsider to long term care when he became director of the for-profit Elmbrook Management Co. in Ardmore, Okla. A long-time executive trained as a systems analyst, he started at the top and worked his way down. <br></p> <p>Along the way, Coble found that cost and quality don’t have to be mutually exclusive. (If it matters, three of Coble’s for-profit homes are rated four stars by Nursing Home Compare.)<br></p> <p></p> <div>Coble’s route to quality started from a desk at an offshore natural gas drilling operation on Feb. 28, 1993. <br></div> <div>“On March 1, 1993, I was sitting behind a desk in the business office of a 126-bed skilled nursing facility, having never worked a day in health care in my life,” he says. “My background was in systems. When I got in the long term care business, it was very evident that the old system didn’t work.” </div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-6-3">Finding A New Way</h2> <div>Coble’s view may seem like it’s coming from the stratosphere. But Ardmore, Okla., where Elmbrook is based, is the town where he was born and raised, so he knew better than anyone that those numbers he was crunching represented people he’d grown up with and cared about all his life. </div> <div><br>Like many providers, Elmbrook was squeaking by on that wobbly combination of Medicaid and private pay. </div> <div>“If you could change to Medicare, you could profoundly impact quality and cost in the health care setting, in general,” he says. And Coble figured out soon (and has remembered it ever since) that pitting costs against quality is making a distinction without much of a difference. Each time an ambulance took a former friend or neighbor to the hospital, it took lots of wasted dollars with it, Coble says. Saving the one meant saving the other. </div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-6-3">‘Once I Caught My Breath’</h2> <div>“Not only are we sending people to the hospital that didn’t need to go, but they’re coming back sicker than they were when we sent them over,” Coble says. “Once I caught my breath from realizing what I’d gotten myself into, it became very apparent that we could take care of the majority of these people in our facilities, but guess what? The rules don’t allow us to.”</div> <div><br>Pursuing the quality benchmarks of a Medicare-certified care center allowed Elmbrook to “realign” its services to meet the growing acuity of Elmbrook’s residents, Coble says. </div> <div><br>But by tackling Medicare quality standards, Coble found that he was also addressing another nagging problem: reassuring his friends and neighbors that the people they cared about were being cared for. </div> <div>“The hardest decision any family makes is to put their loved one in a nursing home,” he says. “I don’t care what anybody says.”</div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-6-3">They Have A Voice</h2> <div>The data Coble crunches routinely don’t show how often a resident is hospitalized simply because his or her family is stressed out by the enormity of the new life changes in a skilled nursing center, Coble says. But he saw that making the residents and their families feel at home at Elmbrook meant that they were less likely to push the panic button. That, in turn, made the experience in the home that much better, which in turn made things feel much more like home. <br></div> <div><br>Today, whenever a resident is admitted to an Elmbrook center, he or she is observed using the “Stop and Watch” tool of the INTERACT system, Coble says. It’s written in plain language, and it’s handed out to everyone who has any dealing with the residents. </div> <div><br>“We put those in admission packets, we give them to our therapists that work in our buildings and to family members, so that if they think there’s a problem or something going on that we’ve missed in caring for their loved one, they have a voice,” he says. </div> <div><br>Coble continues to crunch his numbers. But he knows enough about person-centered care to know the limits of his own expertise, he says. “I’m the last one who needs to be involved in care decisions,” he says.</div> <p></p>2014-06-01T04:00:00ZColumn6
Beyond The Biology: How Nurse Practitioners Lead The Wayhttps://www.providermagazine.com/Issues/2014/Pages/0614/Beyond-The-Biology-How-Nurse-Practitioners-Lead-The-Way.aspxBeyond The Biology: How Nurse Practitioners Lead The Way<p><br></p> <div> </div> <div> </div> <div> </div> <p><img height="215" width="150" src="/Issues/2014/PublishingImages/0614/DGifford.jpg" alt="David Gifford, MD" class="ms-rtePosition-1" style="margin:10px 15px;" />Nearly a decade’s worth of research is showing that nurse practitioners may hold the key to reducing needless hospitalizations. But a growing number of quality advocates and experts say it may not be because of what the nurse practitioners do—it’s how they do it. <br></p> <div> </div> <div> </div> <div> </div> <p></p> <div> </div> <div> </div> <div> </div> <div>The Centers for Medicare & Medicaid Services (CMS) has already opened up a five-city project testing whether nurse practitioners can help forestall trips to the hospital. CMS officials declined to discuss their results with Provider, but those familiar with the early returns say that the nurse practitioners are making a huge difference for the better. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2 ms-rteForeColor-10">Cardiac Readmissions Cut In Half</h2> <div> </div> <div> </div> <div> </div> <div>Just last month, the Journal of Cardiovascular Nursing published a study that found that adding a nurse practitioner to cardiac teams reduced readmissions by nearly half. In fact, the absence of a nurse practitioner on the team was the second-leading indicator of a return to the hospital, behind heart failure and before diabetes, the researchers found. <br><br></div> <div> </div> <div> </div> <div> </div> <div>Clinical nurse and Northeastern University Jonas Scholar Daniel David led the journal study. He says that, by their training, nurse practitioners tend to have “an interesting outlook on the entire health care process.” </div> <div> </div> <div> </div> <div> </div> <div>“They have the medical training to take care of patients in a clinical way, but they’re also looking at barriers of care,” he says. “Their view extends beyond the biology to what really helps and hurts patients.”</div> <div> </div> <div> </div> <div> <span class="ms-rteForeColor-10"> </span></div> <h2 class="ms-rteElement-H2 ms-rteForeColor-10">Phy<span></span>sical Presence<span class="ms-rteForeColor-10"></span></h2> <div> </div> <div>David Gifford, MD, senior vice president of quality for the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), says that nurse practitioners are trained to diagnose and treat diseases, but their real gift is simply being closer to the resident, more often. </div> <div> </div> <div> </div> <div> </div> <div><br>“If you look at the literature on readmissions, in many of the rehospitalizations that were preventable, people showed earlier, little signs. Having a nurse practitioner there to lay their hands on the person, to take a look at subtle changes, you can now prevent things from blossoming into a full-blown infection,” he says. </div> <div> </div> <div> </div> <div> </div> <div><br>Gifford and David agree that the research shows that a “team-oriented” approach to care is vital, with open lines of communication between and among residents, family, and staff. </div> <div> </div> <div> </div> <div> </div> <div><br>They also agree that those skills that benefit a nurse practitioner—being able to think like a doctor and a patient advocate—should be easily transportable if caregivers are focused on quality. </div> <div> </div> <div></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> <span class="ms-rteForeColor-10">‘It’s Transferable’ </span></h2> <span class="ms-rteForeColor-10"> </span><div> </div> <div> </div> <div>This kind of observation and empathy “is not specific to nurses,” Northeastern’s David says. “I think it’s transferable to anyone interested in taking care of people. </div> <div> </div> <div> </div> <div> </div> <div><br>"We’re shifting our focus not only to the things that are lab-valuable, but also in psychosocial factors, such as whether people adopt the recommendations we give them.” <br><br></div> <div> </div> <div> </div> <div> </div> <div><img height="185" width="149" src="/Issues/2014/PublishingImages/0614/DanielDavid.jpg" alt="Daniel David" class="ms-rtePosition-1" style="margin:5px 15px;" />In fact, David and his colleagues are already at work on a follow-up study. They’re poring over thousands of discharge papers to see whether there are differences between the ways doctors and nurse practitioners write out instructions for patients. </div> <div> </div> <div> </div> <div> </div> <div><br>AHCA/NCAL’s Gifford says providers shouldn’t focus on working titles as much as they should focus on what the resident is telling them. </div> <div> </div> <div> </div> <div> </div> <div><br>“There are a number of nurses I’ve worked with who have better medical skills than many doctors I’ve worked with,” he says. “And I’ve worked with many doctors who have better bedside manners and compassion than many nurses I’ve worked with.”</div> <div> </div> <div> </div> <div> </div> <div><br>Besides, Gifford adds: “You don’t need any clinical training to think necessarily about what it’s like to be a patient and how to be more person-centered. Many, many family members take care of their relatives without any medical training.”</div> <div> </div> <div> </div> <div> </div> <p></p>2014-06-01T04:00:00ZColumn6
Interoperability Key To Tech Integrationhttps://www.providermagazine.com/Issues/2014/Pages/0614/Interoperability-Key-To-Tech-Integration.aspxInteroperability Key To Tech Integration<p><span><span class="ms-rteForeColor-2">Sponsored by<span style="display:inline-block;"></span></span></span><span class="ms-rteForeColor-2"><img width="142" height="16" class="ms-rtePosition-4" src="/Issues/2014/PublishingImages/logos/PointClickCare.jpg" alt="" style="margin:5px;" /><br></span></p> <p>Interoperability was the focus of another recent <em>Provider</em> roundtable in Las Vegas, in which long term and post-acute care executives gathered to discuss issues of concern and share successes with regard to health information technology (HIT) in the sector. </p> <p>Participants discussed how emerging technologies are impacting the full spectrum of the aging services continuum, with particular emphasis on assisted living and nursing home care.</p> <p>Sponsored by PointClickCare, the event was well-attended by owners and operators who had much to say about electronic medication administration records (eMars), electronic health records, pharmacy integration, and physician engagement. <br></p> <p>For Bartley Healthcare in Jackson, N.J., Chief Executive Officer (CEO) Phil Scalo said he works closely with local hospital systems, and his concerns with interoperability stem from being able to connect with them seamlessly.<br></p> <p>“It’s not easy to do,” he said, “but it would save us a lot of time” to have that ability. <br></p> <p>Don Pellegrino, who owns two skilled nursing and two assisted living centers in New Jersey, has also been active with local hospitals. <br></p> <p>“We are a provider they are looking to because we are very progressive, and we have mobile devices,” he said. “Trying to get the hospitals to integrate with our systems has been a bit of a challenge.”<br></p> <p>Ralph Marrinson, president and CEO of Marrinson Senior Care Residences, noted his frustration with not being able to get his pharmacy provider to integrate with his communities. <br></p> <p>“We now have an integrated system,” he said, and the benefits are multiple, including saving time, greater efficiencies, and “closing the gap of errors.” <br></p> <p>Marrinson, who has been in the business for just under 50 years, believes that providers have an opportunity with technology to be leaders. “The more we can advance in technology, the more we can show we are frontline players in health care, the better our industry will be.”<br></p> <p>Dave Wessinger, co-founder and chief technology officer of PointClickCare, offered his perspective on the trials and tribulations of HIT interoperability. <br></p> <p>Pharmacy integration, he said, has been one of the “most active conversations in any opportunity that we have. It’s a much heavier lift than people think.” <br></p> <p>If a pharmacy provider is using a proprietary system, it is very unlikely it will ever get integrated, he said. His advice: Find a pharmacy that’s on a system that is designed to integrate. <br></p> <p>Wessinger and other participants agreed that when it comes to implementing everything from eMars and pharmacy records to physician order systems, change management is critical. <br></p> <p>Others expressed concern about getting doctors to buy into new systems and the importance of buy-in from staff. <br></p>Sponsored by PointClickCare, the event was well-attended by owners and operators who had much to say about electronic medication administration records (eMars), electronic health records, pharmacy integration, and physician engagement. 2014-06-02T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/Roundtable_thumb.jpg" style="BORDER:0px solid;" />Management;TechnologyColumn6




Guiding Principles For COPD Treatmenthttps://www.providermagazine.com/Issues/2014/Pages/0714/Guiding-Principles-For-COPD-Treatment.aspxGuiding Principles For COPD Treatment <p></p> Chronic obstructive pulmonary disease (COPD) is a progressive, incurable respiratory disorder characterized by airflow obstruction. For health care professionals working in long term care, it’s important to understand every aspect of this debilitating disease and follow clear protocols in order to provide effective care. <div><br>COPD encompasses emphysema, chronic bronchitis, irreversible asthma, and some forms of bronchiectasis. Cigarette smoking is the main cause of COPD, although air pollution and occupational dusts are also common causes. </div> <div><br>About 3 percent of individuals have a genetic form of COPD called Alpha-1 Antitrypsin (ATT) Deficiency.</div> <div>In the beginning stages of the disease, individuals with COPD experience minimal shortness of breath that might be noticed only during exercise. As the disease progresses, shortness of breath worsens and physical activity is diminished. Making a COPD diagnosis relies on a combination of patient history, physical examination, and confirmation of airflow obstruction using a spirometry test.</div> <div><br>Long term care residents with COPD often fall into a cycle of disability. They become short of breath and lose energy, which has a negative impact on their level of activity. In many cases, patients will avoid exercise and over time experience diminished mental acuity, depression, and a physical decline that, in many cases, can be slowed down. </div> <div><br>Prolonged sitting in a wheelchair may cause residents to adopt a flexed spinal posture and posteriorly tilted pelvis. Because these individuals may be unable to physically reposition without considerable assistance, their bodies can be subject to considerable positional strain and immobility, with detrimental physical repercussions, including the formation of pressure ulcers, low back pain, lumbar immobility, and joint stiffness. </div> <h2 class="ms-rteElement-H2">Management</h2> <div>Several guidelines for the diagnosis and management of COPD in long term care residents emphasize the need for a multidisciplinary approach. The aim is to treat and prevent chronic symptoms, optimize and preserve activity level, and maximize pulmonary function. </div> <div><br>Nonpharmacological interventions include smoking cessation, adequate exercise, healthy diet, and avoidance of secondhand smoke. </div> <div><br>Several states and municipalities have enacted 100 percent smoke-free laws for all nursing homes, including common areas and private rooms, in order to protect employees, patients, and visitors from secondhand smoke exposure. <br><br></div> <div>All COPD patients should receive annual influenza vaccine prophylaxis and pneumococcal vaccine administration, as well as pulmonary rehabilitation—an important intervention in patients who have severe exercise limitations. <br><br></div> <div>Pharmacological therapies can improve symptoms, quality of life, and decrease exacerbations. Long-acting bronchodilators are a primary treatment in the majority of patients with mild to moderate disease. Individuals with severe disease and those with a history of recurrent exacerbations may benefit from treatment with inhaled corticosteroids. </div> <h2 class="ms-rteElement-H2">Bronchodilators</h2> <div>Inhaled bronchodilators include beta-2 agonists and anticholinergics (antimuscarinics), which are equally effective. These consist of short-acting beta-2 agonists (SABAs) to relax bronchial smooth muscle (albuterol) and long-acting beta-2 agonists (LABAs), which are preferable for individuals with more significant symptoms. Recently, “ultra-long-acting” LABAs have been developed that require once-daily dosing (indacaterol). <br><br></div> <div>Anticholinergics relax bronchial smooth muscle through competitive inhibition of muscarinic receptors (M1, M2, and M3) (ipratropium). A long-acting quaternary anticholinergic, which is M1- and M3-selective (tiotropium), may have an advantage over ipratropium, as M2-receptor blockade may limit bronchodilation. </div> <div>The frequency of exacerbations can be reduced with the use of anticholinergics, inhaled corticosteroids, or LABAs. The initial choice among SABAs, LABAs, anticholinergics (which have a greater bronchodilating effect), and combination beta-2 agonist and anticholinergic therapy is often a matter decided by a physician.</div> <h2 class="ms-rteElement-H2">Inhaled Corticosteroids</h2> <div>Inhaled corticosteroids (ICSs) inhibit airway inflammation. Their effects are additive to the effect of bronchodilators and diminish the frequency of COPD exacerbations. ICSs are highly effective at controlling asthma, but their effects on pulmonary and systemic inflammation in COPD are unclear. Therefore, their use in COPD is limited to specific indications. <br><br></div> <div>Long-term treatment with ICS is recommended for individuals with severe COPD and frequent exacerbations that are not adequately controlled with long-acting bronchodilators.</div> <div><br>Combinations of a LABA (salmeterol or formoterol) and an ICS (fluticasone propionate or budesonide) are more effective than either drug alone in the treatment of stable disease. </div> <h2 class="ms-rteElement-H2">Acute Exacerbations</h2> <div>Treatment of acute COPD exacerbations aims to minimize the impact of the current exacerbation and prevent the development of subsequent exacerbations. The underlying cause of an acute exacerbation is usually unknown, although most acute exacerbations result from bacterial or viral infections. Smoking, irritant inhalation exposure, and high levels of air pollution may also contribute. </div> <p></p> <p>Individuals with comorbidities, a history of respiratory failure, or acute changes in arterial blood gas measurements may need hospital treatment. Physicians may determine that individuals with life-threatening exacerbations manifested by uncorrected moderate-to-severe acute hypoxemia, acute respiratory acidosis, new arrhythmias, or deteriorating respiratory function despite hospital treatment should be admitted to the intensive care unit and their respiratory status monitored frequently.<br></p> <p>For the nursing-home-to-hospital transition, several studies recommend the use of standardized transfer forms as a way of improving communication, which ultimately helps improve the patient’s safety and quality of care. <br></p> <p>In order to give individuals with COPD the best possible care, doctors should always focus on improving identification of the condition and prescribing treatments based on the most up-to-date clinical and cost-effectiveness evidence. While COPD is progressive and currently incurable, it is still treatable with the potential for a good quality of life. </p> <br><p></p> <div><em>John Walsh, who</em><em> was diagnosed with Alpha-1-related genetic COPD in 1989, is the president and co-founder of the COPD Foundation, a not-for-profit organization dedicated to preventing and curing chronic obstructive pulmonary disease and improving the lives of all people affected by COPD. Walsh can be reached at (866) 316-COPD (2673) or <a title="Email John!" target="_blank" href="mailto:info@copdfoundation.org">info@copdfoundation.org</a>. Byron Thomashow, MD, is chair of the board of directors of the COPD Foundation, clinical professor of medicine, Columbia University Medical Center, and attending physician, New York-Presbyterian Hospital. </em></div> <p></p>COPD encompasses emphysema, chronic bronchitis, irreversible asthma, and some forms of bronchiectasis. Cigarette smoking is the main cause of COPD, although air pollution and occupational dusts are also common causes. 2014-07-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0714/caregiving_t.jpg" style="BORDER:0px solid;" />CaregivingColumn7
Design Gets Person-Centered Guidelineshttps://www.providermagazine.com/Issues/2014/Pages/0714/Design-Gets-Person-Centered-Guidelines.aspxDesign Gets Person-Centered Guidelines<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div>The Facility Guidelines Institute, an organization dedicated to creating a minimum design and construction guideline for state licensing agencies, has completed a four-year revision cycle through the Health Guidelines Revision Committee (HGRC), resulting in the new “Guidelines for Design and Construction of Residential Health, Care, and Support Facilities,” as well as a sister document, “Guidelines for Design and Construction of Hospitals and Outpatient Facilities.”</div> <div> </div> <div>The hospital and outpatient facilities’ guidelines were published in March, and the long term care facilities’ guidelines were published in May 2014. </div> <h2 class="ms-rteElement-H2">Small House Models On The Rise</h2> <div>These two documents used the 2010 “Guidelines for Design and Construction of Healthcare Facilities” as the basis for revision. The 2014 revisions have separated the long term care design guidelines from the acute and ambulatory care design guidelines because of the desired shift away from institutional settings being used for the care of elders.</div> <div><br>With the advent of the Green House Project and other small-scale household models, there is a push for creating more residential, comfortable, and familiar care environments for residents requiring a higher level of care. </div> <div><br>The HGRC, a multidisciplinary committee, used a consensus process in creating the new guidelines. A specialty subgroup of more than 40 volunteer industry experts was brought together as part of the 2014 cycle to update, improve, and create the new design guidelines for residential care communities.</div> <div><br>The ultimate goal is to provide the framework for environments that support positive resident and staff outcomes and serve to promote the national movement of integrating person-centered practice in the built environment. </div> <h2 class="ms-rteElement-H2">Breaking Down Regulatory Barriers </h2> <div>The evolution of communities integrating person-centered values of choice, dignity, respect, self-determination, and purposeful living resulting in the transformation of services has significant implications for the design and construction of the residential communities in which those services are delivered. </div> <div><br>One of the unintended barriers to creating positive person-centered care models in long term care settings is often outdated and obsolete regulations and licensing. </div> <div><br>This is one of the reasons for the new guidelines, which provide minimum design requirements, as well as appendices that provide additional references for users.</div> <div><br>The goal is to provide a set of guidelines that will streamline the design portion of the licensing process for long term care settings, such as nursing homes and assisted living, help authorities having jurisdiction to evaluate design documentation, provide consistency between states, and improve resident care environments and outcomes. </div> <h2 class="ms-rteElement-H2">Operations On Board</h2> <div>In order for culture change and person-centered care to occur, it is essential that leadership of a community understand the necessity of evaluating every aspect of operations. This includes the changes required to meet each function from a person-centered perspective and commit the time and resources to educate and train staff. </div> <div><br>In addition, every community setting may be different in its approach to its culture change care model. Overall, the goal is to deinstitutionalize and create better outcomes for residents living in the environment. There is no one correct answer or solution that solves the goal and requirements of each individual community.</div> <div><br>Whether a provider is completing a new building or repositioning an existing community, every function requires evaluation for centralized versus decentralized services and what creates a successful operational change and implementation for its specific community needs and care population. </div> <div><br>For example, in a community located in Pleasant Hill, Tenn., it was determined that a decentralized household model would work for them; however, they had a cook who was very good and created terrific food in the existing institutional setting.</div> <div><br>In lieu of completely decentralizing the food service operations, the evaluation of the cooking and serving process included maintaining their well-liked cook. </div> <div><br>This was reflected in the operation and design decisions to include two smaller commercial kitchens that would be located and shared between two households. The replacement nursing home included two duplexes with four total households. </div> <div><br>Another example is the Wharton Care Center, whose team wanted all private rooms; however, Medicaid reimbursement necessitated some double-occupied rooms.</div> <div><br>With this as a requirement, the rooms were not designed in the traditional, institutional manner with beds next to one another. </div> <div><br>Instead, person-centered care principles and goals established in the programming process were used to create two sleeping alcoves with a shared bathroom. This worked operationally and still provided resident privacy, while meeting the financial requirements of the community and the population being served.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Organization Of The Guidelines </h2> <div>Part 1 of the new guidelines not only includes information on creating a functional program, but also includes guidance on planning, evaluation of risks, and considerations for the environment of care—all crucial to the success of a residential care setting. The risks are included in the Resident Safety Risk Assessment portion of the guidelines (see Table 1, left).</div> <div><br>Common elements, as well as an overlay for designing environments for residents and participants with dementia, a sustainable design section, and information on bariatrics, are provided in Part 2, which is referenced from all of the specific facility sections. Part 2 was established to minimize duplication of information throughout the guidelines and to provide ease of access to common information that impacts all or most health, care, and support environments. </div> <div><br>Each facility chapter (Parts 3 through 5) of the guidelines covers different categories and typologies for a variety of care models, providing an understanding and direction for the development of a wide range of senior living environments. </div> <div><br>The categories of health, care, and support settings include: nursing homes, hospice, assisted living centers, independent living settings, adult day care facilities, wellness centers, and outpatient rehabilitation centers.<br><br></div> <div>Within each category, typologies are used and designated by both the scale and the model of care in the environment being designed.</div> <div><br>For example, the nursing homes section includes information on three different models of care, each of which is supported by a different built environment: traditional, cluster/neighborhood, and household/small house. Each type includes basic descriptions, minimum requirements, and supportive reference information for each type of setting. </div> <h2 class="ms-rteElement-H2">A Call To Action </h2> <div>Design professionals should become familiar with and utilize the guidelines, as this initiative requires designer and provider support for adoption by states. Please consider becoming an advocate to removing barriers to person-centered environments by organizationally supporting the new guidelines. </div> <div>For more information, go to <a target="_blank" href="http://www.fgiguidelines.org/">www.fgiguidelines.org</a>. </div> <div><br><em>Jane Rohde, AIA, is the founding principal of JSR Associates, Ellicott City, Md. Rohde champions a global cultural shift toward deinstitutionalizing senior living and health care facilities through person-centered principles, research, advocacy, and design of the built environment. Her clientele includes nonprofit and for-profit developers, government agencies, senior living and health care providers, and design firms. She can be reached at <a target="_blank" href="mailto:jane@jsrassociates.net">jane@jsrassociates.net</a>. </em></div> <div> </div>A specialty subgroup of more than 40 volunteer industry experts was brought together as part of the 2014 cycle to update, improve, and create the new design guidelines for residential care communities. 2014-07-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0714/feature_t.jpg" style="BORDER:0px solid;" />Policy;Management;DesignColumn7
Workforce Fatigue Raises Concernshttps://www.providermagazine.com/Issues/2014/Pages/0714/Workforce-Fatigue-Raises-Concerns.aspxWorkforce Fatigue Raises Concerns<div>A primary responsibility for the post-acute care provider is to ensure the safety of all residents and patients. This requires a focus on the environment in which care takes place, as well as who is delivering that care. </div> <div> </div> <div>Part of the challenge in health care delivery is that it is not a nine-to-five endeavor. Caregivers are needed 24/7/365 in some settings and at varied times and days in other settings. To accomplish this and provide for the accommodation of a work/life balance that includes personal time off, holidays, and vacation time, as well as equitable distribution of undesirable shift work, a caregiver’s work hours are most often scheduled in a varied pattern of weekdays and sometimes varied shifts.</div> <h2 class="ms-rteElement-H2">Varied Patterns, Shifts Weary Workers</h2> <div>The different combinations of weekdays and shifts have the potential to create diverse levels of fatigue in the worker. In addition, the length of a shift can increase the likelihood of fatigue. Shifts of 12 or more hours are more frequently the norm because the workforce finds them desirable or because overtime is required to address vacancies or absenteeism.</div> <div><br>Work-hour patterns can cause worker fatigue, and a fatigued worker is not a safe worker. </div> <div><br>The aviation, petroleum, and transportation industries, whose workforces are also deployed using varied patterns of shifts and weekday schedules, have long since recognized the risk to safety that a fatigued worker represents. They have addressed the issue of worker fatigue through regulations or standards of practice in scheduling to limit fatigue-generating scheduling practices. </div> <div><br>It is time for the health care industry to do the same.</div> <h2 class="ms-rteElement-H2">Survey Reveals Alarming Rate Of Fatigue</h2> <div>As an industry, health care has acknowledged that errors in care occur at an alarming rate. The types of errors are also significant, with either temporary or permanent harm being inflicted on the care recipient. </div> <div>Additionally, the impact of the error results in residents and/or patients being returned to acute-care hospitals for treatment. The emotional and financial costs are not acceptable. <br></div> <div><br>In March 2014, the Department of Health and Human Services Office of Inspector General released a report on adverse events for Medicare beneficiaries in skilled nursing facilities (SNFs).</div> <div><br>The results were startling, with 33 percent of those studied experiencing an adverse event or temporary harm. This was a higher rate than the 27 percent rate found in a study of the same population in an acute-care hospital. Over half of the residents that experienced harm in the SNFs required a return to the hospital for treatment.</div> <div><br>Clearly, safety is an issue in the post-acute care environment. Though there are many causes that trigger errors, worker fatigue is known to be among those that can and should be addressed. </div> <h2 class="ms-rteElement-H2">Caregivers Self-Report Safety Concerns</h2> <div>To understand the potential magnitude and impact of worker fatigue in the health care industry, Kronos Incorporated, a leader in workforce management issues in health care, in partnership with HealthLeaders Media, conducted a survey of caregivers. The results were alarming; they confirmed that worker fatigue is pervasive and resident/patient safety is currently at risk in the health care industry. <br></div> <div><br>Of the 150 respondents surveyed, 69 percent reported that feeling fatigued had caused them concern about their ability to provide care safely. Surprisingly, 27 percent actually admitted to having made an error because of being fatigued.</div> <div><br>Besides the potential negative impact to the care recipients that a fatigued worker represents, the survey revealed a concern over the safety of the worker, with 92 percent reporting feeling tired while driving after their shift. </div> <div><br>The risks in drowsy driving should not be underestimated. Workers who drive as part of their work are themselves at risk when fatigued. As an industry, the safety of the worker is also a responsibility.</div> <h2 class="ms-rteElement-H2">Scheduling Key To Relief </h2> <div>With the confirmation that worker fatigue in the health care industry is a significant issue, the question becomes: how to address it? There is significant research available on the impact of shift lengths, shift patterns, shift rotation, overtime, and overall worked hours as these relate to worker fatigue. </div> <div><br>Ann Rogers, PhD, RN, professor at Emory University, led a research study that provided evidence that shifts exceeding 12 hours in length, as well as overtime, lead to overall work hours exceeding 40 hours per week, which increases the risk of errors in care. </div> <div><br>So much is known and validated about the issue that the Joint Commission, a well-respected health care organization providing accreditation services across the continuum of care, released a sentinel alert to the industry warning of the risks of worker fatigue pertaining to safety. </div> <div><br>Included in the sentinel alert are recommendations for health care organizations to assess their policies related to scheduling practices, including shift lengths and consecutive shifts, as well as involving the workforce in the actual schedule creation.</div> <div><br>When the survey respondents were asked about work scheduling practices, more often than not the schedules were reportedly being created manually. </div> <div><br>Manual schedule creation is time-consuming, fraught with potential for errors, and not guided by alerts or warnings to ensure compliance with policies or regulatory requirements related to labor management. The lack of automation in scheduling workers is both inefficient and inherently risky. </div> <h2 class="ms-rteElement-H2">Involve Workers In Scheduling </h2> <div>Fewer than 28 percent of workers reported that they were involved in the schedule creation. With little involvement in the process, it is unclear how work/life balance can be achieved. Work schedules out of sync with the realities of life—such as family, child care, school, and, increasingly, elder care demands—can have a negative impact on a worker’s ability to get restorative sleep and thereby increase the likelihood of fatigue. </div> <div><br>There is perhaps no better place in workforce management technology to prove its value in supporting the creation of a safe environment for both the caregiver and the care recipient. With the rules-based automation of work schedules, health care organizations can be assured that safe scheduling practices are adhered and alerted to worker schedules that pose potential risk. </div> <div><br>The implementation of employee self-scheduling adds yet another layer of protection in ensuring that employees have control over their own schedules and have the opportunity to directly manage their work/life balance.</div> <div><br>The negative impact of worker fatigue on the quality of care provided to residents and patients in the post-acute care environment is real. It is the responsibility of the health care industry to minimize the adverse impact of worker fatigue and provide for a safer care environment. </div> <div><br>The implementation of research-based worker scheduling practices that are supported by scheduling technology is available to address the problem today. </div> <div> </div> <div><em>Susan Reese, MBA, RN, CPHIMS, is chief nurse executive and director of health care practice group, Kronos Incorporated. She can be reached at (727) 741-0712. </em><em> </em><br></div>Caregivers are needed 24/7/365 in some settings and at varied times and days in other settings. The different combinations of weekdays and shifts have the potential to create diverse levels of fatigue in the worker. In addition, the length of a shift can increase the likelihood of fatigue.2014-07-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0714/HR-t.jpg" style="BORDER:0px solid;" />Management;WorkforceColumn7
Three Steps To Successful EHR Implementationhttps://www.providermagazine.com/Issues/2014/Pages/0714/Three-Steps-To-Successful-EHR-Implementation.aspxThree Steps To Successful EHR Implementation<div>With the growth of accountable care organizations (ACOs) and other value-based care delivery models, long term and post-acute care providers have become an increasingly crucial partner in the care continuum. </div> <div> </div> <div> </div> <div> </div> <div>In fact, hospitals and health systems now receive financial incentives or penalties to ensure that providers are able to effectively manage the health statuses of discharged patients. </div> <div> </div> <h2 class="ms-rteElement-H2">Improve Implementation</h2> <div> </div> <div>Partnering with these other health care organizations is one of the most significant reasons that providers should implement electronic health record (EHR) technologies that promote the interoperability of data. Not only does an effective EHR system support safe transitions of care, one of the core objectives of the Centers for Medicare & Medicaid Services program that provides incentives for the meaningful use of EHRs  includes meeting minimum data exchange requirements with external providers. <br><br></div> <div> </div> <div>Although long term and post-acute care providers are ineligible for the financial incentives associated with the program, eligible care delivery organizations are eager to capture that revenue and are inclined to align with an organization that supports those efforts.</div> <div> </div> <div><br>A successful EHR system implementation, however, can be a daunting process without the appropriate strategy. The initiative requires the provider to assess the potential impact to the organization; form a detailed implementation plan; and select an enterprise-wide software suite that addresses all clinical, financial, and operational functions of the organization. </div> <div> </div> <div><br>By following these steps, facilities will rapidly be equipped with the tools to easily create documentation, streamline workflows, and analyze data to improve staff and provider productivity, while also ensuring the best possible care for residents. <br></div> <div> </div> <h2 class="ms-rteElement-H2B">Step 1: Understand How EHRs Will Impact Workflow</h2> <div> </div> <div>When considering EHR systems, centers should avoid implementing technology that replicates the inefficiencies of paper-based workflows. Providers and staff need to learn how to adapt their workflows so that the EHR software’s access to data and documentation can help them work more productively. <br><br>Partnering with a knowledgeable and experienced software vendor will help organizations understand the differences between paper-based and electronic workflows and assess the training and transition impact to providers and staff.</div> <div> </div> <div><br>During this impact assessment, facilities must determine the training, costs, and technical requirements involved in a successful EHR transition. This is also where organizations will begin to understand how providers’ daily workflows will change, which is often underestimated. Once again, an experienced software partner can offer valuable consultative assistance that will help avoid disruptions down the line.</div> <div> </div> <div><br>A typical fully staffed facility can expect a three- to four-month EHR transition, but this timeline is highly dependent on the software selection. An enterprise-wide software suite, including the EHR system, deployed with a software partner experienced in the long term and post-acute care industry can streamline the process because there will be fewer internal systems to integrate and only one new interface for staff and providers to learn.</div> <div> </div> <div><br>This implementation support should include training on financial, operational, and clinical documentation systems, as well as the physical conversion of paper charts to ensure care continuity is maintained and the facility continues to meet all relevant regulatory requirements.</div> <div> </div> <h2 class="ms-rteElement-H2B">Step 2: Develop An Implementation Plan </h2> <div> </div> <div>Once the impact assessment is complete, facilities must develop an implementation plan, in conjunction with their software vendor, which describes all duties and recommendations for affected providers and staff. This implementation plan will include the training methods, which may vary depending on the facility’s size and/or preference. <br></div> <div> </div> <div><br>Some facilities will elect to train a small internal team on the software and process changes first, who will then serve as trainers to the rest of the staff. Others may ask the vendor to perform all administrative staff and clinician training.</div> <div> </div> <div><br>Regardless of the method, most organizations discover that having providers and staff conduct workflow simulations incorporating real-life scenarios is particularly effective in helping understand the paper-to-electronic transition.</div> <div> </div> <div><br>From a technical perspective, the implementation planning process is when facilities must include ample time to ensure that integration throughout the care continuum will be incorporated into the EHR-equipped workflows. </div> <div> </div> <div><br>The selected software vendor should assist the center in understanding how the system will collect, normalize, and flow data from external providers and how to leverage that information for improved clinical and financial performance.</div> <h2 class="ms-rteElement-H2B"> Step 3: Implement An Enterprise-Wide Software Suite </h2> <div>While crucial, the EHR system should be only a portion of a community’s enterprise-wide software suite. Long term and post-acute care are unique from other health care organizations in that facilities need to integrate the clinical data, supplied by the EHR, but also financial, operational, marketing, and point-of-sale information for a truly targeted, resident-centric approach to care. <br><br></div> <div> </div> <div>Furthermore, an enterprise-wide software suite reduces the time spent searching for information stored in diverse departments and can also eliminate documentation redundancies, which can help improve the quality of care, as well as analysis and reporting.</div> <div> </div> <div><br>For safe and effective transitions of care, these data—shared through the enterprise-wide system—also need to include information collected from external providers, such as pharmacies, laboratories, and other testing facilities, all of which could help alert providers to resident issues that could lead to a potential adverse event.</div> <div> </div> <div><br>After admission to the facility, these integrated data, gathered from across the software suite, allow providers to better concentrate on resident needs and simplify the data exchange across the clinical, administrative, and operational areas of the facility. External providers are also automatically kept in the loop, which helps them better monitor outcomes and control costs.</div> <div> </div> <div><br>EHR systems have proven to be a necessity for providers interested in establishing themselves as an integral member of the health care continuum. By selecting an experienced software partner and following a step-by-step process, these organizations can streamline their transition to EHRs and an enterprise-wide software suite. These tools will not only help them improve resident care and financial outcomes, but they will also support external care delivery partners’ goals of cost-effective, high-quality care. <br><br><em>Aric Agmon is president and chief executive officer of AOD Software, delivering integrated clinical, financial, operational, and point-of-sale solutions to long term care providers. He can be reached at <a href="mailto:president@AODsoftware.com">president@AODsoftware.com</a>. </em><br></div>Partnering with these other health care organizations is one of the most significant reasons that providers should implement electronic health record (EHR) technologies that promote the interoperability of data. 2014-07-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0714/tech_t.jpg" style="BORDER:0px solid;" />TechnologyColumn7
Interconnecting Trends Reshape Assisted Livinghttps://www.providermagazine.com/Issues/2014/Pages/0714/Interconnecting-Trends-Reshape.aspxInterconnecting Trends Reshape Assisted Living<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div> <p>The increasing medical needs of assisted living residents, the growing pressure to incorporate technology into operations brought to bear by more tracking of quality data, the expanding investor interest in assisted living projects—these are some of the dominant trends affecting assisted living directors, administrators, operators, staff, and others involved in the profession, and one overlaps the others.<br></p> <p>More medical care is generating greater interest from accountable care organizations (ACOs) and regulators, who rely on technology to provide them with the data they need. </p> <p>Families want to be kept in the loop as assisted living staff struggle to navigate a resident’s treatment through the continually larger circle of providers and other parties involved in that care. Investors, including real estate investment trusts (REITs) with their escalating activity, are drawn to assisted living communities and portfolios smiled upon by the powers that be. <br></p> <p>Provider offers a look at three of today’s biggest assisted living trends: care, technology, and the world of the REITs.</p> <h2 class="ms-rteElement-H2B"><div>Care, Therapy Offerings Expanding</div></h2> <p>These days, assisted living is increasingly about providing quality care beyond the traditional safer living environment it’s offered since its inception, say providers.</p> <p>Physician and Administrator Tim Giancarlo is president and chief executive officer (CEO) of a company founded by his physician father almost 50 years ago: The Allendale Community for Senior Living.<br></p> <p>The privately owned Allendale Community offers skilled nursing, post-acute care with an extensive rehab program, assisted and independent living, dementia care, and day care spread across 12 acres. The community features waterfalls and fountains in the suburban Allendale, N.J., community 25 minutes away from New York City. <br></p> <p></p> <div>Giancarlo was literally raised to become who he is today. Many of his earliest memories are of The Allendale Community; his parents began bringing him there to be part of the community’s life from the time he was a baby.</div> <h2 class="ms-rteElement-H2">Meeting Multiple Needs</h2> <div>Assisted living providers are increasingly called upon to provide higher and more complex levels of medical care, says Giancarlo, and providers are responding with an astonishing array of care and therapy offerings.<br><br></div> <div>“Caregiving is going in all kinds of directions in assisted living,” says Giancarlo. “There’s assisted living for people who are still somewhat independent, and assisted living for people suffering from dementia, and everything in between.</div> <div><br>“There’s respite care for people in assisted living. We’re dealing with more complex care these days, such as congestive heart failure, diabetes, and all kinds of conditions.”</div> <div><br>The Allendale Community’s assisted living residence, like many assisted living providers, has turned to hiring staff with higher levels of clinical training. “We’re bringing in more trained personnel,” he says. “We’re going with an all-LPN [licensed practical nurse] staff in our assisted living [residence],” and he says other assisted living providers are making similar decisions. </div> <div><br>Just managing the greater complexity of residents’ medication regimens makes the change necessary. In fact, underneath the glamorous environment, private rooms, and astonishing array of activities and social opportunities at the assisted living residence, “we are pretty much running it like a nursing home” of years past, he says.</div> <div><br>Along with physical, occupational, and speech therapy, many of Allendale’s activities serve a therapeutic purpose: the Zumba, tai chi, and karate classes, for example, or aroma and music therapies, along with a host of other wellness activities.</div> <div><br>“With the increase in [the national population’s] age, you’re seeing a rise in elderly people with cognitive issues,” says Giancarlo. “Dementia’s becoming a big sector in this industry. People are living from 90 to 100 years and are walking around healthy from the neck down, but cognitively [compromised].” Because of this, The Allendale Community provides cognitive therapies, such as its recently implemented Brain HQ program, which has been recognized by the state’s Department of Health.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Activities List A Mile Long</h2> <div>“We’re putting a lot of focus on assisted living,” says Giancarlo. “It’s all about community, so even though we’re running the assisted living facility very medically, we try to run it from an activity standpoint.” </div> <div>And activities are numerous. </div> <div><br>Because assisted living residents “are getting hipper,” says Giancarlo, the residence features an Internet café, game room with free video games and WiFi, 24-hour theater, 24-hour diner with free coffee and snacks, putting green, bridge room, and miniature golf, as well as a daily 5 p.m. “happy hour” with live entertainment, followed by the cocktail “hour” that runs from 6 p.m. to 8:30. Oh, and of course, a library, billiards room, and, naturally, shuffleboard.</div> <div><br>Cultural offerings include concerts featuring classical music or show tunes (as well as the live music the community offers daily), poetry readings, plays, and day-long celebrations of Shakespeare or opera.</div> <div>Educational opportunities are offered not only for residents but the surrounding community, such as the forums on such topics as elder law, finance, or health-related issues, as well as lectures on a wide array of subjects.</div> <div><br>Good old family-inclusive events abound, such as the annual strawberry festival and the heritage-based festivals like the community’s Filipino Festival.</div> <div><br>Time-honored activities are also abundant, such as the quilting circle, gala events such as the recent Evening in Paris, no-holds-barred birthday bashes, spiritual activities, and field trips to nearby cultural sites like the aviation museum.</div> <div><br>“There’s always something going on,” says Giancarlo. “As long as you keep [residents] youthful, I think you will keep them living longer,” while leading more fulfilling lives.</div> <h2 class="ms-rteElement-H2">Quality Focus</h2> <div>The Allendale Community’s assisted living residence is an “Advanced Standing” facility, which means that it has been singled out by the state’s Department of Health as providing outstanding care. Achieving that status wasn’t cheap, says Giancarlo, but it was an important goal to him and his staff. </div> <div>“We had to increase resident satisfaction,” he says, “so we had resident and family council meetings frequently.” </div> <div><br>Although turnover is a big issue for many assisted living facilities, The Allendale Community was ahead of the game on that one. “We don’t have a lot of turnover,” he says. “We try to keep the staff happy; happy staff members provide higher-quality care.” Keeping turnover low is also important to Giancarlo because he wants residents and families to see familiar faces providing their care.</div> <div><div> </div> <div>Quality indicators also get a lot of attention, he says. “We’re very active in data tracking, such as indicators like rehospitalizations.” Tracking quality data will be more and more important to assisted living providers, says Giancarlo, as ACOs turn their gaze toward assisted living. “ACOs track all that,” Giancarlo says. “ACOs are approaching us and want to make sure we have all that documentation available.” <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2B">Technology More And More Important To Assisted Living</h2> <p>For Todd Stivland, MD, owner and CEO of Bluestone Solutions and provider of onsite medical care for assisted living facility (ALF) residents, technology has become pretty much a way of life.</p> <p>A family physician for 19 years, Stivland oversaw clinical tool development and implementation of a Duluth clinic’s electronic health records, directed the creation of custom software for onsite care models, and serves on Minnesota state policy committees. <br></p> <p>In 2012, Stivland founded Bluestone, now the largest provider of onsite coordinated care and advanced care coordination for complex patients in Minnesota. <br></p> <p>“From what we’re seeing, the biggest trend [in assisted living] is ALFs are becoming much more of a medical model than they used to be,” says Stivland. “They’re caring for some of the sickest people in the community. There’s not much difference between assisted living and skilled nursing anymore in their complexity. That’s forced assisted living to be more aggressive about their medical model. There’s really been a big push to make the medical model more balanced.”<br></p> <p>That’s true of health care in general, and in keeping with the whole health care sector, assisted living is seeing “a boom in technology,” Stivland says. <br></p> <p></p> <div>Of course, not all ALFs have embraced this trend yet, he says. “We have customers who don’t even have Internet in the building, and others who’ve installed very advanced systems.”</div> <h2 class="ms-rteElement-H2">Necessity Again Proves The Mother Of Invention</h2> <div>One of the biggest issues in health care—one that technology has the power to solve—is the difficulty in coordinating care, Stivland says. </div> <div><br>“We have multiple organizations providing care on different [computer] systems, so getting people able to communicate with each other is a big issue.”</div> <div><br>It was such a problem, in fact, that Stivland created technology that reconciles all of these different data sources on its varying computer systems and streamlines the process of providing the data to all the parties involved.</div> <div><br>“All of the faxes and phone calls were killing us—they’re so inefficient and time consuming,” he says. “We’ve created a system where anybody involved in the care system can communicate with each other.” The system handles everything from patient monitoring to getting prescriptions filled and follow-up arranged. </div> <div><br>“For instance, say the nurse at the ALF goes to see a resident and finds he has a bladder infection,” says Stivland. “She would send the information to us—the symptoms and that she wants a urine test.” The Bluestone doctor receives the information on a smart phone that’s kept near at all times; reviews the information; and, if a test is warranted, sends an electronic order to the lab.</div> <div><br>“The lab goes out to draw blood for the test. The results come back to us, and we send them to the nurse. We then order the antibiotic.” If the family chose to be informed of health-related activities, Bluestone sends a note to the family saying the loved one has a bladder infection, specifies the manner in which it’s <br>being treated, and asks if they have any questions. If they do, the doctors at Bluestone answer them.</div> <div><br>The system, Stivland says, “keeps everybody in the loop and allows us to treat people very quickly. We turn orders around a lot of times within minutes; always within two hours.” </div> <div><br>Bluestone now provides easily accessed physician services to 4,000 patients, 180 ALFs, and more than 100 home care agencies. Even without any marketing, Bluestone has sold the system to four other local practices, and others are considering a purchase.</div> <div><br>The system was developed over eight years in close consultation with technology companies that make assisted living-specific software. The effort required a $2 million investment. </div> <div><br>“We were just doctors who couldn’t keep up with the phone calls [and developed the system] out of necessity,” Stivland says. “We never intended to sell it, but other people saw it and wanted it.”</div> <div>The needs of the elderly are inspiring more than just Stivland. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Tech Innovations Fostered</h2> <div>The first Aging 2.0 Global Innovation Summit was held in San Francisco in mid-May and brought a select group of technology innovators together with investors and seniors housing providers.</div> <div><br>The Aging 2.0 summit was organized by Generator Ventures, founded by Katy Fike, a 35-year-old gerontologist and former investment banker, and Stephen Johnston, a 2002 Harvard Business School graduate. </div> <div><br>Generator Ventures’ other program, called Aging 2.0 Generator, takes a few hand-picked technology innovators and works with them for six months to help them develop their ideas into companies with marketable products. </div> <div><br>The six-month effort is housed in a senior center—the Bay Area nonprofit Institute on Aging, which provides services for thousands of seniors every year. That gives innovators unique research opportunities as they develop their products.</div> <div><br>The Generator program also provides customized curriculum designed and delivered by industry leaders and facilitates the innovators connecting with investors, distributors, senior care providers, and press. The program culminated with the Aging 2.0 summit, which was also attended by 30 new innovators hoping to get into the next Generator program.</div> <h2 class="ms-rteElement-H2">The Aging 2.0 Innovators </h2> <div>Among those 11 select companies and products developed through Generator and featured at the summit were:<br></div> <div>■ <em>Pixie Scientific.</em> Pixie is developing patches that can be put on the outside of a senior’s diaper. When the diaper is soiled and removed, the caregiver can scan the patch and upload information about the senior’s health condition, such as indicators that a urinary tract infection is developing or the senior is dehydrated.</div> <div><br> ■ <em>Life2.</em> This company is developing a database and program based on predictive analytics that aim to predict which residents are likely to develop specific health issues, such as pulmonary problems. The information would alert staff to keep an eye out for a list of early warning signs and tell them why the resident is at heightened risk. The program would also provide information on what can be done to mitigate the risk. </div> <div><br>■ <em>Jibo.</em> This company hired a Massachusetts Institute of Technology professor to help develop “emotional robotics.” The goal is to develop a robot that a senior can interact with and that will appear to respond with human-like emotions to the senior. The robot would act both as a companion (assisting with crossword puzzles, for example, or helping the senior use the Internet to connect with family members) as well as an entity that provides services like medication reminders and diet and exercise monitoring. The idea is to provide this technology for about the cost of a laptop computer.</div> <div><br>■ <em>Lift Hero. </em>This is a service that allows seniors to request a ride via the Internet or phone. Drivers, who are prescreened, off-duty EMTs and other medical professionals, pick up the seniors, drive them to their locations, assist them inside, and then return them to their homes and help them get situated there again. Rides can be ordered when needed or be pre-booked. Standing arrangements may also be made.</div> <div><br>■ <em>Lively. </em>This is a system of activity sensors that wirelessly transmit information about a senior’s activities to a Web-based app that a family member can check regularly to make sure the senior is up and about and engaging in his or her routine activities.</div> <h2 class="ms-rteElement-H2">Other Brilliant Tech Ideas </h2> <div>Stanford University, in collaboration with Aging 2.0, issued a design challenge from its Stanford Center on Longevity last year with the goal of identifying students around the world with great technology-based ideas useful to seniors, and to help students refine those ideas.</div> <div><br>Among the finalists was Ritika Mathur from the Copenhagen Institute of Design. Mathur’s idea, called Memory Maps, would combine a device with a radio frequency identification reader with a map of the senior’s neighborhood and global positioning satellite technology. The device would be used by someone with early-stage dementia or other cognitive problems. It would allow the senior and his or her family to actually record memories associated with the map and “pin” them to map locations.</div> <div><br>Another finalist was Huabin Kok from Singapore National University whose idea is called Taste+. This is a spoon with electrical stimulation that would be used by someone whose taste sensations have been diminished (common with dementia). </div> <div><br>By tapping a button on the spoon, the device provides a simulated salty or sour flavor when the user puts the spoon (and the food on it) into his or her mouth.</div> <p></p></div> <div><div><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2B">Investment In Seniors Housing Surging</h2> <p>REITs have been significantly expanding their portfolios this year, investing considerable money in assisted living, say industry watchers. REITs can offer seniors housing providers a cost-effective monetization option, making capital available to help them take advantage of growth opportunities or build a hedge against risk. <br></p> <p>And although in the past REITs were reluctant to be involved in new construction or turnarounds, their greater access to capital has made them more flexible in this regard, especially when it comes to seniors housing companies they’ve partnered with successfully in the past.<br></p> <p>The fragmented, $2 trillion health care real estate market is benefiting from competitive capital costs and demographic trends, among other factors. Investor interest will continue to grow, extending the seniors housing recovery into next year, according to Beth Mace, chief economist at the National Investment Center for the Seniors Housing and Care Industry, Annapolis, Md.<br></p> <p>There are several reasons for her optimism, including improvements in the volume and prices of home sales, stock market performance, and consumer confidence and income.<br></p> <p></p> <div>And as the number of people over age 80 grows through the next decades, the number of middle-aged family caregivers will shrink, according to a recent AARP study. Today, the ratio of caregivers aged 45 to 64 to people over age 80 is 7:1, the study showed. That ratio will drop to 4:1 in 2030 and to less than 3:1 in 2050, the study found—a decrease due not only to the aging of the baby boomer generation but also to younger women having had fewer children.</div> <h2 class="ms-rteElement-H2">Big Health Care REITs Getting Bigger</h2> <div>Ventas, a Chicago-based REIT, is already one of the largest health care REITs in the country, and it will soon be easily the biggest if its plan to acquire competitor American Realty Capital Healthcare Trust (ARCHT) is approved by ARCHT shareholders. The offer was announced in early June.</div> <div><br>In fact, Debra Cafaro, Ventas chairman and CEO, said in a video interview at a New York City investor forum that the move will make Ventas “the leading senior housing franchise globally.” </div> <div><br>Ventas has now purchased at least three health care REITs, according to The Seniorcare Investor, published by Levin Associates, based in Norwalk, Conn., and the publication’s editors expect Ventas won’t stop there.</div> <div><br>The unsolicited $2.6 billion deal has been approved by both boards of directors and is expected to close in the fourth quarter. The announcement caused ARCHT’s stock price to rise by 11.1 percent, while Ventas’ dropped by 2.2 percent.</div> <div><br>Ventas also plans to acquire 29 Canadian independent living communities from Holiday Retirement in a $900 million transaction expected to close in the third quarter. The properties will be managed by its portfolio company, Atria Senior Living.</div> <div><br>Ventas is recording notable gains in its funds from operations, Cafaro said at the investor forum, arising from productive assets, refinancing at lower interest rates, and the company’s development and redevelopment efforts. </div> <h2 class="ms-rteElement-H2">Another Company Expands Into Market</h2> <div>Another of the largest health care REITs, Health Care REIT (HCR) based in Toledo, Ohio, also made a significant move in June, completing a $1 billion public offering. HCR plans to use some of the money to increase its investment in seniors housing and other health care properties.</div> <div><br>During the previous month, the REIT sold 14 million shares at $62.35 per share and announced that it has signed preliminary agreements to acquire $414 million of seniors housing and medical office properties during the second quarter. HCR also announced in May the purchase of a 46.8 percent interest in a 10-property Senior Resource Group package. Those properties are in California, Arizona, and Oregon. </div> <div>In April, Irvine, Calif.-based HCP announced a $1.2 billion entry-fee continuing care retirement community (CCRC) joint venture with Brookdale Senior Living. The 49 percent ownership would give HCP the largest CCRC package of any health care REIT in the country.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Mid-Range REITs Active</h2> <div>Griffin-American Healthcare REIT, a public, nonlisted company that claims 73 acquisitions comprising 286 buildings, has an approach President and Chief Operating Officer Dan Prosky describes as “rifle shot”—as opposed to the larger REITs’ “shotgun”—approach to acquisitions. <br></div> <br> <div>Last year, Griffin-American completed $1.5 billion in small acquisitions.<br><br></div> <div>Nontraded REITs like Griffin-American have been very successful with raising capital and, therefore, are aggressive purchasers of property, according to analysts.</div> <div><br>For example, Griffin-American has raised almost $3 billion in the past four years, and its investments haven’t stayed solely in the United States. Griffin-American acquired a $472 million seniors housing portfolio from London-based Caring Homes Health Care Group last year. Prosky doesn’t anticipate as much activity this year, but cites the company’s lack of debt and high percentage of mortgage-free properties as conducive to further acquisitions and development.</div> <div><br>Industry watchers were anticipating the acquisition of Griffin-American itself. A Wall Street Journal story in May listed four companies vying for Griffin-American and predicted a price tag in the $3.7 billion range. </div> <div>Some analysts saw ARCHT as the front-runner, with Ventas close behind. But now that Ventas has announced its plan to purchase ARCHT, guessing is the name of the game again. </div> <div><br>Nontraded REITs aren’t the only active players in the mid-range, though. Chicago-based Aviv REIT, which is public, has announced a new $600 million credit facility that can be expanded to $800 million. Analysts are predicting the company will use the money for acquisitions.</div> <h2 class="ms-rteElement-H2">Small REITs Move Up—At Their Own Pace </h2> <div>The smaller health care REITs are also quite active, although less likely to purchase whole portfolios of properties. <br></div> <div><br>■ <em>Sabra Health Care REIT, Irvine, Calif.</em> Sabra sold 7 million shares at $28.35 per share earlier this year. The company plans to invest between $350 million and $450 million this year, according to Chairman and CEO Rick Matros. </div> <div><br>■ <em>CNL Health Care Properties, Orlando, Fla.</em> CNL’s credit facility, increased in May from $120 million to $275 million, will likely result in portfolio growth, especially since the line of credit has the option of being expanded to $325 million.<br><br></div> <div>“The initial line of credit has helped us substantially grow our senior living and health care portfolio over the last several months,” says Stephen Mauldin, CNL’s president and CEO. “The expanded facility will further assist us in taking advantage of compelling investment opportunities as we continue to broaden and diversify our portfolio.”<br><br></div> <div>■ <em>National Health Investors, Murfreesboro, Tenn. </em>NHI acquired an assisted living community for $11.5 million in April, but its long-range goals don’t include growing itself into a large REIT, according to President and CEO Justin Hutchens; rather, NHI takes pride in its attention to prized, quality customers.</div> <div><br>■ <em>CareTrust REIT, Mission Viejo, Calif.</em> As of June 2, a new health care REIT has entered the field: CareTrust REIT. CareTrust is a spin-off of The Ensign Group and owns substantially all of Ensign’s properties. CareTrust is now trading on the NASDAQ. Global Select Market. The Ensign Group is now the operating company. <br></div> <p></p> <p class="ms-rteElement-P"></p> <div><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em> </div> <p></p></div> <p></p>Families want to be kept in the loop as assisted living staff struggle to navigate a resident’s treatment through the continually larger circle of providers and other parties involved in that care.2014-07-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0714/coverstory_t.jpg" style="BORDER:0px solid;" />Caregiving;TechnologyCover Story7
Investment In Seniors Housing Surginghttps://www.providermagazine.com/Issues/2014/Pages/0714/Investment-In-Seniors-Housing-Surging.aspxInvestment In Seniors Housing Surging<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>REITs have been significantly expanding their portfolios this year, investing considerable money in assisted living, say industry watchers. REITs can offer seniors housing providers a cost-effective monetization option, making capital available to help them take advantage of growth opportunities or build a hedge against risk. </div> <div> </div> <div>And although in the past REITs were reluctant to be involved in new construction or turnarounds, their greater access to capital has made them more flexible in this regard, especially when it comes to seniors housing companies they’ve partnered with successfully in the past.</div> <div> </div> <div><img width="412" height="301" src="/Issues/2014/PublishingImages/0714/cs-reit-stocks.gif" alt="Most REIT Stocks Performing Well" class="ms-rtePosition-1" style="margin:5px 10px;" />The fragmented, $2 trillion health care real estate market is benefiting from competitive capital costs and demographic trends, among other factors. Investor interest will continue to grow, extending the seniors housing recovery into next year, according to Beth Mace, chief economist at the National Investment Center for the Seniors Housing and Care Industry, Annapolis, Md.</div> <div> </div> <div>There are several reasons for her optimism, including improvements in the volume and prices of home sales, stock market performance, and consumer confidence and income.</div> <div> </div> <div>And as the number of people over age 80 grows through the next decades, the number of middle-aged family caregivers will shrink, according to a recent AARP study. Today, the ratio of caregivers aged 45 to 64 to people over age 80 is 7:1, the study showed. That ratio will drop to 4:1 in 2030 and to less than 3:1 in 2050, the study found—a decrease due not only to the aging of the baby boomer generation but also to younger women having had fewer children.</div> <h2 class="ms-rteElement-H2">Big Health Care REITs Getting Bigger</h2> <div>Ventas, a Chicago-based REIT, is already one of the largest health care REITs in the country, and it will soon be easily the biggest if its plan to acquire competitor American Realty Capital Healthcare Trust (ARCHT) is approved by ARCHT shareholders. The offer was announced in early June.</div> <div><br>In fact, Debra Cafaro, Ventas chairman and CEO, said in a video interview at a New York City investor forum that the move will make Ventas “the leading senior housing franchise globally.” </div> <div><br>Ventas has now purchased at least three health care REITs, according to The Seniorcare Investor, published by Levin Associates, based in Norwalk, Conn., and the publication’s editors expect Ventas won’t stop there.</div> <div><br>The unsolicited $2.6 billion deal has been approved by both boards of directors and is expected to close in the fourth quarter. The announcement caused ARCHT’s stock price to rise by 11.1 percent, while Ventas’ dropped by 2.2 percent.</div> <div><br>Ventas also plans to acquire 29 Canadian independent living communities from Holiday Retirement in a $900 million transaction expected to close in the third quarter. The properties will be managed by its portfolio company, Atria Senior Living.</div> <div><br>Ventas is recording notable gains in its funds from operations, Cafaro said at the investor forum, arising from productive assets, refinancing at lower interest rates, and the company’s development and redevelopment efforts. </div> <h2 class="ms-rteElement-H2">Another Company Expands Into Market</h2> <div>Another of the largest health care REITs, Health Care REIT (HCR) based in Toledo, Ohio, also made a significant move in June, completing a $1 billion public offering. HCR plans to use some of the money to increase its investment in seniors housing and other health care properties.<br><br></div> <div>During the previous month, the REIT sold 14 million shares at $62.35 per share and announced that it has signed preliminary agreements to acquire $414 million of seniors housing and medical office properties during the second quarter. HCR also announced in May the purchase of a 46.8 percent interest in a 10-property Senior Resource Group package. Those properties are in California, Arizona, and Oregon. </div> <div>In April, Irvine, Calif.-based HCP announced a $1.2 billion entry-fee continuing care retirement community (CCRC) joint venture with Brookdale Senior Living. The 49 percent ownership would give HCP the largest CCRC package of any health care REIT in the country.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Mid-Range REITs Active </h2> <div>Griffin-American Healthcare REIT, a public, nonlisted company that claims 73 acquisitions comprising 286 buildings, has an approach President and Chief Operating Officer Dan Prosky describes as “rifle shot”—as opposed to the larger REITs’ “shotgun”—approach to acquisitions. <br><br> </div> <div>Last year, Griffin-American completed $1.5 billion in small acquisitions.</div> <div><br><img src="/Issues/2014/PublishingImages/0714/cs-housing-reits.gif" alt="Seniors REITS" class="ms-rtePosition-1" style="margin:5px 10px;" />Nontraded REITs like Griffin-American have been very successful with raising capital and, therefore, are aggressive purchasers of property, according to analysts.</div> <div><br>For example, Griffin-American has raised almost $3 billion in the past four years, and its investments haven’t stayed solely in the United States. Griffin-American acquired a $472 million seniors housing portfolio from London-based Caring Homes Health Care Group last year. Prosky doesn’t anticipate as much activity this year, but cites the company’s lack of debt and high percentage of mortgage-free properties as conducive to further acquisitions and development.</div> <div><br>Industry watchers were anticipating the acquisition of Griffin-American itself. A Wall Street Journal story in May listed four companies vying for Griffin-American and predicted a price tag in the $3.7 billion range. </div> <div>Some analysts saw ARCHT as the front-runner, with Ventas close behind. But now that Ventas has announced its plan to purchase ARCHT, guessing is the name of the game again. </div> <div><br>Nontraded REITs aren’t the only active players in the mid-range, though. Chicago-based Aviv REIT, which is public, has announced a new $600 million credit facility that can be expanded to $800 million. Analysts are predicting the company will use the money for acquisitions.</div> <h2 class="ms-rteElement-H2">Small REITs Move Up—At Their Own Pace</h2> <div>The smaller health care REITs are also quite active, although less likely to purchase whole portfolios of properties. <br></div> <div><br>■ <em>Sabra Health Care REIT, Irvine, Calif.</em> Sabra sold 7 million shares at $28.35 per share earlier this year. The company plans to invest between $350 million and $450 million this year, according to Chairman and CEO Rick Matros. <br><br></div> <div>■ <em>CNL Health Care Properties, Orlando, Fla. </em>CNL’s credit facility, increased in May from $120 million to $275 million, will likely result in portfolio growth, especially since the line of credit has the option of being expanded to $325 million.<br><br></div> <div>“The initial line of credit has helped us substantially grow our senior living and health care portfolio over the last several months,” says Stephen Mauldin, CNL’s president and CEO. “The expanded facility will further assist us in taking advantage of compelling investment opportunities as we continue to broaden and diversify our portfolio.”</div> <div><br>■ <em>National Health Investors, Murfreesboro, Tenn. </em>NHI acquired an assisted living community for $11.5 million in April, but its long-range goals don’t include growing itself into a large REIT, according to President and CEO Justin Hutchens; rather, NHI takes pride in its attention to prized, quality customers.</div> <div><br>■ <em>CareTrust REIT, Mission Viejo, Calif.</em> As of June 2, a new health care REIT has entered the field: CareTrust REIT. CareTrust is a spin-off of The Ensign Group and owns substantially all of Ensign’s properties. CareTrust is now trading on the NASDAQ. Global Select Market. The Ensign Group is now the operating company. </div>2014-07-01T04:00:00ZColumn7
Technology More And More Important To Assisted Livinghttps://www.providermagazine.com/Issues/2014/Pages/0714/Technology-More-And-More-Important-To-Assisted-Living.aspxTechnology More And More Important To Assisted Living<p>For Todd Stivland, MD, owner and CEO of Bluestone Solutions and provider of onsite medical care for assisted living facility (ALF) residents, technology has become pretty much a way of life.<br></p> <p><img width="139" height="174" src="/Issues/2014/PublishingImages/0714/ToddStivland.jpg" alt="Todd Stivland, MD" class="ms-rtePosition-1" style="margin:5px 10px;" />A family physician for 19 years, Stivland oversaw clinical tool development and implementation of a Duluth clinic’s electronic health records, directed the creation of custom software for onsite care models, and serves on Minnesota state policy committees. <br><br>In 2012, Stivland founded Bluestone, now the largest provider of onsite coordinated care and advanced care coordination for complex patients in Minnesota. <br></p> <p>“From what we’re seeing, the biggest trend [in assisted living] is ALFs are becoming much more of a medical model than they used to be,” says Stivland. “They’re caring for some of the sickest people in the community. There’s not much difference between assisted living and skilled nursing anymore in their complexity. That’s forced assisted living to be more aggressive about their medical model. There’s really been a big push to make the medical model more balanced.”<br></p> <p>That’s true of health care in general, and in keeping with the whole health care sector, assisted living is seeing “a boom in technology,” Stivland says. <br></p> <p></p> <div>Of course, not all ALFs have embraced this trend yet, he says. “We have customers who don’t even have Internet in the building, and others who’ve installed very advanced systems.”</div> <h2 class="ms-rteElement-H2">Necessity Again Proves The Mother Of Invention</h2> <div>One of the biggest issues in health care—one that technology has the power to solve—is the difficulty in coordinating care, Stivland says. <br><br></div> <div>“We have multiple organizations providing care on different [computer] systems, so getting people able to communicate with each other is a big issue.”</div> <div><br>It was such a problem, in fact, that Stivland created technology that reconciles all of these different data sources on its varying computer systems and streamlines the process of providing the data to all the parties involved.</div> <div><br>“All of the faxes and phone calls were killing us—they’re so inefficient and time consuming,” he says. <br>“We’ve created a system where anybody involved in the care system can communicate with each other.” The system handles everything from patient monitoring to getting prescriptions filled and follow-up arranged.<br><br></div> <div>“For instance, say the nurse at the ALF goes to see a resident and finds he has a bladder infection,” says Stivland. “She would send the information to us—the symptoms and that she wants a urine test.” The Bluestone doctor receives the information on a smart phone that’s kept near at all times; reviews the information; and, if a test is warranted, sends an electronic order to the lab.</div> <div><br>“The lab goes out to draw blood for the test. The results come back to us, and we send them to the nurse. We then order the antibiotic.” If the family chose to be informed of health-related activities, Bluestone sends a note to the family saying the loved one has a bladder infection, specifies the manner in which it’s being treated, and asks if they have any questions. If they do, the doctors at Bluestone answer them.</div> <div>The system, Stivland says, “keeps everybody in the loop and allows us to treat people very quickly. We turn orders around a lot of times within minutes; always within two hours.” </div> <div><br>Bluestone now provides easily accessed physician services to 4,000 patients, 180 ALFs, and more than 100 home care agencies. Even without any marketing, Bluestone has sold the system to four other local practices, and others are considering a purchase.</div> <div><br>The system was developed over eight years in close consultation with technology companies that make assisted living-specific software. The effort required a $2 million investment. </div> <div><br>“We were just doctors who couldn’t keep up with the phone calls [and developed the system] out of necessity,” Stivland says. “We never intended to sell it, but other people saw it and wanted it.”</div> <div><br>The needs of the elderly are inspiring more than just Stivland. </div> <h2 class="ms-rteElement-H2">Tech Innovations Fostered</h2> <div>The first Aging 2.0 Global Innovation Summit was held in San Francisco in mid-May and brought a select group of technology innovators together with investors and seniors housing providers.<br><br></div> <div>The Aging 2.0 summit was organized by Generator Ventures, founded by Katy Fike, a 35-year-old gerontologist and former investment banker, and Stephen Johnston, a 2002 Harvard Business School <br>graduate. </div> <div><br>Generator Ventures’ other program, called Aging 2.0 Generator, takes a few hand-picked technology innovators and works with them for six months to help them develop their ideas into companies with marketable products. </div> <div><br>The six-month effort is housed in a senior center—the Bay Area nonprofit Institute on Aging, which provides services for thousands of seniors every year. That gives innovators unique research opportunities as they develop their products.</div> <div><br>The Generator program also provides customized curriculum designed and delivered by industry leaders and facilitates the innovators connecting with investors, distributors, senior care providers, and press. The program culminated with the Aging 2.0 summit, which was also attended by 30 new innovators hoping to get into the next Generator program.</div> <h2 class="ms-rteElement-H2">The Aging 2.0 Innovators</h2> <div>Among those 11 select companies and products developed through Generator and featured at the summit were:<br></div> <div><br>■ <em>Pixie Scientific.</em> Pixie is developing patches that can be put on the outside of a senior’s diaper. When the diaper is soiled and removed, the caregiver can scan the patch and upload information about the senior’s health condition, such as indicators that a urinary tract infection is developing or the senior is dehydrated.</div> <div><br> ■ <em>Life2</em>. This company is developing a database and program based on predictive analytics that aim to predict which residents are likely to develop specific health issues, such as pulmonary problems. The information would alert staff to keep an eye out for a list of early warning signs and tell them why the resident is at heightened risk. The program would also provide information on what can be done to mitigate the risk. </div> <div><br>■ <em>Jibo</em>. This company hired a Massachusetts Institute of Technology professor to help develop “emotional robotics.” The goal is to develop a robot that a senior can interact with and that will appear to respond with human-like emotions to the senior. The robot would act both as a companion (assisting with crossword puzzles, for example, or helping the senior use the Internet to connect with family members) as well as an entity that provides services like medication reminders and diet and exercise monitoring. The idea is to provide this technology for about the cost of a laptop computer.</div> <div><br>■ <em>Lift Hero</em>. This is a service that allows seniors to request a ride via the Internet or phone. Drivers, who are prescreened, off-duty EMTs and other medical professionals, pick up the seniors, drive them to their locations, assist them inside, and then return them to their homes and help them get situated there again. Rides can be ordered when needed or be pre-booked. Standing arrangements may also be made.</div> <div><br>■ <em>Lively</em>. This is a system of activity sensors that wirelessly transmit information about a senior’s activities to a Web-based app that a family member can check regularly to make sure the senior is up and about and engaging in his or her routine activities.</div> <h2 class="ms-rteElement-H2">Other Brilliant Tech Ideas </h2> <div>Stanford University, in collaboration with Aging 2.0, issued a design challenge from its Stanford Center on Longevity last year with the goal of identifying students around the world with great technology-based ideas useful to seniors, and to help students refine those ideas.<br><br></div> <div>Among the finalists was Ritika Mathur from the Copenhagen Institute of Design. Mathur’s idea, called Memory Maps, would combine a device with a radio frequency identification reader with a map of the senior’s neighborhood and global positioning satellite technology. The device would be used by someone with early-stage dementia or other cognitive problems. It would allow the senior and his or her family to actually record memories associated with the map and “pin” them to map locations.</div> <div><br>Another finalist was Huabin Kok from Singapore National University whose idea is called Taste+. This is a spoon with electrical stimulation that would be used by someone whose taste sensations have been diminished (common with dementia). </div> <div><br>By tapping a button on the spoon, the device provides a simulated salty or sour flavor when the user puts the spoon (and the food on it) into his or her mouth.</div> <div> </div> <p></p>2014-07-01T04:00:00ZColumn7




A Passport To Better Carehttps://www.providermagazine.com/Issues/2014/Pages/0814/A-Passport-To-Better-Care.aspxA Passport To Better Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><img width="206" height="271" class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/0814/Caregiving3.jpg" alt="" style="margin:10px 5px;" /></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><em>Jan. 18, 2014, 2 p.m.:</em> Molly Malone’s care conference is in progress. The family is not in attendance. Molly sits in a wheelchair that Physical Therapy has customized just for her. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>She is sitting comfortably. Using the Wong Baker Face scale, nursing has confirmed that Molly is pain-free. Her weight remains stable. Just like the previous 90 days, she is brought to daily activities but does not participate. Daily weeping and outbursts disrupt the other residents. She seems to be calmer being in her room where she stares out her window. Molly remains on the antipsychotic risperidone 2 mg po QHS (by mouth every night at bedtime) for behavioral symptoms of her dementia.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><em>Jan. 18, 1994, 2 p.m.: </em>Molly Malone and her husband are almost through customs. Both are in agreement that this has been their best European trip to date. They also agree that they will just have to deal with the jet lag, as they have a very busy schedule over the next week: Besides work, there’s a birthday party for their grandchild, a Mahjong tournament, progressive dinner with their friends, and the list goes on and on. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Tackling Dementia Care</h2> <div> </div> <div> </div> <div> </div> <div>The Centers for Medicare & Medicaid Services (CMS) launched the Partnership to Improve Dementia Care in Nursing Homes program in 2012. The goals of this initiative included a focus on person-centered care and the reduction of unnecessary antipsychotic medication.</div> <div> </div> <div> </div> <div> </div> <div><br>The American Health Care Association, in 2012, launched a quality initiative to safely reduce the off-label use of antipsychotics by 15 percent. Skilled Healthcare also embraced this quality initiative. Simply put—it is the right thing to do.</div> <div> </div> <div> </div> <div> </div> <div><br>A plethora of resources and tools became readily available to address this quality initiative, including educational materials on the side effects of antipsychotic use, gradual dose reduction, and nonpharmacologic strategies.</div> <div> </div> <div> </div> <div> </div> <div><br>Along with implementing these resources, in 2013 Aisha Salaam, senior vice president of Skilled Healthcare’s Professional Services Department, recommended forming a Behavior Management Task Force. She shared that improving the care for those with dementia is not only important for decreasing antipsychotic drug use but would also positively impact other areas such as weight maintenance and fall reduction.</div> <div> </div> <div> </div> <div> </div> <div><br>The task force brainstormed many different areas on which to focus. One discussion item revolved around the feelings of distress and anxiety someone with dementia can experience when they move to a new home or have strangers take care of them. A decision was made that the task force’s first deliverable would be to create a tool to assist staff in getting to know their residents.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Creating A Resident’s Passport </h2> <div> </div> <div> </div> <div> </div> <div>Reviewing documents from a number of resources, including the Alzheimer’s Association and Alzheimer’s Society, the task force created “A Passport Into My Life: Understanding My Journey Will Help You Understand Me.”</div> <div> </div> <div> </div> <div> </div> <div><br>Skilled Healthcare piloted Passport in a few centers, tweaking the document and procedure based on lessons learned. The task force rolled out the program in February of this year. Passport provides information about the person and paints a picture of who the person really is. Passport information includes interests, accomplishments, daily routines, familiar names, traumatic life events, and a number of expressions of needs. </div> <div> </div> <div> </div> <div> </div> <div><br>There are also blank pages for staff to record their observations and updates of what techniques they used that worked and, just as important, anything that should be avoided. </div> <div> </div> <div> </div> <div> </div> <div><br>Building a better understanding of who the resident is enables caregivers to provide more personalized care with an eye toward decreasing the use of antipsychotic medications. Using the Passport program in conjunction with consistent assignment enables the staff and the resident to get to know and become more comfortable with each other. The program also satisfies components of CMS’ dementia care program under quality of care and quality of life:</div> <div> </div> <div> </div> <div> </div> <div><br>■ Identify, to the extent possible, factors that may underlie the resident’s expressions of distress as well as apply knowledge of lifelong patterns, preferences, and interests in activities to enhance quality of life.</div> <div> </div> <div> </div> <div> </div> <div><br>■ Centers should be able to identify how they have involved residents, families, and representatives in discussions about potential approaches to address behaviors (needs expressions).</div> <div> </div> <h2 class="ms-rteElement-H2"> Distributing The Passport </h2> <div> </div> <div>The Social Services Department of each center participating in the program has oversight of distributing the Passport and ensuring it is returned. During the admissions process, if the center knows the resident has dementia, the admissions coordinator escorts the family to Social Services after the paperwork is completed.</div> <div> </div> <div> </div> <div> </div> <div><br>The social services designee explains the purpose of the Passport and asks the family to return the completed Passport within seven days. If the resident can contribute, he or she is encouraged to be part of this information-gathering process.</div> <div> </div> <div> </div> <div> </div> <div><br>When the interdisciplinary team identifies that staff would benefit from having Passport information on a resident already residing in the center, Social Services will introduce the Passport by contacting the family or coordinating with the quarterly care plan invitation.<br><br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Introducing The Passport To Staff</h2> <div> </div> <div> </div> <div> </div> <div>The rollout of the Passport program was done in a train-the-trainer format, with the task force rolling it out via conference calls. The center’s administrator, director of nursing, and social services director rolled it out to department managers during the morning stand-up meeting and to staff during general staff meetings.</div> <div> </div> <div> </div> <div> </div> <div><br>Additional staff training was completed by department managers. </div> <div> </div> <div> </div> <div> </div> <div><br>Other talking points pulled from guidelines include: </div> <div> </div> <div> </div> <div> </div> <div><br>■ Centers should have a consistent process that focuses on a resident’s individual needs and tries to understand behavior as a form of communication. This may help to reduce behavior expressions of distress in some residents.</div> <div> </div> <div> </div> <div> </div> <div><br>■ During interviews with staff, determine if staff have been trained in how to communicate with and address behaviors in residents with dementia.</div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Operationalizing The Passport </h2> <div> </div> <div> </div> <div>Through the pilot, the task force determined that designating a separate binder for the Passports would allow them to be accessible at all times to any staff member who may be involved with the residents’ care. A communication form was placed in front of the binder with a running list that highlights any new Passports or changes to existing Passports. An entry noting new additions or changes is also made in the 24-hour report.</div> <div> </div> <div> </div> <div> </div> <div><br><img width="235" height="224" alt="Staff members review a resident's Passport." class="ms-rtePosition-2" src="/Issues/2014/PublishingImages/0814/Caregiving2.jpg" style="margin:5px 10px;" />The Passport is now part of new employee orientation and is also brought to care plan meetings for review and updates.</div> <div> </div> <div> </div> <div> </div> <div><br>During the pilot, some family members asked to take the Passport with them when their loved one was discharged or passed away, something staff had not anticipated. If the family makes that request, they are given a copy of the Passport, and the original is maintained in the closed medical records.</div> <div> </div> <div> </div> <div> </div> <div><br>As for Molly Malone, she is a fictitious character created to illustrate a point for this article. If Molly were real, this is how the Passport would have helped staff with her care: The family completed A Passport Into My Life, learned about Molly, and went to work. </div> <div> </div> <div> </div> <div> </div> <div><br>The activities director went to a few travel agencies and gathered free brochures about various vacation destinations. The family was asked to bring in an old Mahjong set. Through other<a href="/Issues/2014/Pages/0814/Passport-Success-Stories.aspx" target="_blank" title="Success stories"> residents’ Passports</a>, the activities department identified others who were previous Mahjong mavens. Now, every morning Molly reviews the travel brochures, “planning” her next vacation, and every afternoon after lunch, she and four other residents gather to “play” two hours of Mahjong. Molly’s antipsychotic medication has been <br>discharged. </div> <div> </div> <div> </div> <div> </div> <div><br>Who doesn’t like happy endings? <br></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><em><img width="88" height="123" class="ms-rtePosition-1" alt="Karen Schindler" src="/Issues/2014/PublishingImages/0814/KarenSchindler.jpg" style="margin:5px;" />Karen Schindler, PT, is vice president of quality initiatives at Skilled Healthcare LLC, which serves more than 95 skilled nursing and assisted living centers in eight states. Schindler, whose long term care career spans 30 years, can be reached at <a target="_blank" href="mailto:kschindler@skilledhc.com">kschindler@skilledhc.com</a>.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><em>She would like to thank the task force members for contributions: Betty Cline, RN, Edwin Evangelista, Gabby Martinez, Jenny Johnston, LBSW, Kathleen Rose, Marsha Clark, Rose Brosam, RN, Terri Greaves, Theresa Rohrer, and Tonya McNemee.</em></div> The Centers for Medicare & Medicaid Services (CMS) launched the Partnership to Improve Dementia Care in Nursing Homes program in 2012. The goals of this initiative included a focus on person-centered care and the reduction of unnecessary antipsychotic medication.2014-08-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0814/caregiving_t.jpg" style="BORDER:0px solid;" />Caregiving;QualityColumn8
The Pivotal Role Of The Nursing Home Administratorhttps://www.providermagazine.com/Issues/2014/Pages/0814/The-Pivotal-Role-Of-The-Nursing-Home-Administrator.aspxThe Pivotal Role Of The Nursing Home Administrator<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div> </div> <div> </div> <div> </div> <div>Much is written in the academic literature on how nursing home administrators (NHAs) impact every facet of life in the facility. C. Donoghue and N.G. Castle link NHA leadership styles with staff turnover in an article in The Gerontologist (2009), as do many other theorists. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>The Better Jobs Better Care demonstration reported on by D. Brannon et al., also in The Gerontologist (2007), identifies the impact of the quality of supervision in the facility on intent to leave among direct care staff. The NHA’s impact is thought to directly and indirectly impact organizational commitment. E. Sikorska-Simmons’ research (2005) links work environment to whether or not staff commit in assisted living residences. Castle (2001) links the turnover of the NHA to care outcomes in the facility. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">More Than Academic</h2> <div> </div> <div> </div> <div> </div> <div>Moving beyond the academic, there is an important element of practicality in the discussion of the role the NHA plays in the facility and in the larger organization. It stands to reason that the administrator sets the tone, establishes important aspects of organizational culture, and models what is most important in terms of behavior and priorities. </div> <div> </div> <div> </div> <div> </div> <div><br>This article explores the role the NHA plays in creating positive outcomes for the individual nursing center and for the long term and post-acute care profession. Interviews with a range of stakeholders shed light on the far-reaching influence of NHAs and also identify the competencies required to excel in this critical leadership role. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Collaborative Leadership</h2> <div> </div> <div> </div> <div> </div> <div>The hectic, often harried pace of the nursing center demands a special kind of leadership. This is not the environment for the faint of heart. Leading in the long term care profession requires that NHAs not only be adept at all areas of facility operation, they must also have a keen understanding of the ever-changing post-acute world. </div> <div> </div> <div> </div> <div> </div> <div><br>Because there are so many competing demands on NHAs’ time and attention, it is critical that they build a strong leadership team. </div> <div> </div> <div> </div> <div> </div> <div><br>Patrick Boyle, president and chief executive officer of Miller’s Health Systems headquartered in Warsaw, Ind., puts it well when he says, “The NHA must surround him/herself with competent department managers who are equipped to handle day-to-day issues independently.”</div> <div> </div> <div> </div> <div> </div> <div><br>Having a strong team enables the NHA to function at a more strategic level, knowing that the bench strength of the entire leadership team will keep the facility operating effectively.</div> <div> </div> <h2 class="ms-rteElement-H2"> Transitioning To The New Leadership Model </h2> <div> </div> <div>Recognizing one’s limitations is critical to success in this pivotal role, though it is often difficult to conduct a candid assessment of one’s strengths and developmental opportunities. These opportunities for growth are often overlooked by NHAs who believe they are supposed to not only have all the answers, but also know all of the questions.</div> <div> </div> <div> </div> <div> </div> <div><br>Nowadays, the role of NHA is shifting to more collaborative leadership. An up and coming NHA with just two years at the helm of a very successful building, Erica Cona, NHA of Opis Management Resource’s Bridgeview Center in Ormond Beach, Fla., says, “I think our role is shifting from traditionally more autocratic to being facilitators and coaches.”</div> <div> </div> <div> </div> <div> </div> <div><br>Cona advances the idea that it is important to be humble enough to invite team members, from all levels of the facility, into problem-solving processes. She contends that this collaborative approach yields better solutions and keeps team members engaged.</div> <div> </div> <div> </div> <div> </div> <div><br>Nancy Leveille, senior director of member operational support for the New York State Health Facilities Association, shares Cona’s belief that there is a discernable shift in the roles and responsibilities of the NHA.</div> <div> </div> <div> </div> <div> </div> <div><br>Leveille believes that long term and post-acute care leaders have to develop and implement a “cross-systems mentality” where they are able to build partnerships across the health care continuum. The shift is not just in how NHAs examine their individual facilities, but also in how they understand and evaluate changing health care delivery systems, she adds.<br></div> <h2 class="ms-rteElement-H2">Engagement Builds Commitment</h2> <div> </div> <div> </div> <div> </div> <div>The NHA is responsible for building lasting commitment in staff. That is the most powerful tool available for stemming the tide of rampant turnover. It is up to the NHA, as well every manager and supervisor in the facility, to understand the importance of employee commitment, commitment not only to the company, but also to the patient/resident and to the larger profession.</div> <div> </div> <div> </div> <div> </div> <div><br>Building that commitment requires an awareness of the factors that engender high levels of dedication, such as the emotional attachment that is forged between employer and employee and also between the care provider and the care recipient. Other factors include support for the organization’s mission and strategic goals. </div> <div> </div> <div> </div> <div> </div> <div><br>Building commitment is directly linked to employee engagement. It is incumbent upon NHAs to create opportunities for employees to be involved beyond just the day-to-day function of their jobs.</div> <div> </div> <div> </div> <div> </div> <div><br>Consider asking staff members to serve on committees, to assist with special projects, or to represent the facility in the larger community. When employees represent the facility well they serve as ambassadors for the larger long term and post-acute care profession. These budget-neutral engagement strategies get and keep employees focused on the larger aims of the profession. They also serve as a stabilizing force: Engaged, committed employees are less likely to defect to the competitor offering a nominal increase in wages.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Personal Professional Commitment </h2> <div> </div> <div> </div> <div>Building commitment requires a refined skill set. Boyle of Miller’s Health Systems says that NHAs must be able to foster an environment of continuous learning inside their buildings. This learning begins with the NHA. NHAs who have committed to their own professional development are better able to lead employees on a developmental journey.</div> <div> </div> <div> </div> <div> </div> <div><br>After more than 30 years in the role of NHA, Susan Davis has clear ideas about the competencies required for an NHA to be maximally effective. Davis, executive director of La Loma Village, a nonprofit continuing care retirement community in Litchfield Park, Ariz., contends that the essential skill set includes process management, communication, visioning, and promotion. </div> <div> </div> <div> </div> <div> </div> <div><br>She also believes that it is critical that NHAs be able to promote the profession.</div> <div> </div> <div> </div> <div> </div> <div>Boyle seconds this notion when he says, “The NHA must devote time outside the facility to develop relationships with community leaders, referral sources, and legislators.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Communicating With A Forward Focus</h2> <div> </div> <div> </div> <div> </div> <div>As the long term post-acute landscape continues to change at a lightning pace, it is critical that the NHA be adept not simply at reacting and responding to change, but also to being the catalyst when necessary. </div> <div> </div> <div> </div> <div> </div> <div>The constant evolution of the profession calls for the NHA to be innovative in thought and action.</div> <div> </div> <div> </div> <div> </div> <div><br>NHAs are responsible for partnering to launch pioneering approaches to care, service, and employee and organizational development. </div> <div> </div> <div> </div> <div> </div> <div><br>This requires thinking beyond the present dilemma and imagining new possibilities for the resources available in the facility. </div> <div> </div> <div> </div> <div> </div> <div><br>It also requires that the NHA understand how important it is to convincingly persuade change, skillfully leverage resources, and move the organization forward.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Importance Of Being Fast On Their Feet</h2> <div> </div> <div> </div> <div> </div> <div>Boyle advises that NHAs must begin to function with agility if they are to position their facilities for successful futures. He says, “The job has become more complex, and administrators of the future must be able to think innovatively and plan strategically.” </div> <div> </div> <div> </div> <div> </div> <div><br>This means that the NHA must be able to employ a change communication strategy. There are three key elements of that strategy.</div> <div> </div> <div> </div> <div> </div> <div><br>The first element is creating a compelling vision of a positive future. It is important to begin the process with an image that galvanizes stakeholders of all stripes, from the certified nurse assistant, to the physician, to the floor sweeper.</div> <div> </div> <div> </div> <div> </div> <div><br>The second element of the change communication strategy is to enlist agents and ambassadors to deliver the message far and wide. Whatever the innovation happens to be, it is necessary that multiple champions be able to speak convincingly and about the desired outcomes and the path for getting there.</div> <div> </div> <div> </div> <div> </div> <div><br>The third element, perhaps the most critical, is building dialogue about the intended innovation. Meaningful dialogue is vitally important to creating sustainable change. The mistake many would-be innovators make is using unilateral communication strategies that do not allow them to get candid feedback and to measure dissent. </div> <div> </div> <div> </div> <div> </div> <div><br>A successful NHA needs refined skills to function in the ever-changing world of today and the future. </div> <div> </div> <div> </div> <div> </div> <div>The stakeholders interviewed in this article highlight the myriad skills and competencies required. They range from collaborative leadership, to visioning skills, to the capacity to build commitment. </div> <div> </div> <div> </div> <div> </div> <div><br><span><span><img width="119" height="144" src="/archives/archives-2012/PublishingImages/0612/JoanneSmikle.jpg" alt="Joanne Smikle" class="ms-rtePosition-2" style="margin:5px;" /></span></span>As the profession continues to emerge and evolve, so, too, must its most vital contributors, the NHAs. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><span></span><em>Joanne Smikle provides consulting and leadership education services to health care organizations across the country. Visit <a href="http://www.smiklespeaks.com/" target="_blank">www.smiklespeaks.com</a> to read more articles on current business topics. Smikle can be reached at <a href="mailto:info@smiklespeaks.com" title="Email Joanne!" target="_blank">info@smiklespeaks.com </a>or (301) 596-3140.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> This article explores the role the NHA plays in creating positive outcomes for the individual nursing center and for the long term and post-acute care profession. Interviews with a range of stakeholders shed light on the far-reaching influence of NHAs and also identify the competencies required to excel in this critical leadership role.2014-08-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0814/hr_t.jpg" style="BORDER:0px solid;" />Management;WorkforceColumn8
Why Financial Realities Should Be Sharedhttps://www.providermagazine.com/Issues/2014/Pages/0814/Why-Financial-Realities-Should-Be-Shared.aspxWhy Financial Realities Should Be Shared<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div> </div> <div> </div> <div> </div> <div>Nursing home administrators are often seen by their caregiver and clinical staff as only caring about the financial aspects of the facility. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>They are often reluctant to share facility financial information out of fear that staff would think that’s all management cared about. They may also fear that staff would mishandle the information. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Subconsciously, owners and managers may fear that staff aren’t mature or sophisticated enough to appreciate the need for the facility to make money.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Lack Of Information Detrimental</h2> <div> </div> <div> </div> <div> </div> <div>So, instead of educating staff on the financial fundamentals and enlisting their help to eliminate waste and be efficient as co-owners of the facility and their departments, many administrators ration out just enough information to get staff members to carry out a prepared agenda.</div> <div> </div> <div> </div> <div> </div> <div><br>Staff may be given a budget for hours or expenses for the month, based on the company’s projected census. They toil away under close scrutiny, trying to hit that budget without understanding the larger picture.</div> <div> </div> <div> </div> <div> </div> <div><br>Not to say that this approach doesn’t get the job done, because in many cases it does. But, people who have been hired to care for and protect frail elders need to see the bigger picture, one that outlines how an efficiently run center protects those residents in the long run.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Sharing Realities Makes A Difference</h2> <div> </div> <div> </div> <div> </div> <div>When administrators choose to share the economic realities of the costs of caring for the center’s residents, staff will begin to trust management, and then something powerful happens: Caregivers come alive and take more ownership of their responsibilities. </div> <div> </div> <div> </div> <div> </div> <div><br>Staff who have been briefed on the financial realities of running the center take pride in their new understanding, and they become more creative problem solvers, now that they see the whole scenario and not just their isolated part of it.</div> <div> </div> <h2 class="ms-rteElement-H2"> Inform Team Leaders </h2> <div> </div> <div>Several months ago, this author took on an interim administrator assignment for his company.The newly remodeled building was designed and contracted for 100 percent short-term rehabilitation patients only.</div> <div> </div> <div> </div> <div> </div> <div>After a couple of weeks of assessing the care, talent, systems, and financial situation of the new venture, it was found that significant adjustments needed to be made in the facility’s cost structure.</div> <div> </div> <h2 class="ms-rteElement-H2"> </h2> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Forming A Plan</h2> <div> </div> <div> </div> <div> </div> <div>The predecessor’s belief that “if you build it, they will come” hadn’t panned out, and the company couldn’t continue to take large losses while it worked and hoped for a positive census.</div> <div> </div> <div> </div> <div> </div> <div><br>Fortunately, the leadership team was a strong one. It had a special combination of compassion and commitment to excellence.</div> <div> </div> <div> </div> <div> </div> <div><br>As interim administrator, I decided to show them the entire income statement, including the bottom year-to-date losses, which were significant.</div> <div> </div> <div> </div> <div> </div> <div><br>That meeting was stimulating, educational, and ironically motivating. Each member of the team took a more serious interest and ownership in the financial facets of their jobs. They came up with ideas of how they could run more efficiently, without sacrificing quality.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Expanding The Strategy Facilitywide </h2> <div> </div> <div> </div> <div>If presented properly, sharing the financial realities, both challenges and successes, is an empowering, trust-building lever administrators should pull in the management of their facilities.</div> <div> </div> <div> </div> <div> </div> <div><br>The key phrase, of course, is “if presented properly.” An administrator can be burned by sharing facility financial information, too. </div> <div> </div> <div> </div> <div> </div> <div><br>The best way to empower staff with this lever is to use the metaphor of the Three-Legged Stool. In the scenario presented above, I was so encouraged by the department head team’s response to the information, I decided to venture into the unpredictable waters of the all-staff meeting.</div> <div> </div> <div> </div> <div> </div> <div><br>Here’s how the conversation went at my first all-staff meeting months ago:</div> <div> </div> <div> </div> <div> </div> <div><strong>Me:</strong> “What do you think I care most about?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them:</strong> [Thinking: I’m not stupid enough to answer that question ... suspicious smiles ... long pause.]</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Me: </strong>“Really. It’s okay. What do you think I care most about in running this facility?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them:</strong> [Still thinking: I don’t know him well enough to be honest. He’s just like all the rest, probably. Money. The answer is money.] “Patient care.”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Me: </strong>“Yes. What else?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them:</strong> [Oh, there’s more than one answer. I’ll say it ...] “Profits.”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Me:</strong> “Yes. What else?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them: </strong>[What a dork. He can’t care MOST about more than one thing!] “Ummm … customer satisfaction?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br><img src="/Issues/2014/PublishingImages/0814/mgmt_t.jpg" class="ms-rtePosition-1 ms-rteImage-1" alt="" style="margin:5px 10px;" />Me: </strong>“Yes. But, how can I care MOST about more than one thing? Have any of you ever seen a three-legged stool?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them: </strong>“Yes, of course.”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Me: </strong>“Which leg is most important? Which leg do you care most about when you sit on it?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them:</strong> “The one that’s going to break.”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Me:</strong> “Put yourself in my shoes. If you were me, what would you say make up the three legs holding up our facility?</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them: </strong>“Money, patient care … and … ?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Me:</strong> “And … customer and employee satisfaction. Which one do you think I think is most important?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Them:</strong> “Whichever is weakest?”</div> <div> </div> <div> </div> <div> </div> <div><strong><br>Me:</strong> “That’s right. That’s exactly right. You’ve heard me talk a lot lately about some of our financial challenges. </div> <div> </div> <div> </div> <div> </div> <div><br>“You’ve seen me tighten up our processes around approving overtime and tightening our belt in other ways, too. We’ve had to flex staffing to appropriate levels that match our lower census.</div> <div> </div> <div> </div> <div> </div> <div><br>“Our patient care is great. Our customer satisfaction is high. Our turnover is low. But, financially, the facility has been losing money for a few months in a row because we haven’t adjusted our spending appropriately to our low census.</div> <div> </div> <div> </div> <div> </div> <div><br>“Right now, the leg that’s weakest, the leg that’s breaking, is the financial one, and we have to strengthen it. Here’s what we’re doing (overview of efficiencies we’re trying to regain). </div> <div> </div> <div> </div> <div> </div> <div><br>“What else do you suggest we try? What can you do to help?”</div> <div> </div> <div> </div> <div> </div> <div><br>I then asked if any of them had ever been “cancelled” or sent home early from a shift. One hundred percent of their hands shot up. I asked if they understood the rationale for flexing hours and if they understood nursing hours per patient day and the state minimum requirements. They did not.</div> <div> </div> <div> </div> <div> </div> <div><br>I explained how the hours PPD number is calculated, and we calculated it for our facility. They saw—and <br>understood—how highly we were staffed. I shared with them our bottom line losses for the year. </div> <div> </div> <div> </div> <div> </div> <div><br>They began to ask insightful questions about staffing for acuity and skilled mix and how we derive our staffing goals, which the director of nursing determines based on acuity.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Staff Response</h2> <div> </div> <div> </div> <div> </div> <div>The feedback from the meeting was very positive. The staff members went to work the next day with a sounder understanding of what makes me tick and why we were managing the financial side of things so tightly.<br></div> <div> </div> <div> </div> <div> </div> <div><br>I finished the meeting focusing on the other two legs of the stool. I reaffirmed to staff where my heart and passions lie—in creating an environment where they are free to thrive as caregivers, an environment that creates a surprising experience for our patients and their families.</div> <div> </div> <div> </div> <div> </div> <div><br>It is time to stop rationing financial crumbs to the leaders in the facilities. Let them have a seat at the table.</div> <div> </div> <div> </div> <div> </div> <div>Let’s be more transparent with facility income statements so staff can take ownership, and eventual pride, in the successful operation they’re actually responsible for shaping.</div> <div> </div> <div> </div> <div> </div> <div><br>They deserve it. And, their hearts and minds will be unleashed as they see their role in the bigger picture. <br><br><em>Dave Sedgwick is vice president of operations at CareTrust REIT, a real estate investment trust specializing in sale-leaseback financing in seniors housing and health care. Sedgwick, who has served in key leadership roles at The Ensign Group, from administrator to chief human capital officer and ran five skilled nursing facilities in three states, is a frequent industry speaker and writes about health care leadership issues at LeadingLTC.com.  </em></div> Staff who have been briefed on the financial realities of running the center take pride in their new understanding, and they become more creative problem solvers, now that they see the whole scenario and not just their isolated part of it.2014-08-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0814/mgmt_t.jpg" style="BORDER:0px solid;" />ManagementColumn8
Passport Success Storieshttps://www.providermagazine.com/Issues/2014/Pages/0814/Passport-Success-Stories.aspxPassport Success Stories<br>What follows are a few of the success stories from centers that implemented the A Passport Into My Life program. Resident names have been changed to ensure compliance with privacy and other regulations.<br><br><img width="312" height="183" alt="Jenny Johnston and resident's son" class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/0814/Caregiving1.jpg" style="margin:5px 10px;" />■ <strong class="ms-rteThemeForeColor-8-0">Jenny Johnston, LBSW, at Oak Crest Nursing Center: </strong>Dorothy was very anxious throughout the day. After the family completed the Passport, staff learned that Dorothy had been a hard-working farm woman. She also loved black coffee and was extremely close to a few relatives. Using this information, staff began serving Dorothy coffee and engaging her in conversation about life on the farm, being sure to include the names of those relatives she held dear. Dorothy is no longer anxious and is on a gradual dose-reduction program for her antipsychotic.<br><br>■ <strong class="ms-rteThemeForeColor-8-0">Theresa Rohrer, activities director at Wathena Healthcare and Rehabilitation Center: </strong>Beatrice was at high risk for falls and became agitated every afternoon. After family completed the Passport, staff learned that Beatrice spent her entire life helping others. Every afternoon Beatrice now sits behind the nurses’ station. The center has supplied her with her own notebooks, pens, and stacks of papers. Beatrice is very calm as she “works” through her papers, “helping” the nurses. The order for the antipsychotic medication has been discharged.<br><br>■ <strong class="ms-rteThemeForeColor-8-0">Kathleen Rose, director of staff development at Valley Healthcare Center:</strong> Lillian would continually yell out and become very agitated in the afternoon during change of shift. After her family completed the Passport, staff learned that Lillian had been a high school teacher with a reputation for zero noise tolerance/disruption from her students. Lillian now enjoys sitting in the lobby during change of shift (instead of by the nurses’ station), and staff use their “inside” voices when talking to Lillian. Staff also now play word spelling games when they interact with Lillian. Her antipsychotic medication has been discharged. <br><br>■ <strong class="ms-rteThemeForeColor-8-0">Terri Greaves, director at Vintage Park at Neodesha: </strong>After caring for his wife with dementia for five years at home, the time had come when Abe needed to admit her into a center. Even when it is for the best, it is very hard on the family. Abe completed the Passport in great detail, writing down every nuance that he had come to learn over his time as his wife’s caregiver. When Abe gave the Passport to Terri, he had tears in his eyes as he thanked the center for caring enough to want to know everything about his wife so they could provide her with the best possible care.<br>2014-08-01T04:00:00ZColumn8
Providers, Surveyors Join Forces To Achieve Mutual Goalshttps://www.providermagazine.com/Issues/2014/Pages/0814/Providers,-Surveyors-Join-Forces-To-Achieve-Mutual-Goals.aspxProviders, Surveyors Join Forces To Achieve Mutual Goals<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div>Hidden treasure is not worth much until it is uncovered. And when that treasure is a little-known Rhode Island pilot program that set out to boost resident-centered care (RCC) among nursing home providers but accomplished much more in the process, the payoff in unearthing the hidden gem can be a boon for state <div> </div> <div> </div> <div> </div> <div>and providers alike. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>In this case, the pilot seemed to accomplish the unattainable by transforming hardened nursing home surveyors into ardent supporters of RCC and culture change.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Conceived, implemented, and completed between 2006 and 2008—just before the Great Recession hit the country and changed nearly everything touched by the economy—the program was considered an unqualified success by everyone involved.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>What’s more, its initial mission to boost RCC among nursing home providers in the Ocean State became almost a secondary accomplishment, compared with the way it seemed to convert surveyors’ perspective about the regulations and their capacity to support and foster RCC. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">The Discovery </h2> <div> </div> <div> </div> <div> </div> <div>Evidence of the pilot’s existence was uncovered by a group of determined graduate students in search of a better way to present a model for improving the <a title="Survey process" target="_blank" href="/Issues/2014/Pages/0814/Assisted-Living-Innovates-Survey-Processes.aspx">nursing home survey process</a>. The group in question consisted of this author and three classmates as we reached the halfway point of a master’s curriculum at the University of Maryland Baltimore County’s Management of Aging Services program.</div> <div> </div> <div> </div> <div> </div> <div><br>We were frustrated with the lack of viable models for turning the unpopular and notoriously adversarial survey process into a more collaborative and educational practice. But then Google came through and revealed to us the pearl that is known as the Rhode Island Individualized Care Pilot. </div> <div> </div> <div> </div> <div> </div> <div><br><img width="116" height="177" src="/Issues/2014/PublishingImages/0814/MargieMcLaughlin.jpg" alt="Margie McLaughlin" class="ms-rtePosition-1" style="margin:5px 10px;" />Making the discovery even more serendipitous was the fact that two of the major players in the pilot were now working in my office: David Gifford, MD, who at the time of the pilot was the director of the Rhode Island Department of Health, and Marguerite McLaughlin, who served as senior program administrator for Healthcentric Advisors, Rhode Island’s quality improvement organization (QIO).</div> <div> </div> <div> </div> <div> </div> <div><br>“I think the pilot had as big, if not a bigger effect, on the surveyors than the providers,” Gifford said during a series of interviews for the class project. “When I become director of health, I had always wanted to implement culture change differently.” And so, Gifford, who now serves as senior vice president of quality for the American Health Care Association (AHCA), created the pilot along with Mary Jane Koren, MD, former vice president at the Commonwealth Fund, in an effort to ensure the survey process was not a barrier to culture change.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Helpful Toolkit Lost To Recession Woes</h2> <div> </div> <div> </div> <div> </div> <div>The entire pilot, which began in December 2006 and ended in November 2008 with a successful evaluation and a toolkit that offers states a step-by-step guide, including recommendations and lessons learned, has since been relegated to relative obscurity.<br></div> <div> </div> <div> </div> <div> </div> <div><br>An unlikely victim of the recession, the intention of the pilot’s creators was to take it on a roadshow of sorts and tout it to the masses. But when the economy tanked, the state’s survey agency cut its staff and imposed a hiring freeze. </div> <div> </div> <div> </div> <div> </div> <div><br>“We hit the recession, lost funding and some surveyors, and got to the point where we were treading water,” says Gifford.</div> <div> </div> <div> </div> <div> </div> <div><br>“A lot of things were happening at that time,” says Andrew Powers, who was training coordinator for the Rhode Island Office of Facilities Regulation at the time of the pilot. </div> <div> </div> <div> </div> <div> </div> <div><br>In addition to the recession taking its toll, the states were also moving into the Quality Indicator Survey system (the new survey process of the Centers for Medicare & Medicaid Services [CMS] at the time), Powers notes. “And in our state, we have 18 long term care surveyors, while other states have hundreds. The places we did share it with thought it was interesting, and I don’t remember getting any negative feedback about it,” he says.</div> <div> </div> <div> </div> <div> </div> <div><br>The one question he did get from other surveyors was, “How much time does it take?”</div> <div> </div> <div> </div> <div> </div> <div><br>And so, with no funding to take the show on the road, the toolbox was mailed to the state survey agencies, but little else followed. </div> <div> </div> <div> </div> <div> </div> <div><br>Thanks to the intrepid advocates’ passion about the pilot, however, “the team would still be willing to go help any state that wants to do it,” Gifford says.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Accomplishments</h2> <div> </div> <div> </div> <div> </div> <div>With support from CMS, the pilot had accomplished the following at its completion in 2008:</div> <div> </div> <div> </div> <div> </div> <div><br>■ Asked supplemental questions and observations as part of every standard federal recertification survey in Rhode Island between Nov. 1, 2007, and April 30, 2008 (51 surveys); </div> <div> </div> <div> </div> <div> </div> <div><br>■ Conducted enhanced surveyor training prior to and during the pilot period; and</div> <div> </div> <div> </div> <div> </div> <div><br>■ Provided information about individualized RCC practices to nursing homes during and after the pilot period, in collaboration with Quality Partners of Rhode Island (now called Healthcentric Advisors). </div> <div> </div> <div> </div> <div> </div> <div><br>In addition, 42 surveyed facilities received educational on-site visits from the QIO during or shortly following the survey, and all Rhode Island nursing homes received a binder with educational resources, including copies of CMS’ webinar series, titled “From Institutional to Individualized Care.” </div> <div> </div> <div> </div> <div> </div> <div><br>Ten volunteer nursing homes participated in a “guided change process” with Quality Partners to implement practices to promote individualized, resident-centered care, such as consistent assignment, noise reduction, or resident-directed choice of waking and sleeping.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Goals Target Quality Of Life </h2> <div> </div> <div> </div> <div> </div> <div>The supplemental survey interviews and observations targeted three areas related to individualized, RCC:</div> <div> </div> <div> </div> <div> </div> <div><br>1. Resident-directed choice of waking, sleeping, and bathing.</div> <div> </div> <div> </div> <div> </div> <div><br>2. Personalized environment regarding sound levels, personalized rooms, access to public/common areas, homelike bathrooms, and dining alternatives.</div> <div> </div> <div> </div> <div> </div> <div><br>3. Staff-resident relationships that supported quality care and quality of life via consistent assignment and the resident being known as a person whose concerns were sought after, known, and responded to satisfactorily.</div> <div> </div> <div> </div> <div> </div> <div><br>Through the annual recertification survey, the surveyors asked questions that ferreted out answers to the three targeted areas of RCC, while QIO representatives, attending the surveys in a “ride-along” capacity, worked with nursing home staff to educate them about RCC practices.</div> <div> </div> <div> </div> <div> </div> <div><br>The supplemental interview questions focused on whether resident preferences for waking, sleeping, and bathing were met; whether any systems/processes were in place to assess these or other preferences; and whether the facility was engaged in broader efforts to orient staff and care practices to resident quality of life. </div> <div> </div> <div> </div> <div> </div> <div><br>Online surveys were sent to administrators at all Rhode Island nursing homes pre- and post-pilot. Based on reports from participating homes, the pilot helped nursing home administrators understand, consider, and implement RCC.</div> <div> </div> <div> </div> <div> </div> <div><br>“The findings paint a promising picture about the potential to spur provider change through a multipronged approach centered on the regulatory process,” according to an evaluation of the pilot conducted by Gifford and David Stevenson, PhD, associate professor of health policy at Harvard Medical School.</div> <div> </div> <h2 class="ms-rteElement-H2"> The Power Of Questions </h2> <div> </div> <div>Prior to the pilot’s launch, the state’s nursing home surveyors underwent nearly 20 hours of training to learn about RCC and the protocols of the pilot. In addition to the training sessions, there were follow-up discussions after each pilot survey and during monthly staff meetings. </div> <div> </div> <div> </div> <div> </div> <div><br><img width="140" height="160" class="ms-rtePosition-2" alt="David Gifford" src="/Issues/2014/PublishingImages/0814/DavidGifford.jpg" style="margin:5px 10px;" />Gifford and Stevenson assert in their evaluation that the training “encouraged surveyors to examine their attitudes about RCC, instructed them about how to establish facility compliance with regulatory standards, and educated them about how to approach staff and resident interviews.”</div> <div> </div> <div> </div> <div> </div> <div><br>Gifford sums up how the supplemental questions conveyed the message that the agency was serious about RCC: “When a survey agency goes out and asks a question, word spreads, and that’s a powerful intervention.”</div> <div> </div> <div> </div> <div> </div> <div><br>Representing the QIO during the pilot was McLaughlin, who made many of the ride-along visits. She recalls how conveying some minor aspects of RCC to nurse assistants made a major impact. </div> <div> </div> <div> </div> <div> </div> <div><br>“We started having brown bags where surveyors and providers would get together to discuss a chosen topic,” says McLaughlin, who is now AHCA senior director of quality improvement. “For example, a provider might ask, ‘Can I have soup on my 24-hour food bar?’ and a surveyor would respond with the answer or say, ‘I’ll find out and get back to you.’” </div> <div> </div> <div> </div> <div> </div> <div><br>Those interactions were quite powerful, says McLaughlin, especially in light of the way in which surveyors and providers have traditionally communicated. </div> <div> </div> <div> </div> <div> </div> <div><br>“One thing [the pilot] did for many surveyors was to get them away from the traditional goal of just protecting residents’ health and safety and enabled them to see that while health and safety are very important, people also have rights to make decisions that aren’t always in their best health and safety interests,” says Powers, who now oversees all assisted living surveyors in Rhode Island.<br></div> <div> </div> <div> </div> <div> </div> <div><div><div> </div> <div>“So, before the pilot, a surveyor might say ‘no’ to a resident who was diabetic and wanted to have a doughnut, but now he might recognize that the resident had a right to do what she wanted.”</div> <h2 class="ms-rteElement-H2">From Regs To ‘Second Nature’</h2></div></div> <div> </div> <div> </div> <div> </div> <div>As part of the pilot’s evaluation, the Rhode Island Department of Health conducted <a href="http://www.commonwealthfund.org/interactives-and-data/multimedia/videos/2009/sep/Rhode%20Island%20pilot-surveyor-video" target="_blank">on-camera interviews</a> with the participating surveyors to get their feedback on the process. </div> <div> </div> <div> </div> <div> </div> <div><br>The videos reveal how the pilot changed surveyor attitudes about RCC. “It became second nature to include the resident’s choice in everything we did, even though [the item had always been on the survey],” said one surveyor. </div> <div> </div> <div> </div> <div> </div> <div><br>A statement from another sounds more like the sentiments of an ardent culture change activist: “If we are truly going to call facilities [residents'] homes, then we need to treat it like they are home,” she says.</div> <div> </div> <div> </div> <div> </div> <div><br>Yet another reflects on the specific quality-of-life questions with regard to enabling residents to sleep in in the mornings. “Now I see things very differently in that a resident obviously doesn’t need to be up until he or she is ready to get up, and that starts their whole day in a positive way,” the surveyor says.</div> <div> </div> <div> </div> <div> </div> <div><br>What began as an effort to get government to be an enabler and not a barrier to how the survey process promotes RCC turned into a way for surveyors to make life better for residents, says Gifford.</div> <div> </div> <div> </div> <div> </div> <div><div> </div> <div><div>“What this did was allow [surveyors] to shift their focus from regulatory compliance to understanding that the survey process was about the resident and individualized care. So they were asking questions about practices that were there, and that allowed them to see it in a new light,” he says.<br></div> <h2 class="ms-rteElement-H2">The Beauty Of OBRA '87</h2></div></div> <div> </div> <div> </div> <div>At the heart of all nursing home regulations, of course, is the Omnibus Budget Reconciliation Act of 1987—more widely known as OBRA ’87. Born out of a need to improve resident quality of life and quality of care in nursing homes, OBRA ’87 established a series of uniform standards for Medicare and Medicaid-certified nursing homes. </div> <div> </div> <div> </div> <div> </div> <div><br>According to an evaluation of the pilot, OBRA ’87 reforms “were meant to ensure that residents’ rights and quality-of-life standards had a regulatory status equal to that of medical care quality.”</div> <div> </div> <div> </div> <div> </div> <div><br>“Resident-centered care is arguably at the heart of the OBRA ’87 standards, emphasizing residents’ rights and quality of life,” Gifford and Stevenson say in the evaluation. </div> <div> </div> <div> </div> <div> </div> <div><br>The two further note that at the foundation of the pilot was the promotion of RCC during the annual recertification survey, with the “two primary rationales for the pilot being 1.) resident-centered care is at the <br><br>heart of OBRA ’87; and 2.) despite uncertainty about whether the current survey process performs optimally, regulation can be a powerful tool for change.”</div> <div> </div> <div> </div> <div> </div> <div><br><span><img width="133" height="200" src="/Issues/2014/PublishingImages/0814/CarmenBowman.jpg" class="ms-rtePosition-1" alt="Carmen Bowman" style="margin:5px 15px;" /></span>Carmen Bowman, a former survey or turned consultant, public speaker, and culture change advocate, is passionate about the notion that OBRA ’87 supports RCC. In fact, she often cites Koren, who is the former survey director in New York, in her presentations on the topic: “Often it is the interpretation of the regs by some surveyors that might make things difficult for innovators. That requires a different solution than eliminating the OBRA regs,” Koren has been known to say. </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Other States Partner To Boost RCC </h2> <div> </div> <div> </div> <div>“The regulations are so beautiful and so supportive of culture change,” says Bowman, who is a longtime supporter of the power of collaboration among all long term care stakeholders.</div> <div> </div> <div> </div> <div> </div> <div><br>“When it comes to promoting culture change and person-centered care, we really need to partner with all stakeholders in the process, including surveyors and <a title="Recommendations for the Toolbox" target="_blank" href="/Issues/2014/Pages/0814/Recommendations-For-State--Survey-Agencies-And-Culture-Change-Coalitions.aspx">culture change coalitions</a> in the state. In fact, what good is a culture change coalition if it is not pushing the envelope or asking for meetings with the regulators to discuss it, to talk about, to partner and move forward and to create better?”</div> <div> </div> <div> </div> <div> </div> <div><br>Bowman points to an example from Minnesota, where the survey agency partnered with culture change advocates to get rid of alarms in all nursing homes. Elsewhere, although there is no evidence that the Rhode Island pilot has been replicated, Bowman keeps track of how states are collaborating with survey agencies in an effort to boost RCC.</div> <div> </div> <div> </div> <div> </div> <div><br>In California, the CMS Western Consortium is highly involved in the state’s culture change coalition, along with the survey agency. In Arkansas, the state survey agency was part of the culture change coalition that helped push through legislation that has promoted Green House homes, the Eden Alternative, universal workers, and the rewriting of state regulations to encourage culture change practices. </div> <div> </div> <div> </div> <div> </div> <div><br>In Oregon, a surveyor served on a culture change coalition team, and in Kansas, the state’s secretary of aging was highly involved with culture change.</div> <div> </div> <div> </div> <div> </div> <div><br>Bowman is also a proponent of providers that take risks when implementing RCC practices in their communities. “You risk deficiencies every time survey takes place in your building. You can continue to provide care in the ‘old way’ and risk deficiencies or move toward the ‘new way’ and risk deficiencies,” she says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Replicating The Rhode Island Pilot </h2> <div> </div> <div> </div> <div> </div> <div>Gifford and others remain passionate about the ability of the Rhode Island pilot to transform attitudes about RCC. </div> <div> </div> <div> </div> <div> </div> <div><br>“We just gave surveyors a whole new perspective,” says Gifford, referring to the pilot. “And it also got them out of the chart and talking more to staff and residents about what was going on. So they got a better feel about what was happening in the facility.” </div> <div> </div> <div> </div> <div> </div> <div><br>The team responsible for rolling out the pilot developed supporting material around it, including training videos and tools for other states. But that doesn’t mean states will easily replicate the pilot, says Gifford.</div> <div> </div> <div> </div> <div> </div> <div>“State government is very hierarchical, and if you don’t have leadership from the top down to support it, it won’t happen. And if you don’t have the director of the survey agency on board, it won’t happen.”</div> <div> </div> <div> </div> <div> </div> <div><br>Also key to getting the pilot off the ground was Rhode Island’s partnership with CMS, Gifford adds. </div> <div> </div> <div> </div> <div> </div> <div>Rhode Island’s Powers reflects on how the pilot has changed the way surveyors conduct their business today in the state. “When you do a project like that, even though you’re not formally doing it anymore, there’s still stuff that people learn. They still apply it to their work every day, and so it becomes a natural part of the survey process,” he says. Powers adds that this attitude resonates with new surveyors as well. When it comes to these issues, the culture is different now, he says. </div> <div> </div> <div> </div> <div> </div> <div><br>Also worth noting, Powers emphasizes, is the fact the program supervisors—those who review the surveyors’ work—also went through the trainings. What’s more, some of the surveyors went through Eden Alternative training in Rhode Island. “We really tried to embrace this whole issue and get surveyors to look at it differently,” says Powers.</div> <div> </div> <div> </div> <div> </div> <div><br>Other evidence of the pilot’s impact on the survey process, according to Powers, is the distribution of a brochure that explains residents’ rights.</div> <div> </div> <div> </div> <div> </div> <div><br>“As part of the federal process, one of the surveyors usually interviews the resident council,” he says. “We have a one-page informational sheet that talks about what residents can ask for and what providers are supposed to do.”</div> <div> </div> <div> </div> <div> </div> <div><br>It serves as an educational prompt for surveyors and also as a tool to spur conversation within the group, he explains. “That’s one thing that came out of the Rhode Island pilot that we’re using. It gives people in the nursing home something to walk away with and prompts surveyors to cover these areas.” ■</div>Hidden treasure is not worth much until it is uncovered. And when that treasure is a little-known Rhode Island pilot program that set out to boost resident-centered care (RCC) among nursing home providers but accomplished much more in the process, the payoff in unearthing the hidden gem can be a boon for states and providers alike. 2014-08-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0814/cover_t.jpg" style="BORDER:0px solid;" />Caregiving;Quality;Quality ImprovementCover Story8
From The toolbox: Recommendations For State Survey Agencies And Culture Change Coalitionshttps://www.providermagazine.com/Issues/2014/Pages/0814/Recommendations-For-State--Survey-Agencies-And-Culture-Change-Coalitions.aspxFrom The toolbox: Recommendations For State Survey Agencies And Culture Change Coalitions<p><br></p> <p><span class="ms-rteThemeForeColor-5-3" id="ms-rterangepaste-start"></span><span class="ms-rteThemeForeColor-5-3">For Culture Change Coalitions and State Survey Agencies, hopefully working as collaborators, there are five important and interrelated recommendations based on the experience of the Individualized Care Pilot. </span><br></p> <p><strong>1. Ensure the mandated regulatory process promotes compliance with quality-of-life regulations. The State Survey Agency (SSA) can accomplish this by training surveyors to recognize and enforce compliance with federal and state quality-of-life regulations and through clear communication with providers regarding the meaning of the regulations. </strong></p> <p><span><span><span class="ms-rteThemeForeColor-6-4">■<span style="display:inline-block;"></span></span></span><span style="display:inline-block;"></span> <span style="display:inline-block;"></span></span>Training surveyors includes assuring they understand the spirit and detail of quality-of-life regulations, are familiar with what individualized care practices look like in action, are prepared for typical surveying scenarios that can be problematic, examine personal attitudes about quality-of-life regulatory issues, and become aware of the power of the questions they ask and the relational manner in which they ask them. The SSA communicating about the meaning of the regulations includes creating transparent and open lines of communication with providers regarding the regulatory facts and being available to answer providers’ questions. <br><br><strong>2. Create educational collaborations or connections between the SSA and the Quality Improvement Organization (QIO), or other qualified partner, to assure that providers have the resources needed to implement individualized, resident-centered care practices in keeping with regulatory expectations. </strong><br></p> <p><span><span><span class="ms-rteThemeForeColor-6-4">■<span style="display:inline-block;"></span></span></span><span style="display:inline-block;"></span> <span style="display:inline-block;"></span></span>When providers in a state or region can openly communicate about any perceived regulatory barriers to implementing new practices and are supported by the SSA in their quality improvement efforts, there is excellent potential for systemwide change. The SSA’s participation in an education-regulation partnership is a powerful way to accomplish that. It is a pragmatic format in which to offer resources to providers at all levels of interest and readiness for the journey from institutional to individualized care. QIOs have the quality improvement expertise and resources to be an excellent candidate to partner with the regulatory authority. <br><br><strong>3. Promote opportunities for providers to share their successes, challenges, and solutions so that others can benefit and credibility about new practices grows. </strong><br></p> <p><span><span><span class="ms-rteThemeForeColor-6-4">■<span style="display:inline-block;"></span></span></span><span style="display:inline-block;"></span> <span style="display:inline-block;"></span></span>Resource sharing or cross-pollination among providers regarding culture change practices is a valuable activity for a culture change coalition, the SSA, the QIO, local trade organizations, or, preferably, all of them in collaboration. Systemwide change depends ultimately on providers having confidence in the economic and pragmatic benefits of new practices. There is no better way to convince a provider that a change is doable and financially viable than hearing it from another provider. <br><br><strong>4. Inform residents and families of their regulatory right to quality of life in nursing homes, including the SSA routinely informing them during the survey’s group interview. Coordinate information for consumers with the Ombudsman’s office and other key advocates. Explore ways to involve consumers in understanding and exercising their rights. </strong><br></p> <p><span><span class="ms-rteThemeForeColor-6-4">■<span style="display:inline-block;"></span></span></span> Culture change coalitions and SSAs need to find ways to respond to a key finding of this project: that nursing home residents often did not know they had the right to choices of schedule or a personalized environment—or did not want to “rock the boat” by asking for what they wanted. The educational handout developed by Rhode Island SSA and distributed routinely at the group interview during surveys is a step in the direction of addressing that lack of knowledge. Any SSA can replicate it. But larger efforts to inform consumers at the national, state, and local levels are needed, and coordination of those efforts among all key players is required. <br><br><strong>5. Change state regulations and application processes to support individualized, resident-centered care, if needed. </strong><br></p> <p><span class="ms-rteThemeForeColor-6-4">■</span> The SSA and culture change coalition members need to work together to examine existing state nursing home and long term care regulations for obstacles to culture change practices and to support legislation to remove them. At the same time they must, when appropriate, propose and garner support for new regulations. The question of whether federal regulations alone are sufficient to define and ensure quality of life for nursing home residents is a key topic for all members of culture change coalitions. State licensing application procedures can be updated, as well, to include clear expectation of individualized, resident-centered practices.</p> <p><em>Source: Individualized Care Pilot Toolbox, Rhode Island Department of Health, Recommendations and Dilemmas</em><br></p>2014-08-01T04:00:00ZColumn8
Assisted Living Innovates Survey Processeshttps://www.providermagazine.com/Issues/2014/Pages/0814/Assisted-Living-Innovates-Survey-Processes.aspxAssisted Living Innovates Survey Processes<p></p> <div> </div> <div><br>As nursing home person-centered care (PCC) collaborations proliferate across the country, assisted living providers have followed suit with their own innovative models for ensuring the provision of PCC. </div> <div> </div> <div><br>The Center for Excellence in Assisted Living (CEAL) released in late June the first tool to help providers gauge their ability to provide true PCC to their residents.   </div> <div> </div> <div><br>The new “Toolkit for Person-Centeredness in Assisted Living” was developed through “a close partnership” between the University of North Carolina at Chapel Hill and CEAL, along with providers, residents, family members, and organizational representatives.  </div> <div> </div> <div><br>Available to anyone, the toolkit includes questionnaires to be completed by residents and staff, as well as “simple, easy-to-follow instructions for scoring and interpreting the results.”</div> <div> </div> <div><br>According to a CEAL press release, the questionnaires measure person-centered practices in assisted living—and have been given the moniker of PC-PAL. </div> <div> </div> <div><br>According to the release, PC-PAL questionnaires are based on “research evidence and have been rigorously tested for ease of use and statistical validity.”</div> <div> </div> <div><br>Lead researcher for the tool, Sheryl Zimmerman, PhD, notes that its validity comes from the involvement of a range of stakeholders in the developmental process, thus ensuring “that the questionnaires are relevant to and feasible for use by the people living and working in assisted living communities,” she says.</div> <h2 class="ms-rteElement-H2"> <span class="ms-rteThemeForeColor-5-3"> In Wisconsin, Data Submission</span> </h2> <div>Collaboration among stakeholders is a theme that has carried over to the assisted living survey process in recent years. In Wisconsin, Brian Purtell, executive director of the Wisconsin Center for Assisted Living (WiCAL), was instrumental in constructing a survey category that enables qualifying providers to forgo the “routine” and sometimes onerous system in favor of a less frequent and more collaborative process. </div> <div> </div> <div><img src="/Issues/2014/PublishingImages/0814/BrianPurtell.jpg" alt="Brian Purtell" class="ms-rteImage-1 ms-rtePosition-1" style="margin:15px 10px;" /><br>As Purtell explains, there are two elements of participation in the WiCAL process, known as the Performance Excellence in Assisted Living (PEAL) program: a resident satisfaction survey and the submission of what’s known as quality variables. </div> <div> </div> <div><br>“All of the programs (there are three others) use the same resident satisfaction survey and run it on an annual basis,” says Purtell. “Everyone can compare how they stack up to other facilities in the state. That’s very valuable, as well as congruent with PCC.” </div> <div> </div> <div><br>All PEAL participants must submit quality variables on a quarterly basis. They include the number of falls with injury, outbreaks of infection or influenza or norovirus, and hospitalizations, says Purtell. These variables also enable providers to compare themselves against their peers. </div> <div> </div> <div><br>“That’s the exciting things we’re doing, and it’s very collaborative," Purtell says. “We have the state regulators, we have ombudsmen involved, we have the four provider associations, and we are working with and have grant funding from the Center for Health Systems Research & Analysis [CHRSA].” </div> <div> </div> <div><br>CHRSA is working with the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL) to help it develop and implement internal quality assurance and quality improvement throughout its systems.</div> <div> </div> <div><br>Purtell notes that the original quality variables were created and launched with the objective of  getting  people comfortable with tracking and reporting data. “At some point, we will expand to add additional measures,” he says, “but we don’t want to go so far as to replicate the nursing home minimum data set process in the assisted living setting. However, we also have to balance that with benchmarking and tracking so that the Department of Health can say, ‘we did not give these guys a pass.’”</div> <div> </div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">New Jersey Advances With ‘Advance Standing’</h2> <div> </div> <div>Similar to Wisconsin’s designation is New Jersey’s assisted living designation known as Advance Standing, in which providers apply annually and get a pass from the usual survey process. The New Jersey Center for Assisted Living created the category several years ago in conjunction with the state Department of Health. </div> <div> </div> <div><br>“It was a very collaborative approach with the department,” says Kathy Fiery, New Jersey Center for Assisted Living’s director of the division of assisted living, alternative care. “Buildings apply through us annually and must have approval to participate in the program from the department. Once they are in the program, they are subject to a compliance visit and they monitor the residence to ensure they are in compliance annually.” </div> <div> </div> <div><br>Fiery notes that all buildings must reapply each year and are subject to a compliance visit, “so it ensures the buildings are being seen every year,” she says.</div> <div><br><img width="137" height="166" src="/Issues/2014/PublishingImages/0814/KathyFiery.jpg" alt="Kathy Fiery" class="ms-rtePosition-2" style="margin:10px;" />Another key component of the program is the requirement that all Advance Standing participants join the Patient Safety Organization, launched recently by the National Center for Assisted Living (NCAL) in conjunction with the New Jersey Hospital Association’s Institute for Quality and Patient Safety <br>Organization (PSO) to collect clinical performance data from assisted living members. </div> <div> </div> <div><br>In addition to paying for membership with the PSO, all qualifying assisted living providers must pay to participate in the Advance Standing program as well. </div> <div> </div> <div><br>What are the benefits of participating in the program? “Besides not being subjected to yearly visit from surveyors, which can be a punitive process, our visits are much more collaborative, albeit as aggressive in finding things,” says Fiery. </div> <div> </div> <div><br>“But at the end of the day, these buildings have gone above and beyond the Department of Health’s minimum requirements, and it’s a raise-the-bar-compliance visit. Our consultant will say to members, ‘This is Advance Standing, so we expect that you’re doing more than is required; we expect more from you.’”</div> <div> </div> <div><br>What's more, Fiery says, Advance Standing is “much more collaborative, there’s more training, more education, more back and forth. It’s a more pleasant process on the assisted living side than for nursing homes, certainly. And who wants to go through the ‘gotcha’ survey, when you can speak up during the process and tell your staff to ask questions.” </div> <div> </div> <div><br>Among the 220 licensed buildings in New Jersey, 73 were accepted into Advance Standing this year. “So it’s clearly a distinction that sets them apart from their neighbors,” Fiery says. </div> <div> </div> <div><br>This can be used in marketing and in recruiting staff as well. “It’s really a credential that stands out for them.” </div> <div> </div> <div><br>Elsewhere, Colorado began conducting risk-based relicensure inspections for assisted living residences, on a pilot basis, in January 2013. </div> <div> </div> <div><br>“Under the new system, assisted living providers meeting criteria specified in the law will be eligible for an extended survey cycle,” according to the “2013 Assisted Living State Regulatory Review,” published by NCAL.</div> <div> </div> <p></p>2014-08-01T04:00:00ZColumn8
Does QIS Relate To Value-Based Purchasing?https://www.providermagazine.com/Issues/2014/Pages/0814/Does-QIS-Relate-To-Value-Based-Purchasing.aspxDoes QIS Relate To Value-Based Purchasing?While regulation offers an approach for enforcing a minimum standard of quality that nursing centers are expected to achieve, arguably there are other, better ways for policy to incentivize quality improvement. QIS, which uses standards based on the Institute of Medicine report and enacted in the Nursing Home Reform Act, provides metrics that can be used for more than survey and certification. And, ideally for providers, methods used in other policy initiatives like value-based purchasing (VBP) should use similar metrics to those used in survey and certification so that policies aimed at enhancing quality can be harmonized. <br><br>While regulation is based on a minimum threshold for quality using these metrics, VBP should encourage the highest levels of performance that can be achieved, adjusting for case mix or risk differences between facilities. <br><br>In an attempt to align the metrics used in VBP with those in QIS, I have worked as a contractor to both the Medicare Payment Advisory Commission (MedPAC) and the Centers for Medicare & Medicaid Services (CMS) in the development of their VBP programs. <br><br>In its March 2008 report to Congress, MedPAC said, “A pay-for-performance program for SNFs [skilled nursing facilities] should be established to tie payments to patient outcomes. Two well-accepted measures—risk-adjusted rates of community discharge and potentially avoidable rehospitalization—should be included in a starter measure set…” <br><br>The same rehospitalization measure was part of the CMS “Plan to Implement a Medicare Skilled Nursing Facility Value-Based Purchasing Program.” <br><br>The Admission Sample Record Review in the QIS includes a measure of all-cause hospitalization within 30 days of SNF admission.<br><br>For Stage 1 of QIS, the raw rate is used with a low threshold because in Stage 2 surveyors review cases to take acuity into consideration and determine whether these readmissions were preventable. But VBP needs to use a more refined measure as the basis for payment incentives. Thus, risk-adjusted rates of potentially avoidable readmissions were recommended for VBP. <br><br>Six years after the MedPAC recommendation, potentially avoidable measures have found their way into legislation requiring the establishment of a SNF VBP program. <br><br>In April of this year, the Protecting Access to Medicare Act of 2014 was signed into law, with Section 215 stating that “Not later than Oct. 1, 2016, the secretary shall specify a measure to reflect an all-condition, risk-adjusted potentially preventable hospital readmission rate for skilled nursing facilities.” Furthermore, the legislation says that “the SNF VBP Program shall apply to payments for services furnished on or after Oct. 1, 2018.” <a target="_blank" href="http://www.govtrack.us/congress/bills/113/hr4302">www.govtrack.us/congress/bills/113/hr4302</a><br><br>This VBP initiative is aligned with QAPI opportunities for skilled care because it is the preventable readmissions that SNFs can reduce with QAPI efforts. By reducing potentially preventable readmissions, which represent almost half of the readmissions from SNFs, providers will reduce their all-cause readmission rate such that it will likely be less than the QIS threshold. And even if the QIS raw rate threshold is exceeded, but there are no preventable readmissions, then surveyors should have no reason to cite deficient practice.<br>While regulation is based on a minimum threshold for quality using these metrics, VBP should encourage the highest levels of performance that can be achieved, adjusting for case mix or risk differences between facilities. 2014-08-01T04:00:00ZQuality ImprovementColumn8




Staying Ahead In A Changing Worldhttps://www.providermagazine.com/Issues/2014/Pages/0914/Staying-Ahead-In-A-Changing-World.aspxStaying Ahead In A Changing World<h1 class="ms-rteElement-H1 ms-rteThemeForeColor-5-3 ms-rteFontFace-1">AHCA/NCAL 65th Annual Convention & Expo</h1> <div> </div> <div> </div> <div> </div> <p></p> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0" style="text-align:center;"><strong><img src="/Issues/2014/PublishingImages/0914/National_Mall_Skyline.jpg" class="ms-rtePosition-4" alt="" style="margin:5px;" /></strong></h3> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0" style="text-align:left;"><strong><br>Debunking The Myths About Surveyors’ Expectations For Dementia Care</strong></h3> <div> </div> <div> </div> <div> </div> <div>This session will address surveyor training relative to reducing off-label use of antipsychotics in skilled nursing care centers. Hear from the former Centers for Medicare & Medicaid Services (CMS) director of nursing home survey and certification program about the approach and expectations to better understand how policy will impact you and your organization and help you to be prepared for review of this issue on your next survey.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader: </span><em>Alice Bonner, PhD, RN, associate professor, Northeastern University, Westborough, Mass.</em></div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0"> Building The High-Value Skilled Nursing Facility: Securing An Essential Row In The Market </h3> <div> </div> <div>As delivery system and payment reform transform the health care marketplace, referrer and payer demands necessitate a more effective approach to post-acute care delivery that prioritizes cost-appropriate patient placement and the efficient transition of patients into lower-cost care settings. To meet these demands, skilled nursing facilities (SNFs) must evolve their approach to care delivery by enhancing clinical staffing structures and adopting a “total cost” mindset that reflects the goals of population health. </div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader:</span> <em>Jared Landis, senior consultant, The Advisory Board Co., Washington, D.C.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Utilizing QAPI To Develop A Pressure Ulcer Program </h3> <div> </div> <div> </div> <div> </div> <div>This session will provide your organization with the necessary steps to implement a pressure ulcer program using the Quality Assurance and Performance Improvement (QAPI) approach, ensure systems are in place to meet F314 regulations and standards of practice, provide the wound team training on how to set up a skin care prevention and treatment program, and set up effective wound care team meetings. How to effectively monitor both the skin care prevention and treatment programs will also be discussed. </div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader:</span> <em>Judith Morey, RN, BSN, CWOCN, APN, Pathway Health, White Bear Lake, Minn.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Competence And Confidence: Using Education As A Retention Strategy</h3> <div> </div> <div> </div> <div> </div> <div>When it comes to meeting staff stability goals, progressive organizations are turning their attention to education and competency building as a retention strategy. Organizations that employ strategies to continually educate and build staff skills are creating loyal staff members who are responsive, competent, and confident. This session will show strategies for making education and training a new and powerful retention tool.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader:</span> <em>Marguerite McLaughlin, MA, senior director, quality improvement, AHCA, Washington, D.C.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">How Do You Get A Seat At The Table When You Can’t Get Your Foot In The Door?</h3> <div> </div> <div> </div> <div> </div> <div>Census is on the decline. Hospitals are picking your competitor down the street for rehabilitation for their patients. How do you “up your game” so that you have a seat at the table? How do you secure your future? This session will walk you through an array of tips and strategies to strengthen your position, promote your strengths, and get your staff and families serving as ambassadors.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader: </span><em>Greg Dowdy, chief operating officer (COO), American HealthCare, Roanoke, Va.<br></em></div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">One Year Of Bundled Payments: How Are They Working, And What Does The Future Look Like?</h3> <div> </div> <div> </div> <div> </div> <div>Bundled payments are considered a viable alternative to fee-for-service payment in post-acute care. In the first hour of this session, speakers from Avalere Health and the Center for Medicare and Medicaid Innovation (CMMI) will discuss the current legislative environment around bundled payments, and where they see bundled payment policy going in the future. <br></div> <div> </div> <div> </div> <div> </div> <div><img width="447" height="297" src="/Issues/2014/PublishingImages/0914/PotomacRiver.jpg" alt="Potomac River, Georgetown, DC" class="ms-rtePosition-1" style="margin:20px 10px;" /><br>In the second hour, a panel of AHCA member companies will discuss their first year of experience in the Bundled Payments for Care Improvement demonstration. They will discuss challenges and opportunities, and discuss how bundled payments are working for their centers. Participants will walk away from this session with a much deeper understanding of the policy landscape around bundling, as well as actionable information about how bundling works for providers on the ground.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leaders:</span> <em>Ellen Lukens, vice president, Avalere Health, Washington, D.C.; Joanne Powell, NA, RHIT, RAC-CT, director, reimbursement strategies, The Evangelical Lutheran Good Samaritan Society, Sioux Falls, S.D.; Barry Lazarus, vice president, director of reimbursement & chief compliance officer, HCR ManorCare, Toledo, Ohio</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Federal Town Hall: Enhancing Provider Navigation Of Federal Programs, Assistance, And Waivers Prior To, During, And After A Disaster </h3> <div> </div> <div> </div> <div> </div> <div>This session will describe the federal landscape of programs, services, assistance, and waivers available prior to, during, and after a disaster. Providers will receive a brief overview of health care coalitions and how they can better support emergency preparedness in a community. Participants will hear from federal government experts on navigating the programs and their requirements. Federal-specific questions regarding emergency preparedness, response, and recovery will be answered. </div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader:</span><em> Kristen Finne, senior policy analyst, Health and Human Services/Office of the Assistant Secretary for Preparedness and Response, Office of Policy and Planning, Division of Health System Policy, Washington, D.C.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Developing Effective Partnerships With Your Hospitals</h3> <div> </div> <div> </div> <div> </div> <div>A hospital and SNF partnership is critical to sustaining a SNF’s business model in the new environment of health care delivery. Strategies to build effective partnerships and to present your SNF’s data and services to hospitals will be reviewed. This session will also provide insight from hospitals about their expectations of SNFs, as well as the experience of several centers that have built an effective collaboration with hospitals. A review of innovative partnerships between hospitals and SNFs will be presented. </div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader:</span> <em>Laurie Herndon, MSN, GNP-BC, ANP-BC, director, clinical quality, Massachusetts Senior Care Association, Grafton, Mass.</em>  </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Turning Around Turnover For Greater Staff Stability</h3> <div> </div> <div> </div> <div> </div> <div>One of the challenges in long term care is to retain new hires and facilitate long-term retention. The impact of high turnover can jeopardize staff satisfaction, resident and family relationships, finances, and ultimately quality of care. Fortunately, many providers are successfully adopting practices to retain new hires beyond the make-or-break 90-day threshold. This session will discuss how to implement consistent assignment practices, balance staff assignments, achieve the right amount of flexibility in staffing for higher satisfaction, and hire right. </div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leaders:</span> <em>Mark Woodka, chief executive officer, OnShift, Cleveland, Ohio; Irene Fleshner, RN, MHSA, FACHE, senior vice president, strategic nursing initiatives, Genesis HealthCare, Sarasota, Fla.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3"> <span class="ms-rteThemeForeColor-5-0"> Person-Centeredness And Enabling Technology Solutions </span></h3> <span class="ms-rteThemeForeColor-5-0"> </span><div> </div> <div> </div> <div>This session will address innovation in care delivery aimed at realizing person-centered care. </div> <div> </div> <div> </div> <div> </div> <div>How will technology lessen the challenges to successful aging in place? How will current and emerging technologies play a part in the development and evolution of person-centered care tailored to the function, independence, and quality of life of older adults, their families, and the professionals who support them? How must technology be leveraged to drive the cultural shift from system focus to person-centered care? </div> <div> </div> <div> </div> <div> </div> <div>Examples of technology approaches, solutions, and promising best practices will be provided, along with recommendations on how participants can bring home a strategy and practical action plan to move from a system focus to one that actively embraces person-centeredness, function, independence, and quality of life.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader: </span><em>Richard Della Penna, MD, chief medical officer, Independa, San Diego, Calif.</em></div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Understanding And Responding To Behavior As Communication In Persons With Dementia</h3> <div> </div> <div> </div> <div> </div> <div>Symptoms of dementia, termed behavioral expressions, can be viewed as a form of communication to caregivers. Patients in later stages of dementia are not only unable to communicate their needs, but are often unable to direct their own daily activities. Caregivers and health care professionals strive to anticipate needs for these patients in the hope that they will be able to reduce the person’s distress. Unmet needs may be the result of an inability to communicate, inability to use prior coping mechanisms, or environmental limitations. It is fundamental to any caregiving experience that practitioners utilize techniques and skills that enhance assessment, communication, and quality of life. Learn how health care professionals can utilize nonpharmacological interventions such as aroma, music, or touch therapy; enhanced nonverbal communication techniques; and prayer that have a potential for addressing unmet psycho-social needs.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader:</span> <em>Lena Smith, PhD, clinical director/COO, Retreat Healthcare, Rio Rancho, N.M.<br></em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Approaching A Fork In The Road: Determining What Financial Structure Works For You</h3> <div> </div> <div> </div> <div> </div> <div>The senior care profession features many options for capital funding and resources. Join experts in this area for an in-depth analysis of various funding avenues that are available. Gain competitive knowledge on funding structures you are already familiar with and some that you wish to learn more about. Capital providers will share how they develop and view partnerships, while operators discuss how their funding partnerships have benefited their businesses. </div> <div> </div> <div> </div> <div> </div> <p class="ms-rteElement-P">Learn how to increase profitability, grow your business, and become more familiar with the various capital <span>sources available to you.</span><span class="ms-rteForeColor-2"><br></span></p> <p class="ms-rteElement-P"><span class="ms-rteForeColor-2">Moderator:</span><span class="ms-rteForeColor-2"> </span><em>Roger Bernier, LNHA, MBA, president and COO, Chelsea Senior Living, Fanwood, N.J.</em><span class="ms-rteForeColor-2"><br>Panelists: </span><em>Kenneth Gould, managing director, Lancaster Pollard, Radnor, Pa.; Kyle Henderson, CSH, Washington, D.C.</em></p> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">The SNF PPS: Not Over Yet!! </h3> <div> </div> <div> </div> <div> </div> <div>The Medicare payer landscape is evolving. Various payment/care models are jockeying for position, and the competition will only increase. However, SNF prospective payment system (PPS) fee-for-service will remain viable and critical for some years to come as a stand-alone payer or as part of an accountable care organization’s initial framework. </div> <div> </div> <div> </div> <div> </div> <div><br>Presenter Ellen Lukens will offer an analysis that compares SNF utilization rates across the different current and emerging Medicare programs, examines how changes in enrollment could affect overall industry volume, and demonstrates the relevance and durability of the SNF PPS. </div> <div> </div> <div> </div> <div> </div> <div><br>Presenters Barry Lazarus and Elise Smith will provide an update on the SNF PPS; CMS’ concerns about the vulnerabilities of the system; and Capitol Hill, CMS, and AHCA efforts to push forward with constructive changes to the current system.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leaders: </span><em>Elise Smith, senior fellow, finance policy and legal affairs, AHCA, Washington, D.C.; Ellen Lukens, vice president, Avalere Health, Washington, D.C.; Barry Lazarus, vice president, director of reimbursement and chief compliance officer, HCR ManorCare, Toledo, Ohio</em></div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">The Challenge Of Providing Therapy Services</h3> <div> </div> <div> </div> <div> </div> <div>The challenges continue in the delivery of medically necessary therapy services. The changes in the rules for Part A and Part B services did not seem to be sufficient to alter the belief that too many patients are being provided with too much therapy. At the same time, Medicare advocacy groups are saying that the Jimmo <em>v.</em> Sebelius settlement should result in more therapy. </div> <div> </div> <div> </div> <div> </div> <div><br>CMS has recently released the long-awaited updates to the “Medicare Benefit Policy Manual” addressing maintenance therapy related to the Jimmo settlement. What should a provider do when faced with such contradiction? It is more important than ever to ensure that efficient clinically appropriate rehabilitation results in expected clinical outcomes in order to achieve solid financial performance.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader:</span> <em>Pat Newberry, PT, MBA, director, clinical education, AIS, Huntsville, Ala.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0">Proactive PEPPER Report Use To Mitigate Audit Risk </h3> <div> </div> <div> </div> <div> </div> <div>CMS contractors use data mining to build profiles of providers, networks, billing patterns, and beneficiary utilization. These profiles allow them to quickly identify unusual billing activity that may then trigger audit activity. <br></div> <div> </div> <div> </div> <div> </div> <div><br>SNF providers have the ability to use their claim data to guide compliance auditing and monitoring. The PEPPER report provides data that the SNF can use as a good starting point to prioritize areas for auditing and monitoring activity to mitigate audit risk. </div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leader: </span><em>Shawn Halcsik, DPT, MEd, OCS, CPC, RAC-CT, vice president, compliance, Evergreen Rehabilitation, Wauwatosa, Wis.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3 ms-rteThemeForeColor-5-0"><div>Leadership Imperative: The Role Of The Administrator And Medical Director In Improving Care For Persons With Dementia</div></h3> <div> </div> <div> </div> <div> </div> <div>A positive and collaborative partnership between the medical director and organizational leaders is critical to ensuring the highest quality of care. That partnership is also an important foundation for tackling tough challenges like the initiative to reduce off-label use of antipsychotic medications. This session will explore one organization’s success in building such a partnership and in reducing its use of antipsychotics, providing attendees with practical strategies and lessons learned.</div> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2"><br>Session Leaders: </span><em>Nick Bridges, MS, OT/L, nursing home administrator, Durgin Pines (Continuum Health Services), Kittery, Maine; Jabbar Fazeli, MD, Maine Geriatrics, Portland, Maine. </em></div> <div> </div> <div> </div> <div> </div> <p></p>2014 AHCA/NCAL 65th Annual Convention & Expo Preview2014-09-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0914/convention_thumb.jpg" style="BORDER:0px solid;" />Management;Caregiving;Policy;QualityColumn9
Seize The Dayhttps://www.providermagazine.com/Issues/2014/Pages/0914/Seize-The-Day.aspxSeize The Day<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>For seniors housing professionals with big plans, now is the time to get the financing that will make them possible, say finance professionals. </p> <div> </div> <div> </div> <div> </div> <p>Increased interest from lenders and investors has resulted in a financial environment very favorable to seniors housing. <br></p> <div> </div> <div> </div> <div> </div> <p></p> <div> </div> <div> </div> <div> </div> <p class="ms-rteElement-P"></p> <div> </div> <div> </div> <div> </div> <p class="ms-rteElement-P">Finance experts urge seniors housing borrowers to take advantage of today’s environment; waiting until later to get financing that will clearly be necessary may cost borrowers more than they think.</p> <h2 class="ms-rteElement-H2">Strength Through Recession Convinced Many In Finance</h2> <p class="ms-rteElement-P">That the seniors housing as a whole had weathered the recession more successfully than many sectors wasn’t lost on investors or lenders. </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p></p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"><img src="/Issues/2014/PublishingImages/0914/BrettHolman.jpg" alt="Brett Holman" class="ms-rtePosition-1" style="margin:10px 15px;" />“The fact that [seniors housing] properties held on to fundamentals, such as their value, rents, and occupancy, throughout the last five or six years is very convincing to many people,” says Brent Holman, senior vice president, originations/operations/asset management, of Cambridge Realty Capital, headquartered in Chicago.</p> <div> </div> <div> </div> <div> </div> <div>Imran Javaid, managing director, healthcare real estate, commercial and specialty finance, Capital One Financial Corp., agrees.<br></div> <div> </div> <div> </div> <div> </div> <div><br>“A lot of players recognized that [seniors housing] had performed really well in the recession,” says Javaid. “The demographics are positive, but also important is that it held better in the recession than some other classes they’d typically lend to. They really recognized that it is more resilient to recession and downturns because it’s needs-driven.”</div> <div> </div> <div> </div> <div> </div> <div><br>Even institutional investors were impressed. In 2013, they found seniors housing proved more attractive for new investments than any other commercial real estate property type, according to a recent Kingsley Associates survey conducted for the institutional investor sector.</div> <div> </div> <div> </div> <div> </div> <div><br>The result is that seniors housing providers now have more options for financing than in the past, and that means finding a transaction that adheres closely to their needs will be much easier.</div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Favorable Terms </h2> <div> </div> <div> </div> <div>Along with more options and the fact that interest rates have remained low, terms attached to financial agreements are more favorable now than in the past—or will be in the future, experts predict.</div> <div> </div> <div> </div> <div> </div> <div><br>“Loan terms are better than they have been in several years,” says Holman, and are “an important part of making a good mortgage transaction.” </div> <div> </div> <div> </div> <div> </div> <div><br>Among terms that are often more favorable than in the past is the ability to take equity out of the properties, says Holman. </div> <div> </div> <div> </div> <div> </div> <div><br>“The bank will lend you more than the amount of your existing debt, so you take cash out of the transaction” that can be used for improvements or other goals, he says.</div> <div> </div> <div> </div> <div> </div> <div><br>Holman also says that limiting recourse is more of a possibility now. “Many bank loans have a guarantee that if the business declines so that you can’t repay the loan, the bank can go after your personal assets,” he says. “Right now is a good time to rewrite how much they can go after.”<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Waiting To Finance Could Be Costly</h2> <div> </div> <div> </div> <div> </div> <div>“If you have a plan that five years from now will be absolutely necessary [to implement], do it now,” says Javaid. “Accelerate the timeline, and do it now. Expand or upgrade a facility now, don’t wait for five years from now when you might have a very different environment.”</div> <div> </div> <div> </div> <div> </div> <div><img src="/Issues/2014/PublishingImages/0914/ImranJaviad.jpg" alt="Imran Javiad" class="ms-rtePosition-2" style="margin:5px 15px;" /><br>Holman also emphasizes the importance of acting now.</div> <div> </div> <div> </div> <div> </div> <div><br>“The costs of waiting for your current loan to expire in a couple years and an interest rate that may be higher, as well as the reduced quality of terms of the loan you may get, totally outweighs the cost and hassle of refinancing today,” Holman says. “Longer-term transactions are usually at least five years in length, so any increased costs will be multiplied five times if you wait a year or two rather than take advantage of the current environment.” </div> <div> </div> <div> </div> <div> </div> <div><br>Further, he says, borrowers should consider fully amortizing <a target="_blank" href="/Issues/2014/Pages/0914/Business-Loan-Application-Tips.aspx">loans</a>, which match the term of the loan to the amortization and so never force the borrower to refinance.</div> <div> </div> <div> </div> <div> </div> <div><br>“Capturing a loan like that in today’s environment sets you up very well,” he says, “because you’ll never be forced to go into the capital markets when terms aren’t as good as today or when your business may not be performing as well.”</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Considering Taking Action? What Steps To Take </h2> <div> </div> <div> </div> <div> </div> <div>For providers considering borrowing now while the environment is favorable, the first thing to do, says Holman, is identify exactly what their needs and financing options are.<br></div> <div> </div> <div> </div> <div> </div> <div><br>“Speak with a mortgage broker or other knowledgeable person in the finance industry to help you put together your thoughts of what is needed, as well as help you have a greater world view of the options available,” he says. </div> <div> </div> <div> </div> <div> </div> <div><br>“Frequently, we see people just refinancing with their existing lender without having a good grasp of all the other opportunities available in this market.”</div> <div> </div> <div> </div> <div> </div> <div><br>Lenders will want a lot of information about your business before being able to accurately evaluate the risks and benefits of the transaction, he says.</div> <div> </div> <div> </div> <div> </div> <div><br>Before you request the financing, put together the information they’ll want to see, such as:</div> <div> </div> <div> </div> <div> </div> <div>■ A clearly articulated plan for how you will use the funds;</div> <div> </div> <div> </div> <div> </div> <div>■ What benefit to the business’ financial performance will result from the finance transaction; </div> <div> </div> <div> </div> <div> </div> <div>■ A good description and narrative of your business performance and personal background; and</div> <div> </div> <div> </div> <div> </div> <div>■ Your goals and expected outcomes from the transaction (for example, a borrower who wants to sell the business in three years will need the option to change their debt). Much more information will also be required as well (see below and <a href="/Issues/2014/Pages/0914/Business-Loan-Application-Tips.aspx" target="_blank">Business Loan Tips</a>).<br></div> <div> </div> <div> </div> <div> </div> <div><div> </div> <div style="text-align:center;"><img src="/Issues/2014/PublishingImages/0914/Finance6.jpg" class="ms-rteImage-4" alt="" style="margin:5px;" /></div> <div> </div> <div> </div> <div>One of the most important things to remember when putting the company’s information together and when communicating with financial professionals is don’t try to hide any elements of risk in your operations.</div></div> <div> </div> <div> </div> <div> </div> <div><br>Both Javaid and Holman emphasize the importance of being up front about your company’s risks.</div> <div> </div> <div> </div> <div> </div> <div><br>“Do as much disclosure as possible,” says Javaid—disclose the business’ outstanding aspects, yes, but first disclose the risks. </div> <div> </div> <div> </div> <div> </div> <div><br>“If there were pitfalls, like you had bad surveys, highlight it up front,” he says. “I don’t want to find out in diligence that you hid something from me; that leaves a bad taste in everyone’s mouths. Being up front saves the time and energy of both the borrower and the lender.”</div> <div> </div> <div> </div> <div> </div> <div><br>Being immediately forthcoming with the business’ situation, goals, and desired outcomes will benefit everyone, says Holman.</div> <div> </div> <div> </div> <div> </div> <div><br>“Just express that up front so that all parties can do their best to exceed those goals and outcomes,” he says. </div> <div> </div> <div> </div> <div> </div> <p></p>Finance experts urge seniors housing borrowers to take advantage of today’s environment; waiting until later to get financing that will clearly be necessary may cost borrowers more than they think.2014-09-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0914/finance_thumb.jpg" style="BORDER:0px solid;" />FinanceColumn9
Employers Need To Heed The Exclusion Listhttps://www.providermagazine.com/Issues/2014/Pages/0914/Employers-Need-To-Heed-The-Exclusion-List-.aspxEmployers Need To Heed The Exclusion List<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div> </div> <div>As evidenced by an uptick in reported civil money penalty (CMP) settlements, ranging from $10,000 to $353,248.82, the Office of Inspector General (OIG) is holding nursing home providers’ feet to the fire for employing individuals excluded from federal health programs, including Medicare and Medicaid. </div> <div> </div> <div> </div> <div> </div> <div>By July of this year, reported settlements for alleged incidents of employment of excluded individuals—who were listed as nurses in a number of the cases—topped the numbers reported all of last year. </div> <div> </div> <div> </div> <div> </div> <div>In July alone, there were three cases of alleged false and fraudulent claims, primarily involving the employment of individuals that facility staff knew or should have known were excluded from participation in federal health care programs.</div> <div> </div> <h2 class="ms-rteElement-H2">What Does Excluded Mean?</h2> <div> </div> <div>An excluded individual is someone whom OIG has deemed disbarred or otherwise ineligible from participation in all federal health care programs. Activities that exclude an individual or entity from participation include criminal offenses, such as Medicare or Medicaid fraud; patient abuse or neglect; and felony convictions for health care–related fraud, theft, or other financial misconduct, as well as the unlawful manufacturing, distributing, prescribing, or dispensing of controlled substances.</div> <div> </div> <div><br>Federal law prohibits skilled nursing facilities that participate in federal health care programs from receiving payment for services provided by disbarred people. </div> <div> </div> <div><br>These services include both patient care and non-resident services such as administrative, clerical, and other types. When facility staff either self-report or are found to have billed for services during the time that <br>a disbarred individual provided services, CMPs are likely to be assessed against the facility. </div> <div> </div> <div><br>While the mandate to monitor the OIG exclusion list has been around for a long time, nursing home staff can easily skip this important step in the hiring process. OIG has sought to make compliance as simple as possible by posting a searchable list of excluded entities and individuals at http://exclusions.oig.hhs.gov. </div> <div> </div> <div>The requirement is to check individuals being considered for employment, but staff should be aware that it also includes contractors and vendors.</div> <div> </div> <div><span id="__publishingReusableFragment"></span><br>The Patient Protection and Affordable Care Act mandates that once an individual is excluded in one state, he or she is to be excluded in all states. It is advisable to check not only the national database but also the state-specific database if one is available. </div> <div> </div> <div><br>When using temporary employment agencies, verify that the agency has a system in place whereby potential contract staff are screened against OIG’s list of excluded individuals before being sent to the facility for work activities.</div> <div> </div> <div><br>Conducting a pre-employment check may not be enough. The OIG exclusion list is updated monthly. Since there is a lag time between when individuals are deemed disbarred and when they appear on the exclusion list, it is a good idea to check the list monthly against all employees, contractors, and vendors working in the building. This may sound like a Herculean task, so consider hiring a third-party vendor to cross-check facility-engaged workers against the OIG list. </div> <div> </div> <h2 class="ms-rteElement-H2">Self-Reporting A Must</h2> <div> </div> <div>In one case listed on the OIG enforcement page, a disbarred individual self-reported the violation by her employer, resulting in an expanded OIG investigation for additional violations, which were found. This resulted in increased CMPs assessed against the provider. </div> <div> </div> <div><br>Nursing home staff have a duty to self-report violations to OIG. Self-reporting violations can reduce the CMPs, which, at a minimum, can be 1.5 times the single damages, but OIG reserves the right to increase damages if it deems them appropriate.</div> <div> </div> <div><br>According to OIG’s Provider Self-Disclosure Protocol bulletin, when reporting to OIG, providers must include:</div> <div> </div> <div>■ The identity of the excluded individual and any provider identification number;</div> <div> </div> <div>■ The job duties performed by that individual;</div> <div> </div> <div>■ The dates of the individual’s employment or contractual relationship;</div> <div> </div> <div>■ A description of any background checks that the disclosing party completed before and/or during the individual’s employment or contract;</div> <div> </div> <div>■ A description of the disclosing party’s screening process (including any policy or procedure that was in place) and any flaw or breakdown in that process that led to the hiring or contracting with the excluded individual;</div> <div> </div> <div>■ A description of how the conduct was discovered; and</div> <div> </div> <div>■ A description of any corrective action (including a copy of any revised policy or procedure) implemented to prevent future hiring of excluded individuals. <br></div> <h2 class="ms-rteElement-H2"> Corporate Compliance Follow-Up </h2> <div>In addition, before disclosing the employment of an excluded individual, a disclosing party must screen all current employees and contractors against the List of Excluded Individuals and Entities. Once this has been done, the disclosing party should disclose all excluded persons in one submission.</div> <div> </div> <div><br>As part of an active corporate compliance program, staff should establish policies and procedures outlining how they will ensure that no excluded individuals or entities are involved in facility operations. </div> <div> </div> <div><br>When violations occur, determine the process that will be followed for self-reporting incidents to OIG. </div> <div> </div> <div>The corporate compliance officer and facility council should be involved in the review of information and protocols before, during, and after reportable incidents or when OIG investigations are conducted. </div> <br><em>Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em>By July of this year, reported settlements for alleged incidents of employment of excluded individuals—who were listed as nurses in a number of the cases—topped the numbers reported all of last year. 2014-09-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0914/hr_thumb.jpg" style="BORDER:0px solid;" />Workforce;ManagementColumn9
Tech Boosts Quality, Improves Marketabilityhttps://www.providermagazine.com/Issues/2014/Pages/0914/Tech-Boosts-Quality-Improves-Marketability.aspxTech Boosts Quality, Improves Marketability<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div> <div> </div> <p>There’s plenty to get excited about in terms of how technology can help health care providers and patients. No wonder well-respected publications like <em>The New England Journal of Medicine</em> and leading organizations such as the National Institutes of Health consistently run articles and academic papers on everything from robotic assisted technology to mHealth (the accepted abbreviation for mobile health). <br></p> <div> </div> <p>True, not every health care facility can make use of all the emerging technologies, but the majority of them recognize that technology shouldn’t be ignored. <br></p> <div> </div> <p>At a senior neighborhood campus in Kansas, staff make use of advancements whenever possible to improve clients’ overall wellness.<br></p> <div> </div> <p></p> <div> </div> <div>Three technologies in particular have given the team a measurable impact on the population it serves: a specialized software program, an advanced therapy pool, and exercise equipment using pre-programming technology. </div> <div> </div> <h2 class="ms-rteElement-H2">Platforms Keep Clients’ Data Accessible, Accurate</h2> <div> </div> <div>Every senior at the community has a wide range of information about his or her health, and being able to store that information in one easily accessible remote location, like an encrypted server, has been a boon for them and their caregivers.</div> <div> </div> <div><br>Having invested in software that offers a platform to record clients’ health histories, goals, exercises, routines, and assessment data, it enables the community to run real-time reports, which provide baseline data as well as current data.</div> <div> </div> <div><br>Logins are only available on a “need to know” basis; however, the patient can personally look up anything from a remote location. </div> <div> </div> <div><br>Men and women at the center enjoy being able to use the program to record their medications, supplements, daily blood pressure, weight, and more. It’s more robust than most trainer apps because of its medical history component. </div> <div> </div> <div><br>One of the biggest advantages for the community is utilizing all clients’ data (anonymously) to provide a “snapshot” of the senior community and the people it serves. It enables staff to explore trends and prepare new programming. </div> <div> </div> <div><br>Plus, it’s a definite selling point for getting seniors more invested in the center. </div> <div> </div> <h2 class="ms-rteElement-H2">Exercise Options Turn Techno</h2> <div> </div> <div>While pools aren’t a new technology, specialized therapy pools with variable-depth treadmill floors certainly are. At the community in Kansas, staff invested several years ago in a therapy pool with an underwater treadmill and resistance jets and incorporated it into their rehabilitation offerings and exercise regimens. </div> <div> </div> <div>It is not only a safe environment, but it also eliminates the worries and risks associated with falling. This leads to an increase in self-confidence that fuels healthier behaviors.</div> <div> </div> <div><br>As part of the community’s fall prevention program, the therapy pool is used to ensure participants get effective results. The resistance jets provide an advanced atmosphere to explore gravity training, thus improving strength and balance.</div> <div> </div> <div><span id="__publishingReusableFragment"></span><br>Percentage levels can be recorded for all participants in their personal history records, which are kept on the computer, as noted above. Also, participants can be moved in different directions and angles, worked at different speeds and at different depth levels to challenge them at higher levels. </div> <div> </div> <div><br>With the adjustable treadmill floor, there is the ability to change the depth from zero to six feet. As the participant completes a task at a comfortable level, the floor can be slowly moved up, challenging the participant’s balance more and moving the person toward taking the application to a land-based task. </div> <div> </div> <div>Plus, with a treadmill at the bottom of the floor, speeds can be varied to fit the task and the participant’s level. </div> <div> </div> <div><br>Thus far, there has been an overall 45 percent increase in center of gravity, 64 percent increase in lower body strength, and 35 percent increase in agility in participants, thanks to the program and the therapy pool.</div> <h2 class="ms-rteElement-H2"> Pre-Programmed For Success </h2> <div>The third technological advancement that the community finds vital is programmable exercise equipment, enabling staff to pre-program different workout levels for residents. The machines are self-adjusting and automatically provide the resident with proper weight amount and seat setting. </div> <div> </div> <div><br>Because the program allows staff to constantly switch up the workout, clients are never stuck doing “the same thing.”</div> <div> </div> <div><br>This equipment is a great marriage between technology and simplicity, especially for the senior age population. Residents aren’t always comfortable on gym equipment; with programmable equipment, they get a well-rounded routine without needing a staff person or personal trainer by their side. </div> <div> </div> <div><br>Plus, they can use the therapy pool for endurance exercises and then switch to land-based equipment for strength training as part of a circuit.</div> <div> </div> <div><br>Then, they can record their workouts using a specialized software program. It all works together, which is the aim of any community incorporating different technologies into its day-to-day operations.</div> <div> </div> <div><br>As more technologies bubble to the surface, health care providers at all levels would be wise to investigate the possibilities for the populations they serve. </div> <div> </div> <div><br>Eventually, the Generation X and Generation Y members of today will be in need of senior care. </div> <div> </div> <div>They will not be as reluctant to embrace technological breakthroughs as their modern counterparts sometimes are. Therefore, health care leaders need to be ready to serve them at their comfort zones.</div> <div> </div> <p></p> <div> </div> <p><em>Jackie Halbin is a living well manager in Kansas. She is a Master FallProof and FallProof H2O instructor and is Aquatic Exercise Association-certified. She can be reached at (914) 744-2422.</em><br></p> <div> </div> <p><br></p>Not every health care facility can make use of all the emerging technologies, but the majority of them recognize that technology shouldn’t be ignored. 2014-09-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0914/mgmt_thumb.jpg" style="BORDER:0px solid;" />Management;TechnologyColumn9
Clinical Decision Support Meets EHRshttps://www.providermagazine.com/Issues/2014/Pages/0914/Clinical-Decision-Support-Meets-EHRs-.aspxClinical Decision Support Meets EHRs<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><br>Long term and post-acute care is experiencing a cataclysmic change in health care delivery attributable to two major market forces:</div> <div> </div> <div><br>1. The implementation of regulations aimed at producing outcomes-based, bundled payment structures and increased quality accountability. </div> <div> </div> <div><br>The Affordable Care Act (ACA), the emergence of accountable care organizations (ACOs), and the impending implementation of bundled payments and value-based purchasing have affected providers in many ways, including: </div> <div> </div> <div>■ Increased quality accountability from outside partners;</div> <div> </div> <div>■ Dependence on partnerships for skilled admissions;</div> <div> </div> <div>■ Increasing resident acuity; and </div> <div> </div> <div>■ A need for more clinically competent staff. </div> <div> </div> <div><br>2. The exponential increase in the number of seniors needing care, combined with limited availability of licensed clinical care providers. <br></div> <div> </div> <div><br>While the number of Americans over 65 is projected to double in the next 30 years, the number of physicians and registered nurses is predicted to remain relatively flat. This means that long term and post-acute care providers will have to find ways to leverage fewer clinicians in caring for more residents, with higher levels of acuity.</div> <h2 class="ms-rteElement-H2">Integrating Research, Records</h2> <div> </div> <div>The aforementioned challenges require a range of solutions; however, there are two common denominators: accountability for quality outcomes and increasing the efficiency of clinicians.</div> <div> </div> <div><br>There is little doubt that health information technology is a major component of the solution to address these challenges. The electronic health record (EHR) is now “a need to have rather than a nice to have,” and leaders must view an EHR as a key component of the solution to meet the changing health care demands. That being said, the EHRs of today must evolve to meet the provider needs of tomorrow.</div> <div> </div> <div><br>Another common theme of health care today is the requirement to demonstrate the use of evidence-based practices within all care settings. </div> <div> </div> <div><br>Historically, providers have implemented evidence-based practices using paper protocols, policies and procedures, and clinical guidelines. As providers move from a paper to an electronic health care world, those former paper practices also need to transition to automated systems that facilitate the capture of data in a way that it can be analyzed.</div> <div> </div> <div><br>The volume of medical research continues to grow, especially in the areas of geriatric medicine and wellness, and global access is becoming the norm rather than the exception.</div> <div> </div> <div><br>As the amount of research increases and impacts clinical protocols, it becomes more challenging for clinicians to remain current on best practices. </div> <div> </div> <div><br>The solution that has been embraced in primary and acute care is the embedding of clinical research within an EHR. This solution is termed “clinical decision support.” </div> <h2 class="ms-rteElement-H2"> Understanding CDS </h2> <div>Clinical decision support (CDS) is frequently used in conversation by long term and post-acute care providers relative to features that they would like to see in an EHR solution. However, CDS has more comprehensive and complex functionality than is typically discussed within the profession.</div> <div> </div> <div><br>For the purposes of this column, CDS is defined as providing clinicians or patients with clinical knowledge and intelligently filtered patient information to enhance patient care. </div> <div> </div> <div><br>The research-based clinical knowledge must get the right information, to the right person, in the right CDS intervention format, to the right channel, at the right point in the workflow. </div> <div> </div> <div><br>The value of CDS is supported in the literature as enhancing care and quality. However, if the clinical knowledge is not current, interrupts the end user needlessly, or is not patient-specific, utilization declines.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2">The New Landscape</h2> <div> </div> <div>The primary goals of the ACA are to improve the patient’s experience of care (including quality satisfaction), improve the health of populations, and reduce the per capita cost of health care. </div> <div> </div> <div><br>All sectors of health care, including long term and post-acute care, acute-care hospitals, and ACOs, are feeling the impact of this: Residents are being admitted to skilled nursing facilities with high-acuity needs, with the expectation that competent clinical staff will meet these needs and that further rehospitalizations will be avoided. </div> <div> </div> <div><br>Additionally, the cost of care while achieving positive outcomes is being monitored and is expected to decrease. To achieve success, clinical care must be delivered and supported by research-based interventions, and in a way that leverages the time and expertise of each and every available clinician. </div> <div> </div> <div>The era of “this is the way we have always done it” and the use of non-research-tested assessment tools is over. Clinicians need to use recently published, evidence-based guidelines in the delivery of care. The challenge, however, is keeping pace with relevant information and fewer resources for caring for more residents. EHR solutions, with embedded CDS, assist the care provider in choosing the most applicable interventions and in focusing their time on the residents with the most immediate and acute clinical needs.</div> <div> </div> <h2 class="ms-rteElement-H2">The Benefits Of CDS </h2> <div> </div> <div>The benefits of CDS include: </div> <div> </div> <div>■ Results in standardized documentation by using templates, thereby </div> <div> </div> <div>limiting inconsistent narrative </div> <div> </div> <div>documentation.</div> <div> </div> <div>■ Drives consistency in care decisions as a consequence of implementing evidence-based care guidelines.</div> <div> </div> <div>■ Enhances credibility in relationships with care providers.</div> <div> </div> <div>■ Improves confidence in quality outcomes since care is delivered in a consistent manner.</div> <div> </div> <div>■ Improves quality and safety through alerts and reminders.</div> <div> </div> <h2 class="ms-rteElement-H2">What Providers Need To Know </h2> <div> </div> <div>First and foremost, providers should look for a CDS solution that is embedded in their EHR. The mere integration of parallel systems with overlapping clinical workflows is not a viable solution as it introduces the potential for errors in data entry, decreases staff efficiency, and adds unnecessary costs. </div> <div> </div> <div><br>Second, the CDS solution should embody the best practices of various industry-accepted guidelines and evidence-based research. </div> <div> </div> <div><br>Given the wide range of diagnoses and conditions that need to be addressed in the senior population, and the growing amount of medical research, it is unlikely that any one institution or organization will be the source of all relevant best practices.</div> <div> </div> <div><br>Third, the data collected as a function of implementing CDS should be accessible via business intelligence tools to trend and report on clinical outcomes and drive process improvements. </div> <div> </div> <div> </div> <div> </div> <div><em>Denise Wassenaar, chief clinical officer of MatrixCare, is an evidence-based practitioner experienced in innovative approaches to the delivery of care, including more than 20 years of clinical leadership experience. Wassenaar is a licensed registered nurse and a nursing home administrator and holds a master’s degree in nursing from Purdue University Calumet. She is a frequent national and regional presenter on current clinical and regulatory topics.</em></div>While the number of Americans over 65 is projected to double in the next 30 years, the number of physicians and registered nurses is predicted to remain relatively flat. This means that long term and post-acute care providers will have to find ways to leverage fewer clinicians in caring for more residents, with higher levels of acuity.2014-09-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0914/tech_thumb.jpg" style="BORDER:0px solid;" />TechnologyColumn9
Good Grief: Why It’s Always Mourning In Long Term Carehttps://www.providermagazine.com/Issues/2014/Pages/0914/Good-Grief.aspxGood Grief: Why It’s Always Mourning In Long Term Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p> </p> <div><br><img width="185" height="251" class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/0914/coverstory1.jpg" alt="" style="margin:5px 20px;" /><em>Death has this much to be said for it:</em></div> <div><em>You don't have to get out of bed for it.</em></div> <div><em>Wherever you happen to be </em></div> <div><em>They bring it to you</em><span style="font-size:10pt;font-family:"arial", "sans-serif";line-height:115%;"><em>—</em></span><em>free.</em></div> <div> </div> <div style="text-align:right;"><span style="font-size:10pt;font-family:"arial", "sans-serif";line-height:115%;">—</span>Kingsley Amis</div> <div> </div> <div style="text-align:left;">Pop psychologists like to say that “gallows humor” is a defense mechanism, a way of avoiding what one might call the late unpleasantness (or the unpleasantness of one day having to be “the late”).</div> <div><br>Amis’ doggerel is a nice rebuke to such condescension. The lines on the facing page are mordant, but they’re also defiant. Amis—a hectic novelist-drinker-poet-philanderer-essayist-dirty jokester-newsman—crammed a lot of living into his 72 years. He knew right down to his marrow that just because death gets the last word, it doesn’t have to get the last laugh.<br></div> <div><br>Still, no one will argue that Amis’ chutzpah is universal, and not everyone wants to leave this veil of tears in a puddle of glee. (Ever noticed how rare it is that the poor sap in the noose is the one making with the gallows humor?)</div> <div><br>Yet those who care for the elderly are acutely aware how much death has to be said for it. So why do so many seem to have trouble finding their voice?</div> <h2 class="ms-rteElement-H2"><div><div>Denial Ain’t Just A River</div> <span class="ms-rteFontSize-3">Consider: </span></div></h2> <div>■ In June, the American Heart Association released results of a survey of doctors, nurse practitioners, and doctors’ assistants at the Mayo Clinic. The association found that only 12 percent of providers were openly discussing end-of-life care with their patients. Another 30 percent said they didn’t have enough confidence in themselves to open the discussion, and 21 percent said they were afraid their patients weren’t ready for “the talk.”<br><br></div> <div>■ A 2013 Dartmouth study found that 80 percent of patients would prefer not to spend their last moments in and out of hospitals or hooked up to cumbersome machines or being subjected to radiation or chemotherapy. Yet the Dartmouth researchers found that the number of Medicare patients who saw more than 10 different doctors in their last six months, and spent more time in intensive care, had jumped by 12 percentage points between 2003 and 2010.<br><br></div> <div>■ Stanford researchers just published a survey of more than 1,110 doctors. The doctors reported overwhelmingly that even if their patients had issued clear instructions not to make heroic efforts to save them, it was “unlikely” that the doctors would use “less aggressive treatments.”<br><br></div> <div>■ In that same Stanford study, the doctors also said—also overwhelmingly (90 percent)—that if they had a terminal diagnosis, they wouldn’t want any heroic efforts made to save them. </div> <div>What is going on here? </div> <h2 class="ms-rteElement-H2">‘Death Is Considered Optional’ </h2> <div>It’s true that there is a broader cultural taboo about death and dying that one can sometimes taste as well as feel.<br><br></div> <div>You don’t have to make any concessions to the Dr. Kevorkian style to notice that Americans, broadly, would rather make the entire topic disappear, burying it under a landfill of euphemism and schmaltz. <br></div> <div>“Soon as I was in my forties,” the late, great George Carlin once riffed, “I’d look in the mirror and I’d say, ‘Well, I guess I’m older.’ ‘Older’ sounds a little better than ‘old,’ doesn’t it? Sounds like it might even last a little longer. Bull—, I’m getting old. And it’s okay. Because thanks to our fear of death in this country, I won’t have to die: I’ll pass away…”<br><br></div> <div>It was public health expert and self-described futurist Ian Morrison who, having grown up in Scotland, trained in Canada, and practiced in California, noticed a few cultural differences.<br><br></div> <div>“In Scotland,” he says, “death is considered imminent; in Canada, it’s considered inevitable. In California, death is considered optional.”<br><br></div> <div>(And, indeed, the people of Los Angeles County lead the nation in the amount of medical services taken in the last six months of life. Even healthy Angelino elders get about 65 percent more MRIs than their peers and take three times as many ambulance rides as other seniors.)<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">‘How Honest Do You Want To Be?’</h2> <div>But not all caregivers’ problems with death and dying can be blamed on society. Look again at that Dartmouth study. If death is so taboo, where did that 80 percent who didn’t want a medical-intensive death come from? (And then there are the cultural artifacts, like messages in a bottle, that occasionally pop up and make one wonder whether Americans are really all that immature about The Big Sleep. (<em>See “</em><a href="/Issues/2014/Pages/0914/An-Undertaker-Saves-A-Life.aspx" target="_blank"><em>An Undertaker Saves a Life</em></a><em>.”</em>)<br><br></div> <div>No, providers themselves have their own struggles with the D-word.<br><br></div> <div>■ In March, a study by Canadian researchers found that at least 30 percent of long term and post-acute care workers thought their jobs were depressing. The closer one got to patient care, the more acute the anxieties and depression were, so nurse assistants were reporting a lot more problems with death than, say, administrators.<br><br></div> <div>■ In June, University of Oregon researchers found that more than one-quarter of hospice patients (!) were taking antibiotics in their last few days; more than one in five hospice patients were discharged from the hospital into end-stage care with a script for antibiotics, despite not having a documented infection, the researchers found.<br><br></div> <div>“It’s a real professional dilemma,” says Peter Rabins, MD, a professor of psychiatry at Johns Hopkins University’s medical school. “How honest do you want to be?”</div> <h2 class="ms-rteElement-H2">A Spiritual Problem</h2> <div>Ira Byock, MD, author of “The Best Care Possible,” is the newly minted chief medical officer of Providence Health & Services’ Institute for Human Caring. He thinks that the way most Americans die “is a disgrace, frankly.”<br><img class="ms-rtePosition-2" alt="Ira Byock, MD" src="/Issues/2014/PublishingImages/0914/cs_IraByock.jpg" style="margin:10px;" /><br>“I think American health care approaches illness and dying and grief through the wrong lens,” he says. “We think of death and dying as a medical problem. That puts it already, fundamentally, on the wrong track. Because people who are seriously ill and dying obviously have medical problems, but the overwhelming thing about illness, dying, and grief is that it’s a spiritual matter.”<br><br></div> <div>It is a glory of the modern age that Americans are living longer and healthier than ever before, Byock says. </div> <div>“Yet the fact is, we haven’t made a single person immortal,” he says.<br><br></div> <div>“If all you do is push back against mortality, at some point, the person or the patient is going to feel squished between our efforts to keep them alive and their own sense of mortality.”<br><br>See "<a href="/Issues/2014/Pages/0914/Death,-To-Nonbelievers.aspx" target="_blank">Death, To Nonbelievers.</a>"</div> <h2 class="ms-rteElement-H2">Age-Old Problem For Old-Agers</h2> <div>It’s not like this is a new problem.<br><br></div> <div>It was Cicero who, while noticing that to study philosophy was to study how to die well also, </div> <div>noticed that there’s only so much the doctors can do.<br><br></div> <div>“Indeed,” he said, “as physicians, while curing the whole body, apply their remedies to even the least part of the body if it is in pain, so philosophy, when it has removed grief in its entireness, continues its work …” </div> <div>Still, many experts say that, if people are harming each other with euphemisms about death and grief, they can help one another by talking honestly, openly—and often—about death.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">‘We Deal With The End Of Life’</h2> <div>“There are good deaths and bad deaths,” says Judah Ronch, PhD, dean of the University of Maryland, Baltimore County’s Management of Aging Services program.<br><br></div> <div>“We, as a long term care world, have to look in the mirror and say, ‘We deal with the end of life.’ If we make it as comfortable as it’s possible to be, then we’ve done our job.”<br><br></div> <div>Indeed, mere honesty can have seemingly miraculous consequences. In July, for instance, the <em>Journal of the American Medical Directors Association</em> reported that open discussions of advance care planning led not only to more advance directives, but to better communication among staff, family, and residents and—best of all—the kind of end-of-life care that the residents themselves asked for.<br><br></div> <div>Counterpoise those findings with the earlier Canadian study of attitudes toward death among nursing home staff. Nearly three-quarter of staffers found themselves in conflict with families as their loved ones prepared to die.</div> <h2 class="ms-rteElement-H2">The Many Faces Of Grief</h2> <div>Half of the paradox of grief is that it’s really, really simple. <br><br></div> <div>“Human beings do that all the time,” Ronch says. “You don’t have to teach them how to grieve.”<br><br></div> <div>The other half of the paradox is that grief is also really, really complex.<br><br></div> <div>“When somebody dies, there’s a loss—you know it,” Ronch adds. “But when there’s a diminishing of vision, loss of hearing, loss of mobility, loss of physical resilience—those are things that come with aging. People are aware of it, and they know it’s happening. Losses need to be grieved.”<br><br></div> <div>People grieve in different ways, on different schedules. Families of those afflicted by dementia, for instance, will grieve the person they’re losing long before she dies; for staff, though, the death of a resident with dementia can be devastating, Johns Hopkins’ Rabins says. <br><br></div> <div>“I think, often, the frontline staff who are providing the day-to-day care and who have worked with the person—sometimes for several years—they often seem to have more of an emotional attachment than even the family,” Rabins says.<br><br></div> <div>“Perhaps because they’re living with the person every day and they interact with them so intimately, they often have more sense of the remaining personhood than the remaining family members.”<br></div> <div><br><img class="ms-rtePosition-1" alt="Deborah Bradley" src="/Issues/2014/PublishingImages/0914/cs_DeborahBradley.jpg" style="margin:0px 10px;" />Deborah Bradley is the director of spiritual care at St. Crispin Living Community in Red Wing, Minn. She’s spent her life trying to help people manage their grief. Among the things she’s learned is that grief is both imminent and inevitable—but certainly not optional. <br></div> <div><br>“It’s a long, difficult process for people,” she says. “But it’s a part of life. It is a part of the life spectrum.”</div> <div>There are lots of routes through death and grief, Bradley says (<em>see “</em><a href="/Issues/2014/Pages/0914/A-Good-Way-To-Die.aspx"><em>A Good Way to Die</em></a><em></em>”). But the first step is always—always—to be open about it: with families, with friends, with co-workers, with employees, with residents. Not just to listen to them about how they’re feeling, but to be honest about how you’re feeling, she says.<br><br></div> <div>The second step is to realize that there is no wrong way to grieve.<br><br></div> <div>“When we’ve had people in our lives for years and years and years, they’ve become a part of the fabric of our lives,” she says. “And so it doesn’t matter if it’s one week, or one month, or three years: Your body needs time to catch up to your brain, to understand that the person in room 302 at the long term care facility isn’t going to be there, ever again. Someone else is in there.”<br><br></div> <div>“We tell ourselves, we should be over this by now and we give ourselves a timeline,” Bradley adds. “And it’s really unfair to ourselves and others. This isn’t a contest.”<br><br></div> <div>Bradley likens grief to a rattlesnake bite. “That venom is on the top, and it’s starting to destroy the tissue and the flesh,” she says. “And if you can get that venom out, then the healing can start.”</div> <h2 class="ms-rteElement-H2">‘All I Shall Do For Death’</h2> <div>Providence Health’s Byock says he finds it odd that death is so divisive an issue for people. </div> <div>“Despite all of our diversities and differences, that one’s a constant,” he says. Everybody is born; everybody dies.<br><br></div> <div>“The people who die well … have used this opportunity—this unwanted, difficult opportunity—to get a sense of things left undone, or looking at mending fragmented or broken relationships,” he says. </div> <div>“We’re here to help them in a very difficult and very personal struggle to feel complete at the end of their lives.”<br></div> <div>As things stand, death gets everyone. But that doesn’t mean it must conquer everyone. Those who fight to die well (or fight for others to die well) understand that paradox. To pretend that things are otherwise is to let death not only have the last word, but the last laugh. And, really, doesn’t death have enough friends as it is?<br><br></div> <div>“I shall die,” Edna St. Vincent Millay famously wrote, “but that is all that I shall do for Death.” </div> <p> </p>People grieve in different ways, on different schedules. Families of those afflicted by dementia, for instance, will grieve the person they’re losing long before she dies; for staff, though, the death of a resident with dementia can be devastating.2014-09-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/0914/coverstory_thumb.jpg" style="BORDER:0px solid;" />CaregivingCover Story9




Denver Center Takes Care On The Roadhttps://www.providermagazine.com/Issues/2014/Pages/1014/Denver-Center-Takes-Care-On-The-Road.aspxDenver Center Takes Care On The Road<div><em class="ms-rteThemeForeColor-5-4"><img src="/Issues/2014/PublishingImages/1014/Collins.Back.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 15px;" /><br>“As we crossed the Colorado-Utah border I saw God in the sky in the form of huge gold sun-burning clouds above the desert that seemed to point a finger at me and say, ‘Pass here and go on, you’re on the road to heaven…’” —Jack Kerouac, “On the Road”</em></div> <div> </div> <div>Nick Collins has spent most of his life in a wheelchair. He’d probably tell you that those wheels are all the more reason he needs to answer the call of the road. Earlier this year, thanks to some help from his neighbors and the dedicated staff at St. Paul Health Center in Denver, Collins, 28, was able to answer that call. </div> <div> </div> <div>“I’ll remember this for the rest of my life,” he says of his first trip to the Pacific Ocean. </div> <h2 class="ms-rteElement-H2">An Early Impulse</h2> <div>Diagnosed with Duchenne muscular dystrophy, Collins has always been a traveling man. As a child, he’d gone to New Mexico once, and the Make-A-Wish Foundation had helped him get to Disney World in Florida. That didn’t squash the travel bug, though; it aggravated it, he tells <em>Provider</em>. <br></div> <div><br>“I had always had the idea that I wanted to go on a road trip and see part of the country and travel and go to see the beach and see things I had never seen before,” he says. “But, really, to be honest, what really inspired it was a movie I had seen called ‘Darius Goes West.’”</div> <div><br>In the movie, Darius, a teen with muscular dystrophy, travels from Georgia to California. “And I thought, ‘Well, if it was possible for him, it could be possible for me,’” Collins says. “And, I mean, I didn’t really know if it would ever happen.” </div> <h2 class="ms-rteElement-H2">Planning The Trip</h2> <div>In February, Collins went to see St. Paul Activity Coordinator  Adam Fyler. <br></div> <div><br>“And we just started looking at maps,” Fyler says. “We knew the Pacific would be better. And then we started getting ideas about where we would stop along the way.”</div> <div><img src="/Issues/2014/PublishingImages/1014/Collins.Trail.jpg" class="ms-rtePosition-2" alt="" style="margin:10px;" /><br>Planning was one thing; pulling it off was another. It was apparent, early on, that it would be too expensive to fly to California because of the accommodations for Collins’ chair and the staff that would have to be with him. That meant piling into a van and doing it the old-fashioned way. </div> <div><br>“It wasn’t easy to make happen,” St. Paul Administrator Sara Dent says. “We had to talk to attorneys, we <br>had to budget it. I told the staff that if they could raise half of it, I’d match it.”</div> <h2 class="ms-rteElement-H2">Support Pours In</h2> <div>St. Paul staff and families got behind the project in a big way, from a crowdsourced webpage to bake sales. “People were coming out from the neighborhood,” Dent recalls. “People were buying a jar of pickles for $100.”</div> <div><br>With the money in hand, Collins, his mom, Fyler, and several caretakers piled into the van to hit the open roads. They ranged the great West, from the Hoover Dam to Vegas to the Grand Canyon. Every stop seemed to have its own adventure, Fyler and Collins say.</div> <div><br>The group was just outside of the canyon, when they discovered their campsite couldn’t accommodate Collins’ chair. Desperate, hungry, and “a little emotional” after a 10-hour drive, the team wound up at a hotel in Williams, Ariz., run by the mayor. The mayor ordered his staff to get some wheelchair ramps in place and comp’ed Collins’ entourage for a vast meal. </div> <div><br>Finally, though, the team reached Santa Barbara and Nick heard the waves crashing into the beach. “I thought, I must be dreaming or something.” </div> <div><img src="/Issues/2014/PublishingImages/1014/Collins.Soaks.jpg" class="ms-rtePosition-1" alt="" style="margin:15px 10px;" /><br>The dream may not be over: Collins met up with a man in Boulder City, Colo., who was moved enough by Collins’ trip to hand over $400—and to keep in touch with him throughout. It turns out that the Boulder City man has a friend near Phoenix who has one of the world’s largest car collections. (Collins is a gearhead: There are lots of cars he likes, as long as “they go fast.”) The friend has sent a request to St. Paul’s staff, Fyler says: “Get Nick out here. I’ll pay for everything.” </div>Nick Collins has spent most of his life in a wheelchair. He’d probably tell you that those wheels are all the more reason he needs to answer the call of the road. Earlier this year, thanks to some help from his neighbors and the dedicated staff at St. Paul Health Center in Denver, Collins, 28, was able to answer that call.2014-10-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/collins_t.jpg" style="BORDER:0px solid;" />Caregiving;ManagementColumn10
Managing Reasonable Accommodationshttps://www.providermagazine.com/Issues/2014/Pages/1014/Managing-Reasonable-Accommodations.aspxManaging Reasonable Accommodations<div>The Americans with Disabilities Act (ADA) increasingly poses compliance challenges and attracts significant attention from plaintiffs’ lawyers and the Equal Employment Opportunity Commission. The resulting litigation illustrates that a failure to maintain effective reasonable accommodation policies and adequately engage in the “interactive process” makes for costly litigation and exposure. <br></div> <div> </div> <div><br>To comply with the ADA and combat the potential for disruptive and expensive litigation, employers must engage in an individualized analysis of each request for accommodation by an employee with a disability and document each step of the way. These actions are even more important since the ADA Amendments Act and implementing regulations went into effect. </div> <div> </div> <div><br>A much greater proportion of the workforce is now considered “disabled” and thus entitled to reasonable accommodation under the law. What does this mean? </div> <div> </div> <div><br>Litigation now focuses on determining when and whether an accommodation is reasonable and required, rather than determining whether the employee is “disabled.” </div> <div> </div> <div><br>Long term and post-acute care employers are not strangers to the many challenges presented by accommodation obligations. Given the increase in requests for accommodation and lawsuits associated with these issues, employers are wise to review and ensure their policies and practices are compliant with the ADA before faced with litigation. </div> <div> </div> <h2 class="ms-rteElement-H2">Understanding The Legal Obligations </h2> <div> </div> <div>What exactly is a reasonable accommodation? The regulations describe it as a change in the work environment or in the way a job is customarily done that gives an individual with a disability equal employment opportunities. </div> <div> </div> <div><br>Reasonable accommodations generally fall into one of three categories that require modifications or adjustments: the job application process, the work environment or the way a position is customarily performed, and enabling an employee with disabilities to enjoy the same benefits and privileges of employment as other employees. </div> <div> </div> <div><br>An employer can only determine whether such accommodations are required by conducting an interactive, individualized analysis of the circumstances. The results of these efforts should reflect either a resolution of the situation or proof that the employer made good-faith efforts to accommodate an individual. </div> <div> </div> <div><br>For example, when a hospital’s explanation for terminating an employee turns on the employee’s unreasonable behavior during the accommodation process, it will be critical to have the documentation showing the employee’s behavior. </div> <div> </div> <div><br>At the outset, an employer’s duty to accommodate an employee with disabilities generally is triggered when an employee tells the employer that he or she needs an adjustment or change at work because of a disability. </div> <div> </div> <h2 class="ms-rteElement-H2">Interactive Process</h2> <div> </div> <div>Upon receiving the request, or otherwise knowing the employee needs an accommodation, an employer should engage in an interactive process to determine the appropriate accommodation. <br></div> <div> </div> <div><br>Steps in the interactive process include: </div> <div> </div> <div><br>1.) Identifying the job’s essential functions; </div> <div> </div> <div><br>2.) Consulting with the employee and/or employee’s physician to determine the specific physical or mental limitations at issue; </div> <div> </div> <div><br>3.) Consulting with the employee and identifying potential accommodations, including assessing each accommodation’s effectiveness; </div> <div> </div> <div><br>4.) Selecting the accommodation that best serves the needs of the employer and the </div> <div> </div> <div>employee. </div> <div> </div> <div><br>To engage in these steps effectively, employers should have processes and paperwork in place that allow them to easily monitor and document the dialogue between the company and employee. </div> <div> </div> <div><br>These include having an accommodation request form for employees to complete and communicating in writing to the employee all offers or explanations associated with any and all accommodations. </div> <div> </div> <div><br>For example, this might include documentation reflecting the employer and employee’s agreement on the job’s essential functions.</div> <div> </div> <div><br>The mere failure to engage in, or to continue to engage in, the interactive process generally will not violate the ADA if no reasonable accommodation exists. Nevertheless, an employer should engage in the process because a good faith effort to accommodate is a defense to certain damages. </div> <div> </div> <div><br>Further, when accommodation is possible and the process breaks down, courts will determine who is responsible for the breakdown. </div> <div> </div> <div><br>These challenges presented themselves in Zombeck v. Friendship Ridge, in which a nurse aide sued her long term care facility employer for failing to provide a reasonable accommodation. The employee requested that she be allowed to use a mechanical lift to transfer residents who could not bear their own weight. </div> <div> </div> <div><br>However, not only did the parties disagree about whether lifting was an essential function, the employer did not discuss the request with the employee and appeared to reject it out of hand. </div> <div> </div> <div><br>Based on these facts, the court denied the employer’s request for summary dismissal, finding that a jury would need to hear the case. </div> <div> </div> <h2 class="ms-rteElement-H2">Tips For Making Accommodations </h2> <div> </div> <div>Once an employer has notice of the need for an accommodation, it should first consider those accommodations that allow the employee to remain in the same job, which may include a leave of absence. </div> <div> </div> <div><br>If none are possible, then reassignment to another position may be an option. Although a variety of potential accommodations exist, common examples include: modified work schedules; reduced work schedules, such as a temporary part-time schedule; equipment that enables an employee to do his or her job; and leaves of absence. </div> <div> </div> <div><br>As to leaves, application of an inflexible (bright-line) limit on leave may violate the ADA. If granting more leave beyond a company’s established limit would not create an “undue hardship” and would enable the employee to return to performing the job’s essential functions, an employer may have to permit the additional time off. </div> <div> </div> <div><br>Lastly, transfers are yet another form of accommodation but are a last resort. In most jurisdictions, employees with disabilities should not be required to compete for the new position as long as they are qualified for it. </div> <div> </div> <div><br>Certain accommodations are not reasonable as a matter of law, such as those requiring the elimination of essential job functions or quantitative standards. Employers may hold employees to the same performance and conduct standards and are not required to rescind discipline as a reasonable accommodation in most circumstances, even if the misconduct is caused by the employee’s disability. <br></div> <div> </div> <div><br>If misconduct does not result in termination and the employee claims his or her disability caused the violation, reasonable accommodations to assist the employee to meet the conduct standard in the future may be appropriate.</div> <div> </div> <div><br>Of course, accommodations are not required if they impose undue hardships on employers; that is, if they are “excessively costly, extensive, substantial or disruptive,” would “fundamentally alter the nature or operation of the business,” or make the employee’s co-workers have to work harder or longer. </div> <div> </div> <div><br>Unless an employer’s company is extremely small, it generally will not be able to establish a financial undue hardship.</div> <h2 class="ms-rteElement-H2"> Policies, Documentation Best Bet For Prep </h2> <div>ADA accommodation issues arise frequently in the workplace, and there is no standard, one-size-fits-all solution for managing them. Successfully managing these situations includes maintaining lawful accommodation policies, having guidelines and documentation in place for the interactive process, engaging effectively in that process, and training managers to recognize and report accommodation requests. </div> <div> </div> <div><br>As to training, managers may be the first to face an accommodation request, and the employee with disabilities might not use the term “reasonable accommodation” in his or her request. Given this dynamic, employers should educate managers to recognize potential issues and confer with the company’s human resources experts or legal advisors when such situations arise. </div> <div> </div> <div> </div> <div> </div> <div><em>Christine Howard, regional managing partner of the Tampa office of Fisher & Phillips, focuses on the defense of employment discrimination and harassment complaints and wage-and-hour and benefits litigation. She can be reached at choward@laborlawyers.com or (813) 769-7503. Marci Britt, associate with the Tampa office of Fisher & Phillips, represents employers in all areas of labor and employment law, including retaliation claims, whistleblower claims, and family and medical leave issues. She can be reached at: mbritt@laborlawyers.com or (813) 769-7500.</em></div>To comply with the ADA and combat the potential for disruptive and expensive litigation, employers must engage in an individualized analysis of each request for accommodation by an employee with a disability and document each step of the way.2014-10-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/legal_t.jpg" style="BORDER:0px solid;" />LegalLegal Advisor10
Data Rich And Insight Poor?https://www.providermagazine.com/Issues/2014/Pages/1014/Data-Rich-And-Insight-Poor.aspxData Rich And Insight Poor?<div>Thousands of long term and community-based providers already measure resident and family satisfaction and experience. But experience measurement without context is one-dimensional. If you present your resident satisfaction and recommendation scores from last year to a local hospital, hoping to differentiate your organization, they will more than likely ask you to qualify those numbers. </div> <div> </div> <div>They may ask you to provide trended improvement metrics for the past three to five years. They may request staff engagement metrics. They may ask what initiatives you have in place to improve resident experiences, staff engagement, and person-centered care at your organization. They may point to negative mentions of your home or community from past residents or family members on social media or online reviews such as Yelp—and ask what you have done to protect and restore your reputation. And the list goes on.</div> <h2 class="ms-rteElement-H2">How Are You Differentiating Your Organization?</h2> <div>Providers of long term and community-based services must go beyond experience measurement to position an organization as a highly favorable care coordination partner with hospitals, health systems, and accountable care organizations (ACOs). You’ll need proof that you are improving over time—or at least have action plans in place with improvement objectives. If you know how to make use of your data, you’ll not only become a much more promising candidate to forge lasting strategic partnerships, you’ll improve your reputation and brand equity (which are also important to hospitals).<br></div> <div><br>Do you understand how to use the data you have? Have you set realistic improvement goals and prescriptive action plans? How do you measure staff engagement and communicate out to your stakeholders? Can you prove that your culture cultivates person-centered care? Are you doing everything you can to improve your organization’s reputation?</div> <h2 class="ms-rteElement-H2">What Are You Doing With Your Data?</h2> <div>More often than not, providers will measure resident and family satisfaction—and then stop. Potential for greater intelligence is wasted when no steps are taken to enact improvement initiatives. For those who do attempt improvement plans, many don’t know average rates of improvement, set unrealistic improvement goals, and then become discouraged when they fall short. Staff end up disenchanted, adoption is abandoned, and culture suffers.<br></div> <div><br>Some ways you can set successful action plans in motion include making use of resources you have access to already. Whether it’s an electronic health record vendor or an experience measurement firm, you should confirm that they do more than just measure. Ask what types of improvement content they make available, what educational resources come with their solutions, and find out if they feature action plan templates and prescriptive reporting tools. This is a good place to start.</div> <h2 class="ms-rteElement-H2">How Does Staff Engagement Drive Customer Recommendations?</h2> <div>Providers that are serious about improvement and effectively moving scores upward understand you need frontline staff to gain adoption for quality initiatives. Measuring staff engagement is essential.<br></div> <div><br>For example, according to the 2013 National Research Report for Post-Acute Providers, six of the seven top drivers for resident and family recommendation of skilled nursing homes (n=6,500+) are staff driven:</div> <div><br>1. Care (concern) of Staff</div> <div><br>2. Competency of Staff</div> <div><br>3. Registered Nurse/Licensed Vocational</div> <div>     Nurse/Licensed Practical Nurse Care</div> <div><br>4. Choices/Preferences (only driver not staff driven)</div> <div><br>5. Responsiveness of Management</div> <div><br>6. Certified Nurse Assistant/Nurse Assistant Care</div> <div><br>7. Respectfulness of Staff</div> <div><br>When National Research Corporation asked top-performing providers that measure employee satisfaction and staff engagement using the My InnerView Employee Program, we found similarities in how they use the data to improve. Most employ a model known as “simplify, push, prescribe.” Simplify the data findings into bite-sized insights that are jargon-free. Push the information out to staff to give them a proactive stake in improving their culture. Prescribe ideas to improve, invite staff participation and feedback, and gain consensus on organizational initiatives to address areas that need attention.<br><span class="ms-rtestate-read ms-reusableTextView">:##:</span></div> <h2 class="ms-rteElement-H2">Why Does Brand Reputation Matter?</h2> <div>Customer and staff experience measurement and improvement plans are one of the best ways to invest in building brand reputation. But the proliferation of social media makes word of mouth and the ability to evaluate reputations online easier than ever. As consumers of health care become increasingly informed and empowered to make their own health care decisions, reputation has become an integral part of the selection process.</div> <div><img src="/Issues/2014/PublishingImages/1014/MIV3.jpg" class="ms-rtePosition-2" alt="" style="margin:10px 5px;" /><br>Back in the day, long term care and senior living providers were all about location, location, location. Today, that notion is far less important—with the possible exception of ultra-rural zones—and the trend of empowered consumerism is expected to continue. Referral sources now trump location. And now reputation is the single biggest factor that new residents follow. </div> <div><br>Hospitals know this. Hospitals understand this. Hospitals live this.</div> <div><br>In a 2012 Market Insights survey fielded nationwide by National Research Corporation, 87 percent of almost 270,000 consumers indicated that reputation is important when selecting a hospital. </div> <div><br>What makes this study remarkable is that the results of correlation analyses indicate that patient experience (two global Hospital Consumer Assesment of Healthcare Providers and Systems [CAHPS]* measures for recommendation and overall hospital rating) and hospital reputation are positively and significantly related (Dr. Katie Johnson, “The Link Between Patient Experience and Hospital Reputation,” National Research Corporation, February 2014).</div> <div><br>What’s more, low-quality patient experiences were found to be more predictive and powerful in impacting hospital reputation. Whether this is because poor experiences are more memorable or more likely to cause consumers to share experiences, poor quality becomes well-known in the marketplace. And considering Market Insights data show providers of long term and community-based services are least trusted in health care—rating below doctors and nurses, hospitals, pharmacies, home health services, and insurance companies—you can gain a sense of how brand and reputation impact consumer behavior.</div> <div>Bottom line, health care organizations need to realize that the consumer is now empowered. They are finding more information, asking questions online and through social media networks. </div> <div><br>Your brand, reputation, and resident experiences no longer begin and end with admission and discharge. The best way to manage your brand and reputation is to better understand the drivers of resident, employee, and consumer experiences and make greater use of your data and enact improvement plans to gain insights that matter most to consumers and care coordination partners. </div> <div> </div> <div><em><strong>*Hospital CAHPS is a public reporting initiative mandated by the Centers for Medicare & Medicaid Services (CMS) that asks patients to rate their experiences with respect to various health care delivery systems. These ratings are shared by CMS publicly through Hospital Compare, and CMS reimbursement is now tied to these scores.</strong></em><br><br><em>Jason Stevens is Senior Vice President of Business Development for National Research Corporation. He oversees sales and strategic thought leadership efforts for the company’s experience measurement products and services, including My InnerView by National Research. He is located out of the company’s headquarters in Lincoln, Neb. National Research Corporation is the leading experience and quality measurement firm in the United States, specializing in evidence-based insights that empower customer-centric health care across the continuum.</em></div> <span style="display:inline-block;"></span>Thousands of long term and community-based providers already measure resident and family satisfaction and experience. But experience measurement without context is one-dimensional. If you present your resident satisfaction and recommendation scores from last year to a local hospital, hoping to differentiate your organization, they will more than likely ask you to qualify those numbers. 2014-10-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/MIV_t.jpg" style="BORDER:0px solid;" />Management;QualityColumn10
2014 AHCA/NCAL Annual Awardshttps://www.providermagazine.com/Issues/2014/Pages/1014/2014-AHCA-NCAL-Annual-Awards.aspx2014 AHCA/NCAL Annual Awards<div><span class="ms-rteFontSize-3 ms-rteForeColor-2">St. Benedict’s Health Center and Benedict Court </span></div> <div>Not-For-Profit Program of the Year</div> <div> </div> <div><img src="/Issues/2014/PublishingImages/1014/PACE.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 15px;" />The 2014 AHCA/NCAL Awards recipient for the Not-For-Profit Program of the Year is St. Benedict’s Health Center and Benedict Court, Dickinson, N.D., for its community benefit, called Program of All Inclusive Care for the Elderly (PACE). Jon Frantsvog is administrator/chief executive officer of the health center, and Michelle Hinrichs, RN, manages the Benedict Court Housing and Home Care Services, which houses the PACE program, operational since 2008. </div> <div> </div> <div>“The program offers a team approach and individualized attention to health care and in-home services for participants,” Frantsvog explained. “A care team includes a physician, nurses, social worker, aides, rehabilitation specialist, and dietician. PACE participants have full access to Benedict Court’s services and activities such as dining, religious services, beauty shop, and so on,” he said. </div> <div> </div> <div>“PACE is truly a community benefit. It is designed to allow seniors who otherwise may need skilled nursing care to stay at home and live independently,” said Hinrichs. “Quality of life is improved via detailed care planning and comprehensive access to health care services.”</div> <div> </div> <div>According to Timothy Cox, president of Northland Healthcare Alliance, of which St. Benedict’s is a part, “We have a significant impact on the well-being of those we serve,” he said. “Our regular surveys indicate that participants love the program, and in many cases their health improves because for the first time they have a team that is helping them with their health services.”</div> <div> </div> <div>One family member in an endorsement letter noted that because of “the efforts of the PACE program and the experienced care and support of PACE staff, my mother is aging with dignity, and we are eternally grateful for this wonderful program.” Music to the ears of anyone involved with the long term care community.</div> <div style="text-align:right;">—Tom Burke</div> <div> </div> <div></div> <div class="ms-rteFontSize-3 ms-rteForeColor-2">Alicia Durham</div> <div>Intellectual and Developmental Disabilities (ID/DD) Hero of the Year</div> <div> </div> <div><img alt="Alicia Durham" class="ms-rtePosition-2" src="/Issues/2014/PublishingImages/1014/AliciaDurham.jpg" style="margin:5px 15px;" />Alicia Durham, Eureka, Calif., is the 2014 AHCA/NCAL recipient of the Intellectual and Developmental Disabilities (ID/DD) Hero of the Year award. Durham works at Butler Valley, Carole Sund Center. <br><br>Butler Valley cares for individuals with Downs syndrome, autism, cerebral palsy, and other forms of mild to profound developmental disabilities under the banner of “We serve with respect, compassion, and skill, building lives and reaching potential.”</div> <div><br>“Alicia was instrumental in establishing our Carole Sund day care center, which is a small farm. The farm allows our clients to learn valuable life and vocational skills through growing crops, caring for farm animals, landscaping, and the like,” explained Suzette Ott, executive director of Butler Valley. “Clients have the added benefit of eating the organic produce and eggs that they worked to produce.” </div> <div><br>If life is about dedication to a cause larger than oneself, then Durham is a perfect role model. She ensures that residents live a quality life and a life filled with pride in their accomplishments of self-sustaining farming, physical exercise, and earning a wage based on the proceeds of the farm.</div> <div><br>“Everyone benefits as Alicia also fosters relationships in the community to help with sales of the produce <br>to local businesses,” Ott said. “In turn, the community has become a great supporter of our mission and clients.”</div> <div><br>It may sound like this honoree is all business, but that is far from the case. Common terms in her nomination included “inspiration,” “joy,” and “respect.” </div> <div><br>Some people say it takes a village to care for someone, yet at Butler Valley that caring starts with Alicia Durham doing her best for her buddies. </div> <div style="text-align:right;">—Tom Burke</div> <div> </div> <div></div> <div class="ms-rteFontSize-3 ms-rteForeColor-2">Bailey Austin Combs</div> <span class="ms-rteForeColor-2"> </span> <div>Young Adult Volunteer of the Year</div> <div> </div> <div><img src="/Issues/2014/PublishingImages/1014/BaileyAustinCombs.jpg" class="ms-rtePosition-1" alt="Bailey Austin Combs" style="margin:5px 15px;" />Sixteen-year-old Bailey Austin Combs, Amburgey, Ky., is the 2014 AHCA/NCAL recipient of the Young Adult Volunteer of the Year award. Combs volunteers at the Knott County Health and Rehabilitation Center, Hindman, Ky. <br></div> <div><br>“Bailey has an unparalleled ability to connect with our elderly population. I like to say he is an ‘old soul’ wrapped in a young body,” said Ruby Pigman, administrator at Knott County Health and Rehab Center. “His activity of choice is gardening, and every year he manages to involve residents in growing tomatoes, onions, and a variety of luscious green vegetables.”<br><br></div> <div>Tilling the land is seen in terms of resident experiences. “Farming and gardening play a significant role in our home town, and Bailey enables our residents to continue doing something they have long cherished,” Pigman said as she explained how gardening goes hand in hand with the care center’s mission to create a homelike, person-centered environment. “He is a mirror image of our residents’ younger years,” she said. </div> <div><br>“He involves each and every resident who wants to help to the extent possible,” said Hollie Thacker, activity director. “Bailey has the utmost patience with residents, whether they can help him hoe or just offer sage advice. He truly is a people person.” </div> <div><br>The busy teen volunteer also recently involved his high school football team in making visits to the residents and helping with various activities. Not surprisingly, Combs’ nomination was supported by his high school football coach at Knott Central High School, Steve Hollon, who wrote, “In my 21 years of experience of interacting with young adults, some individuals stand out for their great qualities, and Bailey is one of those people. He is truly a positive, motivated leader with amazing potential.” </div> <div><br>Folks he interacts with in the long term care community agree.</div> <div style="text-align:right;">—Tom Burke</div> <div></div> <div> </div> <div class="ms-rteFontSize-3 ms-rteForeColor-2">Ruth-Ann Harrod</div> <span class="ms-rteForeColor-2"> </span> <div>Adult Volunteer of the Year</div> <div> </div> <div><img src="/Issues/2014/PublishingImages/1014/RuthAnnHarrod.jpg" class="ms-rtePosition-2" alt="Ruth-Ann Harrod" style="margin:5px;" />Ruth-Ann Harrod, Wesley, Maine, is the 2014 AHCA/NCAL recipient of the Adult Volunteer of the Year award. Ruth-Ann volunteers at the Maine Veterans’ Home in Machias, Maine. <br><br></div> <div>“Ruth-Ann connects with the residents as soon as she walks into the facility, bringing smiles to their faces with just her presence,” said Marcia Jackson, RN, administrator at the Maine Veterans’ Home. </div> <div><br>“She excels at projects and activities that are resident-centered and designed to stimulate memory. Ruth-Ann creates ways to focus on person-centered dementia care and connects with residents through sights, sounds, and smells.”  </div> <div><br>Harrod’s creative connections help engage residents with Alzheimer’s or other dementias. She delights in bringing back childhood memories, which is popular with residents. Her unique ideas include creating pinecone angels to watch over residents, a royal baby shower anticipating Prince George’s birth (gifts were donated to organizations that provided baby items for mothers in need), and even crafting a portable Morse code device for a World War II veteran who had been a Morse coder operator. </div> <div><br>Harrod is committed to residents, families, and staff. She arrives with a smile on her face and acts as a great motivator. “If a resident is having a bad day, she can bring on a smile just by sitting one on one and sharing a story or a walk with somebody,” says Activity Coordinator Jennifer Wood.</div> <div><br>“She has a friendly persona, difficult to match,” noted resident Edward Browne. Other residents she has met notice Harrod’s generosity with her time, money, crafts, food, and going that extra mile to reach out to residents and staff. She also engages the community, especially through social media, and contributes to developing a positive image of long term health care. </div> <div><br>The bottom line for the Maine Veterans’ Home is that Harrod is fulfilling its mission of “Caring for those who served,” and she does it with great compassion and tenderness. </div> <div style="text-align:right;">—Tom Burke</div> <div> </div> <div></div> <div class="ms-rteFontSize-3 ms-rteForeColor-2">Amory High School Health Class, with Sara Beth Pearson</div> <span class="ms-rteForeColor-2"> </span> <div>Group Volunteer of the Year</div> <div> </div> <div><img alt="Sara Beth Pearson" class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/1014/SBPearson.jpg" style="margin:5px 15px;" />This year’s award honorees demonstrate a model of behavior that is selfless, compassionate, and enhances the lives of the elderly and individuals with intellectual or developmental disabilities in their communities.</div> <div><br>The Amory High School Health Class, Amory, Miss., and teacher Sara Beth Pearson, who supervises the program, are the 2014 AHCA/NCAL recipients of the award. Pearson’s class has been visiting the residents of the Golden Living Center for the past two years, and it accounts for approximately 73 hours of visitation per week during the school year. Students participate in their junior and senior years of high school.</div> <div><br>This program represents a model of behavior that is compassionate and enhances the lives of the elderly and individuals with disabilities at the care center and introduces students to experiences and lessons that will endure throughout their adulthood. </div> <div><br>“The high school juniors and seniors provide residents with undivided attention and one-on-one time that is such a precious gift,” said Margaret Deaton, executive director of Golden Living Centers - Amory.</div> <div><br>“Students also help with all social activities, especially at Christmas time, call games like Bingo, organize crafts, and assist with the restorative exercise program. An especially good project for the students is interviewing residents for their life stories. This activity helps residents reminisce about the ‘good old days’ with the teens,” she noted. </div> <div><br>“The students improve the quality of life for residents, and they learn life lessons about life, illness, and death,” said Dian Wilemon, recreation services director at the Amory care center. “This environment will help the student volunteers decide if they want to pursue a career in health care, but for some the lessons learned are about aging, tolerance, and matters of the heart,” she said. </div> <div><br>Many students also volunteer on their own time for additional projects or just to be nice. In fact, one Christmas day Pearson was at the care center and happened to see a student there, too. When asked about being there, the student replied that he “wanted to wish the residents a Merry Christmas.” That is not bad for a teenager, eh?</div> <div style="text-align:right;">—Tom Burke</div> <div> </div> <div class="ms-rteFontSize-3 ms-rteForeColor-2">Jean Cannon</div> <span class="ms-rteForeColor-2"> </span> <div>NCAL Administrator of the Year</div> <div> </div> <div><img alt="Jean Cannon" class="ms-rtePosition-2" src="/Issues/2014/PublishingImages/1014/JeanCannon.jpg" style="margin:5px 10px;" />Jean Cannon, Loveland, Colo., is the 2014 NCAL Administrator of the Year. Cannon is the executive director of Aspen House Memory Care Assisted Living, where all residents have Alzheimer’s disease or other forms of dementia. </div> <div><br>During her four-year tenure, Cannon has been instrumental in promoting person-centered care for her residents. She encourages families and residents to decorate the community with the residents’ personal items, paintings, and photos. Cannon also carefully examines the processes of the community to ensure residents are comfortable.</div> <div><br>“When Jean recognized that a couple of the residents were unsettled every day at 2:00 p.m., she realized it was because of the staff shift-change activity,” said Carmy Jerome, assistant director of Aspen House. “She immediately implemented a different process to ease the anxiety of the residents.”</div> <div><br>Cannon understands that each resident is unique and develops care plans specific to their needs, preferences, and interests. “A resident enjoyed dining at a local restaurant but was unable to travel,” said Jerome. “Jean brought him takeout once a month.”</div> <div><br>The community’s attention to end-of-life care is another way Cannon honors the individuals residing in Aspen House. She has provided training to all staff members on the death and dying process to ease the strain on care partners. Cannon provides families an assortment of goods and rearranges furniture to provide families with small comforts.</div> <div><br>Cannon not only respects each individual resident, but also her staff. Under her leadership, Project Visibility was launched at Aspen House to help staff become aware and affirming of the lives of elders who are lesbian, gay, bisexual, or transgender (LGBT) and their families. Cannon enhanced the training to incorporate sensitivity toward LGBT staff members as well.</div> <div><br>Accolades are nothing new for Cannon. She was named Administrator of the Year by the Colorado Health Care Association in 2013, and Aspen House won first place for Best Customer Service in the city of Loveland.</div> <div style="text-align:right;">—Rachel Reeves  </div> <div></div> <div> </div> <span class="ms-rteForeColor-2"> </span><span class="ms-rteFontSize-3 ms-rteForeColor-2"> </span><div class="ms-rteFontSize-3 ms-rteForeColor-2">Laura Cardillo, RN, CDP, CVW</div> <span class="ms-rteForeColor-2"> </span> <div>NCAL Nurse of the Year</div> <div> </div> <div><img class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/1014/LaruaCardillo.jpg" alt="" style="margin:5px 10px;" />Laura Cardillo, Hillsborough, N.J., is the 2014 NCAL Nurse of the Year. She has been director of wellness at The Avalon at Hillsborough since it opened more than seven years ago. </div> <div><br>Cardillo is credited with maintaining the high standard of care at the deficiency-free Avalon at Hillsborough through her infectious enthusiasm and encouragement. “Staff often comment on her genuine compassion, respect, and dedication to the well-being of our residents,” said Ella Furlong, executive director of the community. “Residents trust her, and family members express the peace they have in knowing their loved one is in her care.” </div> <div><br>Recognizing the staff at The Avalon is one way Cardillo keeps morale high. She posts letters of appreciation in the staff lounge and relays kind words from families. Furlong said staff respond to her leadership with “cooperation and teamwork.”</div> <div><br>As a certified dementia care practitioner, certified validation worker, and an Alzheimer’s Association Caregiver Support Group facilitator, Cardillo likes to spread her dementia knowledge to those at The Avalon. </div> <div><br>During National Alzheimer’s and Dementia Staff Education Week, Cardillo organized interactive classes for employees, outside speakers for residents and their families, and a visit from the mayor, who issued a proclamation on the importance of dementia education. Cardillo’s program won a first place award from the National Council of Certified Dementia Practitioners. </div> <div><br>Beyond her own expertise, Cardillo also seeks input from family members, staff, and other professionals to determine the best care plan for each resident. </div> <div><br>“I’ve seen the relief in the faces of residents who come to her for medical attention or advice,” said Furlong. “With kindness in her voice and positive words, she discusses difficult topics with gentleness, always keeping the resident’s dignity in mind.”</div> <div style="text-align:right;">—Rachel Reeves</div> <div></div> <div class="ms-rteFontSize-3 ms-rteForeColor-2">Riverside Lodge Retirement Community</div> <span class="ms-rteForeColor-2"> </span> <div>NCAL National Assisted Living Week® Programming</div> <div> </div> <div><img src="/Issues/2014/PublishingImages/1014/CathyRoark.jpg" alt="Cathy Roark" class="ms-rtePosition-2" style="margin:5px;" />Resident Services Coordinator Cathy Roark and the staff at Riverside Lodge Retirement Community, Grand Island, Neb., are the recipients of the 2014 NCAL National Assisted Living Week® (NALW) Programming award.  <br><br></div> <div>As NALW approached September 2013, Roark considered what memories residents cherish and how they could be incorporated into the activities during NALW. Staff decorated the community with items from the past, including an old sewing machine, which reminded one resident of “the one my mother taught me how to sew on.” A butter churn stirred another resident, who said, “I had forgotten there was a time when I was young.” </div> <div><br>Riverside Lodge kicked off NALW with Family Day, which included a Sunday dinner with favorites like roast beef, fried chicken, homemade biscuits, and apple pie. Families could purchase baked goods and homemade soaps and bath scrubs—all made by the residents—to raise funds for the local Cub Scouts. The Boy and Girl Scout troops also joined the residents to make pinewood racers and rag dolls. “It is important for our residents to feel connected and vital to the community they live in,” said Deb Friend, executive director of Riverside Lodge. </div> <div><br>Residents showcased their patriotic values by writing letters and making Christmas cards for men and women serving overseas. Additionally, Riverside Lodge put on a pet show and cooking competition, and the community tailgated for University of Nebraska football game. </div> <div><br>Roark also recognized staff for their efforts. Each day, a different department of staff members were honored as Happiness Heroes and invited to share a meal with the residents. “Our staff is so ready to jump right in to encourage the residents to attend and participate in the activities, not just [this week], but all year long,” said Friend.</div> <div style="text-align:right;">—Rachel Reeves</div> <div> </div> <div></div> <div> </div> <div class="ms-rteFontSize-3 ms-rteForeColor-2">Connie Leinberger</div> <span class="ms-rteForeColor-2"> </span> <div>Noble Caregiver in Assisted Living</div> <div> </div> <div><img src="/Issues/2014/PublishingImages/1014/ConnieLeinberger.jpg" class="ms-rtePosition-1" alt="Connie Leinberger" style="margin:5px 10px;" />Connie Leinberger is the 2014 NCAL Noble Caregiver of the Year. Leinberger has been the activity coordinator at Riverview Village, Menomonee Falls, Wis., for just over a year and has already transformed a traditional activity program into one that is individualized and improving the quality of life for residents. “From the moment she walked into my office, inquiring if there were volunteer opportunities at our community, her joy of service shone through,” said Riverview Village Director of Operations Lisa Benfield. “Our lives have been blessed from the moment Connie began as activity coordinator.”<br></div> <div><br>Included among the many person-centered activities Leinberger has developed for residents is a hand bell choir that holds monthly concerts for the community and families. Twice a month, residents enjoy Spa Day with hand and foot massages from a licensed massage therapist, along with aroma and music therapies. </div> <div><br>Those interested in spending time in the kitchen now enjoy a regular cooking class, thanks to Leinberger. <br>Riverview Village patrons have savored chicken dumpling soup, German potato salad, and desserts created by their fellow residents.</div> <div><br>Leinberger has helped residents give back to the surrounding Menomonee Falls community. During the holiday season, residents packed and delivered packages of supplies to Operation Christmas Child—Samaritan Purse. </div> <div><br>Outside organizations and volunteers have become more connected with the community as well. The local Girl Scout troops, pet therapists, Seniors Helping Seniors, high school students, families from the community, and spiritual leaders have extended their services to Riverview Village. </div> <div><br>Due to her successes, Leinberger is now a trainer within the Harmony Living Center company.</div> <div><br>“There isn’t a day that goes by that her heartfelt exuberance of giving to our residents is not expressed by the endless smile on her face,” Benfield said.</div> <div style="text-align:right;">—Rachel Reeves</div> <div> </div>Here are stories about some very special people and groups who have won annual awards from the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL).2014-10-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/AnnualAwards_t.png" style="BORDER:0px solid;" />Quality AwardsAHCA/NCAL Annual Awards10
The QIS Experthttps://www.providermagazine.com/Issues/2014/Pages/1014/The-QIS-Expert.aspxThe QIS ExpertThe recent New York Times article entitled, “Medicare Star Ratings Allow Nursing Homes to Game the System,” caused quite a stir with the claim that the Five-Star Quality Rating System from the Centers <br>for Medicare & Medicaid Services (CMS) is “…based in large part on self-reported data. …”<br><br>As providers well know, the base rating comes from survey results, which are anything but self-reported. The self-reported staffing and Quality Measure (QM) ratings are then applied to upgrade or downgrade the survey ratings. These latter two domains, as acknowledged by CMS, cover “only a brief snapshot in time” or “just a few aspects of care.” <br><br>In focus groups of providers conducted shortly after the Five-Star system was publicly reported, facilitators found that providers also expressed concerns about the limitations of the staffing and QM ratings. But why not focus on the basis of the Five-Star system—a facility’s survey results?<br><br>This is where QIS can make a difference. The QIS process is based on objective measures of quality of care and quality of life, offering providers the best chance for improvements in survey results by improving quality. With 40 percent of surveys using the QIS last year, it is only a matter of time before the QIS rollout begins again.<br><br>More importantly, using the QIS methods as the basis for a center’s internal Quality Assurance and Performance Improvement (QAPI) process will result in a substantial improvement in survey results. <br>Improving survey results is not about conducting mock surveys, or trying to predict when surveyors are coming and which residents they will observe. <br><br>Rather, studies have shown that providers can improve their survey results and reduce complaint deficiencies by improving resident-centered care through continuous and comprehensive QAPI. <br>But what if one’s state uses the traditional survey process? <br><br>Studies have also shown that providers can improve traditional survey results as well as QIS survey results using QIS methods in QAPI. <br><br>After all, the regulations are the same, and the traditional survey process has become progressively more resident-centered through evolving surveyor practices. <br><br>So why tinker around at the margins of the Five-Star Quality Rating System when performance can be improved in the most influential domain, with enhanced quality that will be evident to consumers and referral partners alike? <br><br>Providers can’t afford not to focus on the survey when it is evident that their health inspection ratings are regarded as the most credible domain in the Five-Star system.<br><br>The most important takeaway for providers from the recent Five-Star publicity should be that health care consumers and partners are increasingly relying on these ratings for making decisions that are critical to a center’s success. <br><br>Skilled nursing and post-acute providers are under growing pressure to compete for residents by improving their reputation and by demonstrating their capabilities and quality to acute-care and managed care partners.A recent article has caused quite a stir with the claim that the Five-Star Quality Rating System from the Centers for Medicare & Medicaid Services (CMS) is based on "self-reported data."2014-10-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/5star.jpg" style="BORDER:0px solid;" />QualityColumn10
Achieving That Award Can Dovetail With QAPI Planshttps://www.providermagazine.com/Issues/2014/Pages/1014/Achieving-That-Award-Can-Dovetail-With-QAPI-Plans.aspxAchieving That Award Can Dovetail With QAPI Plans<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div> </div> <div>Quality Assurance and Performance Improvement (QAPI) is a hot topic for long term care providers. The Affordable Care Act of 2010 introduced QAPI to the long term and post-acute care community. The statute requires nursing homes to have an acceptable QAPI plan within a year of the promulgation of the regulation.</div> <div> </div> <div> </div> <div> </div> <div>While the regulations are still outstanding, the Centers for Medicare & Medicaid Services has provided initial direction and guidance on QAPI through its publication of “QAPI at a Glance.” This document provides an overview of QAPI features, details the five elements of QAPI, describes action steps for implementing QAPI principles, and provides tools and resources that nursing centers may use as they further develop their systems. </div> <div> </div> <h2 class="ms-rteElement-H2">Concepts To Build On</h2> <div> </div> <div>The concepts that support QAPI are not all new. Continuous quality improvement has always been a focus of the profession and of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).<br></div> <div> </div> <div><br>In 1996, to meet the growing demand from members for quality-focused programs, AHCA/NCAL developed its National Quality Award Program. The program criterion, based on the Malcolm Baldrige Health Care Criteria for Performance Excellence, encourages organizations to take a systematic approach to quality improvement.</div> <div> </div> <div><br>Organizations apply for recognition at three increasingly rigorous and demanding levels, characterized as Bronze, Silver, and Gold. The criteria for each level require a more comprehensive and rigorous evaluation of the participating organization’s quality, service to residents and families, process improvement, and performance outcomes that are critical to success. Since the program’s inception, more than 3,000 centers have earned Bronze recognition, 350-plus have earned Silver, and 24 have earned Gold.</div> <div> </div> <div><br>Organizations interested in using QAPI will benefit from applying the Quality Award Criteria because they are aligned with the QAPI principles. This article summarizes the key linkages among the first two QAPI features, as defined in “QAPI at a Glance,” and the criteria requirements at the Bronze, Silver, and Gold award levels. </div> <div> </div> <h2 class="ms-rteElement-H2">Relationship To The Bronze </h2> <div> </div> <div>At the Bronze award level, applicants focus on basic elements underpinning the success of their organization, such as defining the vision, mission, and core competencies in which they excel. They also describe their principal customers, such as residents/patients and families, and their requirements for health care and other services. This aligns with QAPI’s emphasis on improvements that elevate the care and experience of all residents and enhance the work environment for caregivers. <br><br></div> <div> </div> <div>This understanding of their customers’ desires and expectations helps organizations emphasize improvements that elevate the care and experience of all residents and improve the work environment for caregivers.</div> <div> </div> <div><br>QAPI also encourages organizations to use a systems approach to actively pursue quality, not just respond to external requirements. At the Bronze level, applicants describe their main health care service offerings—the things most important to the success of their businesses—and also describe the key elements of their performance improvement system, including processes for evaluation and improvement of key organizational projects and processes.</div> <h2 class="ms-rteElement-H2"> Relationship To The Silver </h2> <div>At the Silver award level, applicants demonstrate the use of effective processes to enhance performance excellence. The systems approach used by senior leaders to pursue quality must also create an environment for resident and other customer engagement, for innovation and for high performance—processes essential to organizational sustainability.<br></div> <div> </div> <div><br>The organization must develop a strategy with clear outcome-based objectives and goals to address strategic challenges and leverage strategic advantages and opportunities. </div> <div> </div> <div><br>To enhance the work environment for caregivers, the organization must manage workforce (caregiver) capability and capacity to accomplish the organization’s work and maintain a supportive and secure work climate.</div> <div> </div> <div><br>Furthermore, organizations must deliver health care services that achieve value for residents and other customers, achieve organizational success and sustainability, and innovate for the future. This provides both a look at the current environment and future opportunities. </div> <div> </div> <div><br>Lastly, organizations are required to implement fact-based, systematic evaluation and improvement and show evidence of organizational learning, including meaningful, value-added change. These themes are critical to sustain the success of organizations as they face future challenges, such as aggressive competitors, additional government regulations, lower reimbursement rates, and more discerning and demanding customers.<br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Relationship To The Gold </h2> <div> </div> <div>At the Gold level, applicants demonstrate even more comprehensive systems for many of the same factors they put in place at the Silver level. <br></div> <div> </div> <div><br>For example, senior leaders of top-performing organizations create the following: </div> <div> </div> <div>■ An environment for performance leadership and organizational and personal learning;</div> <div> </div> <div>■ A workforce culture that fosters engagement and delivers a consistently positive experience for residents and patients;</div> <div> </div> <div>■ A culture of safety;</div> <div> </div> <div>■ A motivated workforce to reinforce high performance; and</div> <div> </div> <div>■A focus on action that will achieve the organization’s objectives, improve its performance, enable innovation, and create value for residents and patients.</div> <div> </div> <div><br>As a part of strategy development, the organization creates an environment that supports innovation, identifies strategic opportunities, and decides which intelligent risks are worth pursuing.</div> <div> </div> <div><br>Also at the Gold level, organizations address workplace environmental factors to improve health, security, and accessibility. They assess workforce engagement and satisfaction and take steps to improve.</div> <div> </div> <div>From an operations perspective, organizations address each resident’s expectations through effective processes that explain health care service delivery and set realistic patient expectations. They also factor resident/patient decision making and preferences into the delivery of health care services.</div> <div> </div> <div><br>In addition, top-performing organizations take effective steps to improve health care ser-vices and performance and reduce variability. To do this, organizations might implement approaches such as a Lean Enterprise System, Six Sigma methodology, ISO quality system standards, and Plan-Do-Check-Act methodology.</div> <div> </div> <h2 class="ms-rteElement-H2">A Voice Of Experience</h2> <div> </div> <div>The linkages between QAPI and the AHCA/NCAL National Quality Award criterion are best explained through the words of an organization that has completed its journey through the Bronze, Silver, and Gold award levels. <br><br></div> <div> </div> <div>Nina Willingham, senior executive director of Life Care Center of Sarasota, a 2013 Gold recipient, shared her experience with the Quality Award program and how it has helped her center prepare for the QAPI regulations.</div> <div> </div> <div><br>“Our senior leadership team saw a dramatic improvement in our organizational results following the implementation of the AHCA/NCAL National Quality Award criteria,” she says. The Silver criteria and feedback taught the company the importance of identifying its strategic challenges, advantages, and opportunities as it focused on its strategy for the future, Willingham says.</div> <div> </div> <div><br>“Planning became more deliberate, with measurable outcomes expected and evaluated. We considered new aspects for root cause analysis and the evaluation of our data in our problem solving. The resulting improvement in outcomes led to the implementation of meaningful changes for our residents, patients, and for the organization as a whole,” she says.</div> <div> </div> <div><br>As Life Care Center of Sarasota moved into the Gold criteria, staff began to review their processes and systems more routinely, which ultimately led to meaningful change. They also focused on workforce engagement and satisfaction, which has a direct impact on the satisfaction and engagement of their customers, Willingham says. </div> <div> </div> <div><br>“The implementation of QAPI will be almost seamless in our organization,” she says, as all the components are already in place, thanks to the Quality Award criteria and the feedback received through the application process. <br><br><em>Barbara Baylis, RN MSN, vice president of clinical services at Sava Senior Care Consulting, is a nurse executive accomplished in clinical and quality improvement systems. She serves as an AHCA/NCAL Quality Award Examiner as well as a member of the Quality Award Board of Overseers. Mark Blazey, PhD, is a leading expert in the application of the Baldrige criteria for performance excellence. Blazey is currently serving as a member of the AHCA/NCAL Quality Award Panel of Judges and is a member of the Quality Award Board of Overseers.</em></div> <div> </div> <div> </div>Quality Assurance and Performance Improvement (QAPI) is a hot topic for long term care providers. The Affordable Care Act of 2010 introduced QAPI to the long term and post-acute care community. The statute requires nursing homes to have an acceptable QAPI plan within a year of the promulgation of the regulation.2014-10-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/trophies_t.jpg" style="BORDER:0px solid;" />Caregiving;QualityColumn10
Cultural Competence: Bringing It Homehttps://www.providermagazine.com/Issues/2014/Pages/1014/Cultural-Competence-Bringing-It-Home.aspxCultural Competence: Bringing It Home<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div> <div> </div> <p>Hello. Wéi. Bonjour. Hola. Guten Tag. Moshi Moshi. Habari. Ciao. These are just some of the greetings one might hear in the modern nursing home. <br></p> <div> </div> <p>Up to 40 percent of the U.S. population is made up of immigrants or first-generation Americans, and fewer and fewer facilities are homogeneous. While it is unrealistic to expect everyone to know about all of the world’s ethnicities, languages, and cultural traditions, facilities should promote cultural competence among staff and mutual respect among residents from different backgrounds.<br></p> <div> </div> <p></p> <div> </div> <div>Cultural competence generally is defined as a set of behaviors, attitudes, and policies that enable staff to work and function effectively and congruously in cross-cultural situations. According to the National Institutes of Health (NIH), cultural competency is “critical to reducing health disparities and improving access to high-quality health care…that is respectful of and responsive to the needs of diverse patients.”</div> <div> </div> <div>NIH further says that cultural competency benefits consumers, stakeholders, and communities and supports positive health outcomes. </div> <div> </div> <h2 class="ms-rteElement-H2">Now In The Rulebook</h2> <div> </div> <div>While cultural competence is a greater challenge for facilities that have staff or residents from all over the world, it is something all facilities need to consider. The implementation of the Affordable Care Act (ACA) has increased the urgency for cultural competence, as the bill includes several provisions aimed at reducing health disparities and improving care for racially and ethnically diverse patient populations.</div> <div> </div> <div><br>For example, the ACA calls for data collection and reporting by race, ethnicity, and language and monitoring of diversity in the health care workforce, including long term care. It also allocates aid for the development and dissemination of model cultural competence training and education curricula.</div> <div> </div> <div><br>Of course, national attention to diversity and cultural competency didn’t begin with the ACA. Back in 2004, the Institute of Medicine released the report, “In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce.” The report recommended specific steps to improve admissions policies and practices, reduce financial barriers to health profession training, encourage diversity efforts through accreditation, and improve institutional climates for diversity. </div> <div> </div> <div><br>It also called for applying community benefit principles to diversity efforts and developing mechanisms to encourage support for them.</div> <h2 class="ms-rteElement-H2"> A Growing Need </h2> <div>“There is a tremendous need to get to know the values, beliefs, customs, and practices of individuals who live in today’s nursing homes,” says Jay Sackman, president of Jay M. Sackman Consulting Services in Redding, Conn. “This should start with a proactive role by admissions to get to know people’s backgrounds, etc. Direct care staff need to know about their residents from day one.” The need to address diversity is going to get more urgent, in part due to changing demographics in nursing homes, Sackman says. For example, he says, “We have orthodox Jewish people moving into homes that aren’t orthodox. And this is just one example. How do these facilities adapt?” He adds, “Addressing diversity is an area that has been neglected. But you can’t generalize about it. It requires careful assessment of individuals and monitoring to ensure they have quality of life and staff are caring for them appropriately.”<br><br></div> <div> </div> <div>For those who think a little cultural misunderstanding can’t make a big difference, Sackman offers this story.<br><br></div> <div> </div> <div>A nursing home in New York City had a large Korean population. They trained staff a little regarding customs and language, but there were some important gaps. They didn’t realize that Korean people actually have three different birthdays. Facility staff members were celebrating the wrong one, and they didn’t understand why the residents reacted badly. <br><br></div> <div> </div> <div>The misunderstanding led to an organizational effort to achieve a deeper understanding of Korean culture and be more responsive to Korean residents’ values and traditions. This, in turn, led to a better relationship between residents and staff.<br><br></div> <div> </div> <div><a href="/Issues/2014/Pages/1014/Steps-For-Building-Cultural-Competence.aspx">Cultural competence</a> and diversity training need to go beyond practitioners and nursing staff. “We need adequate training for everyone—recreation staff, social workers, even food service and housekeeping employees,” Sackman says. He stresses that caring appropriately for a diverse population is “all about individualized care planning and strongly advocates for the use of regular ‘huddles’ on units to gain insights from those who spend time with residents and know them best.”</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">No Need To Reinvent The Wheel</h2> <div> </div> <div>While there are many challenges to providing cultural competence, the good news is that there are many templates, resources, and best practices available that can be adapted or duplicated. For example, the Evanston, Ill.-based Mather LifeWays Institute on Aging developed a <a href="/Issues/2014/Pages/1014/Increasing-Cultural-Awareness.aspx" target="_blank">paper that includes checklists</a> addressing diversity and cultural competency in health care settings. These lists are designed to help organizations evaluate their cultural competence. <br><br></div> <div> </div> <div>“By checking the items that best describe your organization, you will gain a clearer picture of your current strengths and, most important, areas of opportunity,” says the Mather LifeWays Institute on Aging document. “After the three checklists have been completed and reviewed, you will be in a better position to determine the course of action needed to achieve cultural competency in your workplace and workforce.” <br><br></div> <div> </div> <div>The paper includes three checklists:<br><br></div> <div> </div> <div>■ Areas of an organization’s culture that can negatively impact quality of care. These include beliefs (for example, staff hold different beliefs about the nature of health and illness), attitudes (staff disrespect nontraditional health practices), behaviors (staff rely on technology/procedures to identify problems), and rituals (staff don’t consider residents’ attitudes and beliefs regarding the physical exam). <br><br></div> <div> </div> <div>■ Barriers to cultural competency in organizations. This addresses concerns regarding residents, such as the lost capacity to communicate in their secondary language that some elders experience, individuals from different cultures who find it difficult to adapt to dietary changes and different foods, and individuals who need assistance in completing washing rituals before prayers but are unable to find staff to help them.</div> <div> </div> <div>Also addressed in this checklist are organizational barriers, such as increasing pressure on staff and resources from escalating levels of care; difficulty in recruiting staff that reflect diversity; operational logistics that make it difficult to provide the most linguistically, culturally, and spiritually appropriate care possible; and potential for stereotyping and misdiagnoses that lead to misinterpretation of behaviors as hostility and agitation. <br><br></div> <div> </div> <div>■ Recommendations for culturally competent care. For example, to increase cultural awareness, the paper suggests decreasing ethnocentrism by being aware of one’s own cultural values and biases, understanding that there may be racist attitudes and beliefs among families and residents, and learning how to communicate more effectively to decrease racist attitudes.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Finding Red Flags</h2> <div> </div> <div>“These checklists are a starting point. We set our expectations based on this,” says Linda Hollinger-Smith, PhD, RN, FAAN, vice president of Mather LifeWays Institute of Aging. However, she adds, facilities also need performance evaluation systems based on competence that looks at each person’s knowledge, <span><span><img width="130" height="196" class="ms-rtePosition-1" alt="Linda Hollinger-SMith" src="/Issues/2014/PublishingImages/1014/LindaHollinger-Smith.jpg" style="margin:15px;" /></span></span>skills, and behaviors. If an individual is just providing lip service to cultural competence, it will come out in <span></span>some way in his or her performance.<br><br></div> <div> </div> <div>For example, she says, a red flag might be a nurse who performs assessments and doesn’t include aspects of ethnic diversity in her questioning.<br><br></div> <div> </div> <div>Hollinger-Smith notes that it actually is possible to identify people who may not fit in with a culture of diversity and tolerance before they even are hired.<br><br></div> <div> </div> <div>“A lot depends on the interviewer’s skills. It is helpful to ask questions such as, ‘What kind of people do you dislike working with? What would you do if you heard a fellow worker say something insensitive?’ A lot of times, their answers will provide insights into any issues they have,” she says.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Training And Beyond</h2> <div> </div> <div>The Mather LifeWays Institute on Aging document encourages adherence to the Department of Health and Human Services Culturally and Linguistically Appropriate Services standards. These were developed in 1997 to provide a comprehensive alternative to the wide array of independently developed definitions, practices, and requirements concerning the provision of culturally and linguistically appropriate services. The standards represent input from many stakeholders, including hospitals, community-based clinics, nursing homes, managed care organizations, and home health agencies. <br></div> <div> </div> <div>The 14 standards are organized by themes: culturally competent care, language access services, and organizational supports for cultural competence.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Coaching Supervision Vs. Diversity Training</h2> <div> </div> <div>“Instead of cultural diversity training, we’ve chosen to focus on coaching supervision, which trains on the fundamentals of a respectful workforce. We’ve really prioritized getting at the issues that arise through diversity in a respectful workplace,” says Mary Tess Crotty, vice president of quality, Northeast Division, for Genesis HealthCare.<br><br></div> <div> </div> <div>The coaching supervision training was developed by the Paraprofessional Healthcare Institute to develop coaching skills in those who supervise or work with direct care workers in long term care. All skills are taught in the context of  real-world work settings and focus on communication and problem-solving.</div> <div> </div> <div>The curriculum addresses four primary goals: active listening (using skills such as asking clarifying questions), self-management (setting aside emotional reactions), self-awareness (being aware of assumptions and biases that lead to prejudging people), and presenting the problem (using objective language to identify performance problems and promote accountability).<br><br></div> <div> </div> <div>“This course centers on supervisors’ ability to establish and maintain relationships with their workers. Problems, then, are addressed through these relationships,” says Crotty. “The curriculum creates an educational environment where participants feel safe to share their personal views, experiences, and ideas without judgment.” <br><img src="/Issues/2014/PublishingImages/1014/BarbaraFrank.jpg" alt="Barbara Frank" class="ms-rtePosition-1" style="margin:10px;" /><br></div> <div> </div> <div>Many of the problems related to diversity result from the expectations people bring with them, says Crotty. She observes that the curriculum helps encourage and enable the “enormous amount of mutual understanding and appreciation necessary to bridge gaps caused by these expectations.” </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Working Together </h2> <div> </div> <div>Barbara Frank, MPA, of B&F Consulting, agrees that cultural competence starts with staff who respect each other and work together harmoniously. If people have ways of working together where each individual’s contributions count, she suggests, cultural differences enhance the way they contribute.<br></div> <div> </div> <div>“If staff don’t have ways to regularly work together, respect each other, and problem solve, differences in their cultures actually magnify,” she says. “We saw this in New Orleans after Hurricane Katrina.” People there threw titles out of the window, worked together, and took care of each other, and the issues of race, class, and national origin were non-factors, Frank says.<br><br></div> <div> </div> <div>Cultural competence training will “fall completely flat” if people don’t have ways to collaborate and work together. “You need an organizational systems approach that works on an everyday basis,” Frank says.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Celebration!</h2> <div> </div> <div>Once staff are trained and a culture of trust and mutual respect is established, Crotty says, the facility can implement diversity-related activities to celebrate everyone in a positive environment. This is where the fun starts, Frank says.<br><br></div> <div> </div> <div>“It’s great to have fairs where people wear their native clothing, play traditional music, and have tasting stations to share ethnic foods. These events celebrate the community rather than focusing on cultural differences.”<br><br></div> <div> </div> <div>Hollinger-Smith suggests that cultural celebrations are most effective if staff and residents are allowed to take ownership of the events.<br><br></div> <div> </div> <div>For example, she says, “We had an Asian resident who had been a chef in her own country. We asked her to share some recipes with our chef, and we integrated these into our menu.”<br><br></div> <div> </div> <div>The resident was proud to share her ethnic dishes—which are reflective of what she was able to accomplish in her life—with others.<br><img width="197" height="171" src="/Issues/2014/PublishingImages/1014/SherylZimmerman.jpg" class="ms-rtePosition-2" alt="Sheryl Zimmerman" style="margin:10px;" /><br>Sheryl Zimmerman, PhD, professor and director of aging research, School of Social Work, University of North Carolina at Chapel Hill, says, “We did a project where families brought in what was special to them and their loved one—food, music, etc. This is more reasonable than thinking that you’ll do a Hanukkah celebration for everyone in the facility who is Jewish.” Even within a single faith or culture, she says, people have different ways of celebrating.<br><br></div> <div> </div> <div>“Cultural celebrations are valuable, but they need to be more than window dressing,” says Sackman. They need to be an extension of an ongoing and committed cultural competence effort and not just a shallow attempt to showcase diversity, he says.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">On The Job: When Training Isn’t Enough</h2> <div> </div> <div>“There is so much about people’s lives to celebrate, and you become better for knowing them. Diversity is part of the fabric of our being. When you hear people’s stories, they’re amazing,” says Crotty. She shares a story of a caregiver who was sending money back to his home country to help build a school. Here in his adopted home, he was a natural leader who thrived on the job. Another staffer, a recreation director from West Africa, was able to draw on her background to help nurses interpret the behaviors of their colleagues who were from her country. Unfortunately, however, even after staff have undergone training and been introduced to a positive organizational culture, there still may be problems and conflicts. It is important to have ways of identifying staff and residents who are expressing intolerance or prejudice or who feel discriminated against.<br><br></div> <div> </div> <div>Sometimes, residents may be hesitant to express concerns about cultural issues, says Hollinger-Smith. However, she says, issues may come to light through satisfaction surveys. Residents “may express concerns such as they don’t feel staff are listening to them or they don’t feel that staff understand their culture,” she says.<br><br></div> <div> </div> <div>Concerns expressed by family members also may be culture-related. For instance, Hollinger-Smith says, “A family member may say that Mom doesn’t like the food—it’s too bland or the community doesn’t serve her favorite dishes.”<br><br></div> <div> </div> <div>Instead of finger-pointing or blaming, Hollinger-Smith suggests looking at diversity-related problems as learning opportunities.<br><br></div> <div> </div> <div>“For example, we had a conversation with one of our administrators. They were showing old movies in the facility that included stereotypes about Native Americans, and there was concern expressed that we shouldn’t show these movies because they might offend Native American staff members,” she says. Hollinger-Smith suggested that the administrator meet with staff, seek their input, explain to them that residents with dementia are soothed by these familiar movies and that they are not intended to be offensive, and reach a mutually agreeable solution.<br><br></div> <div> </div> <div>Problems often can be resolved with education, says Hollinger-Smith. <br><br></div> <div> </div> <div>“Ask the people involved to put themselves in the other person’s shoes. Encourage and enable them to look for similarities in each other’s cultures. It helps if they can find common connections and shared experiences,” she says. </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Encourage Residents To Share Their Culture </h2> <div> </div> <div>Having visual cues around a resident’s room can help remind staff about what is important to each person. Zimmerman says, “Encourage families to hang Christmas stockings, menorahs, crucifixes as desired by the resident. This has to be personalized. You can’t know what is important to a person just because of his or her culture, religion, or ethnicity.” She cautions that some residents may not want to announce their roots.<br><br></div> <div> </div> <div>For example, residents who are Holocaust survivors may not want to display their Judaism, and some people are just very private about their backgrounds and beliefs.<br><br></div> <div> </div> <div>It is helpful to enable people to recognize their own perceptions about diversity, Zimmerman notes. “What are their cultural sensitivities? How important are your holidays? What is your cultural identity, and what does this mean to you?”<br><br></div> <div> </div> <div>Zimmerman stresses that “we have to give people an opportunity to talk about their feelings—both good and bad. And we need to help people become sensitive to the language they use about elders and various cultures.” She adds, “We need to point out generalizations that involve words or behaviors that are prejudicial or hurtful.”<br><br></div> <div> </div> <div>When a resident is expressing disrespect for a staff member’s culture, it may be necessary to change assignments as part of the solution. When this happens, Hollinger-Smith says to make it clear to the staff member that “you understand their feelings and realize that they aren’t to blame. Reinforce their value to your team.”<br><br></div> <div> </div> <div>Despite training, outreach, and personal attention, some staff still may not embrace cultural competence and diversity. “If cultural competence is an expectation at the organizational level and they’re not making the effort, it may be time to say that it’s just not a good match,” says Hollinger-Smith. </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Homes Are Like Snowflakes</h2> <div> </div> <div>“I’ve been in this field a long time, and I’ve always said that if you’ve been in one nursing home, you’ve seen one nursing home. They all are so different. There is no one way to deal with diversity,” says Sackman. “Administrators, [directors of nursing], and others have to be role models and model behaviors that they expect of staff when they are engaging with residents. Staff will respond to this. But, ultimately, there is no cookie cutter answer.”<br><br></div> <div> </div> <div>Ensuring cultural competence is not an impossible task, but it is an unending one. “Developing cultural competence is a process. It takes time, and communities must make a long-term commitment to it,” says Hollinger-Smith. “They must always be looking for ways to build staff’s cultural competence.” ■</div> <div> </div> <p><br></p> <p><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em><br></p>It is unrealistic to expect everyone to know about all of the world’s ethnicities, languages, and cultural traditions, facilities should promote cultural competence among staff and mutual respect among residents from different backgrounds.2014-10-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/coverstory_t.jpg" style="BORDER:0px solid;" />Management;Quality;CaregivingCover Story10




Top 10 Myths Of Nursing Home Management: The Nursing Departmenthttps://www.providermagazine.com/Issues/2014/Pages/1114/TOP-10-MYTHS-OF-NURSING-HOME-MANAGEMENT.aspxTop 10 Myths Of Nursing Home Management: The Nursing Department<div><h2 class="ms-rteElement-H2"><span><span class="ms-rteForeColor-8">Myth No. 1.</span> </span>Being licensed as a registered nurse (RN) or licensed practical nurse/licensed vocational nurse (LPN/LVN) means that the nurse has management skills.<br></h2></div> <div> Historically, most LPN/LVN programs have focused on providing students with basic knowledge of nursing, including vital sign assessment, medication administration, and wound care technique.</div> <div><br></div> <div> </div> <div> </div> <div> </div> <div>Although these graduates often work in charge nurse positions, they likely have not been exposed to management or leadership strategies. Even bachelors-prepared RNs may not have received any specialized coursework in management.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Administrators need to recognize that nursing education focuses on the clinical aspects of care and that supplemental courses, in-services, or support will likely be required to help transition nurses into management positions. The LPN/LVN charge nurse may require formal guidance in understanding the role of supervisor—techniques to motivate staff, coaching skills, and methods for teaching certified nurse assistants (CNAs). </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span><span class="ms-rteForeColor-8">Myth No. 2.</span> </span>The best director of nursing (DON) candidate is one who has held the position at several facilities and is willing to bring his or her staff along. <br></h2> <div> </div> <div> </div> <div> </div> <div>Nursing staff with a proven history within a nursing home may be more ideal candidates for the DON position than someone who has a history of working at multiple buildings. The seasoned DON may have extensive experience; however, a pattern of moving from one facility to another may prove problematic, particularly if the person has limited longevity at these facilities.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Beware of the DON candidate who is willing to bring staff along, thus leaving the former building devoid of sufficient nursing personnel. It also may adversely affect a facility’s current core of nurses, who may feel alienated from the new DON who brings a team of known performers, pitting established employees against the new group. Most importantly, consider what may happen when the DON decides to leave and take those staff members to the new facility.<br><br></div> <div> </div> <div> </div> <div> </div> <div>A better choice may be to promote a nurse with clinical and administrative skills who can be given a mentor to help the transition. Always identify nurses with the potential to move up the ladder, while planning for the education and support they will need in order to be successful.<br></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> <span><span class="ms-rteForeColor-8">Myth No. 3.</span> </span>Medication administration can be completed within the two-hour window. </h2> <div> </div> <div> </div> <div>Observe staff during a med pass at 8:00 a.m. Does the med pass continue to 11:00 o’clock? Does it seem that one medication administration flows to the next without a break? Do nurses seem unable to perform other tasks such as assessments, resident teaching, staff supervision, and care planning because they are continually administering medications?<br><br></div> <div> </div> <div> </div> <div> </div> <div>Consider having the pharmacy consultant observe an entire medication administration to determine if there are efficiencies that can be built into the system. Can some of the morning medications be moved to the afternoon or evening? Perhaps the number of medications can be separated by having one portion of the unit’s residents receiving pills at 8:00 a.m. and one portion at 9:00 a.m. This would provide a three-hour window in which the morning medication pass can be completed.</div> <div> </div> <div> </div> <div></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteForeColor-8">Myth No. 4.</span> Nurses inherently understand how to perform the Braden Scale for the assessment of pressure ulcer risk.</h2> <div> </div> <div> </div> <div> </div> <div>Don’t assume that any nurse inherently understands how to complete a Braden Scale, as the questions may not be as intuitive as they look. <br><br></div> <div> </div> <div> </div> <div> </div> <div>For example, the domain “sensory perception,” the ability to respond meaningfully to pressure, may be affected by diminished cognition from dementia, narcotic use commonly found in hospice residents, or people affected by strokes who cannot feel or respond to pressure on their sacrum or heels.<br><br></div> <div> </div> <div> </div> <div> </div> <div>It may be difficult for nursing staff to determine if a resident has adequate nutrition upon admission if the resident’s weight history is unknown or if their nutrition laboratory values (albumin, prealbumin) were not sent from the hospital.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Asking a resident if clothing fits more loosely may be a better indicator of weight loss than </div> <div> </div> <div> </div> <div> </div> <div>asking the resident about his or her weight history.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Specialized in-service education addressing the six domains of the Braden Scale may be a valuable tool in accurately identifying risk, as well as implementing appropriate interventions at the time of admission. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteForeColor-8">Myth No. 5. </span>The DON is the best person in the nursing department to develop the staffing schedule.</h2> <div> </div> <div> </div> <div> Although sufficient numbers of appropriately trained staff is one of the most important factors in the provision of clinical care, the DON needs to delegate this responsibility. The most clinically relevant person in the building should not be devoting time to completing the schedule, but should have oversight in its completion and implementation. </div> <div> </div> <div></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteForeColor-8">Myth No. 6. </span>CNAs should continue to perform nonclinical duties.</h2> <div> CNAs have traditionally performed activities that could be performed as efficiently by the staff of other departments, providing greater opportunity for them to engage with residents, to understand the individual resident preferences, and to perform restorative nursing activities such as ambulating residents from the entrance of the dining room to the table so they may sit in dining room chairs rather than wheelchairs. </div> <div><br>Since salivation is the first stage of digestion, discussing what is on the menu for the upcoming meal and asking residents about how they prepared certain dishes may stimulate their ability to eat.<br><br></div> <div> </div> <div> </div> <div> </div> <div>So instead of having CNAs pass fresh water or fill ice pitchers, let this task be done by the dietary department. Instead of bed making, assign it to housekeeping. Instead of CNAs attending to residents for outside appointments, therapeutic recreation staff could do it. It is likely that dietary, housekeeping, and therapeutic aides’ pay rates are less than that of CNAs and are easier to hire. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteForeColor-8">Myth No. 7. </span>Staff enjoy and derive benefit from attending the same in-services given by the same staff in the same format.</h2> <div> </div> <div> </div> <div> </div> <div>Staff who have been loyal employees for years are punished for their loyalty when the same educational programs are provided year after year. Instead, consider identifying CNAs that excel in certain areas and have them perform the in-services, such as body mechanics. CNAs may value the in-services demonstrated by their peers, as well as appreciate the opportunity to be recognized by the facility for their skills. <br><br></div> <div> </div> <div> </div> <div> </div> <div>In-service programs that engage staff by having games, quizzes, or other forms of interaction may provide better outcomes. Avoid posting in-service programs using the word “mandatory.” Instead, offering food may increase the likelihood of attendance, participation, and carryover to clinical care. <br><br></div> <div> </div> <div> </div> <div> </div> <div>Asking staff for educational topics, having the medical director and consultants provide programs, and using YouTube videos may enhance the experience and translate to improved resident outcomes. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteForeColor-8">Myth No. 8.</span> CNAs should obtain vital signs and report significant changes to the licensed nurse.</h2> <div> </div> <div> </div> <div> </div> <div>Although many CNAs are competent in obtaining temperature, pulse, respirations, blood pressure, and pulse oximetry readings, the interpretation of vital signs is an important skilled nursing intervention than cannot be delegated.<br><br></div> <div> </div> <div> </div> <div> </div> <div>While it is important that CNAs (and other staff) be encouraged to stay alert to and report any changes they note in a resident’s condition, finding mechanisms to ensure that CNAs are providing the licensed nurses with timely vital sign readings may prove difficult. Instead, it may be more efficient to have licensed nurses take the vital signs, particularly for targeted residents, so that abnormalities can be appropriately identified and acted upon. </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteForeColor-8">Myth No. 9. </span>Abuse education programs should focus primarily on the nursing staff.</h2> <div> </div> <div> </div> <div> </div> <div>An abuse prevention program, focusing on the definitions and examples of abuse, neglect, financial exploitation, and passive and active neglect, will be more effective if all staff of all departments participate in the program. Although nursing staff have the most intimate interactions with residents, all departments have the ability to see abuse and intervene.<br><br></div> <div> </div> <div> </div> <div> </div> <div>When reporting new, unexplained bruises, nursing staff must include the color, shape, and location of the bruise in order to know which staff to interview during an investigation. In most cases, fresh bruises are red, blue, or purple, and when they age, they become brown, green, and yellow. A resident with bruises of multiple colors has likely been injured over a period of time, not just one incident. A resident with finger-like bruises on the upper arms may have been roughly handled. All incident reports should contain information about these characteristics. </div> <div> </div> <div> </div> <div></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteForeColor-8">Myth No. 10. </span>Nurses are proficient in documentation, and their notes fully reflect their assessments, interventions, and clinical decision-making skills.</h2> <div> </div> <div> </div> <div> </div> <div>The ability to capture appropriate information in clinical records remains elusive to many providers in all health care settings. Practitioners should keep in mind that while notes are intended to communicate care needs within and between disciplines, notes should also describe what special services the facility provided that justify the cost of resident care. <br><br></div> <div> </div> <div> </div> <div> </div> <div>Rather than documenting that wound care was provided, the narrative note should identify if the wound is improving or deteriorating, since the treatment administration record is the source of documentation that wound care was provided.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Instead of writing that all due medications were administered, the nursing staff should comment on the resident’s response to one or more drugs that were given. <br><br></div> <div> </div> <div> </div> <div> </div> <div>Instead of simply recording vital signs in the narrative notes, the skilled nurse should interpret these findings in relationship to the resident’s baseline vital signs. <br></div> <div> </div> <div> </div> <div> </div> <div>Nursing staff who include the statement “will monitor” in a narrative note should instead specify what should be monitored so that subsequent staff can monitor those factors as well.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Administrative staff should take the opportunity to review a number of clinical records throughout the course of the week and identify areas in which the professional staff could improve their note-writing skills.</div> <div> </div> <div> </div> <div> </div> <div>Addressing these 10 nursing department myths should enhance the administrator’s ability to improve the function and oversight of this critical clinical entity.  </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><em>Ilene Warner-Maron, RN, PhD, is assistant professor, health services director, Interdisciplinary Health Services, at Saint Joseph’s University in Philadelphia. She can be reached at (610) 660-1586 or <a href="mailto:iwarnerm@sju.edu">iwarnerm@sju.edu</a>.</em></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div>Maximizing skilled nursing talent in the most effective ways will result in a better distribution of staff time and better outcomes for residents.2014-11-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1114/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn11
How To Build A Simple Emergency Planhttps://www.providermagazine.com/Issues/2014/Pages/1114/How-To-Build-A-Simple-Emergency-Plan.aspxHow To Build A Simple Emergency Plan<div><img width="215" height="215" class="ms-rtePosition-1" src="/Issues/2014/PublishingImages/1114/mgmt1114.jpg" alt="" style="margin:15px 10px;" /><br>On an administrator’s first day on the job, a call reaches him at home: There is a fire in the building!<br></div> <div>February 2006 wasn’t an unusually cold month for Illinois, but a lack of insulation near the business office of an assisted living community in Illinois was a recipe for disaster.</div> <div> </div> <div>When a fire broke out, below-freezing temperatures, followed by a brief thaw, caused the plastic fire sprinkler piping to fail, sending water cascading through the ceiling and down the walls onto the floor. One hundred thirty-two gallons (as measured by the water meter) flooded the office, lobby, and adjacent offices. Quick thinking by the staff, generous help from the local hardware store, and expert handling by the fire department’s salvage and damage control personnel limited the damage to $36,000. There were no injuries, no evacuation or relocation of residents. So, were staff perfect in planning for the unexpected? Certainly not. Here’s what they learned.</div> <h2 class="ms-rteElement-H2">What Is Required By Law</h2> <div>Local or state laws may require fire department and emergency management services to review and sign off on an assisted living community’s emergency plan. Not to enlist the expertise of these folks is a big mistake—for, after all, it is what they do. Getting input from firefighters before tornadoes, evacuations, power outages, blizzards, or even fire drills occur can help administrators understand what the authorities expect to see in a plan. And most emergency plans should be tailored specifically to each building the company owns or manages.</div> <div><br>Local firefighters can provide valuable information on variables such as weather extremes, geographies, and personnel. They can also help administrators develop a specific system that is easy to implement and modify. </div> <div><br>A simple approach used by firefighters since the 1970s is called incident management. The Illinois community has, since its emergency, adapted the model to create a simple yet effective and feasible way to respond in the event of another one. <br></div> <h2 class="ms-rteElement-H2">The Centralized Tub System</h2> <div>The plan is straightforward: All the information needed to manage an emergency incident is stored in a plastic tub in the nursing station on each floor. Each tub contains five packets of information with step-by-step instructions and the resources to follow them for fast implementation. </div> <div><br>All staff know that when disaster strikes, they should “get the tub.” </div> <div><br>Based on incident management principles, the Illinois community divided responsibilities into five sectors, each with its own “commander” and simple assigned duties. Sectors used at the community include Incident Commander, Assistant, Safety Officer, Staging Officer, Financial Officer, and Supply Officer. The sector names can vary, but the plan needs to distribute the responsibilities evenly and keep them simple for each sector. In an emergency, the first certified nurse assistant (CNA) who can get to the tub becomes the Incident Commander. The next CNA becomes the Assistant, and kitchen staff fill the other positions. This simple approach gets the response started even before alerting the corporate office to the situation.</div> <div>The information packets include key information on no more than two sheets of paper. Packets answer questions such as how to shut off water sprinklers, who has the key to access the water valves, calling 911, an employee contact list, and the administrator’s cell phone number.</div> <div><br>Each packet contains information about the specific sector. For example, the Supply Officer’s packet includes instructions for procuring a walkie-talkie, arranging for event-dependent supplies (such as food and water), directing residents to safe havens, procuring an emergency contact list, notifying the hospital house supervisor if evacuation is a possibility, contacting utility companies, and having a face-to-face meeting with the Incident Commander. List all necessary phone numbers on a single sheet of paper, including emergency and after-hours telephone numbers. </div> <div><br>Including a master key to the building in the tub was controversial at first, but it is important to trust staff. To slow access to the master key and other content at nonemergency times, the tubs are sealed with wire ties, and a wire cutter is taped to the top. </div> <h2 class="ms-rteElement-H2">The Plan In Action<br></h2> <div>Staff at the Illinois building participate in practice sessions with the tubs every six weeks, with frequent changes to the scenarios. Information in the tubs is reviewed annually. The tubs have helped manage emergencies at the facility, including tornado warnings, a record flood, and six lightning strikes. <br></div> <div><br>This incident management system works for any disaster and can be tailored to any need. However, emergency preparedness is about more than information, so also plan to have emergency supplies on hand. For the Illinois community, supplies include five-gallon jugs of water in the sprinkler room, a portable generator, rechargeable flashlights and batteries for walkie-talkies, and a gas grill big enough to serve 60 residents with food for eight days. Providers have to ask the question, “If we are to be stuck here for a week, what provisions do we need?”     </div> <div><br>Being prepared for an emergency needs to be more than just a collection of differently colored binders or a tabbed notebook placed strategically in the business office. A simple plan—with some help from local fire department experts—can help assisted living communities be prepared for any disaster so staff can respond easily and with confidence. </div> <div> </div> <div><em>TIM LEADER, RN, RAC-CT, has been a nurse for 25 years. He also has 20 years of experience as a firefighter and paramedic. He can be reached at tfireemsrn@aol.com or (352) 419-7278.</em></div>Local firefighters can provide valuable information on variables such as weather extremes, geographies, and personnel. They can also help administrators develop a specific system that is easy to implement and modify. 2014-11-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1114/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn11
A Journey Of Learninghttps://www.providermagazine.com/Issues/2014/Pages/1114/A-Journey-Of-Learning.aspxA Journey Of Learning<div>In a small rural town in Missouri, set against the splendor of the Ozark Mountains, the employees of a long term care center must be celebrating. They certainly have great cause. These individuals undertook a journey—a lengthy, arduous, often exhausting and frustrating journey—so they could give their residents the very best care possible.</div> <h2 class="ms-rteElement-H2">No Resting On Laurels At GLC-St. James</h2> <div>And Golden LivingCenter - St. James (GLC-St. James) already had an impressive record of providing care and services at a level of quality superior to all but a small percentage of its peers nationwide.</div> <div><br>Their list of accomplishments includes:</div> <div><br>■ Earning and keeping a Five-Star rating from the Centers for Medicare & Medicaid Services without a single lapse since December 2008—and hence being named one of the nation’s top nursing homes in <em>U.S. News and World Report</em> every year since 2008; and<br><br><span><span><img src="/Issues/2014/PublishingImages/1114/Stonebrook1.jpg" alt="Stonebrook Healthcare Center" class="ms-rtePosition-1" width="239" height="170" style="margin:10px;" /></span></span>■ Ranking in the top 10 percent—both state- and nationwide—for many key quality measures, such as acquired pressure ulcers and the elimination of physical restraints. </div> <div><span></span><br>This year they added another item to that list. One that demanded far more from everyone involved, but produced results far greater than any they’d achieved in the past. It was truly a red letter day when GLC - St. James learned it had earned the 2014 Gold National Quality Award from the American Health Care Association/National Center for Assisted Living (AHCA/NCAL). It’s the highest quality award the long term care profession can bestow, and over the 18 years since the award’s inception, the Gold has only been achieved by 24 providers.</div> <div><br>Six of those gold awards were earned this year. The five centers that joined GLC-St. James in this very exclusive circle are:</div> <div><br>■ Altercare of Louisville Center for Rehabilitation and Nursing Care (Louisville, Ohio) <span><img src="/Issues/2014/PublishingImages/1114/Altercare_staff2.jpg" alt="Altercare staff" class="ms-rtePosition-2" width="370" height="200" style="margin:25px 5px;" /></span></div> <div><br>■ South Davis Community Hospital (Bountiful, Utah)</div> <div><br>■ Stonebrook Healthcare Center (Concord, Calif.)</div> <div><br>■ Glen Hill Center - Genesis HealthCare (Danbury, Conn.)</div> <div><br>■ Oregon Veterans Home (The Dalles, Ore.)</div> <h2 class="ms-rteElement-H2">Increasingly Rigorous Award Levels</h2> <div>AHCA/NCAL’s National Quality Awards Program, based on the exacting and comprehensive Baldrige Health Care Criteria for Performance Excellence, requires applicants to move through three levels of progressively rigorous criteria. All applicants must start at the beginning and take each level in order. Only after achieving the first level’s award—the Bronze Commitment to Quality Award—will an applicant be eligible to apply for the second level and from there to the third.</div> <h2 class="ms-rteElement-H2">Applicants Embark On A Journey …</h2> <div>Providers that embark on this three-level program of criteria will find themselves on what so many award-winning providers describe as a “journey” that leads them through obstacles to a solid understanding of how to design processes and systems that reliably lead to consistent and sustainable quality improvement. This improvement in turn results in improved outcomes and performance excellence throughout the organization’s culture.</div> <div><br><img src="/Issues/2014/PublishingImages/1114/ReneeRidling.jpg" alt="Renee Ridling" class="ms-rtePosition-1" style="margin:5px 10px;" />It’s an intense learning process, to which Renee Ridling, executive director of GLC-St. James, can attest. “Going from Bronze to Gold is very much a journey of learning,” says Ridling. </div> <div><br>“It made us take a step back and say, ‘We have really good outcomes in whatever the indicator is. How did we get those?’” says Ridling. “It meant really learning about our facility, defining its systems and processes, looking at and analyzing what we’re doing to be a quality organization and deliver a quality service to all of your stakeholders. It really makes you think.”</div> <div><br>Working toward the Gold award results not just in earning a particular award, but in a center’s staff gaining that fundamental knowledge of quality that allows them to perform center tasks not by just doing what’s always been done, but understanding what the goal is, how to achieve it, and why what they did worked.<br></div> <h2 class="ms-rteElement-H2">… That Leads To Understanding Precisely What Results In Improved Quality </h2> <div>“My staff and I can all sit down and talk about what it is that makes us better,” says Ridling, “and they can say exactly what it is that makes us better than our competitors, and why people come to St. James. </div> <div>“I can sit down and say to the team, ‘Do you understand what and why we do what we do? Do you understand what the steps are that we take, and why they get us there? And they really do understand.” </div> <div>Staff who really understand what actions result in improved quality and why they do is immeasurably valuable, Ridling says.</div> <img src="/Issues/2014/PublishingImages/1114/ORVetHome2.jpg" class="ms-rtePosition-1" width="276" height="183" alt="" style="margin:15px 10px;" /><br><div>“Because quality doesn’t just happen,” she says. “It’s not a matter of, ‘Here’s what we do, and we just do it because.’ It’s really a matter of knowing how did we get there, what steps did we take, and what did we learn at each step along the way to get to this point.”<br></div> <div><br>All that learning will pay off big far into the future, “because the goal is to have a repeatable process that creates a sustainable organization,” Ridling says. “If you left today, how would the facility go on? Would the staff and leadership team know how to keep growing and sustaining the organization? Your organization’s process has to ensure it can be sustained.”</div> <div><br>And that’s why staff who have a thorough understanding of how it all works are so </div> <div>essential.</div> <div><br>“If any piece is pulled out but you understand how to sustain that growth, you can plug somebody in there and you’ll continue to grow and sustain,” Ridling says. <br></div> <h2 class="ms-rteElement-H2">But Journey’s End Is Priceless: Thorough Understanding Of How To Create Organizationwide Excellence</h2> <div>Ridling says working through the exhaustive awards program has proven extremely valuable to GLC-St. James’ efforts to instill constantly advancing quality throughout their services.</div> <div><br>It was a tad taxing, she admits.<br><br></div> <div>“It’s a very arduous process that you go through to achieve this level of recognition and excellence. Our team invested a lot of time and energy. But you really learn about your organization from the inside,” Ridling says. </div> <div><br>“This is not just a surface award. This program really is an intensive look at every area of your operation to determine how to be successful,” Ridling concludes. <br><br><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em></div>In a small rural town in Missouri, set against the splendor of the Ozark Mountains, the employees of a long term care center must be celebrating. They certainly have great cause. These individuals undertook a journey—a lengthy, arduous, often exhausting and frustrating journey—so they could give their residents the very best care possible.2014-11-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1114/quality_gold_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality AwardsSpecial Feature11
Caring For Those Who Servedhttps://www.providermagazine.com/Issues/2014/Pages/1114/Caring-For-Those-Who-Served.aspxCaring For Those Who Served<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div> </div> <div>“We are always looking for opportunities to recognize the service of our veterans,” says Joel Dutton, administrator of the Maine Veterans’ Homes (MVH) in South Paris. <br><br></div> <div> </div> <div>Dutton recalls an occasion when one of MVH’s residents received an American flag from his son. The flag had been flown over the military base where his son was serving in Afghanistan. “The resident let us fly that flag at our facility on Veterans Day to recognize his own service, his son’s service, and the service of veterans within our community,” Dutton recalls.</div> <div> </div> <div><br>The mission of the Maine Veterans’ Homes is “Caring for those who served.” Embedded within this mission is the understanding that veterans are unique and that their service to their country should be honored. In a sense, every day is Veterans Day at MVH, Dutton says.</div> <div> </div> <h2 class="ms-rteElement-H2">Planning A Memorable Anniversary</h2> <div> </div> <div>As the 70th anniversary of the attack on Pearl Harbor approached, a member of a local veterans service organization mentioned he had heard that Congress had authorized the U.S. Navy to donate pieces of the U.S.S. Arizona to organizations such as veterans groups, historical organizations, and educational institutions for display and memorial purposes.</div> <div> </div> <div><img width="272" height="204" src="/Issues/2014/PublishingImages/1114/joel-and-arizona.jpg" class="ms-rtePosition-2" alt="Joel Dutton" style="margin:15px 5px;" /><br>In early 2012, Dutton began working with the Western Maine Veterans’ Advisory Committee to develop a plan to create a Pearl Harbor Memorial featuring a piece of the Arizona. The group easily gained support from U.S. Sen. Olympia Snowe (R-Maine).</div> <div> </div> <div><br>Dutton, also a veteran, was well aware that this project would not be easy as there were significant administrative hurdles to clear, but he knew it would be worth it for all the residents—each either a veteran or a veteran’s spouse. </div> <div> </div> <div><br>On Dec. 7, 2012, a metal piece of the Arizona’s deck house was unveiled during MVH’s Pearl Harbor Remembrance Ceremony and 71st anniversary of the sinking of the ship. The home’s large, multipurpose room was filled with residents, family members, community members, staff, and media. Additionally, there were several WWII veterans in attendance.</div> <div> </div> <div><br>The actions of one resident, who was stationed aboard a destroyer during the attack on Pearl Harbor, were narrated by Dutton as the resident no longer speaks. The resident was a crew member on a nearby Navy destroyer, from which he launched and piloted one of the ship’s small boats. He made several trips into the oil- and fire-filled waters around the Arizona to rescue survivors of the Japanese attack. Although suffering from advanced dementia, the resident seemed to recognize the story during the ceremony, as evidenced by his tears. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Staff Have A Mission</h2> <div> </div> <div>“Caring for those who served” is something the staff at MVH do with pride. With five other veterans homes in Augusta, Bangor, Caribou, Machias, and Scarborough, MVH provides skilled nursing and long term care for Maine’s veterans and their spouses. <br><br></div> <div> </div> <div>After hearing countless stories of veterans’ selfless service and sacrifice, it is easy to see why the staff of more than 1,100 employees at MVH are committed to providing quality care and services. </div> <div> </div> <div><br>The homes regularly participate in veteran-centered events. Several of the homes also partner with their local newspapers to spotlight veterans in a Veteran of the Month feature that tells the resident’s stories and service. Families of the residents also get involved in this feature and bring in photos and memorabilia to display.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2">State And Local Partnerships</h2> <div> </div> <div>MVH works closely with the Bureau of Maine Veterans’ Services and the state’s legislative leaders to assist veterans and their families in claiming military service medals that the veterans weren’t even aware they had been awarded.</div> <div> </div> <div><br>The Scarborough home also partners with a nearby middle school during the school year. For several hours each week, the students and veterans socialize. Sometimes it is a group setting, and sometimes it is one-on-one interaction. The veterans learn what today’s students experience and how technology has transformed how they navigate life. </div> <div> </div> <div><br>Some students even assist the veterans with various forms of technology, enabling them to better communicate with their family and friends outside the home.</div> <h2 class="ms-rteElement-H2"> Quality Award Achievers </h2> <div>All six homes, with 640 total beds, have been recognized by the American Health Care Association/National Center for Assisted Living National Quality Award program. <br></div> <div> </div> <div><br>This year three of the homes, Machias, Scarborough, and South Paris, received the Silver Award. In 2012, the Caribou home received the Bronze Award, as did the Augusta and Bangor homes in 2010.</div> <div> </div> <div><br>“Recognizing the unique needs of veterans and providing them with programs that you typically don’t encounter at other facilities is what really sets us apart,” says Col. (Ret.) Kelley Kash, MVH chief executive officer. “There is a strong sense of camaraderie, not only for our residents, but also for our employees, as the military banter is catching.”</div> <div> </div> <div><br>Additionally, MVH was recognized as one of the 2014 Best Places to Work in Maine by the Maine State Council of the Society for Human Resource Management. This program was designed to identify, recognize, and honor the best places of employment in Maine.</div> <div> </div> <div><br>“MVH’s success is directly attributable to every employee’s unwavering commitment to our mission,” says Kash. “I think our staff take pride in going the extra mile for our residents because they are very aware of the commitment our veterans made to serve our nation.”</div> <div> </div> <h2 class="ms-rteElement-H2">States Support Their Veterans Homes</h2> <div> </div> <div>Each state in the union has at least one state veterans home. There is a common misperception that the homes are part of the U.S. Department of Veterans Affairs (VA). Instead, many of the more than 150 homes across the country operate as part of their state’s government, receiving a portion of funding through VA. Levels of care range from adult day care to skilled nursing.<br><br></div> <div> </div> <div>In Maine, MVH will be celebrating Veterans Day this year with a number of special activities. </div> <div> </div> <div>Residents of the center will ride in a parade in an MVH bus designed with a flag wrap, and some residents will be taken out for special Veterans Day meals at local restaurants. </div> <div> </div> <div><br>Of course, each home holds its own ceremony to honor veterans, open to the public, with guest speakers and music. </div> <div> </div> <div><br>Staffing during a holiday like Veterans Day can be difficult for any facility, but not MVH. Being a part of their special day is just one of the ways staff care for those who served. <br><br><em>Joel Dutton is administrator and Jeff Roosevelt is the former director of public relations at the Maine Veterans’ Homes in South Paris. Dutton can be reached at (207) 743-6300 or <a target="_blank" href="mailto:jdutton@mainevets.org">jdutton@mainevets.org</a>.</em><br></div>The mission of the Maine Veterans’ Homes is “Caring for those who served.” Embedded within this mission is the understanding that veterans are unique and that their service to their country should be honored. In a sense, every day is Veterans Day at MVH.2014-11-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1114/feature_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn11
Using Data To Drive Quality Improvementhttps://www.providermagazine.com/Issues/2014/Pages/1114/Using-Data-To-Drive-Quality-Improvement.aspxUsing Data To Drive Quality Improvement<div>The QAPI feature that will be the focus of this article is something with which many providers struggle—effectively using data. The QAPI feature reads: Using data to not only identify quality problems, but to also identify other opportunities for improvement and then set priorities for action.</div> <h2 class="ms-rteElement-H2">Relationship To Bronze Criteria</h2> <div>Recognizing that the effective use of data can be a difficult concept for many organizations, the Bronze criteria focus on the basics to help providers build a foundation of important facts. The Bronze criteria ask that Bronze applicants simply list their key sources of comparative and competitive data that are available from within and from outside the health care industry, as well as list any limitations that affect their ability to obtain or use these data. Listing data sources and limitations requires providers to consider the availability and use of data in the organization.<br><br></div> <div>Applicants at the Bronze level are also required to report one health care-focused outcome that was improved through their established performance improvement system.<br><br></div> <div>Other important facts that should be reported in the Bronze application reflect the foundation of the applicant’s business, which sets the context for examiners as they evaluate the maturity of processes required at the Silver and Gold levels.<br><br></div> <div>For example, the Bronze criteria ask applicants to do the following:<br><br></div> <div>■ Define your main health care services;</div> <div>■ Define your core competencies (the abilities and skills that are critical to your organization’s success);</div> <div>■ Describe your workforce, including different employee groups and volunteers;</div> <div>■ List the applicable health and safety regulations and accreditation, certification, or registration requirements with which your organization must comply;</div> <div>■ List your key patient, resident, family, and other customer groups and define the key requirements and expectations of each group;</div> <div>■ Identify your key strategic challenges and advantages (factors that may hinder or help your organization achieve success); and<br></div> <div>■ List your techniques for fact-based evaluation and improvement of key processes.<br><br></div> <div>The data and information listed above directly support the QAPI feature of this article, namely to use data to not only identify quality problems, but to also identify other opportunities for improvement and then set priorities for action.</div> <h2 class="ms-rteElement-H2">Relationship To Silver Criteria</h2> <div>At the Silver award level, applicants are asked to discuss how they measure, analyze, and then improve organizational performance. They must describe how they review organizational performance by using data and information at all levels and in all parts of the organization and how they use comparative and customer data to support decision making. This includes both the effective use and analysis of data. </div> <div>The Performance Excellence Criteria, like the QAPI framework, assert that measurement and analysis of performance are required for good decision making at all levels of an organization. <br><br></div> <div>Organizations must determine which measures relate to the organizational outcomes and strategies they have defined as important. This includes health care outcomes, but also could encompass business outcomes such as administrative and process performance, competitive or collaborative comparisons, customer satisfaction, and governance and compliance results. Outcome measures should also tie directly to the accomplishment of the organization’s strategic objectives.<br><br></div> <div>Senior leaders must be able to extract larger meaning out of the data and information for their analyses to be truly useful. This may include determining trends, projections, and cause-and-effect relationships that might not otherwise be evident. In high-performing organizations, data support evaluation, decision making, improvement, and innovation.<br><br></div> <div>Also, when reviewing the maturity of an organization’s systems and processes, examiners for both the Silver and Gold applications base their analyses, in part, on the factual background information reported in the Bronze application, such as basic health care services, core competencies, employee groups, applicable health and safety regulations, and accreditation requirements. <br><br></div> <div>They also look at key patient or resident groups and their key requirements and key elements of the center’s performance improvement system.</div> <h2 class="ms-rteElement-H2">Relationship To Gold Criteria </h2> <div>Gold recipients must demonstrate all of the principles and requirements laid out for Silver recipients, and more. In Gold recipient organizations, organizational decision making, continuous improvement, and innovation are supported by the use of data and information. Fact-based analyses support effective decision making, which enables the organization to improve continually.<br><br></div> <div>Gold recipients support their patient-focused culture through the effective use of voice-of-the-customer and market data and information. Patients, families, and residents benefit when the organization has a deep understanding of their needs and requirements and sets priorities based on what is most important to them. Senior leaders use data to track both daily operations and overall organizational performance in addition to developing and monitoring specific strategic objectives and action plans. Effective use of performance measures and analysis of findings helps the organization set and achieve high-performance improvement goals and also identify opportunities for innovation. </div> <h2 class="ms-rteElement-H2">Nursing Center Results</h2> <div>Maryruth Butler, executive directorof Kindred Nursing and Rehabilitation - Mountain Valley, Idaho, shares the following story on behalf of the center’s journey to achieve the Gold National Quality Award in 2011.</div> <div>Kindred, Mountain Valley, quickly realized that going through the three-level process toward the Gold award was educationally rewarding, Butler says.<br><br></div> <div>“The senior leadership team continues to recognize issues before becoming problems, effectively determines the root cause when problems arise, and applies the appropriate process improvement steps for long-term solutions.”<br><br></div> <div>Staff learned their most essential lessons when responding to the Baldrige criteria and reviewing the examiner feedback on the effectiveness of their use of data in driving desired quality outcomes, Butler says. <br><br></div> <div>One area that has been an industry focus is reducing hospital readmissions. Butler says that as Kindred, Mountain Valley, developed its strategic objective to reduce hospital readmissions by 8 percent in 2013-14, staff identified the sources of data to be monitored, how often they needed to be monitored, what benchmark data to use, and the format to communicate their progress. </div> <div> </div> <div><em>Barbara Baylis, RN MSN, vice president of clinical services at Sava Senior Care Consulting, is a nurse executive accomplished in clinical and quality improvement systems. She serves as an AHCA/NCAL Quality Award Examiner as well as a member of the Quality Award Board of Overseers. Mark Blazey, PhD, is a leading expert in the application of the Baldrige criteria for performance excellence. Blazey is currently serving as a member of the AHCA/NCAL Quality Award Panel of Judges and is a member of the Quality Award Board of Overseers.</em></div> This is Part 2 in a periodic series of articles linking the Centers for Medicare & Medicaid Services (CMS) impending Quality Assurance and Performance Improvement (QAPI) procedures with the requirements of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) National Quality Award Program.2014-11-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1014/trophies_t.jpg" style="BORDER:0px solid;" />QualityColumn11
Congress Gears Up For Lame Duck Sessionhttps://www.providermagazine.com/Issues/2014/Pages/1114/Congress-Gears-Up-For-Lame-Duck-Session.aspxCongress Gears Up For Lame Duck Session<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><div style="text-align:center;"><img src="/Issues/2014/PublishingImages/1114/coverstory.jpg" class="ms-rtePosition-4" alt="" style="margin:5px;" /></div> <div> </div> <div>Americans will have voted by the time some <em>Provider</em> subscribers read this article. But for many providers, the critical votes may come after this year’s elections. It has become a feature of modern political life that the post-election sessions of Congress, while the old guard waits to give way to the new, are the most frenetic periods in the legislature. Whomever uses the phrase “lame duck,” in other words, hasn’t seen the circling falcons. </div></div> <div> </div> <div>Consider: Last year, Congress came the closest it has in years to coming up with a permanent solution to Medicare’s physician pay rate. The annual ritual of self-abuse known as the so-called “doc fix” looked like it might be over after both parties agreed (in principle, at least) to replace the Medicare sustainable growth rate with a bill that would have given doctors a small raise over a number years.</div> <h2 class="ms-rteElement-H2">Heading Toward Crisis</h2> <div>The plan couldn’t get traction, a victim of Washington’s continuing slipperiness, but Sen. Ron Wyden (D-Ore.) has promised that he’ll work with Republican counterparts to revive a permanent fix this year. </div> <div>In fact, the work has already begun, U.S. Rep. Kevin Brady (R-Texas) tells <em>Provider</em>. <br><br></div> <div>“We can’t not do it,” he says. “Nearly half the doctors in my state are already refusing to take Medicare patients, and I’m sure, if you look around the country, you’ll find similar numbers. We’re heading toward crisis.”<br><br></div> <div>Brady adds: “The way we’re doing it isn’t sustainable. And if we’re really going to come up with a permanent solution in the lame duck, we have to start laying the groundwork for it now.”</div> <h2 class="ms-rteElement-H2">Can’t Take Sides, But Can’t Ignore, Either</h2> <div>Brady chairs the Health Subcommittee on the House Ways and Means Committee. But, he, too has a critical vote coming in the lame duck session. He has already announced his candidacy to chair Ways and Means. He’ll be taking on U.S. Rep. Paul Ryan (R-Wis.), one of the GOP’s biggest stars (as well as one of the House’s most respected members).<br><br></div> <div>Ways and Means is critical to providers because of its vast jurisdiction over tax and economic policy. Brady, also respected by members on both sides of the aisle, is soft-spoken (especially for a Texan), but he’s no lightweight: He chairs Congress’ Joint Economic Committee, one of four standing committees made up of members from both sides of Congress.<br><br></div> <div>Many experts see Brady as a long-shot against Ryan. But, as so often happens in Washington, watching the debate itself unfold can be profitable. Ryan is thought by many to have national aspirations. And, like Brady, he is taken seriously by his political enemies because he puts a lot of critical thinking behind his proposals. (Ryan, for instance, is one of the first conservative Republican congressional leaders to argue seriously about fighting poverty through social welfare.) <br><br></div> <div>The arguments the two men have as they campaign may well frame the Republican party’s direction on critical questions such as Medicare and Medicaid for the next Congress and beyond, experts say. </div> <div>It’s a post-election race that many providers won’t take sides in, but certainly can’t ignore.</div> <h2 class="ms-rteElement-H2">No Champion, But Heroes Emerging</h2> <div>Like many groups in Washington, long term and post-acute care providers lack a champion—a congressman or -woman who will fight tooth-and-nail for the sector in the same way, say, that some lawmakers can be reliably counted on to defend against gun control.</div> <div><br>But provider advocates have been working hard to cultivate “heroes,” says Clifton Porter II, senior vice president of government relations at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL). </div> <div><br>Provider advocates are still fighting against an age-old reputation as places where old folks go to die, badly, Porter says. But advocates hadn’t helped themselves by simply fighting against cuts to their sector, he adds. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Building Credibility</h2> <div>Over the past few years, provider advocates have changed their approach, and now offer themselves—in advertising but also in fact—as “the solution” to health care woes, Porter says. “It’s a differentiator for us in the health care space,” he says. “It builds credibility for us.” </div> <div><br>Over the course of the summer and fall, provider advocates have invited dozens, if not hundreds, of congressmen and -women into their centers. And opening congressional eyes to how frail skilled nursing residents are, and how well they’re cared for in those centers, is worth its weight in legislative gold, Porter says. </div> <div><br>“I’ve never done a tour where the [lawmaker] was not positively shocked and surprised by how much we do and how well we do it,” Porter says. Meanwhile, short-stay residents and their families are scoring their satisfaction surveys into the 90 percentiles, Porter says. </div> <div><div> </div> <div><div>Add a high-turnover population of happy customers to newly converted lawmakers, and the sector is “creating a multiplier effect.” </div> <h2 class="ms-rteElement-H2">Go On Offense</h2></div></div> <div>Returns are early, but constructive engagement appears to be paying off. By targeting specific lawmakers for specific legislative issues, not only have provider advocates been able to ward off slash cuts, but they’ve been able to advance some goals of their own—from provider agreements in the Department of Veterans Affairs to bills reforming or scrapping observation stays in hospitals (see <a href="/Issues/2014/Pages/1114/The-Pantheon-Congressional-Profiles.aspx" target="_blank">congressional profiles</a>). </div> <div>Indeed, earlier this year, AHCA/NCAL President and Chief Executive Officer Mark Parkinson urged his colleagues to “go on offense.” </div> <div><br>Advocates have actually hammered out their own bipartisan coalitions on matters and have found heroes behind them as diverse as Sen. Wyden in Oregon and <a href="/Issues/2014/Pages/1114/Rep-Jackie-Walorski.aspx" target="_blank">Rep. Jackie Walorski</a> (R-Ind.).</div> <h2 class="ms-rteElement-H2">IMPACT Act</h2> <div>In fact, providers had one of their biggest victories in years this year, when Congress passed the IMPACT Act. IMPACT requires the federal government to come up with quality measures across the different modes of post-acute care services. </div> <div><br>Provider advocates backed IMPACT in and of itself, but also saw it as the camel’s nose under the tent, leading inevitably to a site-neutral system. </div> <div><br>Wyden saw the bill as proof that both parties can work together.</div> <div><br>“This bipartisan bill is an important and welcomed accomplishment in our quest to provide patients, consumers, and the federal government the best tools for evaluating the quality of care patients receive and the way our health care dollars are spent,” Wyden said at the time.<br><br></div> <div>“It’s also an example of how members of Congress from both parties and both Houses can come together to address an important need. I’m looking forward as we build on this experience to achieve additional reforms.”<br><br></div> <div>Among those invited to the White House in October for the IMPACT Act’s signing was AHCA/NCAL’s Parkinson. </div> <h2 class="ms-rteElement-H2">Slow, Deliberate Path</h2> <div>A permanent doc fix will certainly be on the agenda this fall. Experts say that its passage is a long shot, but the point—for advocates—is to show that they’re engaged and not simply putting their hand out every couple of years. <br></div> <div><br>“It’s a very, very slow, deliberate path,” AHCA/NCAL’s Porter says. “But we want to demonstrate that we’re the answer—offering the best care at the best price.”</div> <div><br>In fact, provider advocates aren’t just waiting for events to overtake them. Already, AHCA/NCAL has convened a select committee of leaders, hoping to come up with a payment model that saves money without crippling care. </div> <div><br>“We want to be ahead of the curve,” AHCA/NCAL Senior Vice President of finance policy and legal affairs Mike Cheek told assembled leaders at the Provider executive roundtable held in conjunction with the AHCA/NCALconvention in National Harbor, Md.,this year.</div> <h2 class="ms-rteElement-H2">‘How Can We Change The Program?’</h2> <div>Once there, provider advocates may be surprised how willing politicians will be to greet them. </div> <div>“I was a governor for about 10 years,” says <a href="/Issues/2014/Pages/1114/Sen-John-Hoeven.aspx" target="_blank">Sen. John Hoeven</a> (R-N.D.).<br><br></div> <div>“What I tried to do is go to the health care providers and the long term care providers and say, how can we change the program so that we can cut costs and improve care?<br><br>“I think that’s true at the state level, and I think you’ve got to do it at the federal [level]. They’re the experts. How can we enable them to do what they do so well?”<span style="display:inline-block;"></span></div>Americans will have voted by the time some subscribers read this. But for many providers, the critical votes may come after this year's elections.2014-11-01T04:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1114/coverstory_thumb.jpg" style="BORDER:0px solid;" />Policy;CaregivingCover Story11




Art is Ageless And Inclusivehttps://www.providermagazine.com/Issues/2014/Pages/1214/Art-is-Ageless-And-Inclusive.aspxArt is Ageless And Inclusive<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​<img width="283" height="212" src="/Issues/2014/PublishingImages/1214/art1.jpg" class="ms-rtePosition-1" alt="" style="margin:10px 15px;" />It began as a thought that gave rise to a question: Assuming artistic expression stimulates the mind, body, and spirit, how might an art program be designed to meet the needs not only of high-functioning long term care residents, but those with cognitive and physical impairments? <br></p> <p>And so began a conversation during the care planning process that grew into a pilot project that eventually blossomed into Middlesboro Nursing and Rehabilitation Facility’s Artistic Enrichment Program, winner of the Kentucky Association of Health Care Facilities’ 2013 Innovation in Care Award. <br></p> <p></p> <div>Developed by Activities Director Christy Bean and Assistant Director Charmaine Moore in November 2010, the well-designed therapeutic program aims to reach all residents at the facility. </div> <h2 class="ms-rteElement-H2">Focus On Individuality</h2> <div>The objective is not only to provide fun activities through art, but to focus on the creative journey individuals, regardless of ability, undergo during the artistic process. Goals aren’t set, they’re individually met. No expectations or boundaries are placed on residents, because the intent of the program is not to create “fine art,” but to create art by fine people. </div> <div><br>The center’s artistic enrichment program requires its activities staff to invent projects that encourage creativity; stimulate memories, emotions, and imagination; foster self-expression; reduce stress and dementia-related behaviors; and provide the sense of personal achievement and independence that leads to increased communication, confidence, and healing in residents spanning the spectrum of cognitive and physical ability. </div> <div><br>One way the activities staff achieve this is by encouraging residents to work with a variety of mediums that allow for success, not frustration and failure. Thus, residents with reduced cognitive function who are unable to follow simple directions, or “stay within the lines,” so to speak, are still able to tap into their own creativity by using paint mixed in spray bottles, a process that results in unique and colorful abstract paintings. They might hold blow-dryers, which necessitate less manual dexterity, to melt crayons on canvas to make colorful collages, or use celery stalks as paint stamps to create rose bouquets.</div> <div><br>Tissue paper can be used to make stained glass and chalk or oil to create pastel drawings. Male residents particularly enjoy using hammers and nails to stamp antique cars on solid sheets of aluminum. Higher-functioning residents pursue ongoing projects that can take four weeks to complete. As in a regular art class, they learn techniques such as line, shading, and depth.</div> <div><br>Activities directors do not need to be artists to generate unique projects. Pinterest offers a wealth of ideas, as does the work of famous artists easily accessed on websites and Google. Moore, for example, showed residents paintings by Georgia O’Keefe, whose abstracts capture the emotion and power of natural objects (most notably, flowers and barren Southwestern landscapes). Residents then turned their eyes on the landscapes of their own experience to convey their own abstract art. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Activities Enhance Skills</h2> <div>Soon the center’s occupational therapist recognized that artistic enrichment projects can help residents improve fine motor skills, hand-to-eye coordination, sequencing, dexterity, and powers of attention in a fun and rewarding way. Stroke patients benefit from the opportunity to strengthen their non-dominant sides or hands through adaptive equipment. </div> <div><span><img width="196" height="262" src="/Issues/2014/PublishingImages/1214/art2.jpg" class="ms-rtePosition-2" alt="" style="margin:15px 5px;" /></span><br>There have been many “ah-ha” moments, reassuring activities staff that their vision for the program has been realized. One involved a 98-year-old resident, whose only family, her son, resides in California. Because he is able to visit only twice a year, she spends much of her time thinking of ways to make his visit all the more special. Enter the Artistic Enrichment Program, which allowed her to spend months in her room painting a beautifully shaded horse to give her son as a gift. When he arrived, she felt not only the joy that comes from time spent with family but the thrill of accomplishment. </div> <h2 class="ms-rteElement-H2">Program Expands To Community</h2> <div>But the Artistic Enrichment Program’s target audience is not confined to residents only. Family members, volunteers, and staff also participate, as do members of the larger community. <br><br></div> <div>For example, art students from nearby Lincoln Memorial University, in Harrogate, Tenn., have assisted Middlesboro Nursing residents with various projects, an outreach initiative that has proven to be an entertaining social event for residents, and an eye-opening and educational experience for young adults who leave the facility with new-found awareness that art is ageless.</div> <div><br>The local Girl Scout troop visits the facility to learn about art from the residents and earn special badges for their participation. And in the evenings, employee children come to the center to work on art projects with residents.</div> <div><br>The program also serves as a unique marketing tool for the facility. When prospective residents and their families arrive for tours, they find resident artwork displayed throughout the building, either in showcases or in photos streaming across the Activity Department’s Smart TV bulletin board.</div> <div><br>Photographs of artwork and articles about the program also appear in Middlesboro Nursing’s newsletter and on the Activity Connection website. The walls of Administrator Alice Maddox’s office display professionally framed resident artwork as well. The message signaled to visitors is loud and clear: The minds, emotions, spirits, and imaginations of residents can thrive here. <span><span><img src="/Issues/2014/PublishingImages/1214/art4.jpg" class="ms-rtePosition-1" alt="" style="margin:20px 15px;" /></span></span></div> <h2 class="ms-rteElement-H2">Consumers Take Notice </h2> <div>Thanks to the innovative program, Middlesboro resident artists have become celebrities in the larger community, too. When a local young woman sought donations for an auction to be held to raise relief money for tornado victims in Missouri and Oklahoma, residents got busy. Their artwork was so well-received that the residents have since established a Community Benefit Fund financed primarily with sales of resident art projects. </div> <div><br>“Future projects include an art show at the local mall and hosting an art class with an area church that teaches community art classes,” Bean says. </div> <div><br>Ultimately, Middlesboro’s Artistic Enrichment Program can serve as a source of inspiration for activities staff at other long term care facilities. “Art provides the perfect venue for communication and expression, fun and smiles,” says Bean. “There should be no boundaries restricting residents with cognitive impairments from participating in art programs, or limitations when it comes to the tools they can use for creativity and expression.”</div> <div><br>A successful art program does not require an actual artist on staff, Bean says. With research and Internet<span><em><img width="104" height="130" src="/Issues/2014/PublishingImages/1214/AliceMaddox.jpg" alt="Alice Maddox" class="ms-rtePosition-2" style="margin:5px;" /></em></span> access, all facilities can access tools and project ideas. “Art enrichment requires no talent, but allows residents to uncover the emotions that help them to tap into their imaginations. The result is improved communication skills, increased confidence, and, ultimately, healing.” <br><br><em>Alice Maddox is administrator of Middlesboro Nursing and Rehabilitation Facility in Middlesboro, Ky. She would like to thank Elizabeth Lamont, PhD, for assistance in editing this article.<br><br></em></div> <p></p>Developed by Activities Director Christy Bean and Assistant Director Charmaine Moore in November 2010, the Middlesboro Nursing and Rehabilitation Facility’s Artistic Enrichment Program aims to reach all residents at the facility. 2014-12-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1214/art_t.jpg" style="BORDER:0px solid;" />By You, For You;QualityColumn12
A Younger Resident Finds Her Place In A Caring Communityhttps://www.providermagazine.com/Issues/2014/Pages/1214/A-Younger-Resident.aspxA Younger Resident Finds Her Place In A Caring Community<div>Imagine yourself as a person in her early 40s coming to a nursing facility for rehabilitation. When I came through the door I was pleasantly surprised. What I had in my mind as an “old folks home” quickly became a place where real people worked, lived, and seemed like a family. </div> <div> </div> <div>After I went home and had to come back again for more rehabilitation, I knew where I wanted to go. I knew I didn’t want to burden my family, and if I couldn’t be home, I wanted to be here at Carillon Nursing and Rehabilitation Center. In the back of my mind, I didn’t want to admit that I would ever need to be in a nursing home. It was a difficult decision, but my health was failing, and I had no choice. More importantly, I wanted to be in the hands of people who I knew and trusted. </div> <h2 class="ms-rteElement-H2">Freedom To Choose</h2> <div>When the times come to talk about my care, I am fully involved and make decisions about how I am cared for and what my preferences are. Family and friends can come and go, there’s no restriction on visiting me, I am given the choice to get up when I want and go to bed when I want. <br><br></div> <div>I felt depressed in the beginning, knowing that I wouldn’t be going home, but the nurses, doctors, and all of the people who work in the departments helped me come through it. <br><br></div> <div>What I want everyone to know is that a long term nursing home can be a place where a young person can feel alive. I found myself becoming involved in activities and making longlasting friendships. A nursing home has to adjust its regular schedules for someone like me, and Carillon has. We don’t play Bingo every day, we have beautiful parties, Wii Games, socials. Playing Black Jack, trivia games, and cooking programs here are better than a nap any day. Sometimes I get together with a special friend, and we enjoy a meal together. </div> <h2 class="ms-rteElement-H2">Finding A New Outlet</h2> <div>The staff listen to me, and when I ask, they always try to accommodate my dialysis schedule so I can be a part of the things I enjoy. They suggested that I become part of the Nursing Home Leadership Group, where we meet at each other’s nursing homes. We talk about our rights and how we can accomplish changes in nursing homes all around. I like having a voice that is heard, and this group has a voice. This makes me feel independent, as I travel to other homes in the community. <br><br></div> <div>In a place where 315 people live, my privacy is respected, and I can always decide if I want to be with others or find a quiet corner to read a book.<br><br></div> <div>I have had to learn to deal with other residents that may not be so friendly and just accept them as they are. I found that when I came to this realization, life got better. It’s not so hard to take people as they are, say hello, and go about my day. </div> <div><br>If you told me 20 years ago I would have ended up in a nursing home, I wouldn’t have believed it, let alone thought I would actually enjoy it. And I do. </div> <div> </div> <div><em>Ida Cuomo is a resident at Carillon Nursing and Rehabilitation Center in Huntington, N.Y.</em></div> When the times come to talk about my care, I am fully involved and make decisions about how I am cared for and what my preferences are. Family and friends can come and go, there’s no restriction on visiting me, I am given the choice to get up when I want and go to bed when I want. 2014-12-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1214/IdaCuomo_t.jpg" style="BORDER:0px solid;" />By You, For You;Caregiving;Management;QualityColumn12
20 Years Really Doesn’t Bring That Much Change—Does It?https://www.providermagazine.com/Issues/2014/Pages/1214/20-Years-Really-Doesn’t-Bring-That-Much-Change—Does-It.aspx20 Years Really Doesn’t Bring That Much Change—Does It?<div>Flashback! It’s April 1995 and I am writing an article for a large long term care (LTC) publication titled the “Grassroots Training of a Young Administrator.” In this article I would be sharing what I felt were critical attributes to becoming a successful nursing home administrator after completing a year-long administrator-in-training course by a leading company in LTC. Yep. Back then we still called them nursing homes. </div> <img src="/Issues/2014/PublishingImages/1214/JohnVrba_t.jpg" alt="John Vrba" class="ms-rtePosition-2" style="margin:15px 5px;" /><br><div>Flash to today. Today I sit here typing this letter as an independent owner of a post-acute/skilled nursing facility. </div> <div> </div> <div>One thing I can tell ya: Live for today, as tomorrow is promised to no one, whether in your personal or professional lives. So, we all know we are in a new age of health care, but the foundation for operating a quality post-acute/skilled nursing facility (SNF) really hasn’t changed, has it?</div> <h2 class="ms-rteElement-H2">What Builds A Strong Foundation</h2> <div>Back in 1995 I wrote that textbooks provide you an education, but solid “hands-on” training is what gets you out of the shallow end of the pool and into the deep end and jumping off the high diving board!<br></div> <div>I also wrote that the need for cooperation and communication across departments stood out as paramount. These days, as back then, any reference to a “team approach” in the SNF-post-acute sector tends to sound like a cliché, but teamwork is exactly what it was all about in 1995, and the same stands true today almost two decades later.</div> <div><br>If you know you have that within your facilities walls, good for you. If you are not quite sure or think you have it somewhat, try harder—do not accept less. If you know you don’t have strong teamwork, it may be time to change some players on the field. Everyone needs to be focused on one thing and one thing only—quality care in a compassionate environment. </div> <div><br>Back in 1995 I wrote that my belief was that more administrators need to get out from behind their desks and interact (boy, that word sure sounds familiar) and listen to their residents, patients, family members, and staff. It’s ironic, but that is our mission statement today: “We will take care of the residents, patients, families, and staff...and the rest will take care of itself.” </div> <div><br>Back in 1995 I wrote about how much I learned about positive reinforcement and how vital it is to the staff member who often ends up doing the most distasteful and challenging work, yet tends to receive the fewest rewards or appreciation. Teach others to take time to walk in another person’s shoes before taking the easy way out and judging them.</div> <h2 class="ms-rteElement-H2">Remember To Be Human</h2> <div>So yes, health care has changed exponentially! But the foundation for the current leaders and future leaders of health care in 2015 and beyond hasn’t changed—and I venture it never may. The individual touch, the lending of an ear, the dropping to a knee to speak with someone in a wheelchair, the handwritten thank you note (okay, or email/text) is better than nothing, the note under the windshield wiper saying, “Thank you—what you did today really made a difference.” The golden rule is: “Treat others as you would like to be treated.” So easy to say but often not so easy to do.</div> <div><br>I am truly afraid that this ever-changing world of health care is becoming too much about technology and metrics and less about the human touch. All the metrics, all the technology, all the programs—they all contribute to successful outcomes, and they definitely enhance our care delivery system—but the true outcome will always be quality care and compassion. What sets the top echelon apart is the human touch.</div> <div>Health care is one rewarding calling, and I thank each of you for dedicating your career to serving others! <br><br><em>John Vrba is chief executive officer of Burgess Square Healthcare and Rehab Centre, Westmont, Ill. He is also president of the Illinois Health Care Association.</em><br></div>Live for today, as tomorrow is promised to no one, whether in your personal or professional lives. 2014-12-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1214/JohnVrba_t.jpg" style="BORDER:0px solid;" />By You, For You;ManagementColumn12
A Lake Is Like A Mirrorhttps://www.providermagazine.com/Issues/2014/Pages/1214/A-Lake-Is-Like-A-Mirror.aspxA Lake Is Like A MirrorA lake is like a mirror;<br>it reflects the mood of the sky.<br>When the clouds are dark and threatening<br>the lake has anger in its eye.<br>But when the sky is clear and blue<br>and the sun is shining bright,<br>the lake’s a thing of beauty,<br>its face with radiance alight!<br><br>And so it is with people;<br>your personality shines through.<br>Your thoughts and deeds are never hidden,<br>because they’re reflected back to you<br>in the thoughts and deeds of others<br>who react in the same way.<br>Thus we have the power to set the mood <br>for every passing day!<br><br><span><em><img width="169" height="150" src="/Issues/2014/PublishingImages/1214/poetry_Peterson.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 10px;" /></em></span><em>It is the reason we do what we do. Be inspired by the gifts, talents, and history of the long term care <br><br>residents and assisted living tenants who live in your organizations. Seek their passions, glean their wisdom, and admire their resiliency. </em><br><br><em>At 100 years old, Dr. Allan Peterson, a tenant of The SUMMIT Assisted Living, is a soft-spoken gentleman whose life experiences quickly captivate the listener. A professor of entomology, Dr. Peterson describes how a well-placed original poem, in a lecture, would be just the secret to keep a college student on his toes. It is no wonder his classes were bulging at the seams with engaged students as Dr. Peterson’s published works are as inspiring and interesting as he. </em><br>It is the reason we do what we do. Be inspired by the gifts, talents, and history of the long term care residents and assisted living tenants who live in your organizations. Seek their passions, glean their wisdom, and admire their resiliency. 2014-12-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1214/poetry_lake_Peterson_t.jpg" style="BORDER:0px solid;" />By You, For YouColumn12
Care Has Been Constant, But Data A New factorhttps://www.providermagazine.com/Issues/2014/Pages/1214/Care-Has-Been-Constant,-But-Data-A-New-factor.aspxCare Has Been Constant, But Data A New factorCaring for the frail and elderly has remained a near constant, but the manner and means of analyzing care is constantly revolving, and is changing everything for everyone, a diverse group of provider executives agree. <br><br>Convening <em>Provider’s</em> Executive Roundtable, Van Dyk Health Care President and Chief Executive Officer (CEO) Bob Van Dyk noted that “data seems to be king.”<br><br>“Can I assume that’s pretty much across the board, all of us are finding ourselves collecting data that perhaps in the past we never really paid much attention to?” he asked his colleagues. <br>Most agreed. <br><br>“I have been in the profession for many years, and I think our care has not changed a lot,” Sterling Healthcare CEO Bob Hagan said.<br><br>What has changed, though, is the demands of regulators for several different streams of information, Hagan said. “We’re a medium-sized company,” he said. “Having that ability to collect the data and put it out in the different ways that each of the different managed care [organizations] and [what] the state <br>wants is, I think, one of the biggest changes I’ve seen in the way we have to make an investment.”<br><br>The executives, gathered at the American Health Care Association/National Center for Assisted Living Annual Convention & Expo in October, largely acknowledged that they were beefing up their information technology departments to meet the demands of the Information Age. But while tech has been a great resource, it has created its own challenges, some of the executives said. <br><br>“I think one of the challenges is just when you engage these various products that they integrate with each other, so that you are not just working with three different systems that don’t talk to each other. And it is very costly,” Vetter Health Services’ Chief Financial Officer (CFO) Joani Schelm said. <br><br>There doesn’t seem to be any consensus about how to build those vital tech elements, though. Welcov Healthcare President and Chief Operating Officer (COO) Thomas Boerboom created his company’s own tech department earlier this year after discovering that outsourcing wasn’t answering Welcov’s needs, “and we really found that in order to get what we wanted, we needed to bring it in-house.”<br><br>Sterling’s Hagan decided simply to hire a different consultant. The key is to be patient, he said.<br>“I had to hire a smarter person than I was,” Hagan said. “We had been with the same software company for about 15 years … but they could not keep up with the demand at all.“<br><br>The transition has been “tough, very tough” on staff, “but it is coming together,” Hagan said. <br>The key to any tech moves, Prestige Care President and COO David Henderson said, is “to have a software company that will listen to the provider and make changes, because they’re not in the business [of operating] a nursing home.”<br><br>Care Initiatives Vice President and CFO Steve Marlow said that his company has decided to take its tech investments beyond regulatory requirements and put a lot of money into going on offense.<br><br>“What we’ve tried to do is really focus our investments now around analytics,” Marlow said. “So we’re doing a lot more in trying to mine our own data in preparation for some of the new payment model issues that are coming, like the bundled payment program.... Now, whether or not we ultimately go that far is still way up in the air, but we want to be in the position to know our data ourselves” before it becomes a government demand or issue.<br><br>Data analysis can also become part of frontline care, Vetter Health COO Patrick Fairbanks said. <br>“We’ve added additional nurse assessment coordinators’ support … to make sure that we are getting the right data going into it,” he said. “We’ve also hired a couple of health information managers at the home office level that … help us in understanding what is the right system that we should be using.”<br>In fact, good data analysis can put providers in a great position to capitalize on the revolutions in health care, Welcov Vice President Sharon Thole said. <br><br>“I think the hospitals don’t necessarily have a good strategic plan right now because their payment systems are all over the place,” Thole said. “So they’re looking at what their provider networks are going to look like, and who they want to line up with, and who is going to have those outcomes to help them.”<br><br>The opportunities may be an unintended consequence of the creeping spread of managed care, Avamere CEO John Morgan said. <br><br>“So you can call it whatever you want—ACO, NCO, CCO, ABCDO—they all have a similar flavor. And so they’re all very much about managing that total episode of care, trying to do it most  efficiently.<br><br>“And I think what we are trying to do is to come to them and find out where their bottlenecks really are,” he said. “And it’s been very interesting how that tide has shifted. Our relevance, in their minds, has gone up pretty dramatically, and so it’s not like you have to struggle to get an appointment these days.”Caring for the frail and elderly has remained a near constant, but the manner and means of analyzing care is constantly revolving, and is changing everything for everyone, a diverse group of provider executives agree. 2014-12-01T05:00:00Z<img alt="" src="/Issues/2014/PublishingImages/1214/roundtable_t.jpg" style="BORDER:0px soli