June 2018

Vol. 45 No. 6

June

Cover Story

https://www.providermagazine.com/Issues/2018/June/Pages/The-Many-Shades-of-Boomer-Health.aspx

The Many Shades of Boomer Health

<div></div><div>Baby boomers have often been defined by the social changes they have launched, including political engagement and protests. The generation—usually defined as those born in the United States between 1946 and 1964—also is often associated with greater sexual expression, experimentation with drugs, and environmental concerns.</div><div> <br>Now, this generation that once chanted, “Don’t trust anyone over 30,” is turning 60 … and 70, and as they age, they are bringing clinical care needs, strong opinions, <a href="/Issues/2018/June/Pages/Financial-Frets-and-Boomer-Bank-Accounts.aspx" target="_blank" title="Financial Frets and Boomer Back Accounts">financial issues,</a> and family dynamics that will pose challenges for facilities.</div><div> <br>Understanding what it means to be an aging boomer is essential for long term and post-acute care (LT/PAC) providers to position themselves to care and advocate for this population.</div><h2 class="ms-rteElement-H2">Boomers and Health</h2><div>As boomers age, providers will see many of the same illnesses and conditions they currently manage. For instance, Mike Wasserman, MD, CMD, geriatrician, and chief executive officer of Rockport Healthcare Services in Los Angeles, says, “Because of the societal increase in diabetes, this will continue to be an important issue.”</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Brubaker.jpg" alt="J. Kenneth Brubaker" class="ms-rtePosition-1" style="margin:5px 15px;" />A related concern, says J. Kenneth Brubaker, MD, CMD, medical director of Masonic Villages in Elizabethtown, Pa., is obesity. “We are seeing more obese patients. And in addition to diabetes, they often have heart disease, strokes, early-onset dementia, and vascular problems.” These problems include peripheral vascular disease, diseases of the blood vessels outside the heart and brain, and vascular dementia, a common form of dementia caused by an impaired supply of blood to the brain.</div><div> <br>“We also will continue to see an increase in Alzheimer’s disease and dementia,” Wasserman says. “In fact, this may be the single-most important disease state in relation to its impact on society as the boomers age.”</div><h2 class="ms-rteElement-H2">The Alzheimer’s Issue</h2><div>Alan Horowitz, RN, a health care attorney with Arnall Golden Gregory, agrees. “By mid-century—according to the Alzheimer’s Association—someone in the U.S. is expected to develop Alzheimer’s disease every 33 seconds. Therefore, one of the biggest challenges for the industry will be caring for the increasing number of people with dementia,” he says.</div><div> <br>A related concern to the growing rate of Alzheimer’s, says Horowitz, is sexuality in the context of cognitive impairment. “Some people with Alzheimer’s disease or other forms of dementia become hypersexual, and many boomers who lived through the summer of love had more relaxed attitudes about sex,” he says. “Hardly a week goes by where someone from a skilled nursing facility doesn’t ask me about sexuality and dementia.”</div><div> <br>It is important for providers to recognize that merely because a resident has Alzheimer’s disease or another form of dementia, that doesn’t necessarily mean that he or she lacks the decision-making capacity to be sexually active, Horowitz says. “Consequently, the growing challenge for providers is to strike the appropriate balance between respecting resident rights and protecting and promoting resident safety.”</div><div> <br>An interesting trend, according to a recent study in the Journal of Gerontology, is that people seem to be developing dementia later and living with the illness for a shorter period of time. The authors suggest a possible connection between the later development of dementia and better prevention and care of stroke, a major risk factor for dementia. At any rate, this will be a trend worth watching as boomers age.</div><h2 class="ms-rteElement-H2">Patients with HIV/AIDS</h2><div>The human immunodeficiency virus (HIV) is off of most people’s radar screens, says David Nace, MD, MPH, director of long term care and influenza programs in the Division of Geriatric Medicine at the University of Pittsburgh, but it is a real issue and a concern as boomers age.</div><div> <br>“Patients with HIV and AIDS [acquired immune deficiency syndrome] are living longer, and we will start to see more of these patients in post-acute and long term care,” he says. “This illness will pose significant challenges because of the cost and complexity of its care.”</div><div> <br>At the least, he says, facilities should connect with practitioners—such as attending physicians, nurse practitioners, and pharmacists—who have full knowledge of HIV/AIDS medications. Access to an HIV/AIDS specialist would be ideal.</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Nace.jpg" alt="David Nace, MD" class="ms-rtePosition-2" style="margin:5px 10px;" />“People today are more comfortable talking about HIV/AIDS, and society’s perceptions about the disease are changing,” says Nace. However, he suggests that facilities plan for how they will accommodate HIV/AIDS patients. “This can be a struggle,” he says. “There are about 700 nursing homes in Pennsylvania, but not every one will be comfortable managing patients with HIV/AIDS. This is no longer a primary care disease, and not every practitioner or caregiver will have the skills necessary to care for these patients.”</div><div> <br>HIV/AIDS patients present two challenges, Nace says. One is management of the disease itself, which requires specific medical competencies. The second is cultural, which requires facilitywide knowledge (versus lingering myths and misunderstandings) and acceptance. He urges facilities to make use of community resources, where they are available. </div><div> <br>Facilities in more rural or suburban areas may have less access to support. However, Nace suggests some creative solutions. For instance, perhaps they can “share” an HIV/AIDS specialist in the region with other facilities or connect with clinical experts via telemedicine. <br></div><h2 class="ms-rteElement-H2">The HCV Factor</h2><div>According to the Centers for Disease Control & Prevention (CDC), baby boomers are five times more likely to have <a href="/Issues/2018/June/Pages/A-Conversation-with-an-HCV-Specialist.aspx" target="_blank" title="A Conversation with an HCV Specialist">hepatitis C virus</a> (HCV) than other adults. Most boomers, CDC says, likely became infected in the 1960s through 1980s when HCV transmission was highest. Many people with this disease, which can lead to liver damage, cirrhosis, and possibly liver cancer, don’t even know they are infected. This is possible because people with HCV may have the disease for many years without experiencing any symptoms. </div><div> <br>There is no clear reason why HCV is more prevalent in baby boomers. According to CDC, this population may have been infected by medical equipment or procedures from before the time of universal precautions and infection control procedures. </div><div> <br>Others may have been infected by contaminated blood and blood products or sharing needles or equipment used to inject drugs. Whatever the reasons, the disease—and its management—should be a concern of LT/PAC providers and practitioners. </div><div> <br>John Poterucha, MD, a gastroenterologist and professor of medicine at the Mayo Clinic, echoes this urgency. “Liver disease is the ninth-most common cause of death, and liver cancer is on the rise,” he says. </div><div> <br>“One reason for this is that there are more patients with chronic liver disease and cirrhosis. Most of the time, HCV doesn’t cause symptoms until the patient gets cirrhosis and symptoms related to that. At that point, it may be too late to do anything.” </div><div>When symptoms do appear, they include:</div><ul><li>Bleeding and/or bruising easily; </li><li>Fatigue; </li><li>Poor appetite; </li><li>Yellow discoloration of the skin and eyes (jaundice); </li><li>Dark-colored urine; </li><li>Itchy skin; </li><li>Fluid buildup in the abdomen (ascites); </li><li>Swelling in the legs; </li><li>Weight loss; </li><li>Confusion, drowsiness, and slurred speech; and </li><li>Spider-like blood vessels on the skin.</li></ul><div>Chronic HCV starts with an acute phase. However, this often goes undiagnosed because it rarely causes symptoms. When it does, these may include jaundice, fatigue, nausea, fever, and muscle aches. Acute symptoms appear one to three months after someone is exposed to the virus and may last up to three months.</div><div> <br>The good news is that some people clear the virus from their bodies after the acute phase and don’t develop chronic HCV. Up to 50 percent of people with acute HCV may clear the virus, and most respond well to antiviral therapy.</div><h2 class="ms-rteElement-H2">How to Proceed</h2><div>CDC recommends that baby boomers get tested for HCV. Specifically, a blood test called the HCV antibody test can determine if a person has ever been infected with the HCV virus. There are two possible antibody test results:</div><ul><li>Nonreactive, or negative. This means the person doesn’t have HCV. However, if someone has been recently exposed to the HCV virus, he or she will need to be tested again. </li><li>Reactive, or positive. This means that HCV antibodies were found in the blood and the person has been infected with the HCV virus at some point. A reactive test doesn’t necessarily mean the person has HCV. Even if he or she has cleared the HCV virus, the individual’s blood will always have the antibodies.</li></ul><div>If a test is reactive, additional blood tests will be necessary to measure the quantity of the HCV in the blood, or the viral load, and identify the genotype of the virus. The most common genotype in North America and Europe is called Type 1. While the illness follows a similar course regardless of the genotype, this determination will impact treatment recommendations. </div><div> <br> </div><div>If a patient is diagnosed with chronic HCV, the practitioner likely will want to assess liver damage. This involves one or more tests, including:</div><ul><li>Magnetic resonance elastography (MRE), a noninvasive alternative to a liver biopsy; </li><li>Transient elastography, a type of ultrasound; or </li><li>Liver biopsy, typically done using ultrasound guidance and inserting a thin needle through the abdominal wall to get a liver tissue sample.</li></ul><h2 class="ms-rteElement-H2">Treatment Options</h2><div>HCV is treated with antiviral medications designed to clear the virus from the body. Researchers have made significant advances in HCV treatment over the years, and newer drug therapies enable better outcomes, fewer side effects, and shorter treatment times (some as little as eight weeks).</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Poterucha.jpg" alt="John Poterucha, MD" class="ms-rtePosition-1" style="margin:5px 15px;" />These newer medications have been proven highly effective, says Poterucha, with a clearance rate of up to 99 percent. While effective and generally well tolerated, they also may come with a hefty price tag, which can be an issue for some patients. </div><div> <br>In instances where there are serious complications from chronic HCV, liver transplantation might be an option, although this is unlikely to be a viable intervention for older patients. The physician will work with each person (and family members, as appropriate) to choose the best, most cost-effective treatment plan.</div><div>Unfortunately, liver disease isn’t limited to HCV, and illnesses such as alcoholic liver disease and non-alcoholic fatty liver disease are harder to treat. “In the general population, 25 to 30 percent of people have fat in the liver, and a subset of these will develop cirrhosis,” says Poterucha. Risk factors include obesity, high triglycerides/lipids in the blood, and diabetes. However, he says, “Because we’re better at treating all of these conditions, we’re seeing people with liver disease living longer.”</div><div> <br>As more boomers enter LT/PAC centers, it will be beneficial to determine if they have a diagnosis of or are at risk for HCV or other liver disease. Poterucha suggests taking a symptom inventory and finding out if they have had HCV testing and, if so, what the results were. If the patient has symptoms of liver disease, testing may be advisable.</div><div> <br>Any diagnosis of HCV or other liver disease should be addressed in the care plan. “For the most part, there is not much we can do if a patient has advanced disease, and expensive treatments wouldn’t be advisable,” Poterucha says. However, symptom management and comfort care, including addressing fluid retention, are viable goals for these patients, he says.</div><div> <br> </div><h2 class="ms-rteElement-H2">Alternative Therapy Aficionados </h2><div>Baby boomers grew up in an era of experimentation, health food stores, and holistic treatments, so it’s only natural that many will want access to some of these in LT/PAC. One of the greatest challenges this represents for care centers is a demand for medical marijuana.</div><div> <br>“To date, 46 states, the District of Columbia, Puerto Rico, and Guam have legalized medical marijuana, and facilities are struggling with the question of how to address residents’ desire to access this unorthodox form of therapy, while not running afoul of federal laws,” says Horowitz.</div><div> <br>While medical marijuana is legal in most states, it remains illegal under the federal Controlled Substances Act, so facilities face a dilemma regarding a host of issues. As more boomers enter this care setting, says Horowitz, “Facilities would be wise to have policies and procedures so that staff fully understand what is and is not permitted regarding medical marijuana.”</div><div> <br>Geriatricians tend to be more holistic to begin with, says Wasserman. “We’re attuned to ways we can help patients beyond traditional medicine.” For instance, he says, “If I can get people to start exercising regularly, I can usually stop at least one medication.” He is seeing positive lifestyle trends in boomers. </div><div> <br>“They see the value of exercise, healthy diets, and lifestyle changes such as drinking less and not smoking,” he says. At the same time, they are utilizing massage, acupuncture, meditation, and chiropractic care as part of their health care regimens.</div><div><h2 class="ms-rteElement-H2">The Geriatrics Approach to Care </h2></div><div>Even as the population has aged, most medical research still hasn’t involved elders. As a result, says Wasserman, “We’re still operating without a net. We have physicians using new and expensive treatments on a patient population they haven’t been tested on—older adults. When you use procedures, tests, and devices on a 90-year-old that were tested on 50-year-olds, we shouldn’t be surprised when they don’t have the same outcomes,” he says. “We need to go back to the geriatrics approach.” </div><div> <br>For instance, he says he had an 88-year-old patient who was being aggressively treated for prostate cancer. The patient was weak and hospitalized. </div><div> <br>“I know that patients over 80 rarely die from prostate cancer, so I took him off the cancer treatment and put him on testosterone. He was able to get out of the hospital and feel better,” Wasserman says. “This year, my two-year-old grandson, Bailey, and I joined that patient to celebrate his 100th birthday.</div><div> <br>“If we want to do a better job for baby boomers, we need to talk more about the geriatrics approach to care and teach it to our students.” </div><div> <br>This requires a change from “a society where there is a push to use every treatment, medication, and intervention possible, even when there is no basis for them or when they don’t consider the patient’s goals,” he says. “This could be one reason we are seeing the average life expectancy stagnating.”</div><div> <br>Advance care planning will be hugely important with boomers, says Wasserman, and this comes back to how physicians are trained to care for older patients. “Most don’t know how to have these discussions,” he says. Wasserman says he asks his older patients: “What do you think of this statement: No aggressive treatment if poor quality of life is expected?” Ninety percent of the time they will agree, he says. </div><div> <br>While there are many forms and tools patients and families can use to help support and document end-of-life planning conversations, Wasserman says that those tools are no substitute for one-on-one conversations with the clinician. “For advance directives to have meaning, it is critical for the clinician to be able to have person-centered care discussions with his or her patients.”</div><h2 class="ms-rteElement-H2">The Boomer Niche</h2><div>While baby boomers are still a few years away from descending on long term care en masse, seniors housing organizations are already appealing to them. </div><div> <br>For example, Latitude Margaritaville, inspired by singer-songwriter Jimmy Buffett, is advertising planned communities featuring recreation, dining, and live entertainment aimed at boomers. As boomers age and have illnesses that require short- or long-stay care, LT/PAC providers may consider offering services that appeal to them.</div><div> <br>“There is a benefit to specializing in boomer care,” Horowitz says. In addition to memory care and other specialized units, boomer-oriented facilities may want to consider providing access to alternative therapies and holistic medicine, as well as various emerging technologies. </div><div> <br>“Even older boomers are very computer-savvy, counting on email, social media, Skyping, and other technology to stay in touch with family and friends,” Horowitz says. “They have laptops, tablets, and cell phones. At the very least, they will demand easy access to Wi-Fi.” At the same time, he notes, boomers and their families increasingly will be attracted by settings that offer cutting-edge technology that will enable <a href="/Issues/2018/June/Pages/Becoming-Like-Dad-and-Mom-Another-Perspective.aspx" target="_blank" title="Becoming Like Dad and Mom">mom or dad</a> to stay safe and remain as high-functioning for as long as possible. This might include wearable remote monitoring devices and sensors, GPS and other devices to prevent wandering, telemedicine capabilities, and interactive TV computers.</div><div> <br>Facilities need to consider what services boomers might want and address these services on admission. </div><div>For instance, Horowitz says, “If a person likes and has responded well to aromatherapy or acupuncture, which may not covered, you should discuss on admission if they want to continue such services and how they will pay for them. Admission conversations about what is and isn’t covered should be expanded to address some of the services that boomers are most likely to want.” </div><div> <br>Therefore, it is important to provide the family with a written list of covered services, as is generally required. </div><div> <br>“It’s an emotional time, and people may not retain everything they’re told on admission, so putting it in writing is a practical and easy way to itemize what the facility offers and what costs, if any, a resident or the family may have to bear.”</div><h2 class="ms-rteElement-H2">When it’s Time for Skilled Care</h2><div>Providers can help boomers and their families understand the benefits of skilled nursing centers and why or when they might be the right choice.</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Wasserman.jpg" alt="Wasserman" class="ms-rtePosition-2" style="margin:10px 15px;" />“Across the country, the mood is toward keeping people out of nursing homes. People want to stay in their homes, and their families want that as well—partly because nursing home care is expensive and they think that community-based care will be more cost-effective,” says Brubaker. “We need to engage families and help them understand why it may not be safe for mom or dad to stay in their home.” </div><div> <br>Wasserman adds, “There seems to be this idea circulating that we don’t need nursing homes and that everything should happen at home. The reality is that many nursing home residents enjoy increased socialization, more structure, and the ability to get their needs met by qualified professionals who care deeply about their well-being. They actually are quite happy.”</div><div> <br>With boomers aging and becoming the new LT/PAC patients, he says, “This is the perfect moment to focus on this care setting and what it should be as we move into this new era.” </div><div> </div><div> <em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div>

Baby boomers—usually defined as those born in the United States between 1946 and 1964—are often associated with greater sexual expression, experimentation with drugs, and environmental concerns.

2018-06-01T04:00:00Z

Caregiving;Management

Understanding Millennials’ Impact on Employee Turnover	https://www.providermagazine.com/Issues/2018/June/Pages/Understanding-Millennials-Impact-on-Employee-Turnover.aspx	Understanding Millennials’ Impact on Employee Turnover	<div></div> <div>Why is today’s new workforce, Millennials (born 1980–2000) in particular, job hopping as much as they do? Is it because they have no loyalty? Is it because they are too entitled and they think they don’t have to pay their dues? Or is it because their supervisors and managers aren’t very effective? The answer is a combination of all of the above.</div> <h2 class="ms-rteElement-H2">A Lack of Loyalty</h2> <div>The workforce has evolved dramatically over the past decade, and it is true that many of the new hires brought into a facility today will not be loyal for loyalty’s sake. That is because they were raised in a different time than most leaders within the long term and post-acute care (LT/PAC) space.</div> <div><br>While older managers and supervisors were taught by their parents to “stick it out” in jobs where they were unhappy, Millennial parents taught their children the opposite, saying, “Don’t be unhappy for too long because life is short.” </div> <div><br>Millennials’ parents did not want to see their own children suffer in jobs they hated, nor did they continue to believe the companies had the workers’ best interests at heart. After all, companies in various industries laid off masses of workers to whom they had promised long-term work and/or pensions. As the loyalty from companies to workers began to fade from the 1980s on, younger employees were taught to look out for themselves. </div> <div><br>Does this seem selfish? Of course, because it is. But what do buildings do when occupancy is down? They cut worker hours. In LT/PAC, it is nearly impossible to live up to schedule promises made upon hire when <br>staffing stability today is shaky at best. Facility leaders must make cuts (in hours or positions) when needed, and it is imperative that leaders understand their workers know that.</div> <h2 class="ms-rteElement-H2">Increasing Entitlement, Decreasing Patience</h2> <div>It is absolutely true that today’s young workforce expects most things to happen in an instant; they demand choices, and they have much less patience than did previous generations. But it can be easy to understand why when leaders realize how much has changed in society over the past 30 years. </div> <div><br>Drive-thru windows are everywhere. Digital streaming allows people to access anything, anytime. People no longer have to “save up” for things because adults have access to credit cards and can pay off the bills later for things they want today. Millennials only know a world of instant gratification and personalized customization, so it’s no wonder those expectations trickle into the workplace.</div> <div><br>Millennials have learned from the video-game days that it feels great to “level up” in life, and they want that same advancement opportunity at work. They are likely to get bored in the same role for too long because they have only lived in a fast-paced lifestyle where things are constantly changing and opportunities are endless.<br></div> <h2 class="ms-rteElement-H2">Wanted: Great Managers</h2> <div>Unfortunately, too many LT/PAC organizations cut soft-skills training and development for many front-line leaders years ago, and now it is coming back to haunt them. When certified nurse assistants are promoted into supervisor positions without being given the tools to be successful in that new role, it can sometimes do more harm than good if they do not have a natural skill set for effective leadership.</div> <div><br>Plus, most people with a supervisor or manager title still have a full-time workload to complete, and they do not have time to hand-hold and mentor new hires. They just expect everyone to “do their job,” which isn’t happening today like it used to.</div> <h2 class="ms-rteElement-H2">The Turnover Impact</h2> <div>Since unemployment is so low and the current market is considered an employees’ market, where employees and candidates have the option to go elsewhere, employers must see and treat all current and future employees as internal customers.</div> <div><br>Most LT/PAC facilities have evolved dramatically to adjust their services to the residents they serve—offering dining options, person-centered care, and Wi-Fi—but what has been done to evolve for the staff in recent years? Is the organization still scheduling the way it scheduled five years ago? Are the leaders still managing the way they managed 10 years ago? Are there still policies in place against hiring those with purple hair (like the author of this article)?</div> <div><br>For organizations continuing to manage the Millennial workforce the same way they managed GenXers <br>(born 1965–1979) the past 20 years, it is a struggle to get and keep talent. </div> <div><br>But the Millennials should not be viewed as the disloyal, ungrateful workers many label them as. Instead, they should be viewed as the canaries in the coalmine, letting leaders know that no one (of any age) wants to be treated the “old school” way, and that organizations that remain set in their ways may not be sustainable much longer.</div> <h2 class="ms-rteElement-H2">How to Keep Staff Longer</h2> <div>All employees want to feel appreciated for a job well done—even if it is their job to do so. Unfortunately, some workers don’t show up for their shifts, and some who do are unable to make it in on time. In these situations, LT/PAC leaders must dig deep and realize how grateful they truly are for those employees who show up—on time—and do their jobs well. It is critical that every administrator, department director, manager, and supervisor thank their people on a regular basis for taking great care of the residents they serve.</div> <div><br>Workers today are looking for flexibility via scheduling options. Yes, the building operates 24/7 and needs full coverage, but does the organization offer various shift lengths (12, 10, eight, six, and four hours) and different start and end times? A 7 a.m. to 7 p.m. shift will not work for a single mother whose children go to a daycare center that is only open from 6 a.m. to 6 p.m.</div> <div><br>Plus, aging nurses will often stay in their roles longer when shorter four-hour and six-hour shift options are made available. This alleviates the workload burden on other nurses when they extend their tenure and delay retirement. Are innovative scheduling options being considered for all employees?</div> <div><br>What’s working? What’s not? What else could be done to create a place where people want to work? How much voice should employees have regarding changes within the organization? And how much is it costing in unnecessary employee turnover for those companies that refuse to adjust their staffing approach and do not demand management effectiveness? </div> <div><br>Every LT/PAC facility leader should be asking these questions and leading the retention conversations in a new direction. </div> <div> </div> <div><em><img src="/Issues/2018/June/PublishingImages/CaraSilleto.jpg" class="ms-rtePosition-1" alt="Cara Silletto" style="margin:10px 15px;" /><br>Workforce thought leader, keynote speaker, and “entitled” Millennial herself Cara Silletto, MBA, works with organizations to reduce unnecessary employee turnover by bridging generational gaps and making leaders more effective in their roles. She is president and chief retention officer of Crescendo Strategies and is the author of the 2018 book, “Staying Power: Why Your Employees Leave & How to Keep Them Longer.” More information is at <a href="http://www.crescendostrategies.com/" target="_blank">www.crescendostrategies.com</a>, or she can be reached directly at <a href="mailto:cara@crescendostrategies.com" target="_blank">cara@crescendostrategies.com</a> or 812-207-0739. </em></div>	While older managers and supervisors were taught by their parents to “stick it out” in jobs where they were unhappy, Millennial parents taught their children the opposite.	2018-06-01T04:00:00Z	<img alt="" src="/Issues/2018/June/PublishingImages/hr_t.jpg" style="BORDER:0px solid;" />	Workforce;Management	Human Resources
Managing Cyber and Data Security	https://www.providermagazine.com/Issues/2018/June/Pages/Managing-Cyber-and-Data-Security.aspx	Managing Cyber and Data Security	<div></div> <div>Organizations with significant amounts of personal data, like skilled nursing and other long term and post-acute care (LT/PAC) centers, are appealing targets for cyber-criminals. This puts them at risk for actual damages, government fines, and private legal actions. It also puts them at risk for damage to their reputations. Who wants to admit themselves or a loved one into a center that has proven to not keep its patients’ health or personal information safe? </div> <div><br>The good news is that there are steps that even the smallest community can take to help mitigate cyber risks and better weather the fallout. </div> <h2 class="ms-rteElement-H2">Assessing Cyber Risk</h2> <div>Reputable risk management advisors will say the first thing a provider should do is assess its risk. Don’t let scare tactics alone dictate the center’s course of action. Investing time and resources into understanding how at-risk the organization is can save dollars later by focusing other resources into those areas in which the center is most exposed or likely to incur the most damage. </div> <div><br>This is an area where engaging a professional will likely yield the best results. There are numerous professionals who offer penetration testing and overall information technology (IT) security analysis. It is best to go beyond IT issues, though, because data risk is not limited to the IT department: It is also a cultural and people issue.</div> <div><br>If an employee opens a phishing email or falls victim to a spear-phishing scam, IT won’t be aware of it until it’s too late. The center’s risk level will include how aware its teams are of the potential dangers and their ability to identify potentially harmful activity. </div> <div><br>Not only does a center need to understand what data it has (this can be in electronic or paper form), but also all the possible ways that data are and could be accessed. </div> <div><br>A trained professional can help analyze a center’s IT security. Are password updates required regularly? Do employees use two-step verification processes when logging into IT systems? How difficult is it to hack the center’s systems?</div> <h2 class="ms-rteElement-H2">Noncompliance Costly</h2> <div>Another significant risk to assess is the possibility of noncompliance fines from state and federal agencies. </div> <div>According to an article posted July 5, 2016, in Healthcare IT News, after a Philadelphia nursing center operator paid a fine of $650,000 to the U.S. government, the Health and Human Services Department’s Office of Civil Rights (OCR), which investigates Health Insurance Portability and Accountability Act (HIPAA) violations, cited the operator’s lack of required risk analysis and risk management plan.</div> <h2 class="ms-rteElement-H2">Preparing for an Attack </h2> <div>Few, if any, LT/PAC facilities would consider operating without an evacuation plan. Yet, many operate without a post-data breach plan, which helps the community be prepared if and, more likely, when a cyber-attack occurs. The post-data breach plan—a critical component of the center’s risk management plan—is designed to ensure the company makes it through the incident, especially given that the average cost of a breach within the health care industry is $12.47 million, according to a 2017 report titled, “The Cost of Cyber Crime Study” conducted by Ponemon Institute and jointly developed by Accenture.</div> <div><br>Insurance, specifically cyber liability insurance, is often considered to be the solution. However, there is a lot to understand about insurance coverage, limits, and other options to ensure that it will provide the protection the center wants and needs. Second, there are a lot of things that basic insurance policies won’t cover that should be included in any recovery plan. </div> <h2 class="ms-rteElement-H2">Choosing the Right Insurance</h2> <div>Following the risk assessment, there will be a more detailed understanding of the actual and specific risks the center faces, but it doesn’t stop there. Most LT/PAC organizations should consider at least three areas of coverage. They need to make sure their cyber insurance program provides coverage for losses related to 1.) HIPAA data; 2.) spear-phishing—the fraudulent practice of sending emails ostensibly from a known or trusted sender in order to induce targeted individuals to reveal confidential information; and 3.) the associated business interruption that is likely to result following a data breach. </div> <div><br>It is important to work with an insurance broker or agent experienced in not only the LT/PAC industry, but also this unique type of coverage. They can help staff understand and find products with the appropriate limits, deductibles, and coverage. This is a relatively new set of insurance products, with new providers, new customers, and new risk coming into play all the time.</div> <div><br>Insurance carriers are becoming more sophisticated with their risk assessments and premium pricing, while new competition and new customers are keeping prices in check (for now, at least). It’s typically recommended that a center’s cyber insurance program be evaluated annually. </div> <div><br>The best cyber data insurance program is really a data breach recovery program with the financial backing to help make the center whole again. Not all policies are created equally, and it’s important to identify the best policy that provides the right options to protect the organization.</div> <h2 class="ms-rteElement-H2">Safeguarding the Future</h2> <div>Part of preparing for an attack should also be minimizing its likelihood of occurring. Besides having a solid insurance program in place, there are other measures that can help. </div> <div><br>A nonexhaustive list of low- and no-cost options to consider include ongoing employee awareness training; implementing enhanced password protection protocols; locking up computers; eliminating old, nonrequired records (paper and electronic); limiting employees’ access to data; verifying all information/data requests keeping software up to date; and maintaining security on all mobile devices.</div> <h2 class="ms-rteElement-H2">After an Incident</h2> <div>In the event of a cyber or data incident, it’s critical that a center act quickly and decisively. Without a plan in place, this becomes extremely difficult. </div> <div><br>Given that resources are often scarce, having a fully developed plan is unlikely, but, fortunately, many cyber liability insurance policies essentially contain a disaster plan and road map for what to do immediately following an incident in addition to the financial backing to remunerate and help make the center whole again. </div> <div><br>Better policies will provide a “cyber coach” who, in the event of an incident, will share additional resources (typically provided for no additional cost) to help manage the situation. Following an event, the response is to call this coach to help navigate and access a variety of professional and expert resources to mitigate and contain the damages. These resources typically include a public relations firm to help protect the center’s reputation; a breach notification firm to help ensure compliance with each state’s unique set of requirements for notifying those affected; an IT forensic expert to identify the source of the breach, understand what data have been compromised, how it happened, and stop it from occurring again; and a cyber law attorney to help with any legal matters, whether civil, regulatory, or criminal. </div> <div><br><img src="/Issues/2018/June/PublishingImages/DavidHosack.jpg" alt="David Hosack" class="ms-rtePosition-1" style="margin:10px 15px;" /><br>The cyber and data breach experts referenced above can help a center arrive at the correct level of transparency that will keep it compliant, minimize additional damages, and mitigate any reputational damage that can result following an event. </div> <div> </div> <div><em><a href="mailto:dave.hosack@marshmma.com" target="_blank">David Hosack</a> is an insurance and risk management professional with Marsh & McLennan Agency and specializes in helping long term care and other health care organizations. </em></div>	Organizations with significant amounts of personal data, like skilled nursing and other LT/PAC centers, are appealing targets for cyber-criminals.	2018-06-01T04:00:00Z	<img alt="" src="/Issues/2018/June/PublishingImages/tech1_t.jpg" style="BORDER:0px solid;" />	Technology	Technology in Health Care
How have the new regulation and the new survey process changed the issues that surveyors are citing?	https://www.providermagazine.com/Issues/2018/June/Pages/The-Quality-Forum.aspx	How have the new regulation and the new survey process changed the issues that surveyors are citing?	<br>Even with the relatively small number of surveys that have been completed and reported in Nursing Home Compare using the new “Hybrid Survey” process (total of 2,436 surveys), the changes in deficiencies are dramatic. Although civil money penalties are temporarily suspended on many of the new regulations, and many system-wide regulations are yet to be implemented (Phase 3 beginning November 2019), providers can begin now to align their QAPI programs with the priorities of the new rule.<br><br>Looking at the most frequently cited deficiencies to date in the new survey offers some early indications of what is to come. At the top of the list, with citation on 39 percent of surveys since Phase 2 was implemented, is F880, Provide and Implement an Infection Prevention and Control Program. <br><br>The changes to this tag have been substantial, reflecting current infection control practices as articulated by the Centers for Disease Control for all health care settings. More will arise in Phase 3 with antibiotic stewardship and an infection prevention and control officer. Given the frailty of today’s nursing center residents, and the growing number of drug-resistant organisms, this must be a priority for all nursing centers. <br><br>Person-centered care, a major emphasis of the new rule, is being cited under several different tags. On 30 percent of the new surveys to date F656 was cited, Develop and Implement a Complete Care Plan that Meets all the Resident’s Needs. This is the starting point for person-centered care. However, also in the top 10 citations at 17 percent was F550, Honor Resident’s Rights re: Dignified Existence and Self-determination. F684 was also cited in 17 percent of surveys, Provide Appropriate Treatment and Care According to Orders, Resident’s Preferences and Goals. Not far behind, cited in about 11 percent of surveys was F584, Honor the Resident’s Right to a Safe, Clean, Comfortable, and Homelike Environment. In about 8 percent of surveys, still in the top 25 tags, was F578, Honor the Resident’s Right to Request, Refuse, and/or Discontinue Treatment, and to Formulate an Advance Directive.<br><br>Among the most frequently cited tags to date in the new survey are many clinical topics, including accident prevention; pressure ulcer prevention and care; and incontinence care, including catheter care and urinary tract infection prevention. Medication tags are also common, with frequent citations related to medication errors, unnecessary medications, proper storage of medications and pharmaceuticals, and monthly pharmacist review. <br><br>With the modest proportion of total new surveys completed to date, and the learning curve in early implementation, I am not suggesting you presume that these will necessarily be the emphasis of your first experience with the new survey. The message that I would like to convey is that the new regulations pertaining to both clinical and resident quality-of-life areas are causing a shift in the outcomes of the new survey. This shift reflects today’s expectations of health care. Some of these changes take time to permeate an organization, so I encourage you to start today to prepare for the future.	Looking at the most frequently cited deficiencies to date in the new survey offers some early indications of what is to come.	2018-06-01T04:00:00Z	<img alt="" src="/Issues/2019/December/PublishingImages/AndyKramer_2015.jpg" style="BORDER:0px solid;" />	Quality	The Quality Forum

How Metrics Help Deliver Better, More Efficient Care	https://www.providermagazine.com/Articles/Pages/How-Metrics-Help-Deliver-Better-More-Efficient-Care.aspx	How Metrics Help Deliver Better, More Efficient Care	<div></div> <div><img src="/Issues/2018/June/PublishingImages/BrianPeters.jpg" alt="Biran Peters" class="ms-rtePosition-1" style="margin:10px 15px;" /><br>Long term and post-acute care (LT/PAC) has been behind the curve when it comes to employing metrics. But with the skilled nursing profession becoming more competitive, and with reimbursement rates being squeezed by new regulations and value-based care initiatives, making important decisions without analyzing relevant data is no longer a sustainable strategy.</div> <h2 class="ms-rteElement-H2">A Powerful Platform</h2> <div>CarDon & Associates, a family-owned and -operated LT/PAC company with more than 2,000 patients cared for on a daily basis across Indiana, embarked on a culture shift to infuse data analytics into day-to-day decision making. </div> <div><br>CarDon provides rehabilitation, memory support, long term care, assisted living, and independent living in 21 communities. The goals for the initiative were three-fold: improve the patient care experience, improve the overall health of patients, and reduce the per capita cost of care.</div> <div><br>In 2017, CarDon activated an analytics platform that imports data from various sources, including electronic medical records, admissions/discharge, and staffing and supplies. The platform allows the provider to easily analyze the data for trends in near real time, while built-in alerts prompt staff to take action.</div> <div><br>Use of the platform has grown. Today, it is widely used by the chief operating officer, regional directors, clinical officers, and marketing executives to make informed decisions to improve service and drive efficiencies in a number of areas.</div> <h2 class="ms-rteElement-H2">Smoother Admissions and Discharges</h2> <div>Admission and discharge managers at CarDon’s various facilities thought they had a good idea about the timing of admission and discharge spikes, but without data, they were working with hunches.</div> <div><br>The prevailing thought was that admissions where highest on Fridays from 4 to 7 p.m. After activating the analytics platform, managers found a similar spike on Wednesdays from 3 to 6 p.m. The data showed that these patients most likely were orthopedic patients who had surgery on Monday and were ready for rehab on Wednesday.</div> <div><br>CarDon also now knows that the bulk of discharges happen from noon to 3 p.m., so discharges and admissions sometimes overlapped, creating unnecessary stress on nurses. To reduce this overlap, clinical personnel are able to use the analytics platform to work with specific doctors and hospitals to admit patients to CarDon facilities earlier so new patients can get the full attention they need before evening.</div> <div><br>In addition, nurses can work with families to get current patients discharged earlier in the day, creating a better flow of admissions and discharges.</div> <div><img src="/Issues/2018/June/PublishingImages/tech2-1.jpg" class="ms-rteImage-1 ms-rtePosition-1" alt="" style="margin:15px;width:506px;height:306px;" /><br>Finally, using the analytics platform, CarDon is able to view the average length of stay for specific admissions, which enables discharge nurses to begin having conversations with families at an appropriate time to ensure they are prepared for the patient to come home.<br></div> <h2 class="ms-rteElement-H2">Improved Staffing</h2> <div>With a full understanding of admission and discharge trends, facility managers are able to staff more appropriately. For example, a review of staffing on Wednesdays showed that nurses and housekeeping staff were scheduled for 7 a.m. to 3 p.m. shifts. This meant that nursing shifts were switching just as orthopedic patients were arriving, which did not set the stage for a welcoming environment for new patients. </div> <div><br>Likewise, with the bulk of discharges happening from noon to 3 p.m., housekeepers are busiest from noon to 5 p.m. cleaning rooms to prepare for new patients. </div> <div><br>Managers agreed there was no reason to be fully staffed with housekeepers beginning at 7 a.m. since the bulk of their work takes place later in the day. CarDon managers were able to change the shifts of registered nurses, licensed practical nurses, and housekeepers to ensure a smooth transition for patients and a better working environment for staff.</div> <h2 class="ms-rteElement-H2">Enhanced Patient Care</h2> <div>One of CarDon’s goals is to constantly become a better partner for referring facilities and doctors. With the help of the analytics platform, CarDon is now able to identify trends based on evidence that can be communicated to hospitals and physicians to provide value to the relationship and to drive better patient care.</div> <div><br>For example, CarDon will be using this analytics platform to look at ways to reduce falls in the facility. If clinicians feel that patients are at risk of falling, it is easy to generate a report on patients who have fallen and look for common threads, such as medications. Trends can be presented to doctors, who are more likely to make changes to prescribing behavior with evidence-based research.</div> <div><br>Key metrics from CarDon also can be used to pinpoint emerging health scenarios and to create workflows to act on before reaching an emergency. For example, if a patient’s blood pressure has gone down during four consecutive readings, CarDon can alert nurses to proactively take appropriate clinical steps to address the issue before it turns into a transfer to the emergency room. </div> <div><br>Enabling faster decision making via alerts allows the clinical staff to focus on providing better care for the patient.</div> <h2 class="ms-rteElement-H2">Reduced Readmissions</h2> <div>Readmission rates are a focus for all skilled nursing facilities (SNFs), so better understanding the data around readmissions is crucial to reducing their frequency. CarDon tracks exactly how many patients are readmitted to specific facilities, why these readmissions are occurring, and when readmissions are happening. By reviewing the information and highlighting trends and issues, CarDon can better understand the root cause of readmissions and serve patients better to prevent more readmissions from happening.</div> <div><br><img src="/Issues/2018/June/PublishingImages/tech2-2.jpg" class="ms-rteImage-1 ms-rtePosition-2" alt="" style="margin:10px 15px;width:506px;height:314px;" />An example of how this works: A SNF found that 60 percent of patients with chronic obstructive pulmonary disease and heart failure with diabetes were readmitted to the hospital after the first week at the facility, and that readmissions happened between 10 a.m. and 3 p.m. Medical staff can now study this information to find out the underlying cause, asking questions such as what is happening during these dates and times, which hospitals are referring these patients, and what medications are these patients taking? By having access to this information, medical staff can make evidence-based decisions to reduce or eliminate these readmissions.</div> <h2 class="ms-rteElement-H2">Changing a Mindset</h2> <div>The switch to a data-first culture takes time and a lot of communication. As with any LT/PAC organization, CarDon has experienced some pushback from management staff who felt their experience provided the evidence they needed to provide the best care.</div> <div><br>However, as management staff have become exposed to the kind of detailed data available through the analytics platform, and how these data can be used to deliver even better care, they are embracing the change. CarDon is also considering using metrics for supply management and food waste reduction. <br></div> <div> </div> <div><em>Brian Peters is chief information officer at CarDon & Associates. He can be reached at <a href="mailto:bpeters@cardon.us" target="_blank">bpeters@cardon.us</a>.</em></div>	With the skilled nursing profession becoming more competitive, and with reimbursement rates being squeezed by new regulations and value-based care initiatives, making important decisions without analyzing relevant data is no longer a sustainable strategy.	2018-06-01T04:00:00Z	<img alt="" src="/Issues/2018/June/PublishingImages/tech2_t.jpg" style="BORDER:0px solid;" />	Technology	Special Feature	Brian Peters	45	6
Interview: Deborah Meade	https://www.providermagazine.com/Articles/Pages/Interview-Deborah-Meade.aspx	Interview: Deborah Meade	<div></div> <div><img src="/Issues/2018/June/PublishingImages/DebbieMeade.jpg" alt="Debbie Meade" class="ms-rtePosition-1" style="margin:5px 15px;" />Many skilled nursing and assisted living providers have the profession in their blood, with families passing down or recasting their businesses from one generation to the next. A case in point is Deborah Meade, chief executive officer (CEO), Health Management, Warner Robins, Ga., a third-generation owner-operator with “28 years in” in a profession she loves.</div> <h2 class="ms-rteElement-H2">Speaking for her Gender</h2> <div>A board member of the American Health Care Association (AHCA), Meade’s story is one that she wishes there were more of, which is to say more examples of women CEOs in the long term and post-acute care </div> <div>(LT/PAC) space. </div> <div><br>“When I originally got into the business in 1999, there were few of us female owners,” she says. “In the nursing profession and among administrators, you see a lot of females, but as you go up, you see fewer females. And, I don’t know why. If I could do anything in this article, it would be to encourage women to believe in themselves, believe in their leadership, and know that they can do these jobs.”</div> <div><br>Meade says she certainly has experienced nothing but positive relationships among fellow CEOs from her time on the AHCA board and in her regular, professional interactions. She says while there is much sharing of best practices and how to handle the current challenges of today’s LT/PAC profession in the C-Suite, there is always room for different voices. </div> <div><br>“When I got on the AHCA board, I did not think I would be of any help or have any input. There are a roomful of extremely intelligent people, and at times it can be intimidating. However, you come to realize we are all serving the same people, offering the same services, and all want the same goals in the big picture,” Meade says. “The bottom line is you have a voice and an opinion, and they want to hear it.”</div> <h2 class="ms-rteElement-H2">The Health Management Story </h2> <div>In her own story, Meade says the key was to take what she knew from the way her father had built the family skilled nursing organization and evolve that model. So, in 1999, Meade leased a pair of buildings from the existing family business to create her own company. </div> <div><br>“I started Health Management then with two of the facilities, and grew that to include assisted living in 2001, and added two more skilled facilities in 2002. So, I have four skilled and one assisted living, which covers post-acute care, skilled care, traditional nursing home, and assisted…really a little bit of everything,” she says.</div> <div><br>All told, this portfolio translates to 368 skilled beds, 88 assisted living units, and 39 independent apartments, with 400 employees overall.</div> <div><br>Meade appreciates the balance of her current community makeup and her role as a small provider. “I like to be a small provider and to have my thumb on the triggers,” she says. “I like to know what is going on in my homes and know the people who are providing that care. I personally don’t see getting any larger, but I do see transitioning some, and I would do some more assisted living.”</div> <h2 class="ms-rteElement-H2">Climate Could Profit From Changes</h2> <div>As she evolves her business, Meade would also like to see more forward-thinking regulations, for the sake of her own business and that of her peers. </div> <div><br>“Yes, everybody needs an audit, and everybody needs oversight. But a reasonable amount, which can free up dollars for a company and not have to use people and their skills in places just for compliance,” she says.</div> <div><br>To put her beliefs into action, Meade has worked in Georgia to help defeat legislation that would have increased the regulatory burden. From that experience and others, she learned that lawmakers need to understand LT/PAC to see why more rules are not always necessary.</div> <div><br>“I got involved in politics 14 years ago and was shocked that they [lawmakers] don’t get what we do, nor the population we serve. They don’t know anything about it, like how frail and sick our residents are on the skilled side, for instance,” she says.</div> <h2 class="ms-rteElement-H2">Occupancy Levels Force Added Discipline</h2> <div>There is no way to talk about the business climate in <span style="background-color:initial;">LT/PAC without addressing how providers can best manage the current occupancy challenge. Meade says for Health Management it is all about budgetary discipline, which means looking at what is real and what is doable.</span></div> <div><br>“We know that our population right now will not support an 85 to 90 percent census that we have all been accustomed to. So, you adjust your budgets,” she says. “What I have done is I have met with my leaders and my administrators, we have adjusted our budgets to a reasonable census.”</div> <div><br>The company has around a 50 percent Medicaid and Medicare reimbursement structure in its PAC facility, and 73 percent Medicaid for its other skilled buildings. “It is nice to have the split (50-50), but not reasonable to think most facilities will have that. You find yourself getting extremely creative in surviving under Medicaid reimbursement.” </div> <div><br>Communicating the pressures to staff is key, too, allowing Health Management to hold everyone accountable to that budget. </div> <div><br>“You cannot have overages or you don’t survive. Then we keep employees educated on where we are at and why we need to [keep to the budget] to be efficient,” she says.</div> <h2 class="ms-rteElement-H2">Another Generation Awaits</h2> <div>And one of those staff brings Meade back to the matter of generational pull to the profession. Yes, there is a fourth generation behind Meade to continue the family tradition.</div> <div><br>“My daughter Kaelyn, she is 23, came onboard last May and is doing work to become an administrator. She wants to take over the company when it is her time. I am very proud to say we have a fourth generation,” she says.<br></div>	A board member of the American Health Care Association (AHCA), Meade’s story is one that she wishes there were more of, which is to say more examples of women CEOs in the long term and post-acute care (LT/PAC) space.	2018-06-01T04:00:00Z	<img alt="Debbie Meade" src="/Issues/2018/June/PublishingImages/DebbieMeade_t.jpg" style="BORDER:0px solid;" />	Quality;Caregiving	Special Feature	Patrick Connole	45	6
More From "Providers Test International Waters"	https://www.providermagazine.com/Articles/Pages/More-From-Providers-Test-International-Waters.aspx	More From "Providers Test International Waters"	<h2 class="ms-rteElement-H2"><span>Care In India</span></h2> <div><br><span style="background-color:initial;"></span><div>Cascade Healthcare Senior Communities is an American-owned company with three of its centers in China. A year ago, it acquired a large senior living operator in India, which is focused on independent living. While the company is growing, the challenges for growth are similar to those the Cascade is experiencing in China. </div> <div><br></div> <div>“Really the challenges are very much the same,” says Nate McLemore, managing director at Columbia Pacific Management and spokesperson for Cascade Healthcare. “This includes finding available real estate that’s affordable, getting the right staff, and maintaining high service and clinical quality.”</div> <div><br></div> <div>In India, the services offered are span independent living to assisted living. In China, says McLemore, Cascade is focusing more on assisted living to skilled nursing care. </div> <div><br></div> <div>Synergy between providers is strong, says McLemore. Cascade has an orthopedic hospital in shanghai, and a multispecialty clinic. Those providers work together, he says, and this applies to providers outside the company, too. </div> <div><br></div> <div>“We work with a number of the public hospitals and make doctors and nurses aware of our services,” says McLemore. “Just as you would in the US, help educate them as a potential referral source.”</div> <div><br></div> <div>Read the May 2018 <a href="/archives/2018_Archives/Pages/0518/Providers-Test-International-Waters.aspx" target="_blank">cover story</a>.</div> <div><br></div> </div>	Cascade Healthcare Senior Communities is an American-owned company with three of its centers in China.	2018-06-05T04:00:00Z	<img alt="" src="/Articles/PublishingImages/150x150/May18cover.jpg" style="BORDER:0px solid;" />		Special Feature	Amy Huaiquil	45	6

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