January 2019

Vol. 46 No. 1

January

Cover Story

https://www.providermagazine.com/Issues/2019/January/Pages/When-Eating-Stops-Problems-Start.aspx

When Eating Stops, Problems Start

<div><br></div> <div><div><br></div> <div>“Have you lost weight?” This question is often considered to <br>be a compliment. But in older adults—particularly those who are frail and have multiple comorbidities—weight loss can cause a cascade of illness, disability, mental or cognitive issues, and physical decline.</div> <div><br></div> <div><div>The challenge is to catch it early, reverse it when possible, and balance interventions with personal preferences. This requires a team where everyone is on the same page, communicates effectively, and has the latest, best tools at their disposal.</div> <div> </div> <h2 class="ms-rteElement-H2">The Many Ingredients of Weight Loss </h2> <div> </div> <div>Older adults are generally at risk for weight loss and malnutrition because of the problems and deficits related to aging—some physical, some mental or emotional, and others socioeconomic or cultural. All of these issues can contribute to poor appetite and weight loss and a cascade of conditions and illnesses.</div> <div> </div> <div><br></div> <div> </div> <div>The cause of weight loss may seem obvious—the person isn’t getting enough calories and nutrients. However, it is much more complex. This problem often results from a combination of factors. Among the many problems that can contribute to weight loss and malnutrition are:</div> <div> </div> <div><br></div> <div> </div> <div>Dementia or other cognitive impairments that cause people to lose their appetite or forget to eat;</div> <div> </div> <div>Malignancies or other illnesses, such as heart disease, thyroid disease, and infections;</div> <div> </div> <ul><li>Depression;</li> <li>Certain prescription medications <em class="ms-rteStyle-Normal">(se<span>e tab</span>le, below)</em>;</li> <li>Restricted diets;</li> <li>Lack of access to preferred foods;</li> <li>Limited income;</li> <li>Lack of transportation;</li> <li>Alcoholism or drug addiction; and</li> <li>Dental or oral health pain or problems.</li></ul> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Watch for Red Flags</h2> <div> </div> <div>It is important to note that unplanned weight loss in an elderly patient should always be a red flag and should lead to some assessment. “When I get a call from a nurse that a patient has triggered for weight loss, I have a protocol that I use,” says David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, Texas. “Tier one involves some historical questions and observations to uncover any circumstances that would indicate common reasons for weight loss or reasons that are uncommon but easy to identify—such as dental problems or other oral issues, distorted body image, or dissatisfaction with the food being served.” </div> <div> </div> <div><br></div> <div> </div> <div>Tier two of Smith’s protocol looks for issues that are a bit more uncommon and are more expensive to evaluate, such as the presence of swallowing problems or metabolic disease. If the cause is still undetermined after tier one and two assessments, Smith goes to tier three, which involves more invasive and costly assessments designed to uncover issues such as a malignancy. </div> <div> </div> <div><br></div> <div> </div> <div><img src="/Issues/2019/January/PublishingImages/TSDharmarajan.jpg" alt="TS Dharmarajan" class="ms-rtePosition-1" style="margin:5px 15px;" />“People often jump to ‘cancer’ as a likely medical cause for weight loss. In truth, there are many other more likely culprits—from heart failure and thyroid issues to infections and depression,” says T. S. Dharmarajan, MD, MACP, FRCP(E), AGSF, vice chair of the Department of Medicine and clinical director of the Division of Geriatrics at Montefiore Medical Center (Wakefield Campus) in Bronx, New York. </div> <div> </div> <div><br></div> <div> </div> <div>“If you encounter weight loss, you need to identify the root causes as quickly as possible, and not make assumptions or leap to conclusions,” says J. Kenneth Brubaker, MD, CMD, medical director of Masonic Village in Elizabethtown, Pa. Start with the “low-hanging fruit,” he suggests, such as drugs that may be causing or contributing to weight loss, or the patient simply doesn’t like the food being served.</div> <div> </div> <div><br></div> <div> </div> <div>Dharmarajan agrees, noting, “Sometimes if you just ask, you will find out that it’s something fixable such as they can’t cut or chew the steak, or they don’t like fish.”</div> <div> </div> <div><br></div> <div> </div> <div>Finding out why someone isn’t eating requires a bit of detective work, Dharmarajan says. The person’s plate is one important clue. “Look at the patient’s tray after he or she eats. You can see what and how much they’re eating,” he says.</div> <div> </div> <div><br></div> <div> </div> <div>While drugs that help depression can lead to improved appetite, Smith says that several nonpsychiatric drugs—such as clonidine, digitalis, levodopa, prazocin, reserpine, amiodarone, and steroids—actually can cause depression and negatively impact appetite and eating.</div> <div> </div> <div><br></div> <div> </div> <div>Even if there is a medical problem, it can be fixed fairly easily. For instance, Dharmarajan says, “I had a new resident who told me that she had no appetite for anything. I asked her simply, ‘Do you miss your grandchildren?’ She started crying. I put her on antidepressants, and within a few weeks, she was eating again. Her daughter thanked me for giving her ‘mom back’ to her.”</div> <h2 class="ms-rteElement-H2"> When Patients Live Alone, Nutrition May Suffer </h2> <div>Particularly when older people live independently—either in the community or senior housing where they have their own apartment—weight loss and/or malnutrition often stem from issues that are easily addressed.</div> <div> </div> <div><br></div> <div> </div> <div>“When they live alone, they often eat alone; and they may eat less. Or they don’t want to cook for one and will skip meals or eat fewer balanced meals,” says Marcie Rittenhouse, RDN, CSG, a consultant dietitian at central Pennsylvania-based LIFE/PACE program. “Some don’t have family checking in on them regularly, so no one notices at first when their eating habits change or they start to lose weight.” Even those elders who live with family can be at risk.</div> <div> </div> <div><br></div> <div>“We have some older people who live with an adult child or other family member who also eats poorly,” she says. In these cases, an occupational therapist or social worker can make home visits and identify issues, such as Mrs. Smith doesn’t know how to use her microwave, or Mr. Jones needs a way to get to the grocery store. Sometimes, the solution is as simple as helping to schedule rides to the store with a neighbor or arranging for the person to participate in a Meals-on-Wheels program or eat lunch at a local senior center.<span style="background-color:initial;"> </span></div> <div> </div> <h2 class="ms-rteElement-H2">Encouraging Elders to Eat</h2> <div> </div> <div>For residents of an assisted living community, they may just need some encouragement and incentive to go to the dining hall for meals. For instance, staff can introduce them to other residents who they can eat and socialize with. </div> <div> </div> <div><br></div> <div>In some instances, a more complex and urgent intervention is necessary. “Sometimes elders are in dysfunctional family situations that are affecting their ability to eat well. For instance, they have an adult child who has an alcohol or drug problem,” says Rittenhouse.</div> <div> </div> <div><br></div> <div>It’s important to realize that people have varying views about and relationships with food. For instance, Rittenhouse had one patient who lived with her daughter, who firmly believed that mom should sit at the table and eat a full hot meal. She was upset because her mother was resistant. “I had to remind the daughter that her mom is in her 80s and doesn’t need as many calories or as much food as a younger person,” Rittenhouse says. </div> <div> </div> <div><br></div> <div>She says another family wanted to use food as a reward or incentive for certain behaviors. “Food should never be used as a punishment or reward, and we shouldn’t pressure or force people to eat,” Rittenhouse says. “We should let them eat when they are hungry, and help ensure that they get food they enjoy.”<span style="background-color:initial;"> </span><span style="background-color:initial;"></span></div> <div> </div> <h2 class="ms-rteElement-H2">Communicating Choices</h2> <div> </div> <div>Sometimes, it may be difficult for families and caregivers not to impose their own feelings about food onto an elder. For instance, Rittenhouse worked with one woman who was emaciated but resisted eating more because she “likes to stay trim.”</div> <div> </div> <div><br></div> <div>If someone is very thin, Dharmarajan says to do a Body Mass Index (BMI) test and assess them for any problems. “If there are no red flags such as an excessively lower BMI, physical weakness, falls, depression, isolation, or lethargy, we shouldn’t push him or her to eat more,” he says.</div> <div> </div> <div><br></div> <div>Smith adds, “You must determine whether this is just cultural and ‘normal’ thinking or a psychological disorder, such as anorexia tardive.” He says that a psychiatric exam might be in order. </div> <div> </div> <div><br></div> <div>To help determine if there is a body image issue that may need to be addressed, ask patients to clip pictures from a magazine of people they identify as “too thin,” “thin,” and “obese.” This type of exercise can be very revealing, he says. </div> <div> </div> <div><br></div> <div>Such personal beliefs, as well as cultural issues and preferences regarding food, should be identified on admission. </div> <div> </div> <div><br></div> <div>“My mother is a lacto-ovo vegetarian, and we made sure the nursing staff at her facility knew this from the start,” Dharmarajan says. “I told them that she particularly loves yogurt, which she ate all her life. But I also told them that she can have anything she wants to eat, although she has diabetes.” At her stage of advanced dementia, her quality of life was more important, and avoidance of restrictive diets was at the top.</div> <div> </div> <div><br></div> <div>Facility staff should meet with families within a few days of admission to have a care planning conversation that includes a discussion of food and dietary preferences, including a review of medications, Dharmarajan says. He also recommends a nutritional evaluation of the patient on admission to determine if they are malnourished or at risk for malnutrition. He also recommends a nutritional evaluation of patients on admission to determine their nutritional status.</div> <div> </div> <div><br></div> <div>Patients often come from the hospital deconditioned and malnourished, particularly after a long illness, he says. “We need to assess them early and determine what needs to be done to help them recover their strength, regain lost weight, and be as nutritionally sound as possible given their condition,” he says.</div> <div> </div> <h2 class="ms-rteElement-H2">Dietary Restrictions: Less <span>Is More</span></h2> <div> </div> <div>Clinicians do not generally recommend restricted diets for older nursing facility residents, particularly those with a life expectancy of five years or less. “Generally, we allow these patients to eat what they want,” says Brubaker. </div> <div> </div> <div><br></div> <div>There have been many studies about the value of certain kinds of diet for cardiovascular and brain health as people age. However, Smith says, “Nutritional research related to diet and outcomes is fraught with difficulty, and the methodology for many population-based nutritional studies is flawed.” Nonetheless, he notes that the Mediterranean diet has been shown to have some value.</div> <div> </div> <div><br></div> <div>“Here in Texas, the Paleo diet is catching on. The philosophy is to emulate the diet of our cave-dwelling forefathers with a focus on meat and vegetables and a de-emphasis on simple carbohydrates and sugars,” he says.</div> <div> </div> <div><br></div> <div>While a healthy diet for all is ideal, maintaining weight and strength is a key goal for the elderly, and this often requires flexibility. “In the not-too-distant past, we were recommending therapeutic diets for the elderly; then expert opinion determined that these diets don’t really benefit this patient population because of their shorter life expectancy,” Smith says. However, he stresses that restrictive diets are appropriate for younger nursing facility patients.</div> <div> </div> <div><br></div> <div><img src="/archives/2015_Archives/PublishingImages/0115/CS_Smith.jpg" alt="David Smith, MD" class="ms-rtePosition-1" style="margin:5px 15px;width:90px;height:135px;" />“While we can’t make them eat healthy, of course, we should always educate younger patients about why they should or shouldn’t eat different foods,” Smith says, admitting that this can be challenging when patients have limited mental capacity or an inability or unwillingness to hear and retain information. </div> <div> </div> <div><br></div> <div>Dharmarajan stresses the importance of discussing liberalized diets with family members up front. “If a man had been a diabetic for years and was on a strict diet, you don’t want his family to see a cookie on his tray and get upset. You want to help them understand why you are liberalizing their father’s diet,” he says.</div> <div> </div> <div><br></div> <div>Brubaker agrees that these family discussions are essential. “Some families are very committed to things such as tight diabetic management. However, when we talk to them about the benefits of a liberalized diet, most will understand,” he says.</div> <div> </div> <h2 class="ms-rteElement-H2">Are Supplements Super?</h2> <div> </div> <div>“I would rather patients eat food than spend their money on things like vitamin waters, energy drinks, and vitamin or herbal supplements,” says Rittenhouse. Another problem with these is that they can be costly. “We had a woman who was buying $2 bottles of mineral water that she couldn’t afford, and whatever benefit she might be getting from it wasn’t worth the cost. We have to consider what is affordable, as well as what will produce the best outcomes.”</div> <div> </div> <div><br></div> <div>Appetite stimulant medications might seem like a quick fix, but Smith cautions against them. None is approved by the Food and Drug Administration for use by the elderly, he says. At the same time, most appetite stimulants are expensive and have more risks than benefits for this patient population. It is better to evaluate patients and find the root cause of weight loss, he says.</div> <div> </div> <div><br></div> <div>Skilled nursing facility patients generally have a need for or can benefit from nutritional supplementation, such as vitamin D, Smith says. However, he says, “These patients don’t need more pills, and nurses don’t need more med passes to make.” One solution might be food additives, Smith suggests.</div> <div> </div> <div><br></div> <div>“Fortify the ‘real food’ so that it better meets the resident’s needs. This could be done across the board so all residents get the benefit. Of course, additives can be individualized to resident needs when giving something to everyone isn’t appropriate or necessary,” he says.</div> <div></div> <div><span style="font-family:georgia, palatino, serif;font-size:1.3em;background-color:initial;">How Surveyors See </span><span style="font-family:georgia, palatino, serif;font-size:1.3em;background-color:initial;">Weight Loss</span></div> <div> </div> <div>The prevalence of weight loss is a quality indicator for skilled nursing centers, and regulations state that facilities must ensure that residents maintain acceptable parameters of nutritional status, such as body weight and <a href="/archives/2019_Archives/Pages/0119/Beef-Up-the-Protein.aspx" target="_blank" title="Beef Up the Protein">protein</a> levels, unless a resident’s clinical condition demonstrates that it isn’t possible. According to the Investigative Protocol for Unintended Weight Loss in nursing centers, a more than 5 percent unplanned drop in weight after a month, greater than 7.5 percent after three months, and 10 percent after six months are considered “significant” losses. </div> <div> </div> <div><br></div> <div>To help ensure that surveyors understand the reason for unplanned weight loss, it is important to document regular weights, interventions taken, and discussions with the patient and/or family members regarding nutrition and weight. </div> <div> </div> <div><br></div> <div>It is important to document efforts to balance patient choice with sound clinical care. This isn’t always easy, Smith admits. “I have encountered surveyors who say that a resident has the right to eat whatever he or she wants, even if the person’s legal guardian and I both agree that the resident shouldn’t be able to spend money on candy and sodas. We have to protect the resident’s rights. But it’s also our responsibility to take charge of decision-making areas where they lack capacity.”</div> <div> </div> <div><br></div> <div>“Staff often worry that weight loss will result in survey citations,” Dharmarajan says. “But surveyors just want to be sure that patients aren’t losing weight because they aren’t getting enough to eat or the food is of poor quality.”</div> <div> </div> <div><br></div> <div>It is key to document how weight loss is assessed and addressed; what care goals related to weight loss are established; and the progress made on the approach, including conversations about the issue with the patient and/or family members, he says. This documentation will show surveyors that staff have identified the problem, are managing it appropriately, and are respecting the patient’s wishes and autonomy.</div> <div> </div> <h2 class="ms-rteElement-H2">The Trouble with Tube Feeding</h2> <div> </div> <div><a href="/archives/2019_Archives/Pages/0119/The-Dysphagia-Dilemma.aspx" title="The Dysphagia Dilemma" target="_blank">Dysphagia,</a> especially as a patient nears the end of life, often leads to conversations about tube feeding. “Family members sometimes believe that a PEG [Percutaneous Endoscopic Gastrostomy] tube will help their loved one and make him or her feel better,” Dharmarajan says. However, “The reverse is true. This intervention doesn’t increase life expectancy or improve quality of life.”</div> <div> </div> <div><br></div> <div><img src="/Issues/2019/January/PublishingImages/cs0119_mechanisms.jpg" class="ms-rtePosition-1" alt="Mechanisms that cause or contribute to weight loss" style="margin:5px 15px;width:168px;height:521px;" />Nonetheless, family members or decision makers often are influenced by factors such as misperceptions about feeding and hunger, an inadequate understanding of the natural course and progression of dementia, lack of understanding about evidence regarding the risks and benefits of tube feeling, and cultural or religious beliefs. This is where a good practitioner-family relationship is so important, he says. </div> <div> </div> <div><br></div> <div>“No tube is placed without informed, educated consent, and this requires a serious conversation with the patient and/or his family or decision maker,” Dharmarajan says. The decision about a PEG needs to be based on understanding and weighing the risks and benefits, not on presumptions. Undue expectations should not be offered.</div> <div> </div> <div><br></div> <div>In instances where the patient lacks decision-making capacity, has no living will, advance directive, or designated decision maker, “Clinicians must assume that a patient wants nutrition therapy until proven otherwise or until evidence is found to the contrary,” Dharmarajan says. However, there is much controversy surrounding the ethics of placing PEGs in patients for whom there is reduced or limited clinical benefit. This intervention is associated with complications that may be related to the tube itself, aspiration pneumonia, and pressure ulcers. </div> <div> </div> <div><br></div> <div>In advanced dementia, PEGs are typically placed to prevent aspiration and pressure ulcers, improve function, and prolong life expectancy. However, the risks in reality outweigh the benefits, Dharmarajan says. For instance, patients can’t move with the tube inserted, so they become bedbound and susceptible to pressure ulcers, deconditioning, muscle weakness, and other issues. Also, he notes, “Converting from hand feeding to a PEG deprives the patient of touch, taste, nurturing, and social interaction.”</div> <div> </div> <div><br></div> <div>In fact, family members or caregivers often are the ones who gain a real benefit from a PEG. “The family’s or caregiver’s quality of life usually improves, as their frustrations may be tempered and they believe—falsely—that they are preventing their loved one from suffering due to hunger or thirst, he says.</div> <div> </div> <div><br></div> <div>An honest, open conversation with the family can help clear up misconceptions. However, this isn’t always the case. “Sometimes, a family member is insistent, even after being presented with all of the information and facts,” Brubaker says. “Often this is because they are dealing with their own feelings about death and dying.”</div> <div> </div> <div><br></div> <div>When this happens, he says, it may be helpful to refocus the discussion on what their loved one would want. “We need to be aware of this and try to determine why someone insists on a PEG, even when the risks outweigh the benefits.”</div> <div> </div> <h2 class="ms-rteElement-H2">Sometimes Weight Loss <span>Is Welcome</span></h2> <div> </div> <div>Obesity is epidemic in the United States, and it is problematic in nursing centers as well. “We are seeing more obese patients, and they often have related problems such as diabetes, heart disease, stroke, and vascular problems,” says Brubaker. </div> <div> </div> <div><br></div> <div>“We can’t expect people to change lifelong habits late in life, but we can try to reduce caloric intake and have discussions about diet and nutrition.” </div> <div> </div> <div><br></div> <div>“You won’t perform miracles with obese patients, but we can always attempt to help them lose some weight and be healthier,” says Dharmarajan. “This includes trying to get them to be more active, if possible.” He says it is important to be positive and encouraging and not make patients feel bad. “Set realistic targets for weight loss, and always praise the patients for positive behavior.” Help them understand how weight loss is related to quality of life.</div> <div> </div> <div><br></div> <div>Particularly for younger patients, bariatric surgery might be an option, Dharmarajan says, but the first approach is always to address lifestyle: diet and physical activity. Always individualize, taking into context the individual’s overall illness and life expectancy.</div> <div> </div> <h2 class="ms-rteElement-H2">Don’t Wait on Weight</h2> <div> </div> <div>Having the ability to monitor weight and quickly address weight loss is essential to keep patients as happy and functional as possible and, importantly, to keep them out of the hospital. “In the hospital, deconditioning happens remarkably quickly, and many patients come to us with malnutrition,” says Smith.</div> <div> </div> <div><br></div> <div>Being proactive and staying on top of weights is essential. At the same time, facilities can be creative about ways to encourage resident nutrition and healthy weights. For instance, Kings Harbor in New York, which caters to Indian seniors, has chefs and dietary teams who make authentic Indian meals. The Lott Residence, also in New York, has its dining hall on a top floor so that residents can enjoy a breathtaking view of the city while they eat. </div> <div> </div> <div><br></div> <div>Other facilities have private dining areas where residents can cook and eat with family members, and many communities offer special meals and celebrations featuring ethnic and regional foods popular among their residents. </div> <div> </div> <div><br></div> <div>“Put yourself in your patients’ shoes,” Dharmarajan says. “If you serve foods I don’t like, I’m not going to eat them. Food is one of life’s great pleasures, and we need to enable our residents to preserve this joy for as long as possible.” </div> <div> </div> <div> </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div></div> <span style="display:inline-block;"></span><br></div>

Older adults are generally at risk for weight loss and malnutrition because of the problems and deficits related to aging. All of these issues can contribute to poor appetite and weight loss and a cascade of conditions and illnesses.

2019-01-01T05:00:00Z

Caregiving;Management

Oral Hygiene and Adults With Dementia	https://www.providermagazine.com/Issues/2019/January/Pages/Oral Hygiene and Adults With Dementia.aspx	Oral Hygiene and Adults With Dementia	<p class="ms-rteElement-P"></p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"> It is necessary that all long term care residents, especially those with dementia, have a daily oral hygiene care plan. This preventive care, when performed daily, saves the tremendous cost of treating oral disease and providing emergency dental care. As dementia advances, and some residents lose the capacity to communicate when they feel pain, daily oral hygiene care becomes even more imperative to prevent pain and infection.</p> <p class="ms-rteElement-P"> </p> <h2 class="ms-rteElement-H2">Collaboration Key</h2> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">By definition, all of the long term care facility’s caregivers—medical director, medical attendings, nursing staff, and certified nurse assistants (CNAs)—are committed to providing the best possible care for the resident as detailed in their interdisciplinary care plans. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Most of the daily oral care is provided by CNAs, who play an important part in a resident’s oral hygiene routine. It is the nursing staff’s responsibility to ensure the care occurs as directed by the dentist and/or dental hygienist in the plan.</p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">This collaborative effort among nurses, CNAs, resident, and family is illustrated by an award-winning video. The 1992 video, published by the South Texas Geriatric Education Center and funded by a U.S. Department of Health and Human Services grant, is still pertinent today and teaches daily oral care for long term care residents who are conscious and unconscious. The video, “Oral Health Care—A Guide for Nurse Aides and Other Caregivers,” portrays CNAs on their rounds as they execute proper dental care, including brushing and denture maintenance, for residents who are aging, immobile, or bedbound.</p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Some key points include the importance of observation and CNAs reporting to the charge nurse if anything in the mouth is abnormal, such as broken teeth or dentures, and any sores on gingivae/gums or other soft tissue. The video also illustrates the concept of an advanced CNA whose job it is to perform or assist in this care for residents who cannot do it all by themselves. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">A career ladder can be developed to train CNAs to take the role of director of the nursing facility’s Oral Hygiene Care Program. This designation gives the CNA an important responsibility, as well as recognition for the leadership role. The advanced CNA is responsible for assuring that daily oral hygiene care is provided at the necessary care level (coaching, partial assistance, or full provision of care) as detailed in the plan, and for training all new CNAs as required by their knowledge and experience. It is expected that each CNA providing daily oral hygiene care will also <a href="/archives/2019_Archives/Pages/0119/Screen-and-Chart.aspx" title="Screen and Chart" target="_blank">screen</a> the resident’s mouth for problems.</p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"> </p> <h2 class="ms-rteElement-H2">Back to Basics</h2> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">When it comes to day-to-day cleaning, it helps to review the basics. The first rule to follow before brushing or examining a resident’s mouth is to not forget to wear gloves. Wearing gloves prevents acquiring an infection in the CNA’s or nurse’s finger, such as herpetic whitlow, also known as whitlow finger.</p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Make sure to clean any removeable partial or full dentures over a wet towel in the sink to prevent breaking them. Clean each prosthesis morning and night. Place clean dentures overnight in liquid in a cup, replacing them in the mouth in the morning. Cleanse the soft tissue under full or partial dentures using very damp plain swabs or gauze, being careful not to tear the soft tissue. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Do NOT use lemon glycerin swabs on the natural teeth instead of a toothbrush because the swabs will make a dry mouth worse and will not remove the plaque on the teeth. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Be sure to hold the toothbrush bristles at a 45 degree angle to the gumline and clean tooth to tooth, not missing any surface, and avoiding soft and hard tissue damage by not scrubbing the gums or teeth. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"> </p> <h2 class="ms-rteElement-H2">Toothpaste Choice Makes a Difference</h2> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Residents with dementia might better appreciate using children’s toothpaste since it foams less. Brush the resident’s teeth twice a day with a fluoride toothpaste, preferably one with more fluoride rather than less. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Ask the dentist to prescribe a strong fluoride toothpaste that also foams less and a special mouth rinse if the dentist thinks it is warranted for the individual resident with dementia. Make the prescribed toothpaste and rinse part of the resident’s daily oral care plan. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Floss the resident’s teeth once a day using a floss holder, squeezing the prongs when threading the holder so the floss will be tight after releasing the “squeeze” when threading the holder is complete.</p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Each resident with teeth should have a new toothbrush every three months. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"> </p> <h2 class="ms-rteElement-H2">Interacting with Residents in a Gentle Manner</h2> <p class="ms-rteElement-P"> </p> Tell the resident with dementia everything that will take place, speaking slowly and using simple words and short sentences. Do not make any sudden moves or accidentally flash a light in the eyes of a resident with dementia. This can help the resident avoid having a whole-body reaction in which his or her arms flail. <p class="ms-rteElement-P"> </p> When the resident needs professional dental treatment and if the resident is incapable of cooperating with the dentist or hygienist, sedation prescribed by the attending physician or dentist might be necessary. <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Each partial and full denture should have a label identifying the owner. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">Both partial and full dentures should be labeled using a nail file to roughen a spot on the pink outside of the denture. The roughened spot should be large enough to print the owner’s last name on it with a SharpieTM or similar permanent marker. Then the name should be covered with a strong, clear nail polish such as Sally Hansen Hard as NailsTM or similar product to protect it.</p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">This identification will last six months to a year. If a prosthesis gets lost or fits poorly, the dentist should make a new one, and will have the lab insert a proper, permanent identification in the full or partial denture.</p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"> </p> <h2 class="ms-rteElement-H2">Benefits for Residents are Critical</h2> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">In order to make a difference in improving the oral care of each resident, be patient with oneself and the resident with dementia. When proper daily oral hygiene care is provided, nursing staff can help prevent aspiration pneumonia, as well as septicemia with oral bacteria, which could have contributed to pain, myocardial infarction, stroke, or other infection. In addition, systemic diseases such as diabetes are more easily controlled and managed if the resident has no oral infection. </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P">If a resident with dementia is not in oral pain, then there could be fewer behavioral management issues when the resident can no longer easily communicate his/her distress. There is no doubt that proper daily oral hygiene care can prevent disease and result in a higher quality of life for residents.<br></p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"><em>Michèle Saunders, DMD, MS, MPH, is adjunct professor and director of the South Texas Geriatric Education Collaborative in the Departments of Psychiatry and Periodontics at the University of Texas Health Science Center at San Antonio. She can be reached at: <a href="mailto:drmjsaunders@gmail.com" target="_blank">drmjsaunders@gmail.com</a> or 210-859-6299.</em></p>	It is necessary that all long term care residents, especially those with dementia, have a daily oral hygiene care plan.	2019-01-01T05:00:00Z	<img alt="" src="/Issues/2019/January/PublishingImages/caregiving_t.jpg" style="BORDER:0px solid;" />	Caregiving	Focus on Caregiving
A New Focus on Nursing Facility Staffing	https://www.providermagazine.com/Issues/2019/January/Pages/A-New-Focus-on-Nursing-Facility-Staffing.aspx	A New Focus on Nursing Facility Staffing	<div></div> <div><img src="/Issues/2019/January/PublishingImages/IainStauffer.jpg" class="ms-rtePosition-2" alt="" style="margin:5px 15px;" />The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently updated its Work Plan with additional topics focusing on nursing facilities that receive Medicare and Medicaid reimbursement. The Work Plan describes new and ongoing OIG audits and evaluations for HHS programs and operations, including Medicare and Medicaid.</div> <h2 class="ms-rteElement-H2">The Staffing and Quality Connection</h2> <div>Earlier in 2018, OIG added a new topic to the Work Plan, which will focus on the Centers for Medicare & Medicaid Services (CMS) oversight of nursing facility staffing levels. The overall concern is the impact of staffing levels on residents’ quality of care. </div> <div><br></div> <div>The Medicare Requirements of Participation state that a facility must provide sufficient nursing staff on a 24-hour basis and a registered nurse for at least eight consecutive hours per day, seven days a week.</div> <div>With this new topic, OIG will be examining nursing staffing levels that are reported by facilities electronically to CMS’ Payroll-Based Journal (PBJ). In addition, the review will address the efforts by CMS to ensure data accuracy and improve quality of care by examining the enforcement of minimum requirements and encouraging the hire of high-quality staff above required levels.</div> <div><br></div> <div>To further emphasize the increased focus on staffing level requirements, this addition to the OIG Work Plan comes recently after the issuance of letter QSO-18-17-NH from the CMS director of the Quality, Safety, and Oversight Group to State Survey Agency directors. That letter addressed the transition to PBJ Staffing Measures, staffing data audits, and the requirement for registered nurse staffing in facilities. </div> <div><br></div> <div>CMS demonstrated its commitment to addressing staffing level requirements with the issuance of letter QSO-19-02-NH in November. This letter addressed the use of PBJ data to help increase oversight of nursing facilities by evaluating sufficient staffing. </div> <div><br></div> <div>In the letter, CMS indicated that it is “very concerned about the risk to resident health and safety” brought about by nurse staffing levels because of the connection between the quality of residents’ care and appropriate nurse staffing. </div> <div><br></div> <div>To assist with oversight, CMS will be providing CMS Regional Offices and State Survey Agencies with a list of nursing facilities with potential staffing issues. </div> <div><br></div> <div>Specifically, CMS has identified two areas of concern: 1.) nursing facilities with several days in a quarter without a registered nurse (RN) present; and 2.) significantly low nurse staffing levels on weekends. To address these concerns, CMS will begin notifying State Survey Agencies of nursing facilities that meet either or both of these criteria. </div> <h2 class="ms-rteElement-H2">Surveying on Weekends</h2> <div>In addition to this notification, the letter said that CMS will now require State Survey Agencies to conduct at least 50 percent of the required off-hours surveys on weekends based on the list of nursing facilities it provides. Also, CMS instructed state surveyors to investigate whether a nursing facility has provided the services of an RN seven days a week, eight hours a day, when conducting a standard or complaint survey. </div> <div>State surveyors are to cite the nursing facility for noncompliance if this requirement is not met.</div> <h2 class="ms-rteElement-H2">Transfer and Discharge in the Spotlight</h2> <div>OIG added another topic to the Work Plan in November focusing on the involuntary transfer and discharge of nursing facility residents. OIG noted data from the Long-Term Care Ombudsman Program that shows complaints related to discharge and eviction are cited more frequently than any other issue. This is an area of concern to CMS because of a belief that an involuntary transfer and discharge of a nursing facility resident could be unsafe and traumatic. </div> <div><br></div> <div>With this new topic, OIG will be examining nursing center compliance with CMS requirements for involuntary transfers and discharges. In addition, the review will examine the extent that state long term care ombudsmen address involuntary transfers and discharges and the extent to which State Survey Agencies investigate and take enforcement actions against nursing facilities for improper transfers and discharges.</div> <div><br></div> <div>OIG updates its Work Plan throughout the year, and the release of an update provides an opportunity for nursing facilities to review their own operations and practices in order to identify areas for compliance improvement.</div> <h2 class="ms-rteElement-H2">Other Areas of Focus</h2> <div>OIG conducts investigative activities that involve allegations of fraud, waste, and abuse in all of HHS’ programs. Medicare and Medicaid constitute a significant amount of its work. Areas that OIG can investigate include billing for services not rendered, provision of medically unnecessary services and misrepresented services, patient harm, and the solicitation and receipt of kickbacks. </div> <div><br></div> <div>In addition to performing investigations, OIG is also involved in facilitating compliance in the health care industry and the exclusion of individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.</div> <div><br></div> <div>In addition to the topics addressed previously, the active OIG Work Plan already has identified several risk areas for skilled nursing facilities (SNFs) and nursing facilities (NFs) in the Medicare and Medicaid programs. Those areas already under review include unreported incidents of potential abuse and neglect, facility reimbursement, prospective payment system requirements, and potentially avoidable hospitalizations of nursing facility residents.</div> <h2 class="ms-rteElement-H2">A Guide for Compliance</h2> <div>The Work Plan provides insight into the areas that could come under scrutiny and ultimately can help guide internal compliance activities for a facility.</div> <div><br></div> <div>These audits and evaluations by OIG serve as an important reminder that facilities must remain vigilant with their reporting and documentation. Also, it is essential that facilities are familiar with applicable requirements for the provision of services— especially staffing and transfer and discharge requirements—and remain current with policies, rules, and regulations. </div> <div><br></div> <div>The recent issuance of CMS letters in April and November and the additions by OIG to the Work Plan indicate it is also a good time for SNFs and NFs to review their compliance plan and internal policies to verify that they address all necessary requirements for the provision of services.</div> <div><br></div> <div>Facilities should review their operations and take the necessary steps now to be better prepared to provide proper and quality care, to achieve and maintain compliance in the current regulatory and audit environment, and to minimize their chances for negative audit findings or rating system scores. </div> <div> </div> <div><em>Iain Stauffer serves as Of Counsel at Poyner Spruill in the Health Law Section. He can be reached at <a href="mailto:istauffer@poynerspruill.com" target="_blank">istauffer@poynerspruill.com</a>.</em></div>	The U.S. Department of Health and Human Services Office of Inspector General recently updated its Work Plan with additional topics focusing on nursing facilities that receive Medicare and Medicaid reimbursement.	2019-01-01T05:00:00Z	<img alt="" src="/Issues/2019/January/PublishingImages/mgmt_t.jpg" style="BORDER:0px solid;" />	Management	Management
A New Page for Skilled Nursing Facilities: The Patient-Driven Payment Model	https://www.providermagazine.com/Issues/2019/January/Pages/A-New-Page-for-Skilled-Nursing-Facilities-The-Patient-Driven-Payment-Model.aspx	A New Page for Skilled Nursing Facilities: The Patient-Driven Payment Model	<div></div> <div> For years, the Centers for Medicare & Medicaid Services (CMS) has been developing a new prospective payment system (PPS) to replace the existing Resource Utilization Group (RUGs) PPS. CMS formally finalized the new system last July; it goes into effect Oct. 1, 2019.</div> <div><br></div> <div>Called the Patient-Driven Payment Model (PDPM), the new PPS is a significant departure from RUGs and, in many ways, a welcome one. </div> <h2 class="ms-rteElement-H2">Move Away from Minutes</h2> <div>Almost since its inception, the RUGs payment system has struggled with a payment bias toward the delivery of therapy. In a 2002 evaluation of the RUGs model, research firm ABT Associates noted that the provision of therapy services would increase among participating facilities, “due to the incentive to provide enough minutes of therapy to qualify Medicare beneficiaries for higher-paying RUG groups.”</div> <div><br></div> <div>As with overarching Medicare payment policy goals, PDPM is intended to move away from service-based metrics for purposes of payment, which in RUGs is the number of therapy minutes delivered. </div> <div><br></div> <div>Under PDPM, therapy minutes have no direct relationship with payment at all. Rather, payment is driven by an array of patient characteristics. These include diagnostic information collected via ICD-10 diagnosis codes assigned by skilled nursing facility (SNF) clinicians, medical record information, functional status using Section GG of the Minimum Data Set (MDS), and a new cognitive assessment scale.</div> <div><br></div> <div>Patient characteristics are used to assign patients to the appropriate case mix group (CMG) by PDPM direct service components (physical therapy, occupational therapy, speech language pathology, nursing, and non-therapy ancillaries). </div> <div><br></div> <div>CMS believes PDPM provides a more holistic approach to patient care by separately adjusting each component, with a particular emphasis on the nursing component and the non-therapy ancillary component.</div> <div><br></div> <div>In short, PDPM is intended to refocus SNF care to medically complex patients and away from therapy. PDPM also is intended to align with the IMPACT Act Quality Reporting Program to more accurately reflect the impacts of a more holistic approach to care. </div> <h2 class="ms-rteElement-H2">Need for Accurate Reporting</h2> <div>Under PDPM, the number of MDS items impacting payment is 161, up from the 20 MDS items that drove assignment to a rehab RUG. </div> <div><br></div> <div>Accurate coding under PDPM is critical, particularly during the Five-Day Assessment window due to the expanded importance of MDS items.</div> <div><br></div> <div>In the Five-Day Assessment, patients are assigned to CMGs for each of the five service-related components. Correct assignment is particularly critical under PDPM because payments under three components—physical therapy, occupational therapy, and non-therapy ancillaries—decline over the course of the stay using a CMS-developed schedule. </div> <div><br></div> <div>While a patient may be re-assigned to a different CMG following the initial Five-Day Assessment, the declining payment schedule does not return to day one of a stay. So, if the assigned CMG and related case mix index result in a rate that’s too low, the declining payment schedule could become problematic later in the stay as the payments continue to decline. </div> <div><br></div> <div>PDPM frees SNFs from counting therapy minutes and a largely outdated payment system. However, with change comes an array of challenges.</div> <div><br></div> <div>With the Oct. 1, 2019, implementation date rapidly approaching, SNFs should be well underway with four <br></div> <div>key PDPM Core Competencies© developed by the American Health Care Association:</div> <div><ul><li>Educate yourself about the new system. SNFs should be assessing how their facilities will position to deliver care to more medically complex patients and shift away from therapy; </li></ul></div> <ul><li>Develop accurate diagnostic and MDS coding capabilities—ICD-10 Diagnosis codes had little impact on payment under RUGs, while under PDPM, ICD-10 and MDS coding become critical to payment;<br></li> <li>Evaluate and strengthen your ability to manage complex patients. Developing clinical care pathways for medically complex patients is at the core of PDPM success; and </li></ul> <ul><li>Align resources. Alignment of resources inside the SNF is key. Clinicians, MDS coordinators, and billing staff will need to communicate far more closely than in the past. Additionally, resources and relationships must be revisited, including information technology and therapy contractors. </li></ul> <div> </div> <div><em>Mike Cheek is senior vice president, reimbursement policy, for the American Health Care Association. PDPM Update is a new Provider monthly feature that will bring more details about the new PPS system as they are released by CMS over the coming year.</em></div> <div> </div>	Called the Patient-Driven Payment Model (PDPM), the new PPS is a significant departure from RUGs and, in many ways, a welcome one.	2019-01-01T05:00:00Z	<img alt="" src="/Issues/2019/PublishingImages/PDPM.jpg" style="BORDER:0px solid;" />	Policy	PDPM Update

A Story of Survival	https://www.providermagazine.com/Articles/Pages/A-Story-of-Survival.aspx	A Story of Survival	<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div></div> <div> Paradise, Calif., was anything but its name on Nov. 8 when an intense forest fire brought tragedy to the town of 26,000 nestled in the Sierra Nevada foothills above the Sacramento Valley. </div> <div><br></div> <div>In what survivors called an ungodly combination of heat, smoke, and speed, the Camp Fire inferno killed dozens and torched most anything in its path. Where churches, gas stations, homes, and schools once stood is now charred earth in most areas of town. Not much was spared.</div> <div><br></div> <div>There was also a skilled nursing facility (SNF) in town, Heritage Paradise. It is no longer there.</div> <div><br></div> <div>This is the story of how the consequences of a disaster played out in real time for this one SNF, and how fast-acting and determined administrators, staff, and volunteers drove residents to safety under extreme risk of peril. Even if they could not save their building, they saved their charges.</div> <h2 class="ms-rteElement-H2">A Day Like No Other</h2> <div>Jessica Johnson was the administrator of the 99-bed facility, which had 66 residents to care for on the day the fire struck. One of the first things noticed when talking to Johnson is how she stumbles over the past tense in her title these days, still shocked to be a “was” when it comes to her job. </div> <div><br></div> <div>She tells <em>Provider</em> that the day in question started with worry right off the bat. Locals were tracking the progress of a forest fire that although nearby seemed far enough away to keep to normal routines. </div> <h2 class="ms-rteElement-H2">Warning Signs </h2> <div>For Johnson, this meant running her two young daughters to daycare and school before arriving at the nursing center. But even as she started off that morning, she made a decision to keep her children close and skip the drop-offs.</div> <div><br></div> <div>“I lived in Paradise and was able to see a huge cloud of smoke that was also raining ashes already, and that was about 7:30 to 7:45 a.m. at that point,” she says. “I kind of had an uneasy feeling, and I called Sonya [Meyer, corporate executive administrator for Heritage] and said, ‘Have you gone outside yet? It is raining ashes already. I am a little nervous.’”</div> <div><br></div> <div>Johnson also had fielded a call from the facility saying the Internet was down, which she thought was a “weird coincidence.” </div> <div><br></div> <div>The uneasy feeling about what lay ahead only intensified as she drove the short distance to work through a thick fog of smoke. When she arrived, Johnson told the staff—who were worried about the fire as well—to start packing for the residents, “getting some outfits together just in case because it did not look great.”</div> <div><br></div> <div>Johnson started getting calls from other staff members who were driving toward the facility and not at work yet, expressing concerns about the smoke as well. These are all people experienced in the ways of forest fires, which strike this part of California often enough. </div> <div><br></div> <div>“The fire was about two canyons over, which is not unusual for Paradise, and normally it will be out before it hits us,” she says.</div> <h2 class="ms-rteElement-H2">Keeping Positive </h2> <div>Meyer joins in the retelling of that day by emphasizing that everyone was trying to stay calm and positive even as the trickle of negative news on the path of the fire increased by the minute.</div> <div><br></div> <div>“I got a call a few minutes after 8 a.m. saying that someone had witnessed the fire go over the canyon and hop the canyon, and it was spreading quickly and the smoke outside was getting worse,” she says.</div> <div><br></div> <div>In reaction, Johnson called the nearby Windsor Chico Creek Care and Rehab in Chico where they have 184 skilled nursing beds some 20 miles from Paradise.</div> <div><br></div> <div>“I knew they would have room for our residents. So, I called them to see if they could just reserve every single room for me. I was told minutes after that other hospitals and skilled nursing centers had called but I had already reserved the beds,” she says.</div> <div><br></div> <div><img src="/Issues/2019/January/PublishingImages/Joe-Miceli.jpg" alt="Joe Miceli" class="ms-rtePosition-1" style="margin:5px 15px;" />Johnson also asked for the SNFs’ vans and made a separate call to Merit Medi-Trans, whose owner Joe Miceli agreed to offer assistance in moving residents. Tommy Davis from Windsor Chico Creek and Steve Brace and Duanne Barr of another helpful provider, The Terraces Assisted Living, were the other van drivers that day.</div> <h2 class="ms-rteElement-H2">No Time to Wait</h2> <div>The point of all these calls was to give Heritage Paradise the option to get out as quickly as possible, and luckily they acted because shortly after 8 a.m., authorities issued the evacuation order for Paradise.</div> <div><br></div> <div>“The fire was on the other side of Paradise at that point but it was moving extremely quickly,” Meyer says. “And then at a certain point, I don’t know what time, we made the call to get the residents [who were not in need of Hoyer lifts] in personal vehicles because we were not going to be able to wait.”</div> <div><br></div> <div>Both Johnson and Meyer said the most striking feature of the evacuation and all that it entailed was the race to get ahead of what was an incredibly fast-moving fire. “We had a Paradise resident who was coming down the Skyway [the only road connecting the town to the evacuation route], and he stopped at our driveway and told us that the fire was about 150 yards up the street. ‘You can wait no longer, you have to go,’ he said,” Meyer recalls.</div> <div><br></div> <div>All of the residents, minus seven who needed lifts, were put into staff vehicles. The wait for the vans was <br></div> <div>just getting started for the others, but a larger problem was that there was really no way to evacuate the area entirely because the Skyway was more parking lot than road at this juncture.</div> <div><br></div> <p class="ms-rteElement-P">“The Skyway was not moving at all,” Meyer says. “When I looked up there were probably four of our cars in our driveway. They were not even able to merge into the traffic yet because it was not even moving.”<span id="__publishingReusableFragment"></span></p> <h2 class="ms-rteElement-H2">Encircled by the Blaze</h2> <div>Meyer remembered thinking about the vans and how they could never get through, given that both lanes of the Skyway were going out of town, whereas the vans would be coming toward town and the facility. It was at this point that another level of fear took over. “We felt we were kind of trapped at this point, I didn’t know what we were going to do,” Johnson says. Calls were made to local authorities describing their situation but only messages could be left.</div> <div><br></div> <div>The immediacy of the pending disaster also took hold, especially when the remaining nine facility staff could feel the water spray on their faces from nearby helicopters trying to put out the fire, she says.</div> <div><br></div> <div><img src="/Issues/2019/January/PublishingImages/Sonya_Jessica.jpg" alt="Sonya and Jessica" class="ms-rtePosition-2" style="margin:5px 10px;" />Amid the feeling of being encircled by the blaze, Johnson and Meyer made decisions on who would stay with the seven residents, allowing staff to get to their own families in some cases. In other cases staff volunteered to stay not only to get the last residents out but also to save the building.</div> <div><br></div> <div>“Our two maintenance guys were on our roof with hoses. They thought they could defend it, and said they have to stay,” Meyer says. “I was like, this is not a good option.” The fire was burning stronger, and the options became one choice really, which was to get out if at all possible.</div> <h2 class="ms-rteElement-H2">Parting the Waters</h2> <div>It was in these scary moments when the traffic was just starting to move a bit, but there were still no signs of the vans to get the Hoyer lift residents out that something amazing happened. The vans appeared, as if by magic, to rescue what had been a smooth evacuation.</div> <div><br></div> <div>“I have to say, I am not a religious person but I said it was like Moses parting the waters,” Meyer says. “Some of our staff members that were already in the evacuation were on the road going the opposite direction out of town and said it was like salmon swimming upstream.”</div> <div><br></div> <div>It turns out the vans did make it through against the two lanes of traffic. “While we all did our jobs with staying and getting the patients out, they [van drivers] did more than their job because they drove vans to get our people out. I don’t know what we would have done, we had no real options,” she says, leaving the thought of the worst-case scenario hanging.</div> <div><br></div> <div>The story of how Johnson and Meyer and all of their staff and residents survived of course did not end with the vans. There were worried, tense, emotional moments on the slow drive out of Paradise, including Johnson running a mile and a half on the Skyway to try and connect with her small children who were in a separate vehicle.</div> <div><br></div> <div>All of these survival stories turned out all right. No one died that day from the Heritage Paradise family. All the residents remain where they were taken and are in good care, Meyer says. But, there is no Paradise anymore. Both Johnson and Meyer lost their homes, as did more than 70 other staff members. There are no jobs. People are just now being allowed to go back to a small part of town and check on where they once lived. The future is uncertain, but at least there is one.</div> <h2 class="ms-rteElement-H2">A Great Job</h2> <div>While a place called Paradise is no longer standing, it is still very much alive as is the gratitude of the people who matter most.</div> <div><br></div> <div>“I had one of the Hoyer residents, she liked leaned over and patted me on the back and said, ‘you guys are doing a great job.’ So, they did really, really well. No panic. I was surprised at how calm they were,” Johnson says.</div> <div><br></div> <div>Through the work of the California Association of Health Facilities, the state affiliate for the American Health Care Association/National Center for Assisted Living, there are ways to help those SNFs and their employees affected by the fires at <a href="http://www.cahf.org/" target="_blank">www.cahf.org</a>. </div>	Paradise, Calif., was anything but its name on Nov. 8 when an intense forest fire brought tragedy to the town.	2019-01-01T05:00:00Z	<img alt="" src="/Issues/2019/January/PublishingImages/fire_t.jpg" style="BORDER:0px solid;" />	Quality	Special Feature	Patrick Connole	46	1
Using Data to Promote Quality Improvement	https://www.providermagazine.com/Articles/Pages/Using-Data-to-Promote-Quality-Improvement.aspx	Using Data to Promote Quality Improvement	<div></div> <div> A lack of coordination of patients from one level of care to the next, whether to a post-acute care setting or home, can lead to preventable readmissions. According to a 2009 <em>New England Journal of Medicine</em> article titled, “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program,” avoidable hospital readmissions directly impact a patient’s health and are burdensome and costly. </div> <div><br></div> <div>In Michigan, hospitals and post-acute settings in metropolitan Detroit drive up the statewide readmission rate and suffer a disproportionate share of readmission penalties. Because they serve a diverse population, including a large proportion of low-income, minority, and vulnerable people, health care providers in southeast Michigan are trying to slow the pace of the readmission-related reimbursement cuts through a variety of quality improvement programs.</div> <div><br></div> <div>A key component in these efforts includes widespread collaboration and targeted strategies to improve care coordination for successful transitions of patients to the community.</div> <h2 class="ms-rteElement-H2">Tri-County Collaborative</h2> <div>Beginning in 2015, five major health systems and more than 100 skilled nursing facilities (SNFs) in southeast Michigan recognized the opportunity to align goals and resources and formed the Tri-County SNF Collaborative with the intent to improve care transitions, enhance communication, provide higher quality of care, and reduce readmissions. </div> <div><br></div> <div>Participating SNFs shared a broad range of characteristics, with a variation in ownership types (for example, for-profit corporation, for-profit individual, for-profit partnership, government-county, nonprofit church related, nonprofit corporation, nonprofit other) and the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Ratings ranging from one to five.</div> <div><img src="/Issues/2019/January/PublishingImages/quality_chart.jpg" class="ms-rtePosition-4" alt="" style="margin:5px;" /> </div> <div><span><strong>This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy.<span style="display:inline-block;"><br></span></strong></span></div> <div><span><strong><span style="display:inline-block;"></span></strong></span><br>MPRO, a quality improvement organization based in Farmington Hills, Mich., represents Michigan in Lake Superior Quality Innovation Network, serving Michigan, Minnesota, and Wisconsin under the CMS Quality Improvement Organization Program. MPRO leveraged established relationships throughout the Southeast Michigan community to engage, build, and organize the Tri-County SNF Collaborative with the aim of improving health outcomes for Medicare beneficiaries. </div> <div><br></div> <div>This unique position led to diverse leadership among the collaborative partners and helped create an environment that aligns resources to achieve low-cost, high-yield impact. All participants agreed that data would serve as a key driver of their efforts; process and outcome measures were tracked and reported by the SNFs to drive continuous quality improvement. </div> <h2 class="ms-rteElement-H2">Aims of the Collaborative</h2> <div>Upon formation, the aims of the collaborative were to improve care transitions, enhance communication, provide higher quality of care, and reduce readmissions. Participating facilities committed to working with each other on aligned care transition measure reporting and shared best practices, with the united goal of improving care for all patients as a shared model.</div> <div><br></div> <div>SNFs reported data metrics on a quarterly basis; site-level feedback reports were shared with SNFs to drive quality improvement. Medicare Fee-for-Service Part A claims data were also used to calculate the percentage of 30-day readmissions for discharges from the health systems to the SNFs. Additionally, metrics related to acuity, transitions, and quality were evaluated to identify opportunities for improvement. Metrics included:</div> <ul><li>Acuity: Average daily census; facility average length of stay; </li> <li>Transition: Time frame for first physician history and physical evaluation upon admission; seven-day follow-up primary care physician (PCP) visits for patients discharged from SNF to community; discharge summary provided to PCP within seven days; </li> <li>Quality: Nosocomial urinary tract infection rate; nosocomial pneumonia rate; falls with major injury rate; short-stay new/worse pressure ulcer rate; 30-day all-cause readmissions with a SNF admission index diagnosis of sepsis; antipsychotic medication rate in long-stay patients; and </li> <li>Readmissions: 30-day all-cause readmission rate.</li></ul> <div>Participants met quarterly to review progress and key outcome data findings. Best practices were identified and shared, and this resulted in grassroots education and the development of a multifaceted portfolio of market-driven strategies to address the needs of the high-risk populations served by the collaborative.</div> <div><br></div> <div>Some examples of the types of strategies that were used include: </div> <div><ul><li>Using data to drive decisions: A quality metric dashboard was created to address key focus areas for the collaborative. </li></ul></div> <div>Regular reviews of the metrics and data allowed for the discussion and agreement on which measures provided the most valuable information. System goals were intentionally made accessible to every member of the collaborative, which gave everyone the opportunity to offer insights. These insights were turned into action by the collaborative to improve the quality of care for patients.</div> <ul><li>Expansion of the collaborative: The collaborative realized its work impacted more than just hospitals and SNFs, and that it needed to include the entire care continuum if change were truly going to be made. The collaborative developed (and is currently piloting) a Home Health Agency (HHA) workgroup that is actively developing its own quality metrics dashboard, with the goal of collecting data that will offer insight into where the group can take action and make change for HHAs as well. </li> <li>Early recognition and management of sepsis program and toolkit: The five regional health systems partnered to facilitate a sepsis program for SNFs in southeast Michigan. Participating SNFs attend five monthly meetings and two coaching calls where they receive education on the prevention of pneumonia, urinary tract infections, and central line-associated bloodstream infections. To date, 33 SNFs have successfully completed the session and another 60 SNFs planned to engage in the program in fall 2018.</li></ul> <h2 class="ms-rteElement-H2">Better Outcomes </h2> <div>The readmission rates are not adjusted or standardized in any way. Calculated rates include both scheduled and unscheduled readmissions due to difficulties in defining and removing “scheduled” readmissions. Data for July 2017 through August 2017 are not fully matured, and rates are subject to change.</div> <div><br></div> <div>Part A Medicare Fee-for-Service standard analytic claims data were used to calculate the 30-day SNF readmission rate. A readmission was defined as a discharge from a hospital to a nursing facility participating in the collaborative and readmitted to a hospital within 30 days of discharge.</div> <div><br></div> <div>A subsequent claim for admission to a SNF within two days of the inpatient discharge was used to determine the SNF to which the beneficiary was discharged. To help quantify results, comparison groups also were formed among the SNFs. SNFs that are participating in the collaborative were grouped into the collaborative SNF group, while all other SNFs in Michigan were grouped into the noncollaborative SNF group. The CMS Certification Number was used to identify the SNF in the dataset. </div> <div><br></div> <div>The SNF collaborative readmission results have fluctuated over time, with a period of downward trending during the first few months, followed by upward movement and proceeded by downward movement in the most recent months of the intervention. The SNF noncollaborative readmission rate showed an increasing trend over time. Figure 1 shows details of the SNF readmission measure.</div> <h2 class="ms-rteElement-H2">Next Steps</h2> <div>With increasing acuity levels, medical complexities, and behavioral health issues within the SNF population, all the major health systems in the collaborative formed a regional network to strengthen their approach and quality improvement efforts. </div> <div><br></div> <div>Data outcomes have helped prioritize the need for a change in strategy and new approaches to care coordination. Subsequently, insights from this large and successful collaborative have led to measure modifications and targeted action plans, which are the result of root cause analysis and other quality improvement strategies. </div> <div><br></div> <div>Through re-evaluation of the collaborative needs, the health systems’ leadership decided to invest time, resources, and education in a more systematic and teachable approach for larger assemblies of providers. </div> <div>The health systems have proactively provided training programs led by subject matter experts for specific diagnoses like sepsis and heart failure. With this new collaborative approach, there has been a renewed surge of dedication and support for ongoing transformation and quality improvement. </div> <h2 class="ms-rteElement-H2">Improved Quality of Care</h2> <div>Since the collaborative began, metrics related to acuity, transitions, quality, and readmissions have demonstrated that joint efforts can impact patient safety and clinical quality. The most recent months have also shown a reduction in SNF readmissions. In turn, the collaborative has fostered the development of sustainable, market-driven best practices to improve quality of care and care coordination. Further study deepened understanding of variation in quality across health care organizations and highlighted the value of the shared responsibility for transforming care delivery. </div> <div> </div> <div><em>Elizabeth Waldman is director, Department of Applied Epidemiology and Evaluation, MPRO, part of Lake Superior Quality Innovation Network. She can be reached at 248-465-7390 or <a href="mailto:ewaldman@mpro.org" target="_blank">ewaldman@mpro.org</a>.</em></div> <div> </div>	A lack of coordination of patients from one level of care to the next, whether to a post-acute care setting or home, can lead to preventable readmissions.	2019-04-03T04:00:00Z	<img alt="" src="/Issues/2019/January/PublishingImages/quality_t.jpg" style="BORDER:0px solid;" />	Quality	Special Feature	Elizabeth Waldman	46	1

January 2019

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