March 2017

Vol. 44 No. 3

March

Cover Story

Technology Comes Of Age In The LTC World

https://www.providermagazine.com/Issues/2017/March/Pages/Technology-Comes-Of-Age-In-The-LTC-World.aspx

Technology Comes Of Age In The LTC World

<div>Long term care and technology are becoming more comfortable partners in the drive to improve the lives of seniors and to create new economic efficiencies.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><img src="/Issues/2017/March/PublishingImages/CS.jpg" class="ms-rtePosition-1" width="188" height="258" alt="" style="margin:15px;" /><br>But the form of this push for high-tech solutions is moving beyond just the latest advances in software for electronic health records (EHRs) and telemedicine to other specialized fields, like sensor technology.</div> <div> </div> <div> </div> <div> </div> <div>It is here, experts say, that real promise is being shown in advancing from relatively basic sensors that track heart rates and oxygen flows to more precise and in-depth health monitoring for seniors living independently and in skilled nursing care or assisted living communities.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">What Sensors Can Do</h2> <div> </div> <div> </div> <div> </div> <div>The goal of sensor technology is to allow clinicians an early peek at possible future chronic illnesses for those not yet under full-time care. <br><br>Then, later it can be an unobtrusive companion in a facility setting to detect falls; measure restlessness while sleeping; and keep nurses, doctors, and residents and their families informed with the latest cutting-edge data.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Sensors and tracking programs like imaging technology are by no means the norm in every skilled nursing care or assisted living community, but the hardware does represent another option for providers to consider.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Sensors Deliver Data</h2> <div> </div> <div> </div> <div> </div> <div>Sensor technology developers say the up-front cost of buying their creations is well worth it, as the aim is to make quality of care better and cheaper in the long run. They point to new-generation hardware that allows not only for the increased safety of the elderly, but also the ability to collect data that will benefit individual seniors and the broader long term care community. </div> <div> </div> <div> </div> <div> </div> <div><br>In seeking a closer look at these tools, it makes sense to start with the University of Missouri. This is where sensor research and development have a home base, considering that the school’s innovative multidisciplinary Center for Eldercare & Rehabilitation Technology and real-life seniors’ health research “laboratory” Tiger Place (named after the school’s mascot) are here. </div> <div> </div> <div> </div> <div> </div> <div><br>Researchers working across the nursing, engineering, and computer fields at the university have come together to dig into the issue of how sensors and imaging hardware can be used to keep seniors living independently for longer durations than was previously possible. And, once in a facility-based setting, the hardware attached to software in EHRs can improve residents’ lives by tracking chronic conditions more ably.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">New Vistas </h2> <div> </div> <div> </div> <div> </div> <div>Some examples of these projects—which have won grant awards from the Centers for Medicare & Medicaid Services (CMS), the National Institutes of Health, the National Science Foundation, and the Agency for Healthcare Research and Quality (AHRQ), among others—include subjects like Linguistic Summarization of Sensor Data for Early Illness Recognition in Eldercare, EAGER: An In-Home Health Alert System with Remote Care Coordination, and Technology to Automatically Detect Falls and Assess Fall Risk in Seniors Housing.</div> <div> </div> <div> </div> <div> </div> <div><br><img src="/Issues/2017/March/PublishingImages/MarilynRantz.jpg" alt="Marilyn Rantz" class="ms-rtePosition-1" style="margin:5px 10px;" />Current and past research at the university is attempting many different things, but the overarching goal is to set benchmarks for those studied at Tiger Place and elsewhere for gauging how sensors and imaging can shift the quality and cost dynamics, says Marilyn Rantz, curators’ professor emerita, nursing lead, <br>School of Nursing at the University of Missouri in Columbia. </div> <div> </div> <div> </div> <div> </div> <div><br>“When Tiger opened [in 2004], we hoped that we would have infrastructure in place to test the development of sensor technology…to give us technological solutions to help people age in place,” Rantz says.</div> <div> </div> <div> </div> <div> </div> <div><br>“So two years before Tiger opened, I went to the College of Engineering and said, ‘We need you to help us and come on this journey.’ I did a presentation and challenged them to build technology to help address the complicated problems of aging, because as a researcher I’ve seen the same problems essentially throughout the whole 40 years of my nursing career.” <br></div> <div> </div> <h2 class="ms-rteElement-H2"> Typical ‘Senior Problems’ </h2> <div> </div> <div>Those “same problems” revolve around functional decline, incontinence, malnutrition, and cognition slippage. </div> <div> </div> <div> </div> <div> </div> <div><br>“Many of us had been researchers who had attempted to define good solutions to those problems, but really over the long haul, we have not made much of an impact,” Rantz says.</div> <div> </div> <div> </div> <div> </div> <div><br>But when the engineering department stepped forward, notably in the form of Marjorie Skubic, PhD, then things started to happen, she says. Skubic is Rantz’s longtime co-conspirator of sorts in seeking technological advances to aid seniors. She is the director of the eldercare center and a professor of electrical and computer engineering at the University of Missouri, Columbia.</div> <div> </div> <div> </div> <div> </div> <div><br>Over the past decade plus, the two, along with others at the school and across the country, have advanced the case for sensors. In the initial days of their work, the team at Missouri developed methods for automating a new depth image sensor, since patented, which focuses on fall detection and fall-risk technology.</div> <div> </div> <div> </div> <div> </div> <div><br>“We did an interesting grant that was funded by AHRQ where we looked at radar technology, and Marge had a hit at the same time on a National Science Foundation grant. So we combined our efforts and installed at Tiger a whole battery of different potential sensors to do the fall-risk assessment and measure it simultaneously while we were doing a clinical trial on measuring fall risk against standardized instruments that you typically used to measure fall risk,” Rantz says.</div> <div> </div> <div> </div> <div> </div> <div><br>What the pair discovered is that vision-based sensors worked better than radar-based devices for the purposes of commercialization, and that is where they continued to put their efforts as new versions of their sensors were developed over the years. The vision sensor looks like a camera with its “eye” or lens, but does not take traditional pictures as it instead “searches for measurements on distances of moving objects in front of it,” Rantz says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">The Ultimate Goal</h2> <div> </div> <div> </div> <div> </div> <div>All told, the lessons learned at Tiger Place are that one can increase the length of stay in seniors housing by 2.5 years by adding sensor technology, along with nurse care coordination, and improve lives in the facility setting.</div> <div> </div> <div> </div> <div> </div> <div><br>“It’s stunning. You can actually do this and measure this,” Rantz says. And it is not terribly expensive and will get cheaper as time moves on, she adds. “With nurse care coordination it is $300 to $350 a month to pay for sensors and the cost of storage for the data.”</div> <div> </div> <div> </div> <div> </div> <div><br>Tiger Place researchers are also working on other applications of technology for facilities. For instance, Rantz says, as part of a project funded by a CMS grant, her team is running a demonstration in 16 skilled nursing care centers. Staff in the centers are learning to use secure communication technology in addition to EHRs. Secure communication with other providers speeds up and improves the accuracy of the work of advanced practice nurses who are providing care to residents with more acute illnesses.</div> <div> </div> <div> </div> <div> </div> <div><br>“For many of [the nursing centers], the only part of the health record that is electronic is billing and for MDS in the nursing home setting. And assisted living is even further behind,” Rantz says. But her team has encouraged the centers to start using secure communication methods and portals to capture EHR <br>information to straighten out medication records when a person goes back and forth to the hospital. “And they’re getting up to speed,” she says.</div> <div> </div> <div> </div> <div> </div> <div><br>The research team also is working on assisted living applications. It is installing sensors so that automated alerts from the data become part of the normal workflow to inform staff decision making. With the sensors helping them, staff can detect increasing fall risk and health changes two to three or more weeks before the resident falls or has a serious change in health that requires hospital care.</div> <div> </div> <div> </div> <div> </div> <div><br>“These are new ideas for clinical staff. At first they react with a healthy dose of skepticism, but after awhile they come to rely on [general] fall-risk alerts, health alerts, and real-time alerts of falls detected by the sensors,” Rantz says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Technology Evolves </h2> <div> </div> <div> </div> <div>From the engineering side, it has been important to make the technology as invisible as possible to the user, Skubic says. Her research team began by using simple motion sensors, coupled with a basic sensor (about an inch wide and several inches long, flexible, and about one-quarter inch thick) that was positioned on top of a mattress under the person’s upper torso, which was not ideal as far as keeping the sensor hidden. The sensor detected energy changes from the person and transmitted it as a wave form that could be analyzed. </div> <div> </div> <div> </div> <div> </div> <div><br>In the case of Skubic’s work of caring for the elderly, the first such sensors deployed on tops of beds and allowed researchers to gauge whether bed restlessness, qualitative heart rates, and respiration rates were low, normal, or high. But the system in use today has evolved and improved with a much better bed-sensor device that is now placed below the mattress, making it less obtrusive. “Some residents had complained,” Skubic says.</div> <div> </div> <div> </div> <div> </div> <div><br>These newer sensors also do much more than their predecessors, giving quantitative measurements of pulse rates, respiration, and restlessness.</div> <div> </div> <div> </div> <div> </div> <div><br>“These are actual heart and respiration rates, and through the data you can see clear ballistocardiogram signals of people as they sleep without the sensor having any contact on the body,” she says. The term ballistic refers to the mechanical effect of the blood flowing through the body. It is similar to the well-known electrocardiogram that most people are familiar with, which measures the electrical activity in the heart. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Data Predict Fall Risk</h2> <div> </div> <div> </div> <div> </div> <div>The Missouri researchers also have been using depth cameras, or depth sensors. These produce a depth image wherein each pixel of the image is measured for its distance to the nearest object.</div> <div> </div> <div> </div> <div> </div> <div><br>“We use that depth sensor to track people. And what we get is a three-dimensional silhouette of people moving around” protecting privacy as the image is not overly detailed, Skubic says. “From that we can compute walking speed, gait parameters, walking time, stride time, stride length, and sway, which sometimes represents balance issues.”</div> <div> </div> <div> </div> <div> </div> <div><br>These walking measurements and movement data are invaluable in determining if fall risk is on the rise for patients. “Of course we would like to eliminate falls,” she says. “So if you know somebody is at increasing risk of falling, then if you can get them some kind of intervention, and usually as this has something to do with balance issues, then you can prevent the fall. We also do automated, immediate fall detection using these same depth sensors, so that people don’t end up lying on the floor for a long period of time.”</div> <div> </div> <div> </div> <div> </div> <div><br>There are other ways these and related sensors can give nurses and other clinicians very early warnings to potential health problems. An example Skubic gives is that sensors indicate when somebody may have a urinary tract infection (UTI). This can be detected through analysis of the sensor data and imaging because some of the many signs of UTI complications, even before they become a full-blown infection, are related to gait and bed restlessness, as well as more frequent use of the bathroom.</div> <div> </div> <div> </div> <div> </div> <div><br>“By monitoring with these motion sensors, it is pretty easy to detect changes in behavior,” she says. “We have caught congestive heart failure because of sleeping patterns, as another example. It is all about breaking the cycle of rehospitalization, which is where these conditions, if not caught, will likely lead.”<br></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">A Company Is Born</h2> <div> </div> <div> </div> <div> </div> <div>The commercial offshoot of the work being done at the University of Missouri is in the control of George Chronis, PhD, chief executive officer and co-founder of Foresite Healthcare in St. Louis, Mo., which started operations in 2013. The company markets products on an exclusive basis from the work done at the university for, among other things, the early detection of strokes and fall prevention, Chronis says. </div> <div> </div> <div> </div> <div> </div> <div><br><img src="/Issues/2017/March/PublishingImages/GeorgeChronis.jpg" alt="George Chronis" class="ms-rtePosition-1" style="margin:5px 10px;" />Foresite has two products for two different platforms. One, called Foresight Patientcare, is for acute care, and another, Foresite Eldercare, is for assisted living, skilled nursing, and memory care centers, as well as independent living, Chronis says.</div> <div> </div> <div> </div> <div> </div> <div><br>The Eldercare platform consists of the actual sensors, the computer software to turn the data collected by the devices into actionable medical information for a patient, and the services that connect the technology to medical staff. The goal of the product is to increase both resident safety and the length of stay for patients at their current level of care.</div> <div> </div> <div> </div> <div> </div> <div><br>“So if you are in independent living you stay there. If you are in assisted living, you stay there as long as possible,” he says.</div> <div> </div> <div> </div> <div> </div> <div><br>The way the technology works is by having the system of sensors installed, which range from motion sensors to bed sensors to imaging sensors and through these devices collect data over long periods of time. This in turn, Chronis says, allows the system to create algorithms via artificial intelligence (AI). </div> <div> </div> <div> </div> <div> </div> <div><br>AI allows for the analysis of the data that can compare changes over time so that caregivers can look for patterns in patients’ medical conditions and behaviors.</div> <div> </div> <div> </div> <div> </div> <div><br>“When such matches between the changes of data are found, then the system will issue an illness alert to the health care professionals,” Chronis says. This allows the nurse or doctor to go into the system and look at what these changes are and potentially discover how they have affected the health of other residents in the past. These benchmarks can lead to better care coordination via <a href="/archives/2017_Archives/Pages/0317/EHR-Coordination,-Standards-A-Possible-Plus.aspx" target="_blank" title="EHR Coordination, Standards A Possible Plus">shareable EHRs</a> as issues arise and are documented.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">A Big Plus For Patients</h2> <div> </div> <div> </div> <div> </div> <div>The combination of having data from sensors for use on the clinical side is where patients can benefit with better and smarter care, and where providers can save money from getting to a problem before it blossoms into something much more serious.</div> <div> </div> <div> </div> <div> </div> <div><br>“The effect we have seen from this technology in length-of-stay statistics is that the stays have more than doubled, almost tripled. We have seen studies by our clients that have shown length of stay moving from 1.8 years to over four years,” Chronis says.</div> <div> </div> <div> </div> <div> </div> <div><br>Like any technology, the sensors have an up-front cost. “But you don’t have to wait too long to see the [return on investment],” he says. “Say you are in independent living and have to have a home nurse: a costly service, present five hours a day for assistance at $20 an hour, which is the typical rate. It is much more efficient and cost-effective [to have] a system like this that can send data and monitor remotely for $200 a month. If it turns out a nurse is needed, they can take it from there.”</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Home Monitoring Assistance </h2> <div> </div> <div> </div> <div> </div> <div>Another player in the commercialized sensor space is Right at Home, which provides in-home monitoring services, according to Mike Flair, vice president of franchise business solutions. He says the company offers two different remote care systems through its partnership with Philips: Well-Being Monitoring service and Routine Check-In service.</div> <div> </div> <div> </div> <div> </div> <div><br>“The Well-Being Monitoring consists of small sensors placed in key areas of the home based on a client’s normal activity. When changes in pattern are examined, Right at Home will contact the client for a well-being check,” he says.</div> <div> </div> <div> </div> <div> </div> <div><br>The Routine Check-In service also schedules virtual, face-to-face visits with clients on a provided tablet in order to engage in light social interaction as well as note mental awareness and hygiene. “At the moment, we have more clients participating in the Well-Being services,” Flair says.</div> <div> </div> <div> </div> <div> </div> <div><br>For seniors not yet in need of skilled nursing or other supervised living, the sensors allow for individuals to live independently in their homes, yet still keep their family members and care providers aware of their health.</div> <div> </div> <div> </div> <div> </div> <div><br>As for privacy concerns or the devices disrupting normal life, Flair notes that feedback from users and their families has been “very positive,” since the technology works for such an important purpose.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Putting IT Into Perspective </h2> <div> </div> <div> </div> <div> </div> <div><img src="/Issues/2017/March/PublishingImages/GregAlexander.jpg" alt="Greg Alexander" class="ms-rtePosition-1" style="margin:5px 10px;" /><br>Bringing technology to bear in health care and, more specifically, in long term care, is something that Gregory Alexander, PhD, a nursing school professor at the University of Missouri, Columbia, has been examining for years. His work has delved into many different aspects of the issues of why technology in long term care has lagged, with the obvious reasons being tight profit margins, along with a lack of executive leadership and a workforce to manage sophisticated systems. </div> <div> </div> <div> </div> <div> </div> <div><br>“I don’t think it is just money. For example, there are differences in for-profit and not-for-profit [long term care providers],” Alexander says. “The not-for-profits tend to have greater sophistication of IT than for-profit, but we don’t necessarily know why.” </div> <div> </div> <div> </div> <div> </div> <div><br>It is also not as easy to say there is better technology in more urban skilled nursing care centers or assisted living communities vs. their rural counterparts, with some rural operators quite ahead of the pack on bringing technology into their daily operations. It just depends on whether the leadership of a center or chain makes technology upgrades a priority or has experience in tech-related work. </div> <div> </div> <div> </div> <div> </div> <div><br>But there are monetary and market-based incentives, like referrals from acute-care hospitals, to avoid rehospitalizations and other medical problems, Alexander says. Citing an initiative in Missouri to improve quality, he says communication and tracking of patients is at the center of the effort, be they with sensors and EHRs or solely <a href="/archives/2017_Archives/Pages/0317/EHR-Coordination,-Standards-A-Possible-Plus.aspx" target="_blank">EHRs and sharing the documents of care</a>.</div> <div> </div> <div> </div> <div> </div> <div><br>“The overall goal is to reduce avoidable readmissions. Both hospitals and nursing homes are being held accountable for readmission rates,” he says. “If we can eliminate them, it helps both sides of the equation.”</div>

Long term care and technology are becoming more comfortable partners in the drive to improve the lives of seniors and to create new economic efficiencies.

2017-03-01T05:00:00Z

Setting The Stage For 2017	https://www.providermagazine.com/Issues/2017/March/Pages/Setting-The-Stage-For-2017.aspx	Setting The Stage For 2017	<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div></div> <div><img src="/Issues/2017/March/PublishingImages/NICFeature.jpg" class="ms-rtePosition-2" alt="" style="margin:5px 15px;" /><br>A lot happened in 2016. It was a year that will go down in the history books as extraordinary.</div> <div><br>Political and economic disruptions (Brexit and the unexpected U.S. election results among them) occurred both globally and domestically. There were several significant shifts—in politics and the economy; in attitudes regarding globalization’s benefits and costs; and in the availability of debt and the cost of capital, particularly with interest rates.</div> <div><br>Seeds of change were planted in the skilled nursing and post-acute care sector, as well, with the ongoing movement away from fee-for-service to value-based payment systems. </div> <div><br>All in all, these changes—whether one considers them to be good or not so good—have set the stage for 2017. This article provides a broad overview of current conditions and serves as a backdrop for the seniors housing and care sector this coming year.</div> <h2 class="ms-rteElement-H2">The Good… </h2> <div>For starters, the economy is in good shape, by many measures. With 5.5 million unfilled job openings, an average of 180,000 jobs being created every month, and an unemployment rate of 4.7 percent as of December 2016, the labor market is close to full employment.</div> <div><br>Since the low point of the recession in 2010, more than 15 million jobs have been created in the U.S. economy, and the jobless rate is half its peak of 10 percent in October 2009. Over the past 12 months, health care alone has generated 407,000 jobs. </div> <div><br>Consumer confidence is strong. The housing market continues to improve. The stock market has established new highs. And largely as a result of gains in the value of real estate and in equities, household net worth rose by more than $1 trillion in the second quarter of 2016, to a record peak of $89 trillion. </div> <div><br>While a lot of those gains have gone to higher-end households, incomes have risen for all households as well. Indeed, inflation-adjusted median household income rose by 5.2 percent in 2015, the largest increase since at least 1968, while the poverty rate fell to a post-recession low (although it remains uncomfortably high at 13.5 percent, compared with 11 percent in 2000).</div> <div><br>For households headed by someone 65 or older, inflation-adjusted median household income rose by 4.3 percent in 2016, less than the 7 percent gain achieved by those households headed by someone aged 34 to 45, but better than the decline of 1.2 percent seen by the older cohort in 2014. </div> <h2 class="ms-rteElement-H2">…And the Bad</h2> <div>On the less bright side are broad measures of economic growth, such as Gross Domestic Product, which grew at a less than 2 percent annualized rate for nearly one year. </div> <div><br>Productivity growth has also been disappointing, averaging less than 1 percent over the past five years. The labor force participation rate remains at levels last seen in the 1970s, due in part to the retirement of baby boomers. </div> <div><br>Wage growth has also been relatively weak, despite a tightening of the labor market. Average hourly earnings grew by 2.8 percent in 2016, higher than the increase of 2.3 percent in 2015 and 2.1 percent in 2014.</div> <div><br>Increases in minimum wage rates in many states and tightening labor markets may start to put further upward pressure on this measure of earnings. Anecdotally, operators of seniors housing and care properties are reporting upward pressures on wage rates, a significant concern since labor expenses often account for two-thirds of an operator’s aggregate expenses. </div> <div><br>And finally, financing costs are rising, although they still remain low by historical standards. The 10-year Treasury bond fell to a record low of 1.3 percent in the immediate aftermath of Brexit last June, and as of Feb. 7, 2017, it stood at 2.4 percent. </div> <h2 class="ms-rteElement-H2">Seniors Housing, Skilled Nursing Trends</h2> <div>With regard to broad trends in the seniors housing and care sector, the NIC MAP® Data Service has timely and relevant measures to gauge recent performance and set the stage for 2017.</div> <div><br>At the national level, the seniors housing sector appears to be in equilibrium. Occupancy has oscillated around 89.8 percent for the past three years. Despite the run-up in construction and the delivery of roughly 36,000 seniors housing units since late 2013 in the nation’s largest 31 metropolitan area markets, demand has largely matched new supply. Moreover, asking rent growth continues to improve and recently reached its highest pace in this cycle. </div> <div><br>At the local level, the data show that not all markets are created equal. In some instances, markets are booming, as in San Jose, Calif., while others are not, such as in San Antonio. As with any real estate, it’s all about location, and, subsequently, it’s all about local market area supply and demand conditions.</div> <div><br>Influencing factors related to supply conditions include the availability of labor, natural and regulatory barriers to entry, entitlement procedures, and the competitive landscape. And for demand, influencing factors often include the concentration and number of adult children and retirees, income levels, net worth, home ownership rates, the velocity of home sales and prices, and broad-based employment conditions and drivers.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Challenges For Skilled Nursing</h2> <div>For skilled nursing, NIC’s third-quarter 2016 Skilled Nursing Data Report, released in December, showed that monthly occupancy remained low, at 82.5 percent in September, up slightly from the five-year low of 82.3 percent in July, but below the recent high of 85.6 percent rate achieved in February 2014.</div> <div><br>There are a number of care delivery and reimbursement initiatives that have continued to play a role in the decline of occupancy, including the increased penetration of managed Medicare (that is, Medicare Advantage).</div> <div><br>For example, acute care providers, managed care payers, and conveners have initiatives in place to divert skilled nursing referrals to home health and other community-based care settings. In addition, patients that are referred to skilled nursing are managed by payers to reduce length of stay, which creates a reduction in Medicare and managed care days. </div> <div><br>Adding to the operational challenges has been the decline in rates from increased enrollment in managed Medicare plans, which has given more pricing power to insurance companies to negotiate reimbursement rates with providers.</div> <div><br>In fact, according to NIC’s data, there has been an 11.6 percent decrease in managed care rates, from $498.65 in September 2011 to $440.78 in the third quarter of 2016. </div> <div><br>Skilled mix, which represents mostly Medicare and managed care residents, continued its downward trend in the third quarter, declining from 24.4 percent in June of 2016 to 23.8 percent most recently. This was driven by the low third-quarter Medicare mix, which was most likely attributable to fewer Medicare patient days. Since higher reimbursement rates are associated with skilled mix, the downward pressure on this mix could influence profitability.</div> <h2 class="ms-rteElement-H2">Change Is In The Air</h2> <div>More broadly, change is the operative word for 2017 with regard to skilled nursing. Despite the change in administration from President Obama to President Trump, it is likely that the push toward value-based purchasing and away from fee-for-service by the Centers for Medicare & Medicaid Services will continue.</div> <div><br>The “new normal” for skilled nursing reimbursement is likely to focus on care transitions—coordinated care—that are built on a foundation of measurable quality outcomes and data sharing. Mandatory and voluntary bundles, accountable care organizations, managed long term care supports and services, and value-based purchasing for hospitals are likely to become more common. Eventually, this transition will incorporate more risk sharing on the part of health care providers. </div> <div><br>Health care reform, or the rolling back of all or some of President Obama’s signature Affordable Care Act (ACA) has been high on the list of President Trump’s stated priorities. Until the details are more fully revealed, it is difficult to determine the impact on seniors housing, although the private-pay sector is not expected to be greatly affected.</div> <h2 class="ms-rteElement-H2">Policy Changes At The Top</h2> <div>Looking ahead more broadly, November’s presidential election results have altered the outlook for the U.S. economy. While specifics are not yet known, comments to date provide clues to the policies likely to be implemented.</div> <div><br>The new administration is expected to follow a fiscally expansive policy of higher spending on infrastructure and defense, while cutting taxes. Immigration reform, a renegotiation of trade agreements, a loosening of restrictions on fossil fuel production, and an overhaul of the ACA are already priority policy changes.</div> <div><br>When all is said and done, President Trump’s policies are just unfolding. Their economic impact will be repeatedly digested, studied, and assessed by analysts in the months and years ahead. Certainly, a critical question that remains on the table is how the federal government will pay for increased spending on infrastructure and defense, while reducing tax rates, without significantly raising the U.S. budget deficit (a key Republican stance). Budget pressures will make it all the more challenging for the government to maintain entitlement programs such as Social Security and Medicare. Stay tuned! </div> <div><img src="/Issues/2017/March/PublishingImages/BethMace.jpg" alt="Beth Burnham Mace" class="ms-rtePosition-1" style="margin:15px 10px;" /><br><br> </div> <div><em>Beth Burnham Mace is chief economist for the National Investment Center for Seniors Housing & Care (NIC). She can be reached at bmace@nic.org.</em></div>	A lot happened in 2016. Seeds of change were planted in the skilled nursing and post-acute care sector with the ongoing movement away from fee-for-service to value-based payment systems.	2017-03-01T05:00:00Z	<img alt="" src="/Issues/2017/March/PublishingImages/NicFeature_t.jpg" style="BORDER:0px solid;" />	Column
OIG Puts Bull’s-Eye On Rehospitalization	https://www.providermagazine.com/Issues/2017/March/Pages/OIG-Puts-Bull’s-Eye-On-Rehospitalization.aspx	OIG Puts Bull’s-Eye On Rehospitalization	<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div></div> <style> .ExternalClass p.MsoNormal, .ExternalClass li.MsoNormal, .ExternalClass div.MsoNormal { margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:Calibri; } .ExternalClass a:link, .ExternalClass span.MsoHyperlink { color:blue; text-decoration:underline; } .ExternalClass span.MsoHyperlinkFollowed { color:purple; text-decoration:underline; } .ExternalClass .MsoChpDefault { font-size:11.0pt; font-family:Calibri; } .ExternalClass .MsoPapDefault { margin-bottom:10.0pt; line-height:115%; } .ExternalClass div.WordSection1 { } </style> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">According to the Office of Inspector General (OIG) 2017 <a href="https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf">work plan</a>, rehospitalizations will be under increased scrutiny in the coming year. This focus is rooted in the alarming findings of a 2014 OIG study on <a href="https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf">adverse events in nursing homes</a>, which found that in just one month Medicare spent nearly $2.8 million on hospital treatments for harm caused by poor nursing care. Even more startling than the cost, many of the adverse events were “clearly or likely preventable” (OIG, 2014, p. 22). The findings have led the OIG to focus its 2017 initiatives on preventing adverse events and avoidable hospitalizations, in addition to improving state survey oversight and bolstering the terms of payment for Medicare residents. </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b> </b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>The Cost of Adverse Events and Avoidable Hospitalization</b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">The 2014 OIG study, <a href="https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf"><i>Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries</i>,</a> looked at <span style="color:black;">Medicare beneficiaries with post-acute SNF stays of </span><span style="color:black;">≤ </span><span style="color:black;">35 days ending in August 2011 and found that approximately one in five experienced at least one adverse event during their stay, amounting to 22% (p. 17).</span> Disturbingly, an <span style="color:black;">estimated 1.5% of </span><span style="color:black;">the study group<span>—</span>1,538 residents—<span>experienced adverse events that contributed to their deaths (p. 19). An estimated 4%, or </span>3,986, <span>experienced at least one “cascade” adverse event, wherein multiple, related events occurred in succession.<i> </i></span><span>An additional 11% experienced events during their SNF stays that resulted in temporary harm (p. 20). </span></span>The OIG found that hospitalizations associated with adverse events (including those related to medication, resident care, and infection) totaled over 20,000, costing $207,979,213. The good news is that since this study was conducted, the overall rate of <a href="https://blog.cms.gov/2017/01/17/data-brief-sharp-reduction-in-avoidable-hospitalizations-among-long-term-care-facility-residents/">hospitalizations has declined by 13%</a><span class="MsoHyperlink"><span style="text-decoration:none;"> (Brennan & Engelhardt, 2017)</span></span>. </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>Preventable Clinical Errors </b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">CMS has identified bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, and chronic obstructive pulmonary disease as the most common preventable causes of hospitalization. The OIG study found that of the estimated 22% of Medicare beneficiaries who during their SNF stays experienced adverse events and the additional 11% who experienced temporary harm events, 59% of both types of events were clearly or likely preventable. Preventable events were attributed to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care (OIG, 2014, p. 22). </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b> </b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>Understanding High Rates of Rehospitalization</b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">The OIG plans to review nursing homes with high rates of patient transfers to hospitals for potentially preventable conditions, in order to determine whether these nursing homes provided services to residents in accordance with their care plans. Prior OIG work indicates that high rates of patient transfers to hospitals could be the result of poor quality of care. For example, in a previous audit, a nursing facility with a high rate of Medicaid resident transfers to hospitals for UTIs was found to often fail to provide UTI prevention and detection services in accordance with its residents’ care plans (OIG, 2017, p. 10). The OIG’s initiative plans to continue to investigate factors contributing to rehospitalization. </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>The Adverse Event Screening Tool </b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">The <a href="http://www.ihi.org/resources/Pages/Tools/SkilledNursingFacilityTriggerTool.aspx">SNF Adverse Event Trigger Tool</a>, developed by the OIG with assistance from clinicians at the Institute for Healthcare Improvement (IHI), aims to improve nursing home care by improving staff’s ability to identify harm. CMS defines the tool as “a resource document that can help nursing homes evaluate systems of care around high-risk medications” (Adler, Moore, & Federico, 2015, p. 7). The tool includes a list of 24 potential adverse events in nursing homes, including those related to medication, infections, and resident care, inclusive of falls, pre-existing conditions, and proper fluids. The list also includes issues that are not common to nursing homes (such as severe gastrointestinal bleeding due to anticoagulant overdose) to promote staff awareness. The purpose of the tool is to increase staff recognition of conditions that contribute to adverse events, giving the staff the opportunity to “correct problems and reduce harm as well as to report problems contributing to events” (p. 28). The OIG plans to release the screening tool with written guidance for the purpose of disseminating practical information about the tool for use by those involved with the skilled nursing field (OIG, 2017, p. 9).</p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> <span id="__publishingReusableFragment"></span></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>State Oversight</b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">In addition to targeting rehospitalization and adverse events, the OIG also plans to focus on state survey oversight. As a follow-up to a 2006 OIG report that found that state agencies did not investigate some of the most serious complaints within required time frames, the OIG will assess these agencies’ investigative time frames, specifically for the most serious nursing home complaints. According to current regulation, all nursing home complaints categorized as immediate jeopardy and actual harm must be investigated within a 2- and 10-day time frame, respectively (OIG, 2017, p. 8). </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>Verification of Deficiency Corrections</b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">The OIG will determine whether state survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys. Correction plans for deficiencies identified during surveys are required by federal regulation. State survey agencies must verify that corrections have been made through on-site interviews or other evidence. A previous review by the OIG discovered that one state survey agency did not consistently verify corrections as required (OIG, 2017, p. 39). </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>Abuse and Neglect</b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">The OIG will also assess the incidence of abuse and neglect of Medicare beneficiaries receiving treatment in SNFs, determining whether these incidents were properly reported and investigated in accordance with applicable federal and state requirements. The OIG will also interview state officials to determine whether each sampled incident was reported, if required, and whether each reportable incident was investigated and subsequently prosecuted by the state, if appropriate. The OIG is pursuing this assessment because of ongoing OIG reviews at other settings that indicate the potential for unreported instances of abuse and neglect (OIG, 2017, p. 8). </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">The recently updated nursing home regulations require facility staff to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. This reporting should take place no later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury, and no later than 24 hours if the events do not involve abuse or result in serious bodily injury. Reporting should be directed to the facility administrator and to other officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures (<a href="https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-07.html?DLPage=1&DLEntries=10&DLSort=3&DLSortDir=descending">483.12, Freedom from abuse, neglect, and exploitation</a><span class="MsoHyperlink">; CMS, 2016</span>).</p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b> </b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"><b>Conclusion </b></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">The OIG’s focus on preventable resident harm; CMS’s increased reporting requirements for resident abuse, neglect, and exploitation; and the Nursing Home Compare Quality Measure for <i>Percentage of short-stay residents who were re-hospitalized after a nursing home admission</i> continue to put the bull’s-eye on improved care outcomes and savings to the Medicare program. Facility leaders who aren’t familiar with the <a href="https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf">SNF adverse events trigger tool</a> should find out more about it today. It just might help them avoid OIG scrutiny in 2017.</p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">References</p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">Adler, L., Moore, J., & Federico, F. (2015, November). <i>IHI skilled nursing facility trigger tool for measuring adverse events</i>. Cambridge, MA: Institute for Healthcare Improvement. Available: http://www.ihi.org/resources/Pages/Tools/SkilledNursingFacilityTriggerTool.aspx</p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">Brennan, N., & Engelhardt, T. (2017, January 17). “Data brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents.” <i>The CMS blog</i>. Available: <a href="https://blog.cms.gov/2017/01/17/data-brief-sharp-reduction-in-avoidable-hospitalizations-among-long-term-care-facility-residents/">https://blog.cms.gov/2017/01/17/data-brief-sharp-reduction-in-avoidable-hospitalizations-among-long-term-care-facility-residents/</a></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">Centers for Medicare & Medicaid Services (CMS). (2016, November 28). “Advance copy—Revisions to State Operations Manual (SOM), appendix PP—Revised regulations and tags”<i> </i>(S&C-17-07-NH). Available: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf</p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">Office of Inspector General. (2014). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. Available: <a href="https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf">https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf</a></p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;"> </p> <p class="MsoNormal" style="margin-bottom:0.0001pt;line-height:normal;">Office of Inspector General. (2017). OIG work plan 2017. Available: <a href="https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf">https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS OIG Work Plan 2017.pdf</a></p> <br><div> <br><img src="/archives/2017_Archives/PublishingImages/AANAC_Provider_Call-out_Box_RGB.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:300px;height:92px;" /><br></div> <div><em>Judi Kulus, NHA, RN, MAT, RAC-MT, DNS-CT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em></div>	According to the Office of Inspector General (OIG) 2017 work plan, rehospitalizations will be under increased scrutiny in the coming year.	2017-03-01T05:00:00Z	<img alt="" src="/Issues/2017/March/PublishingImages/mgmt_t.jpg" style="BORDER:0px solid;" />	Column
Adoption Aids In Staff, Resident Retention	https://www.providermagazine.com/Issues/2017/March/Pages/Adoption-Aids-In-Staff-Resident-Retention.aspx	Adoption Aids In Staff, Resident Retention	<div><br>Many providers struggle with retention within their organizations, but most haven’t given thought to how technology can impact employee and resident retention. </div> <div><br>Believe it or not, technology adoption equals retention, and even more so in the long term care profession. Here are three ways that technology can positively impact retention.</div> <h2 class="ms-rteElement-H2">Employee Turnover</h2> <div>Health care turnover for direct care workers is pervasive. Many new hires are millennials, and they have grown up using technology. Is the company losing employees to the local movie theatre, hot new restaurant, or a competitor?</div> <div><br>Chances are they left because they did not feel engaged. This doesn’t mean that they did not enjoy the work; however, if the company is not using technology, more than likely they were just bored. </div> <div><br>To put this into context, they left the organization for another one that they felt was a better fit for them.</div> <div><br>Think about it: How often do people check their smart phones or smart watches? For many people, there is something about a bright screen that just keeps calling. It’s not that the screen is more important than their work, it’s that they are using the screen to complete their work.</div> <div><br>Today’s workforce is conditioned to be constantly engaged with that bright screen. Need proof? Give a couple of five-year-olds tablets, load up the app that plays their favorite shows or games, and then try to get them to eat. Good luck!</div> <div><br>So why not use this propensity for technology to the benefit of the organization and, ultimately, its residents? Technology is a game changer for hiring and retaining talent. In many facilities, staff turnover continues to be a challenge, which in turn impacts quality and outcomes. Providers that drive employee satisfaction see a positive correlation with resident satisfaction.</div> <div><br>Employee turnover can be managed. By adopting technology solutions that make the organization more efficient, it can keep staff engaged in meaningful ways that help them feel like they are making a difference. </div> <h2 class="ms-rteElement-H2">Resident Care, Satisfaction</h2> <div>The long term care profession has been changing from fee for service to fee for value for some time. Competition can be found on every other corner, as well as at home, meaning that the story the company has been selling is being told similarly by the competition. What does that mean? It means that words sound good, but families want to see action, they want to see measurable data.<br><br></div> <div>If the company makes the claim, “We provide excellent care,” it must be able to provide evidence to show quality outcomes, such as a lower rehospitalization rate. If it claims, “Our residents are happy and engaged,” it needs to be able to show positive reviews as evidence of resident and family satisfaction.<br><br></div> <div>No longer can anyone assume that words alone will lead to winning and retaining business if they expect to continue to operate in this space. <br><br></div> <div>Technology can help tell the center’s story. That story includes not only words, but, more importantly, data to support those words.<br><br></div> <div>For most providers, the biggest reasons why residents leave the facility are dissatisfaction with resident care and quality of food. Think about this: Most people will drive past a conveniently located hotel or hospital to the one that has a reputation for providing the best service.<br><br></div> <div>They will drive even farther when it comes to food choices. It follows that families will do the same when it comes to caring for their loved ones.<br><br></div> <div>Perception is reality, and if a company is not controlling its reputation, someone else is. Without data, its story is merely a perception created by others. </div> <h2 class="ms-rteElement-H2">Capability Checklist</h2> <div>There are several things to consider when adopting technology to improve and document care and satisfaction. Does the company have the tools to:</div> <ul><li>Track the care given by each staff member? </li> <li>Track services delivered, both scheduled and ad hoc? </li> <li>Track time spent with each resident to provide care and later do a time study? </li> <li>Manage medication administration electronically? </li> <li>Receive medication information directly from its pharmacy? </li> <li>Use dashboards to track work flows and key performance indicators (KPIs)? </li> <li>Run ad hoc reports? </li> <li>Communicate each resident’s likes and dislikes? </li> <li>Track resident weight change? </li> <li>Analyze food costs? </li> <li>Use the data to make decisions that impact its bottom line?</li></ul> <div>Tangible data that help a business run more smoothly are evidence of the quality of care the health care center can provide to positively impact a resident’s quality of life. This makes that center more attractive than the one down the street.</div> <h2 class="ms-rteElement-H2">Increased Length Of Stay</h2> <div>There is a popular saying that “time is money.” This statement can be quantified when considering the length of stay for long-stay residents at the center, times the reimbursement/payment for each day that they are there. In long term care, increased length of stays equates to dollars and cents.</div> <div>When looking at a technology for increasing length of stay, ask does it:</div> <ul><li>Improve the quality of resident care? </li> <li>Increase the efficiency of the nursing staff through a streamlined documentation process? </li> <li>Guide clinical decision making through embedded, evidence-based practices? </li> <li>Facilitate communication with health care providers through standardized data? </li> <li>Improve clinical data integrity through the reduction of narrative </li> <li>documentation? </li> <li>Enhance quality assurance and process improvement (QAPI) programs? </li> <li>Positively impact clinical outcomes through the use of research-tested assessments and associated interventions? </li> <li>Track changes in condition through alerts allowing timely notification to physicians? </li> <li>Focus on prevention by anticipating resident risk?</li></ul> <div>If lengthening resident stay is important, then technology should be a critical part of the care center’s workflow. If technology is in place, ensure that all of the tools needed to help realize the expected outcomes are in place, and use them.<br><br></div> <div>Only a fraction of long term care providers actively and regularly utilize the technology they already have to its fullest potential. If the center’s current technology infrastructure cannot provide all of the items on the lists above, do some research and find out about the more innovative tools available in the long term care market today. </div> <div> <img src="/Issues/2017/March/PublishingImages/PatrickHart.jpg" alt="Patrick Hart" class="ms-rtePosition-1" style="margin:5px 15px;" /><br><br></div> <div><em>Patrick Hart is vice president, senior living solutions, for MatrixCare. <br>He can be reached at Patrick.hart@matrixcare.com.</em></div> <div> </div>	Believe it or not, technology adoption equals retention, and even more so in the long term care profession. Here are three ways that technology can positively impact retention.	2017-03-01T05:00:00Z	<img alt="" src="/Issues/2017/March/PublishingImages/tech_t.jpg" style="BORDER:0px solid;" />	Column
Fault Lines And Frontiers In Person-Centered, Long Term Care: Part 2	https://www.providermagazine.com/Issues/2017/March/Pages/Fault-Lines-And-Frontiers-In-Person-Centered-Long-Term-Care.aspx	Fault Lines And Frontiers In Person-Centered, Long Term Care: Part 2	<div></div> <div>When did you last notice a doctor sitting at the bedside, totally absorbed listening to the patient’s story? Danielle Ofri, MD, recalls bygone days whenever she talks with admiration of her mentors. They were white, male doctors in starched shirts and bow ties, schooled in lily white settings.</div> <div> </div> <div>“Their old-fashioned doctoring made them approach the bedside as a sacred act,” Ofri says. “They examined each patient—whether a homeless Ecuadorian alcoholic, a veiled Muslim woman, or a visiting Swiss diplomat—with a thoroughness that in itself exuded respect.” </div> <div> </div> <div>She speaks of Dr. Spenser, blustering in style but who coached young medics-to-be on compassion. He would drag a metal stool to the exam table, swivel it down to the lowest level, and sit on it with his head level to the exam table. Then he would say, “Whenever you speak to a patient, you seat yourself at the patient’s level or lower. You never hover over them high and mighty. They are the ones who are sick. They run the interview, not you.”</div> <h2 class="ms-rteElement-H2">Eclipse Of The Art Of Relating</h2> <div>A kind caregiver whose eyes bespeak concern, whose touch conveys compassion, and whose words reassure, does more than just communicate; kindness and caring speed up recovery and hasten healing more surely than does the cold potency of the formulary. </div> <div><br>Institutional medicine is quick to report that 70 percent of the avoidable, massive acute-care damage inflicted on patients is caused by miscommunication. Such analysis is typical of the biomedical mindset—it skirts the real issue; it begs the question.</div> <div><br>Advances in communication make the world flatter and smaller, and social contact easier than ever. Why then is miscommunication epidemic in health care? The answer is obvious. The communication revolution helps us to connect easily, but it does not help us to relate meaningfully. Relations are the soul of health care. But human contact is turning cold and sterile.</div> <h2 class="ms-rteElement-H2">The Art Of Listening</h2> <div>Surveys of residents, families, and staff are commonplace in long term care (LTC). But the art of listening is in eclipse. Many policies, regulations, and programs are elegantly designed and aimed to benefit LTC residents. But we sadly watch many of these residents flicker, flame out, or linger on as cooling embers. <br><br>Too many LTC initiatives are born of logic that is not always in sync with what beneficiaries want and need.</div> <div>Regrettably, LTC discourse on culture-change is loud in tone, light in theory, and lax in its phraseology. My disappointment sparked a research interest, which in turn resulted in a book I co-authored with my wife, Mary Tellis-Nayak: “Return of Compassion to Healthcare.” Importantly, we reviewed what we had heard from residents, family, and staff in annual surveys—several million respondents over 15 years.</div> <div><br>We asked, “Who is the person in person-centered care?” All lines of inquiry converged on the humanist axiom, which we summarized as follows: Five primal yearnings make us human and endow us our inalienable rights: to be, to become, to belong, to be our best, to reach beyond.</div> <h2 class="ms-rteElement-H2">History’s March Toward Human Rights </h2> <div>These five “Bs” are what make us human. However, many societies throughout history have not recognized select groups as humans, including women, children, slaves, and ethnic outsiders.</div> <div><br>Our forebears paid a heavy price in blood and treasure before reaching a consensus about the humanity that is our ultimate birthright. We believe the five Bs distill the content and spirit that fueled history’s major upheavals—those whose intent was to clarify and ensure that birthright:</div> <ul><li>Milestones in democracy: Magna Carta, Emancipation Proclamation, Women’s Suffrage. </li> <li>Revolutions: American (“life, liberty, happiness”); French (liberty, equality, fraternity); Russian (You have “nothing to lose but your chains”). </li> <li>Religions: Christianity (We are “made in the image and likeness of God”; “People of God”); Hinduism (“Atman is Brahman”); Islam (“All the born are born with the God-given nature”). </li> <li>Caregiver oath: “First, do no harm.” </li> <li>Humanist precept: Maslow, Frankl, Adler (“Our humanity is the measure in all things”). </li> <li>International consensus: 193 signatories to the United Nations declaration of human rights.</li></ul> The five Bs encapsulate the primal yearnings intrinsic to a person, whatever the context or circumstance. We take inspiration from the great humanitarian, Albert Einstein, who advised, “Remember your humanity, and forget the rest.” We propose that the five Bs serve as a preliminary touchstone for new understanding of human yearnings—especially of those under our care. <br> <div><br>The skeletal outline that follows narrowly focuses on LTC residents and is meant to illustrate how the five Bs could be a “GPS” that pinpoints our person-centered destination and guides us on an assured route.</div> <h2 class="ms-rteElement-H2">Five Self-Evident, Inalienable Rights</h2> <ol><li>To Be: To live in a risk-free setting, safe, without fear of injury from medication error, abuse, under-staffing, inadequate infection control, substandard wound care. To live without pain and to die in dignity. </li> <li>To Become: To be respected for your unique self; to participate in care decisions and day-to-day choices; to have ready access to all your health records. To maintain self-reliance and maximize self-care. </li> <li>To Belong: To lead a fulfilling social life, to bond with caregivers and to be mutually supportive of fellow residents; to stay connected to family, children, animals, nature, and the outside world, real and virtual. </li> <li>To Be Your Best: To grow mentally and spiritually as a person; to use your skills to advise, to teach, to mentor; to display your talent and use it to entertain fellow residents; to find meaning in suffering, and to make disabilities and illness a teacher. </li> <li>To Reach Beyond: To find joy in serving others, to be part of resident council, of an advisory group that plans menus; to comfort those in pain and in hospice; to be a foster grandparent.</li></ol> <div>Heed what the residents, families, and staff say, and what they yearn for. Always honor their humanity. That will keep you on the high road in pursuit of life, liberty, and happiness. </div> <div> </div> <div><em>V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, 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. He can be contacted at vtellisn@gmail.com.</em></div>	Advances in communication make the world flatter and smaller, and social contact easier than ever. Why then is miscommunication epidemic in health care?	2017-03-01T05:00:00Z	<img alt="" src="/Issues/2017/March/PublishingImages/blog_t.jpg" style="BORDER:0px solid;" />	Column

March 2017

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