With the tidal wave of people living to old age comes a plethora of serious chronic conditions that must be managed. Most older adults have at least two or more such conditions, including diabetes, heart disease/stroke, and cancer. These conditions can lower quality of life, lead to a wide array of complications, and even shorten lifespans.

So when these patients come into post-acute and long term care centers, the care team must be able to identify what conditions they have, what risk for complications and readmissions they pose, and what interventions are most likely to maximize outcomes and quality of life.

What’s at Stake

Managing serious chronic diseases can help reduce costly hospital readmissions that may introduce new problems for patients, maximize functioning, and enable patients to live better longer.

Policymakers have come to realize the attention chronic illnesses require of practitioners and other caregivers. These concerns led to provisions in the Patient Protection and Affordable Care Act of 2010 to add preventive services to Medicare, including cancer screenings and immunizations. The act’s provisions are designed to prevent debilitating diseases, or at least detect them early when treatment is most likely to be effective.

In essence, managing diseases in skilled nursing care centers requires a holistic approach that balances treatments with preventive measures and a care plan based on the patient’s wishes, needs, goals, and expectations, according to Daniel Haimowitz, MD, CMD, a multifacility medical director in Levittown, Pa. Disease management programs not only pursue the optimal clinical outcome, but also the most cost-effective outcome for a specified patient population.

Managing chronic diseases involves a continuous improvement process that has the ability to identify, measure, and evaluate outcomes. To successfully address chronic diseases, the care team needs to understand the standards of care for these conditions, as well as stay on top of new medications and other treatment interventions.

Specializing in chronic disease state management is becoming more common for skilled nursing centers across the country.

Three of the most common chronic diseases seen in skilled nursing centers are diabetes, heart disease/stroke, and cancer. Examining some recent news, research, and trends regarding these conditions can help facilities establish and update management programs and care standards.


Corralling a Costly Disease
Type 2 diabetes is rampant among the elderly. In long term care alone, the prevalence ranges from 25 percent to 34 percent, according to an article in Diabetes Care from the American Diabetes Association (ADA). This high rate is likely due to age-related physiological change, including increased abdominal fat, sarcopenia, and immobility.

The ADA article also notes that diabetes comes with a hefty price tag (an estimated $19.6 billion for treating diabetes patients in long term care annually). It also increases the risk of cardiovascular and microvascular complications, as well as the likelihood for geriatric syndromes such as cognitive impairment, depression, falls, persistent pain, and urinary incontinence.

Individualized diabetes care is the gold standard in nursing care centers, where tight control and strict dietary restrictions often aren’t the norm. Last year, ADA published a position paper on “Management of Diabetes in Long-term Care and Skilled Nursing Facilities.” Among the paper’s recommendations:
  • Hypoglycemia risk is the key factor to determine glycemic goals in this population. In fact, hypoglycemia, or low blood sugar, is the leading limited factor in type 1 and insulin-treated type 2 diabetes. Factors increasing the risk of hypoglycemia in older adults include impaired renal function, slowed hormonal regulation and counterregulation, varying appetite/nutrition intake, polypharmacy, and slow intestinal absorption.
  • While more attention is focused on hypoglycemia, goals should aim at minimizing hyperglycemia, or high blood sugar, as well. Hyperglycemia increases the risk of dehydration, electrolyte abnormalities, urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome.
  • Simplified treatment regimens are preferred and better tolerated. Use of sliding scale insulin (SSI), a process of administering insulin dosages based on specific blood glucose readings, should be avoided when possible.
  • Restrictive therapeutic diets should be minimized in this patient population to avoid dehydration and unintended weight loss.
  • Physical activity/exercise is important and should be individualized according to each patient’s functional level and risk factors.
The paper notes that care goals for these patients should be established on admission. Patients’ cognitive function should be assessed to determine their capability for self-care, including glucose monitoring, adjusting insulin doses, and recognizing signs of hypo- or hyperglycemia and seeking help accordingly.

The Case Against SSI

The continual use of SSI not only leads to blood sugar fluctuations, but also creates pain and inconvenience for patients and places a burden on nursing time and resources, according to ADA. Its paper suggests steps to move patients from SSI to basal bolus insulin, a longer-acting form of insulin designed to keep blood glucose levels stable without the aggressive finger sticks and monitoring required by SSI.

Reducing the use of SSI has long been a priority of clinicians, and AMDA—The Society for Post-Acute and Long-Term Care Medicine included it in its list of issues for the Choosing Wisely™ campaign, which was designed to identify tests and interventions associated with clinical overuse and waste. AMDA’s website says, “Good evidence exists that SSI is neither effective in meeting the body’s insulin needs nor is it efficient in the long term care setting. ... With SSI regimens, patients may be at risk from prolonged periods of hyperglycemia. In addition, the risk of hypoglycemia is a significant concern because insulin may be administered without regard to meal intake.”

Denise Wassenaar“We need to promote the standards of practice for the population we serve,” says Denise Wassenaar, RN, MS, LNHA, vice president of clinical and regulatory affairs at MatrixCare. “One standard is to reduce the use of SSI, which is still used extensively in this setting.” She suggests that education and communication are keys to making this change.

“Pharmacists definitely should be advocating to only use SSI in specific situations,” she says. At the same time, “We need to educate prescribers about the benefits of moving away from SSI when possible. I think this is something they’ve always done. We need to help them understand why changing from the status quo is important and beneficial for the patients.”

The Family Connection

For skilled nursing centers to manage diabetes, they clearly need staff—including nurses, dietary staff, and others with a strong understanding of the illness. It also is important to educate patients’ family members, so facilities should have educational materials that they can all understand and use.

“The more you get families involved, the more they can engage and encourage compliance with their family member, leading to more positive outcomes,” says Wassenaar. The care team needs to decide which team members will interact with families and how.

Successful diabetes management post-discharge is key to avoiding hospital readmissions. “When patients are discharged from the nursing care centers back to the community, we need to ensure that they are knowledgeable about their medications, diet, and what they need to do regarding glucose monitoring,” says Wassenaar. It isn’t enough just to explain or show them what to do.

To ensure understanding, a team member at the facility needs to watch patients perform necessary tasks to see if they are doing them correctly and have them repeat back key discharge instructions. Staff need to work with the patient until they are confident that the person is proficient in administering insulin, doing blood sticks, and reading glucose levels. It also is important to ensure that the patient will have access to proper nutrition and that they will have any necessary assistance in grocery shopping and preparing meals.


Heart Disease/Stroke Care That Works
Cardiovascular disease is prevalent in the elderly population. According to the American Heart Association, nearly three-quarters of men and woman from ages 60 to 79 reported having some type of heart-related illness or condition. For the 80-plus population, that number jumps to 83 percent for men and 87 percent for women. People aged 75 and older account for about 66 percent of cardiovascular disease-related events. Heart failure is of particular concern in this population, as this condition in the elderly is expected to triple by 2060.

Stroke isn’t quite as prevalent in the older population, but—as the fifth-leading cause of death for Americans—it is still problematic. Patients aged 85 and older account for nearly 20 percent of all strokes, and 14 percent of people aged 80 and older have a history of stroke. Stroke tends to lead to long hospitalization and rehab stays and, often, permanent disability of some kind. In fact, the American Stroke Association suggests that stroke reduces mobility in more than half of survivors age 65 and over.

Cardiac Care without Skipping a Beat

Patients entering nursing centers commonly suffer from heart disease, hypertension, atrial fibrillation, and/or heart failure, and these patients are at high risk for hospital admission. The reason for rehospitalization, says Nicole Orr, MD, assistant professor of medicine at Tufts Medical Center and founder and president of Post-Acute Cardiac Care in Boston, may not be related to their heart disease, but to respiratory illness, infection, electrolyte imbalance, or injuries or complications from a fall, for example.

Many times, Orr says, patients’ heart diseases might be stabilized in the hospital, but they are readmitted for noncardiac causes. “Heart disease is serious, but comorbidities and complications that develop during the [skilled nursing facility] stay can certainly drive readmissions,” she says.

Nicole Orr, MDPreventing readmissions for cardiac patients requires efforts on a granular and global level, Orr says.

“On the granular level, for heart failure patients, for example, it is important to have an understanding of their baseline status, follow their hemodynamics and weights, monitor their electrolytes, provide healthy dietary options and opportunities for physical activity/exercise, and address their comorbidities.”

For other cardiac patients, some drivers of readmission might be related to complications from blood thinners or antiplatelet agents. For these patients, Orr says, “It is important to understand the specific indications for the medications and if they are intended to be temporary or long term.

“Medications for heart failure might have to be adjusted, either titrated up or down, depending on their clinical status,” she says. “Often, staff don’t understand the indications or other specifics about cardiac medications—whether a patient is on blood thinners, antihypertensive medications, or diuretics. In this population, polypharmacy is a concern, so the indications for ongoing therapy should be clear.”

On a global level, for older skilled nursing patients with heart disease, it is important to know patients’ goals of care, preferences, and choices, Orr says. For example, they may not care about a little edema and don’t want their activities to be limited by the use of diuretics. An 80-year-old patient may not necessarily want to live another 10 years; he or she may just want to feel less fatigued or be able to breathe a little more comfortably, Orr says.

“Patients are often continued on treatment with beta blockers for hypertension, but these have unwanted side effects in the elderly such as fatigue. We should consider modifying drug regimens to address their symptoms,” she says. “For these patients who are often afflicted with multiple chronic illnesses, we need to think about shifting from disease-centered care to patient goals-directed care, and think in terms of their preferences and what will make each person feel better every day.”

Cost Savers

Orr says its important to realize that cardiac disease and heart failure management doesn’t necessarily have to be expensive. Patients and families increasingly are looking for cost-effective treatments and interventions that are likely to produce the best results without a prohibitive price tag.

“Patients and families may need to make decisions based in part on costs, but we can help them make smart choices, weigh the advantages and disadvantages of various interventions, and treat them in the context of their preferences,” Orr says. “We can help them understand what unexpected or extra expenses such as transportation or medication costs might arise and how they can lower or minimize these, potentially using lifestyle modifications when they can.”

Knowing what level of care the patient wants and needs can help the care center determine what capabilities, staffing, and resources will be necessary to keep the individual comfortable, safe, and out of the hospital. If centers accept patients with advanced cardiac disease, they need to be prepared to have a practitioner see them on admission and follow them closely, ideally for the first week, when the readmission risk is highest. “These patients can deteriorate quickly and will require close attention and access to specific services and care,” Orr says.

It is essential that staff have the knowledge and skills they need to help manage chronic conditions such as heart disease or stroke. For example, Orr notes that presenting symptoms for heart failure in the elderly are different than for younger patients. “Older patients are more likely to experience atypical symptoms such as confusion, fatigue, or a disinterest in activities or participating in their physical therapy session.
They also can present with chest pain from microvascular ischemia,” she says.

Caregivers who see patients every day or more are likely to notice little changes in behavior and affect, so it is important that staff understand their implications and report them promptly, she says. Any change in condition in a patient with a history of heart failure should prompt a thorough physical exam and proactive treatment.


Cure, Care, and Complications
As with heart disease and diabetes, advancing age is a risk factor for cancer, and the over-65 population accounts for 60 percent of newly diagnosed malignancies and 70 percent of all cancer deaths. Among the most common cancers in this population are breast, colon, and prostate cancer, according to the National Institutes of Health.

There is some suggestion that there is ageism at play in cancer treatment for the elderly; some studies have shown that when appropriate treatment is identified, older patients are less likely to receive the standard of care. There also is a dearth of knowledge about how tumors in the elderly respond to various treatments and how therapeutic agents are metabolized in the aging body.

At the same time, as most elderly patients with cancer have at least one comorbidity, such as heart disease or diabetes, this can complicate how their cancer is managed, and the interaction between treatment-related effects and age-related issues create care challenges.

Screenings and Beyond

Cancer screenings are often skipped or discontinued as patients age. However, guidelines for screenings in this population shouldn’t be based on age alone. Decisions should include considerations about potential risks and benefits of screenings, estimated life expectancy, personal values and preferences, presence of serious comorbidities, and other issues.

J. Leonard Lichtenfeld, MD, MACP, deputy chief medical officer of the American Cancer Society, notes that this philosophy should apply to treatments as well.

“We need to understand these patients’ biologic age, not their chronological age. We can’t assume that just because a person is in their 70s or older that they don’t want or won’t tolerate aggressive or invasive treatments. It depends on the individual patient,” he says. “I have talked to elders who have cure as a goal and younger people with complicating factors who can’t tolerate treatment and just want comfort care. It’s important to have these conversations.”

Even if a patient has an advance directive in place, it needs to be revisited when the person is diagnosed with cancer.

“Advance care planning can take on a whole new meaning with a new serious diagnosis,” Lichtenfeld says. These conversations need to happen early on so that the patient and facility can agree on what care, services, and support can be provided on-site, he says. “If a patient will be pursuing aggressive treatments that require frequent transfers and require significant management of side effects and/or complications, it will be essential to determine in advance if [the treatment regimen] is feasible and how it will be done.”

Patient Choices will Vary

Lichtenfeld notes that the skilled nursing center’s care team needs to realize that not every patient with cancer will make the same choices about treatment, and they should be prepared to respect each person’s decisions.

“Many issues go into these decisions—including concerns about financial constraints—and we should be able to help patients make the best decisions for them based on as much information as we can provide,” he says.

Patients need to understand about costs, he says. “While nursing center staff will not have all of the answers about the costs of various cancer treatment options, they should be able to talk about issues such as costs to transport patients to oncology visits or chemotherapy treatments.”

Facility leaders and staff aren’t expected to be cancer experts, Lichtenfeld says.

“Cancer is such a highly specialized disease, even well-trained oncologists don’t know everything. However, the facility should communicate with the hospital or other transferring setting. There should be seamless transition of information between teams and open lines of communication over time.” The skilled nursing center needs to know what special care and services—such as laboratory tests—will need to be done, and all of this needs to go into the care plan, he says.

“You can’t suddenly train nurses and nurse aids to be excellent providers of cancer care, but you can educate them about red flags, problems, and other issues to be alert for,” he says. “Being able to observe and say, ‘Something isn’t right,’ will never go out of style.”

Research has shown that patients who had access to care teams that reported problems and concerns earlier lived longer. Early recognition of problems in cancer patients can prevent readmission and can be potentially life-saving.

Managing Diseases and Avoiding Readmissions

With serious illnesses comes a risk for acute changes and readmissions. By identifying those at greatest risk, facilities can help anticipate and prevent problems—and address them promptly when they are unavoidable. However, this is sometimes easier said than done.

Haimowitz“No one has figured out the secret sauce for this,” says Haimowitz. “You have to pay attention, notice, and react to change. You have to involve the team and talk to the family over and over.”

Especially for patients with illnesses such as heart disease, diabetes, and cancer, Haimowitz says, “It is our duty to help them get the information they need to make decisions. We don’t want to push people into decisions.”

A good care plan with a current advance directive can make all of these efforts easier and help keep patients—even those with serious illnesses—out of the hospital. “The strongest determinant of whether or not to hospitalize is the advance directive. The facility has the responsibility to get this into the care plan,” says Eric Tangalos, MD, CMD, professor of medicine at the Mayo Clinic and co-director of the Information Transfer Core for Mayo’s Alzheimer’s Disease Research Center in Rochester, Minn.

Skilled nursing centers shouldn’t take on the burden of disease management by themselves. They need to count on health plans, practitioners, specialists, and others. “Disease management is a medical issue. If you do it alone, you’re at a disadvantage,” Tangalos says. “It really comes down to who is at the bedside, who is monitoring the process on a day-to-day basis, and how the players involved communicate with each other.”
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.