Winter 2023

Vol. 50 No. 4

Cover Story

Strengthening the Chain of Wound Prevention and Care

https://www.providermagazine.com/Issues/2023/Winter/Pages/Strengthening-the-Chain-of-Wound-Prevention-and-Care.aspx

Strengthening the Chain of Wound Prevention and Care

<img src="/Issues/2023/Winter/PublishingImages/Winter23_CF-Wound.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />Senior care facilities place a high priority on person-centered care and attending to the body, mind, and spirit of the whole resident. One critical facet of that care is skin health and wound management. The good news is that there are more technologies and treatments, as well as certification and training programs, to help maximize outcomes and quality of life.<h3>The Skinny on Skin Breakdown</h3>Diabetes, malnutrition, vascular disease, immobility, incontinence, and even dry, itchy skin are among the things that can lead to the development of wounds in older adults. Chronic wounds affect up to 10.5 million Medicare beneficiaries, and the incidence of pressure injuries and other chronic wounds increases with age, frailty, and disability. These wounds can lead to various complications, including infections and amputations. It is harder for wounds to heal in nursing home residents who are frail with multiple comorbidities and nutritional challenges. At the same time, aging skin is less resilient and more fragile. It can bruise and tear easily. Essential to effective skin care and wound management in long term care is a strong wound management program. “Wound management is such a complex issue. A good program needs to address numerous elements and have a focus on prevention and improving quality of life,” said Amin Setoodeh, BSN/RN, senior vice president of skin health solutions and clinical services at Medline. He added, “Staff need to know what they’re striving for—zero tolerance of preventable pressure injuries. There needs to be a check and balance system to consistently review staff performance, revise plans, and provide feedback and additional training and support.” <h3>Developing a Team Approach</h3>Like so much in long term care, wound management is a team activity that requires the involvement of everyone—from housekeeping and dietary staff to nursing and physical therapy practitioners. All these individuals need to know the basics of wound prevention, as well as red flags and signs of skin issues to watch for. If they notice any sign of a possible wound—such as red or discolored skin, especially at bony prominences—they should know how to document this and who to report their observations or concerns to. Setoodeh said, “Everyone who comes in contact with residents should have training. This starts with certified nurse aides (CNAs) and families. Then the dietitian should be involved to help ensure the resident is getting the right nutrition; and physical and occupational therapists could be monumental in preventing wounds.” He urged, “Don’t wait until there is an issue to do training. Good programs should be based on assessing staff’s knowledge gaps and developing education from prevention to treatment.” Not only does everyone need to know their role in wound prevention, assessment, and management, but they need to know how to document their findings and observations, as well as who to communicate with and how. This is essential to guide care, set goals, and track outcomes, but it also is key to showing surveyors that you have taken all necessary and appropriate steps to keep residents safe, prevent wounds, and avoid hospitalizations and exacerbations when wounds are unavoidable. However, while everyone has a role in wound care, Jeffrey Levine, MD, a New York-based geriatrics and palliative medicine specialist and recognized expert in wound care and pressure injuries, stressed the need for every facility to have a certified wound care expert. This can be a nurse or other clinical team member, but there needs to be someone who can champion skin care and wound management and serve as a source of information, guidance, and answers. “There are many options to become certified. Some are better than others, so it is important to do the research before choosing one.” He also noted that different certifications have different requirements, such as some experience in the field. “It is extremely important to have an expert on your team to audit the wound management process and provide ongoing feedback to frontline caregivers,” said Setoodeh, stressing that this is especially significant where there are staffing shortages or a proliferation of agency nurses who may have limited experience in geriatrics and skilled nursing care. For instance, he observed that up to 80 percent of residents have some incontinence issues. “Staff need to know the importance of keeping residents dry, and they need to have adequate training and time to deal with incontinence issues and make regular checks of skin condition. The same is true of turning and repositioning immobile residents or those with limited mobility,” he said.<h3>Ensuring Expertise</h3>It is important not to assume that members of your clinical team have wound management expertise. Setoodeh said, “Looking at our curricula, most medical and nursing schools don’t include wound care. This is such a comprehensive, technical science, and it requires a specialized expertise.” Levine agrees. He said, “Wound management is an important medical issue that physicians haven’t been taught in medical school. Unfortunately, this has created a gap in training where practitioners often don’t know how to assess wounds or identify appropriate treatment options. I think this training should be mandatory for licensure.” Ultimately, he stressed, “Everyone needs to be involved and educated. You can’t afford to have one weak link.” Don’t forget families in this education equation, Levine urged, noting, “People often don’t know the basics of skin assessment and care. Families need to be counseled. I hear stories about how families weren’t informed until discharge or even death. They need transparent information up front.” This requires consistency, he noted. Everyone on the team needs to be providing the same information about staging, location, etc. “You can’t have one physician saying it’s a stage 4 wound, another saying it’s stage 3, and the nurse saying it’s a skin tear,” he said. There also is a role for telemedicine in providing access to experts, Setoodeh observed. “This took off during the pandemic, and the technology enables remote practitioners to examine and assess wounds and capture data. There is a great opportunity for telemedicine and technology for improving assessment, product selection, treatment course, and staff and family education,” he said. <h3>Steps to Healthy Wound Management</h3>First, suggested Setoodeh, “Look at wound care from a 30,000-feet perspective. You need to look at skin health holistically, and the number one focus should be on prevention.” At the same time, Levine stressed, “Become familiar with the federal regulations, particularly F-tag 686. This is a very detailed document with guidance for surveyors, and it provides an excellent summary of everything you need for wound care in long term care.” Then, he said, establish a system of care based on this guidance. Jeanine Maguire, MPT, CWS, a wound prevention and management specialist, stressed that wound prevention and management needs to start as soon as residents enter the facility, with a prompt skin assessment. “Skin breakdown can happen fast in older, vulnerable people. A stage 1 or 2 ulcer can happen in a couple of hours. But with prompt attention, it is healable in 30-60 days. It is much harder and more costly to heal a stage 3 or 4 wound.” An integrated team approach with alignment and collaboration, not fear or blame, is also important. “It is important to have photo documentation. All wounds should be visible to the team on a HIPAA-compliant app.” At the same time, skin and wound care should be an essential piece of Quality Assurance and Performance Improvement (QAPI), and there should be a culture of communication and transparency. With limited budgets, product choice to support wound care is key. Levine said, “Wound care is a vast multi- billion-dollar market, and there are always innovations and new products, including diagnostics being developed to detect early injuries.” However, he cautioned that many products haven’t been subjected to research to establish healing efficacy in the long term care population. Maguire noted, “There are no standard guidelines for treatment, and there are thousands of treatments. There is a need for some framework for nursing home operators to understand what is happening in centers across the country, including best practices. Toward this end, we are trying to build a national wound team.” Providers need to be closely intertwined with processes of care so their decision-making is appropriate for each individual, according to Levine. He noted that one big development in the field is the availability of third-party wound care providers who can come in with expert teams and conduct consults. These, he said, can help provide training, documentation, and back-end functions for more effective prevention and treatment efforts. A report in Science Advances earlier this year1 identified the three key principles of wound management as moisture balance, infection prevention, and medical optimization of comorbidities. The authors pointed to advancements such as biomaterials that mimic extracellular biophysical cue to resolve inflammation, therapies to promote healing and reduce scarring (using a cell-penetrating RNA), and new peptide formulas designed to treat venous leg and diabetic foot ulcers. At the same time, however, the report noted that some of these innovations are still being studied and that there is a need for additional strategies, particularly for healing complex wounds. <h3>From Care to Costs to Accountability</h3>Clearly, all the staffing time, education and training, treatments, and technology for wounds come with a cost. However, Setoodeh said, “Wounds are a huge issue that can have tremendous adverse effects. If wounds aren’t assessed properly, the course of treatment won’t be accurate. And wounds, particularly if they progress, take significant nursing time and present a risk for infection, sepsis, and hospital readmissions. At the same time, the risk of mortality increases for patients with wounds, and they can impact the quality of life and the family experience.” He said, “The average facility spends about 3-5 percent of supply costs on preventive skin care, and preventive efforts cost about $115 per day. Compare this to the cost of treating a stage 3 or 4 wound, which is about $3000-4000 per day. Organizations can’t afford not to invest in skin care and wound management.” Accountability is key, said Setoodeh. “This starts with looking in the mirror and determining what you can do. It means a common vision and the assurance that staff have the resources, tools, and time to provide good care. And it means being transparent, doing the best we can, and celebrating positive outcomes.” References1. <a href="https://medicalxpress.com/news/2023-06-breakthrough-treatments-wound.html" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://medicalxpress.com/news/2023-06-breakthrough-treatments-wound.html</a>

A strong wound management program links together a team approach with staff education, a focus on prevention, and cost-effective product choices.

2023-11-13T05:00:00Z

Caregiving

Finding and Cultivating Leaders in Long Term Care	https://www.providermagazine.com/Issues/2023/Winter/Pages/Finding-and-Cultivating-Leaders-in-Long-Term-Care.aspx	Finding and Cultivating Leaders in Long Term Care	<p><img src="/Issues/2023/Winter/PublishingImages/Winter23_CF-Admin.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />Staffing challenges in post-acute and long term care aren’t limited to clinical staff and frontline workers. There is a shortage of skilled administrators as we move closer to the silver tsunami and Gen X exile expected to hit the sector in the next 10-20 years. Where is the next generation of administrators coming from? </p><h3>An Amazing Adventure</h3><p>Most long term care facility administrators are surprised that others wouldn’t want to pursue careers in this care section. Good Samaritan Society’s vice president of operations Aimee Middleton is one such professional. Inspired to become an administrator after her father-in-law’s illness, she saw numerous opportunities to use her business skills and passion for service. “It’s an amazing career. It’s incredibly rewarding, and you have an impact on many lives.” <br></p><p>Yet, the profession seems to be a well-kept secret. According to a recent <em>Skilled Nursing News</em> survey, 58.6 percent of respondents say they expect hiring administrators to get harder than it already is. Over half also said they think it will be more challenging to retain administrators. At the same time, survey respondents identified three common ways to try to attract people to the administrator role: increased wages (56.4 percent), facilitating better work-life balance (38.4 percent), and offering more health benefits (12.8 percent).<br></p><p>Fortunately, there are some passionate innovators in the field who are finding ways to encourage new generations of leaders to consider careers as administrators.</p><h3>Administrator-in-Training Program</h3><p>The Good Samaritan Society has a successful Administrator-in-Training (AIT) Program, which is a paid internal management development program designed to attract those who are interested in the field to get more involved, get them trained and licensed, and move them into jobs where they can make a difference. <br></p><p>“We help people see what the job is and help give them the tools and resources they need to be successful,” said Middleton. She added, “We want to talk to business colleges and universities and educate them. I think we have a story about a career with a human component that a lot of people would find rewarding.”<br></p><p>The leadership team at Good Samaritan doesn’t just bring new administrators into the field and forget about them. “We help them see their career path and how we can help potential leaders. We also are actively engaged in succession planning,” said Middleton. This means having meaningful conversations with staff and encouraging them to speak at educational institutions and community organizations about what a satisfying, desirable career this is and the opportunities it offers.<br></p><p>Tom Syverson, director of government and external affairs at The Good Samaritan Society, said, “You have to reach people when they’re young and keep following them.” In addition to efforts to speak with students, apprenticeship programs, mentorships, internships, and efforts like ‘take a teen to work’ programs can engage young people and get them started on their career path even before they graduate. <br></p><p>California-based HumanGood also has an administrator-in-training program. David Larance-Patterson, director of learning and organizational development at HumanGood, explained, “You can be hired into the program, but we prefer to look internally to identify those who might be a good fit or those who have raised their hand to participate.” Participants get a full perspective of long term care—everything from skilled nursing, budgets and finance, and dining to buildings operations and grounds upkeep. <br></p><p>“It’s a competency-based program that enables people to experience what it means to be an administrator. We track their exposure to difference aspects of the job and have competency-based outcomes.” Program participants are also invited to engage with current residents through the resident council meetings so they can get views and insights from those living in the community. “It’s all done with an onsite preceptor, and we’re currently working to leverage a learning management system for tracking and documenting progress through the program,” said Larance-Patterson.<br></p><p>HumanGood also has a leadership development program called “Good to Grow.” This is a competency-based program that is mapped to diverse business lines, including health care, dining, and affordable housing. It’s a hybrid model with in-person and online learning opportunities. Once people complete this program, they have an opportunity to pursue a degree at the University of Arizona at no cost. Those AIT participants who want more, said Larance-Patterson “get priority seating in a Master’s of Health Administration program, where we always have a waiting list.” He noted, “You really have to be dedicated to do the full program, and earning the Master’s takes about 18 months.”<br></p><p>Larance-Patterson stressed, “We are very transparent up front and make it clear how we will work with them and cover costs. There is a ‘soft ask’ that they stay for a period of time after they complete the program but no agreement to sign. However, for the Master’s program, they have to stay for a year or pay back part of the funds.” People aren’t pressured if they decide this program isn’t for them. He said, “We’ve had administrators in training who went through the program and decided they did not want to finish it. We will work to find a different role within the organization, and that way we get to keep our top talent.” He stressed, “It’s no career killer. People aren’t punished if they decide this isn’t for them.”</p><h3>Leadership Development in Aging Services</h3><p>Steve Chies, board chair of Vision Centre, is one of the many individuals who wanted to share his passion for the field with others. He started thinking about how to attract new people to administrator careers and keep them growing. <br></p><p>In 2004, he worked with AHCA/NCAL to establish the Future Leaders program. The year-long program kicks off with a two-day symposium, “Future Leaders of Long Term Care in America,” held each year in Washington, D.C. Selected participants have demonstrated leadership potential and an interest in presenting the interests of providers at the state and national levels. The program covers the latest theories and practical applications in quality management, customer satisfaction, and leadership.<br></p><p>Chies later partnered with Douglas Olson, chief executive officer (CEO) of Vision Centre, for the Leadership Development for Aging Services program. This relatively new effort is non-profit and designed to inspire passionate students in the field of aging services to meet the leadership needs of the country with quality higher education programs and partnerships for rewarding, impactful careers. The Centre’s goal is to create 25 university and college programs nationwide. It also aims to facilitate from these programs 1,000 paid residencies among senior care and aging services by 2025. The program is off to a strong start with broad support from people like Chies and John Cochrane, CEO of HumanGood, who is on the advisory council of Vision Centre.<br></p><p>“These kinds of leadership programs are essential. We need to invest in our future leaders and have a bench strength,” said Olson, adding, “They provide stable, quality leadership that leads to better organizational performance.” He added that a “secret sauce” to these programs is a paid residency or internship. “If you can engage students and let them know they’ll be paid to learn, it’s an easier sell.”<br></p><p>The Leadership Development in Aging Services program is win-win-win for students, their academic institutions, and hiring organizations. But there still is work to do, suggested Olson. “We have to change the narrative about senior living professions,” he noted. This means spreading the word that if you want a job that has meaning and purpose, you can have an impact beyond what is possible in most other careers. Instead of asking people if they want to be administrators, Olson suggested, “We should ask how they would like a career where every day is different, and they are making a positive impact.” He stressed, “The labor shortage in leadership isn’t going away any time soon, and we need to find the people who are excited about this field. These programs can help the entire broad field of senior living get people engaged in this noble profession.”</p><h3>The Need to Lead</h3><p>The Vision Centre, said Olson, has found that people are often exposed to this field at an early stage in life due to career or family experiences, so organizations need to be paying attention to their existing talent pool. A good administrator can come from just about anywhere, so it is important to open opportunities to all those who may have limited experience but great passion and desire to advance their career. Larance-Patterson said, “It’s better when people opt in, but it’s also fine to go to people who show potential and invite them to participate.”<br></p><p>“I believe in leadership training for everyone. Everyone on your team needs to understand how things work,” suggested Michael Wasserman, MD, a California-based geriatrician and past-president of the California Society for Post-Acute and Long Term Care Medicine. “You never know when someone might be a great leader. It’s important to cast a wide net and enable everyone to have the opportunity to be empowered,” he said. <br></p><p><img src="/Issues/2023/Spring/PublishingImages/JoanneKaldy.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:175px;height:219px;" />Providing team members with leadership skills also can contribute to retention. Wasserman said, “Studies from a decade ago showed the value of leadership styles in terms of quality and turnover reduction. When you have the right type of leadership approach at the administrator, medical director, and director of nursing levels, you dramatically reduce turnover and improve quality.” Leadership training not only helps all team members feel more confident handling challenges and decisions, Wasserman said, it also helps them envision their career paths and seek ways to move up the ladder. “Having various career ladders gives people opportunities that make them better at their jobs wherever they go.” </p><p><em>Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.</em></p>	Promoting the profession, expanding educational opportunities, and offering leadership training can all help remedy the shortage of qualified administrators.	2023-11-13T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_CF-Admin.jpg" style="BORDER:0px solid;" />	Workforce	Cover Feature	Joanne Kaldy	50	4
Getting Back to Basics on Controlled Substance Disposal	https://www.providermagazine.com/Issues/2023/Winter/Pages/Getting-Back-to-Basics-on-Controlled-Substance-Disposal.aspx	Getting Back to Basics on Controlled Substance Disposal	<p><img src="/Issues/2023/Winter/PublishingImages/Winter23_CF-Disposal.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />Back in 2017, the Centers for Medicare & Medicaid Services (CMS) implemented new guidelines about controlled substance management, storage, and distribution. Even though facilities have processes in place for the storage and destruction of controlled substances, it is important to take a fresh look at this issue and ensure you are using the latest technology and best practices to manage destruction and prevent diversion. <br></p><p>“These are high-risk medications. Any mistake or error can be critical in terms of adverse events or diversion,” said Adrienne Hearn, RPh, BCGP, manager of clinical operations at PharMerica. While it can be challenging to keep everyone up to date on appropriate processes, it is essential to make sure training and education about this issue are part of onboarding as well as regular programs and updates. </p><h3>The Background and the Basics</h3><p>First of all, it’s important to understand what constitutes controlled substances. The federal Controlled Substances Act identifies five categories. Schedule I includes illicit drugs (such as heroin) that have no medical use. Schedule II involves drugs that are used medically but also have a high potential for abuse (such as morphine and opioids). Schedule III through V drugs have less abuse potential (sedatives, codeine, etc.). <br></p><p>One challenge is that controlled substance use and destruction are overseen by multiple agencies. The U.S. Food and Drug Administration (FDA) regulations say: “A long term care facility may dispose of controlled substances in Schedules II, III, IV, and V on behalf of an ultimate user who resides, or has resided, at such long term care facility by transferring those controlled substances into an authorized, collection receptacle located at that long term care facility. When disposing of such controlled substances by transferring those substances into a collection receptable, such disposal shall occur immediately, but no longer than three business days after the discontinuation of use as directed by the prescriber, as a result of the resident’s transfer from the long term care facility, or as a result of death.”<br></p><p>CMS’s guidance, which involved an amendment to the State Operations Manual, called for facilities, among other things, to have a system to track the receipt and disposition of controlled substances. This must involve reconciliation, which facilities should do on a regular basis. Additionally, CMS requires records that document the name and strength of each medication, as well as the quantity and date it was received. The recipient’s name also must be documented. Additionally, facilities need careful records of personnel access, usage, and disposition of all controlled medications, as well as details regarding the disposal or destruction of medications.</p><h3>Disposal Renders Drugs Unusable</h3><p>Disposal must be done using a method that prevents diversion and accidental exposure and that renders the medication irretrievable. Specifically, this means that the drug’s physical and/or chemical condition is changed so that it is permanently unusable. <br></p><p>It is important to note that in addition to federal requirements, each state has its own rules for disposal of controlled substances. For example, some states require that a pharmacist be involved in the process, or they may have special forms for issues such as request for approval of disposal/destruction or controlled substance inventory. Check with your state Department of Health or Environmental Protection Agency office for details. <br></p><p>Most states require moving medications from the cart to a secured, double-locked location when they aren’t being used. This process must be carefully tracked, witnessed, documented, and verified. Drugs should only be moved from the secured storage area when the team is prepared for the actual destruction. <br></p><p>There are several ways to destroy these drugs, Hearn said. These include mixing them in a slurry with an undesirable substance, such as coffee grounds or kitty litter, and placing this in impermeable, nondescript containers, such as empty cans or sealable bags. There also are proprietary systems and commercially available products on the market, such as controlled substance wastage programs and chemical dissolution systems.<br></p><p>Ultimately, the destruction processes depend on the drug and the formulation. Whatever destruction processes you use, it is important to remember—and to make sure staff know—that you can’t throw unused controlled substances in the garbage, pour them down the drain, flush them, or return them to the pharmacy. They must be rendered beyond use and the destruction documented and witnessed. </p><h3>When Drugs Should Be Destroyed</h3><p>If a resident is deceased, or no longer needs or wants to take these medications (if someone refuses to take their controlled substance as prescribed, this must be documented in the records), they must be disposed of properly. If a patient is discharged, they must have an order from their physician to take the controlled medications with them. Additionally, there must be two witnesses to the handoff of the medications to the resident, and all three must sign a form documenting this transaction. <br></p><p>If family members take a loved one who is taking a controlled substance out of the facility for a holiday or visit, they can’t just take the drugs with them. With the physician’s sign off and the witnessing of two nurses, the resident can take only the doses they need, and family members may need to sign a release stating that they understand that the resident and just the resident can take these drugs. “It is important to talk to your risk or compliance team to ensure you have appropriate policies and procedures in place for this situation,” said Joe Marek, RPh, BCGP, FASCP, chief pharmacy officer at CommuniCare.</p><h3>Get Everyone in the Know</h3><p>Knowledge is power, and that is certainly true when it comes to controlled substances. Hearn said, “Know both the federal and state regulations because every state will be different. Know who is authorized to dispose of meds and who is allowed to witness the destruction. Everything must be carefully tracked and documented.” <br></p><p>This is an area where one little error could cause serious concerns. For instance, she said, there are some specific recommendations regarding disposal of the fentanyl patch, as it may have medication remaining on it even after use. It will be important to use gloves to handle the patches, and two people need to be present when they are changed on a patient. “If you forget to remove the patch and put on another, this could cause adverse events, and don’t think that just because a patch is used that it can’t be diverted.” You can’t just throw used patches in the garbage can or sharps container. They need to be folded in half and disposed of by flushing, if allowed by state/local law, or a chemical dissolution system like any other controlled substance.<br></p><p>When it comes to these drugs, one error could be deadly. For instance, Hearn observed that morphine sulphates come in two basic strengths for oral solutions: 100mg/5ml and 20mg/5ml. “This is a pretty significant difference, and if you get the strengths confused, there is a high potential for overdose.” It could cause respiratory depression in those not previously exposed to opioids, Hearn said, adding that it is important for patients and families to know what drugs in what dosages are being administered.<br></p><p>Tracking is a common error that can cause problems, Marek said, noting, “It can be a mundane process, and it’s more challenging when there are staffing shortages.” He observed, “The pandemic had an impact. Nurses worked longer hours and were overwhelmed and stressed out. This made it more likely that steps could be missed.” <br></p><p>This can be especially problematic during shift changes. Marek suggested, “Part of the process at shift changes is that controlled drugs are accounted for and what is on the accountability sheet actually is in the med cart.” Getting nurses from both shifts together at the med cart during the shift change or any time the keys are exchanged is critical in ensuring the accountability for the controlled substances, and it also prevents diversion. He stressed that having one or more witnesses to every action taken regarding controlled substances from the time they come into the facility is one key to preventing diversion. <br></p><p>Another common error involves the periodic reconciliation process, said Hearn. This needs to be done with acceptable standards of practice, making sure that tasks such as change of shift counts, documentation of dosages used, number of orders, and pharmacy invoices are reconciled regularly. Again, with staffing shortages and turnover, this is an easy area for mistakes or missed steps to happen. <br></p><p>Watch for signs of diversion. For instance, Hearn said, “When you are administering liquid controlled substances, your initial count should match what is dispensed on the label. As doses are administered and if the counts do not match, it will be important to determine if there was an over- or under-fill or diversion.”</p><h3>The Diversion Dilemma</h3><p>The U.S. Department of Health and Human Services defines drug diversion as “the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber.” The agency further notes, “Prescription drug diversion may occur at any time as prescription drugs are distributed from the manufacturer to wholesale distributors, to pharmacies, or to the patient. Members of the medication profession may also be involved in diverting prescription drugs for recreational purposes, relief of addictions, monetary gain, self-medication for pain or sleep, or to alleviate withdrawal symptoms.”<br></p><p>Drug diversion can happen even in the best facilities. The most frequently diverted medications include opioids, such as hydromorphone, morphine, fentanyl, hydrocodone, oxycodone, and methadone. As Marek noted, “If these drugs aren’t disposed of properly or aren’t tracked properly, this can be considered potential diversion, even if no one moves or uses the medications or takes them out of the building.”<br></p><p>When there are missing drugs or some evidence of diversion, this must be reported promptly. Marek said, “Depending on your state, you have to report to numerous entities, including the police, board of pharmacy, board of nursing, and possibly even the state attorney general.” When a controlled substance or other medication goes missing, he said, this can be considered a potential misappropriation of a resident’s property. Particularly with opioids, which are used to control pain, it may be considered abuse or neglect if residents don’t get medications to manage their discomfort.<br></p><p>The good news about controlled substances destruction is that you don’t have to reinvent the wheel. Marek offered, “Work with your pharmacy and consultant pharmacist to ensure proper policies, procedures, and processes are in place. This should be part of their service offerings, and they should be able to support you and answer any questions you have.” At the same time, he suggested that facility leaders take the time to walk around and look at things—including the handling of controlled substances—on a regular basis. </p>	Be sure your facility uses best practices in disposing of controlled substances by crafting precise procedures, ensuring proper destruction, and avoiding drug diversions.	2023-11-13T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_CF-Disposal.jpg" style="BORDER:0px solid;" />	Management	Cover Feature	Joanne Kaldy	50	4

Accountable Care Organizations in Long Term Care	https://www.providermagazine.com/Issues/2023/Winter/Pages/Accountable-Care-Organizations-in-Long-Term-Care.aspx	Accountable Care Organizations in Long Term Care	<p><img src="/Issues/2023/Winter/PublishingImages/Winter23_PHM.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />Medicare Advantage (MA), institutional special needs plans (I-SNPs), and institutional-equivalent special needs plans (IE-SNPs) are just some of the more well-known models in managed care. Although accountable care organizations<sup>1</sup> (ACOs) are not new to long term care (LTC), the opportunity for LTC providers to play a more significant role in ACOs is new. <em><br></em></p><p><em>Provider</em> magazine had the opportunity to speak to Sarah Sugar and Kristen Ratcliff McGovern of Sirona Strategies and Angie Scally, Kendra Faulk-Edwards, and Zach Cattell of CarDon & Associates who share their experience working with ACOs in nursing homes, post-acute care, and assisted living. CarDon & Associates owns, operates, or manages 20 communities that offer independent living, assisted living, rehabilitation, long term care, and memory support throughout Indiana. Sirona Strategies is a Washington, DC-based government affairs firm that advises a range of different clients, including providers, payers, government contractors, health IT vendors, etc.<em><br></em></p><p><em>Provider: </em>There has been a lot of talk and work on I-SNPs. Why is there an interest in ACOs currently, and what is the opportunity? How do ACOs complement I-SNPs?<br><strong>Sirona Strategies:</strong> Participants in I-SNPs and ACOs both have experience taking on risk for patient outcomes and cost. While activity has largely centered on MA, I-SNPs are not the appropriate model of care for every LTC provider, and ACOs provide the opportunity for LTC providers to engage more meaningfully in the Medicare fee-for-service (FFS) population. <br><strong>CarDon & Associates:</strong> ACOs, particularly those that serve the long-stay resident, complement I-SNPs because not every resident is going to choose an insurance-based solution for their care. ACOs are also complimentary to broader MA products.<em><br></em></p><p><em>Provider</em>: What are some considerations that LTC and assisted living providers need to keep in mind when engaging with ACOs?<br><strong>SS:</strong> ACO financial methodologies, quality reporting requirements, and attribution policies have not been designed with the LTC community in mind, which will inevitably present challenges. However, there are LTC-focused ACOs that have succeeded in the Medicare Shared Savings Program (MSSP) and in the High Needs track of the ACO REACH Model.<sup>2</sup> Finding the right partners, including other LTC providers who have experience in such a nuanced program, is critical.<br><strong>C&A: </strong>It is also important to consider if there is a genuine cooperative partnership with a shared objective between the LTC provider and ACO, and if the ACO actively seeks input from the LTC or assisted living organizations, recognizing their expertise in the field. Collaboration should also extend to defining care expectations.</p><p><em>Provider:</em> What are the challenges for LTC providers when partnering with an ACO? <br><strong>C&A: </strong>ACO leaders often originate from the hospital and primary care sectors where ACO incentives were initially conceived and evolved. While their intentions are commendable, they may lack the hands-on experience and expertise specific to LTC management and operations. Therefore, good collaboration between LTC providers and ACOs is essential.<br></p><p>Also, ACO participants may utilize various hospitals and providers, making it difficult to determine their ACO affiliation. Without this knowledge, LTC providers cannot leverage added resources, care coordinators, or the 3-day waiver benefit, hindering collaboration and care. A robust identification system can help manage unnecessary spending and enhance care quality. Ideally, checking a resident’s Medicare benefits should reveal their ACO affiliation from day one.</p><p><em>Provider: </em>What are the benefits? <br><strong>SS:</strong> Given that I-SNPs typically have limited penetration, an ACO provides an opportunity for LTC providers to benefit from the residents who chose not to enroll in an I-SNP. ACOs also encourage coordination between community-based and LTC providers, who often operate in a silo from one another, and offer more reliable and resilient payment methodologies than traditional FFS.<br><strong>C&A:</strong> Benefits in all settings encompass improved collaboration and the ability to align residents with appropriate resources and care management. This allows for the teams to collaboratively work together to avoid unnecessary treatment ultimately leading to good stewardship of Medicare money while not sacrificing patient care options and treatments.</p><p><em>Provider: </em>What is the future of ACOs in LTC in the next five years?<br><strong>SS: </strong>Long term and post-acute care have played an essential role in the success of most value-based care models, with some of the most significant improvements in care and cost savings generated by intentional and targeted post-acute care partnerships. ACOs will continue to prioritize effective engagement and meaningful partnership with the LTC community to realize increased efficiencies, improved outcomes, and reduced health care costs. <br>As CMS strives to grow the MSSP and achieve its goal of having all Medicare Part A and B beneficiaries in accountable care relationships by 2030, there will be an increasing attention to ensuring the LTC community has a pathway for meaningful participation in ACOs.<br><strong>C&A: </strong>We think the future of ACOs in LTC is bright, and our experience with LTC-focused ACOs is positive due to our ACO partners’ willingness to dig in with us to understand our LTC perspective and then act on it.</p><p><em>Natalie Visnick is senior manager of public affairs for the American Health Care Association/National Center for Assisted Living.</em><br></p><p><span class="ms-rteStyle-Normal">References</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">1. <a href="https://educate.ahcancal.org/products/accountable-care-organizations-2" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://educate.ahcancal.org/products/accountable-care-organizations-2</a></span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">2. <a href="https://www.cms.gov/priorities/innovation/innovation-models/aco-reach" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://www.cms.gov/priorities/innovation/innovation-models/aco-reach</a></span><br></p>	Collaboration between providers and ACOs can lead to success and lower costs.	2023-11-13T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_PHM.jpg" style="BORDER:0px solid;" />	Management	Population Health Management
Going for the Gold Takes Rare Mettle	https://www.providermagazine.com/Issues/2023/Winter/Pages/Going-for-the-Gold-Takes-Rare-Mettle.aspx	Going for the Gold Takes Rare Mettle	<p>Receiving the Gold Quality Award from AHCA/NCAL’s National Quality Award program is like traveling to an important bucket list destination. It’s powerful, inspiring, and immensely satisfying, but it’s not the end of the journey. Instead, it makes the road ahead more enlightening, joyful, and filled with optimism. It sheds light on the power of what’s possible. <br></p><p><img src="/Issues/2023/Winter/PublishingImages/Winter23_QA_Breanna.jpg" class="ms-rtePosition-1" alt="Breanna Jameson" style="margin:5px;" />During the recent Delivering Solutions 23, AHCA/NCAL’s Annual Convention & Expo, in Denver, Colo., <em>Provider</em> magazine hosted a roundtable discussion with representatives from the 2023 Gold Quality Award-recipient facilities and AHCA/NCAL leadership to discuss the unique value of the award, the path from Bronze to Gold, and what it means to the facility, staff, residents, families, and other stakeholders.<br></p><p>The 2023 recipients are two facilities in the same organizational family—Aspen Park of Cascadia and Lewiston Transitional Care of Cascadia, both in Idaho. Breanna Jameson, chief executive officer (CEO) of Lewiston Transitional Care, said, “I’m proud to represent my team and shine a light on their hard work. They have taken ownership of the Quality Award journey, and the organization provided the autonomy to transition to what we wanted to be.” She added that they had “many conversations with our staff to talk about why we were doing this and what we were trying to accomplish.” She stressed that receiving the Gold Award couldn’t have happened without the commitment and involvement of everyone in the facility. <br></p><p><img src="/Issues/2023/Winter/PublishingImages/Winter23_QA_Rachel.jpg" alt="Rachel Zimmerman" class="ms-rtePosition-1" style="margin:5px;" />Rachel Zimmerman, CEO of Aspen Park of Cascadia, said that they focused on financial, cultural, and clinical pillars and “what we do day in and day out.” She added, “Our staff lived this journey, and it aligned with our pursuit of the awards.” Jameson added, “It truly was a beautiful pathway from Bronze to Silver to Gold. The journey pushed us to go where we never imagined we would.”</p><h3>Its Own Reward…and More</h3><p>In many ways, the Quality Award journey is its own reward, and there were many highlights and milestones along the way. As Jameson said, “One ‘aha’ moment came as we started to see the benefits of the strategic planning and goal-setting we did as part of the award application. We talk about quality all the time, but the strategic planning shows that in an ever-changing environment, you can create goals to progress and have quality goals and outcomes.” Her facility started out with opportunities for improvement, and today they are a 5-star building with stronger finances and greater resident/staff satisfaction.<br></p><p>Nonetheless, while the journey comes with many achievements and successes, winning is still a great honor. Zimmerman said, “I was so nervous when I got the email. I had someone else read it to me. I was hoping we would get the Gold. We even planned a celebration.”<br></p><p>Robert Vande Merwe, executive director of the Idaho Health Care Association, noted, “You don’t just pay your dues and that’s it.” Jameson said, “The award has narrowed our processes, focuses, and purpose.” This, she noted, ensures that everyone is better prepared for the future. Zimmerman said, “We have implemented twice-daily huddles to talk about goals, and we get staff involved. We review goals and our strategic plan and adjust them as needed.” Jameson stressed that they may have received the top Quality Award, but they will continue their pursuit of excellence using the tools, knowledge, and resources they gained through the journey to the Gold. Zimmerman further noted, “When you get to Gold, you strive to stay there. This is the work our staff do every single day.”</p><h3>Leadership Lauds the Quest for Quality</h3><p>AHCA/NCAL CEO Mark Parkinson had nothing but praise for the award recipients. “We know what our work means. We get up early in the morning every day and go out there,” he said, adding, “You are inspiring, and your efforts are truly amazing. It is especially remarkable that you accomplished this partly during the pandemic.” He praised the teamwork that took the facilities to the Gold, and NCAL executive director LaShuan Bethea agreed, noting, “I love that you focused on the team and everyone’s role. I’m sure the residents are excited too.”<br></p><p><img src="/Issues/2023/Winter/PublishingImages/Winter23_QA_Cascadia.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:500px;height:237px;" />Vande Merwe observed, “We have a long legacy of quality in Idaho. Maryruth Butler [who mentored this year’s Gold winners] went on the quality journey with her team. It took five years, but it made such a difference; and others were inspired.” Parkinson urged the Gold recipients, “You can inspire other people. Share your story and talk about your journey.”<br></p><p>It is important for everyone to know about the power of the Quality Awards. This includes legislators and policymakers. Parkinson said, “We need you on the Hill. Policymakers have a view that nursing homes are all run by large companies, but there are so many like you.” Congress, he said, needs to hear about how many smaller organizations are out there providing high-quality care with limited staff and resources. </p><p>Read more: <a href="/Issues/2023/Winter/Pages/Tips-for-Quality-Award-Success.aspx" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">Tips for Quality Awards Success</a><br></p><p><em>Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.</em><br> </p>	The 2023 Gold Quality Award recipients explain the path to achieving Gold and what it means to staff, residents, and families.	2023-11-13T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_QA_Cascadia.jpg" style="BORDER:0px solid;" />	Quality Awards	National AHCA/NCAL Quality Awards
Nursing Career Ladder in Skilled Nursing Facilities	https://www.providermagazine.com/Issues/2023/Winter/Pages/Nursing-Career-Ladder-in-Skilled-Nursing-Facilities.aspx	Nursing Career Ladder in Skilled Nursing Facilities	<p>Skilled nursing facilities provide a unique opportunity to let nurses advance their career alongside building meaningful relationships with colleagues and residents. Unlike other professions where you might have to leave the organization to develop skills and have opportunities to use more technical skills, staff can progress from a certified nursing assistant (CNA) to a licensed practical nurse (LPN) to a registered nurse (RN) while remaining at a facility.</p><p><a href="/Issues/2023/Winter/Documents/Winter23_BTN.pdf" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank"><img class="ms-asset-icon ms-rtePosition-4" src="/_layouts/images/icpdf.png" alt="" />By The Numbers</a><br></p>	Unlike other professions where you might have to leave the organization to develop skills and have opportunities to use more technical skills, staff can progress from a CNA to a LPN to a RN while remaining at a facility.	2023-11-13T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_BTN.jpg" style="BORDER:0px solid;" />	Workforce	By the Numbers
Quality Award Program Boosts Community Performance	https://www.providermagazine.com/Issues/2023/Winter/Pages/Quality-Award-Program-Boosts-Community-Performance.aspx	Quality Award Program Boosts Community Performance	<p><img src="/Issues/2023/Winter/PublishingImages/Winter23_AL.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />When the resident call light turns on at senior living communities, some states require that staff respond within 15 minutes of the call.<br></p><p>Brandy Scheer, executive director of Heritage Woods of Minooka, a Gardant assisted living community in Minooka, Ill., said her community’s goal is to reach them within 10 minutes, “and often, we proudly are responding in just a few minutes,” she said.<br></p><p>That’s just one example of improved care that comes from participating in the AHCA/NCAL National Quality Award (QA) program. The program is steadily gaining in popularity, boosting the reputation of those communities that have achieved awards as the industry maintains its impressive rebound in performance and consensus since the pandemic.<br></p><p>NCAL’s Director of Quality Improvement, Pamela Truscott, DNP/HSL, MSN/ED, RN, said recently that interest and participation in the program are up by four times compared to this time a year ago.<br></p><p>Scheer said the program helped her staff learn they perform better when more people are involved in the overall process of care. Heritage Woods is one community within Gardant’s portfolio, which operates 80 properties, mostly in Illinois, Indiana, and Ohio. Gardant set out to achieve these quality improvements through the QA journey in 2019 and today has earned 62 Bronze and four Silver awards. Two of the Silver communities are currently working toward Gold, the program’s most prestigious honor.<br></p><p>Julie Simpkins, co-president, Gardant Management Solutions, Bourbonnais, Ill., said the program’s criteria have helped to fill gaps, address pain points, and serve as best practices for how the company manages its communities.<br></p><p>“The criteria are aligned with continuous quality improvement and demonstrate specific approaches that improve health care outcomes for those we serve,” she said.<br></p><p>A recent independent study by Brown University examining a Silver or Gold QA from 2018-2020 confirmed that there’s a greater than 5 percent lower relative risk of emergency department use for awardees vs. non-awardees.<br></p><p>The study examined five outcomes: any inpatient hospitalization; any ambulatory care sensitive hospitalization; any emergency department visit; any injury-related emergency department visit; and any long term nursing home transition. It excluded emergency department visits and hospitalizations that occurred while residents were in a nursing home.</p><h3>Continuously Moving From Good to Great</h3><p>Sarah Silva, president, Arete Living, Tigard, Ore., said the program is a continuous growth path for those trying to move from good to great. Arete has 26 communities, and since 2013, 22 have been awarded Bronze and seven Silver awards.<br></p><p>“The application process involves participation and input from every level of the organization, from the front-line workers to the leadership team,” Silva said. “During the process, you hear from everyone on your staff. They offer new ideas. This is often where the best ideas come from. It helps communities to cultivate best-in-class operations. The process makes you better.”<br></p><p>Scheer said the program puts an extreme focus on measurement and processes, and “pulls the whole team together to improve overall satisfaction. It improves our monitoring of our measurements by making us more aware of them and we run performance reports more frequently. We learn what we’re doing well and what we need to improve on.”<br></p><p>Silva said she’s seen an “incredible advantage” for her leadership teams when participating in the application. </p><p>“It’s the largest leadership development opportunity I’ve participated in during my career,” she said.<br></p><p>Once Bronze is reached, communities can seek to obtain Silver.<br></p><p>“A lot of that is doing what you did for Bronze, except at a higher performance level,” Silva said. “Obtaining Gold is an incredible achievement. Only one or two communities reach it per year. It usually takes several attempts to get there. We will one day.”</p><h3>Quality Embedded in the Culture</h3><p>Staffing is always a challenge, but by working towards these quality goals, “it is built into your culture in a positive way,” Silva said. “Communities that participate in the process tend to have lower turnover and more stability overall.”<br></p><p>Silva said one key performance indicator (KPI) she tracks is the number of patient falls, which can lead to hospitalizations. Her communities document the number of falls and what caused them and examine if they could have been prevented. The team then contrives an action plan to reduce them.<br></p><p>“Once the plan is in place, it is monitored, reviewed, and tweaked, as necessary,” Silva said. “You discuss it, and you learn from it. This action-plan approach to solving problems and improving is a constant cycle and can be used for anything that is being evaluated. The strategy is embedded in the culture.”<br></p><p>Silva said when her communities achieve Silver, “This truly shows how committed you are to serving your residents. It’s a very powerful message to prospects and their families.”<br></p><p>Truscott said these awards go a long way in attracting and retaining staff and residents.<br></p><p>Simpkins agreed that resident prospects and employees want to live and work in communities that operate at a high level of quality. “If you call a Quality Award-winning community home, you are living in a community that embraces quality improvement and exceptional health care outcomes,” she said.<br></p><p>Even better, Simpkins said achieving greater efficiencies with a focus on quality does not necessarily incur additional costs and contributes to staff retention. The Quality Awards fit perfectly into Gardant’s mission, which is ‘Leading the Way.’<br></p><p>“Leading the way means guiding and inspiring others toward a common goal,” she said. “Our mission also includes inclusion and innovation. Striving towards a quality award fosters innovation in the workplace. It also develops problem-solving, leadership, and creativity.”<br></p><p><img src="/Issues/2023/Spring/PublishingImages/PaulBergeron.jpg" alt="Paul Bergeron" class="ms-rtePosition-2" style="margin:5px;width:175px;height:219px;" />Silva said, as for consensus, “We’ve been working for three-plus years to get back to where we were five years ago. We’re not there yet but are getting closer, and the QA program is a reason why.” Becoming an awardee comes down to your executive director and administrator driving the quality, she said.<br></p><p>“There’s been a loss in those two leadership roles in our industry in recent years,” Silva said. “Many have left or retired and fewer are choosing this as a career. The QA program is a leadership program at its finest.” <br></p><p><em>Paul Bergeron is a freelance write based in Herndon, V</em>a.<br></p>	Participating in the AHCA/NCAL National Quality Award program improves care and reduces staff turnover.	2023-11-13T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_AL.jpg" style="BORDER:0px solid;" />	Assisted Living	Spotlight on Assisted Living
The Value of Effective Rehabilitation in Long Term and Post-Acute Care	https://www.providermagazine.com/Issues/2023/Winter/Pages/The-Value-of-Effective-Rehabilitation-in-Long-Term-and-Post-Acute-Care.aspx	The Value of Effective Rehabilitation in Long Term and Post-Acute Care	<p><img src="/Issues/2023/Winter/PublishingImages/Winter23_Medicare.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />A growing body body of evidence-based research has demonstrated the effectiveness of innovative physical and occupational therapy and speech-language pathology (SLP) programs in long term and post-acute care settings. Innovative programs that reduce costs, improve outcomes, and achieve patient satisfaction are just some of the objectives of the Centers for Medicare and Medicaid Services’ strategic plan to move towards a health system that achieves equitable outcomes through high-quality, affordable, and person-centered care. <br></p><p>On October 1, 2023, the American Health Care Association and ADVION invited four distinguished researchers to a rehabilitation symposium to discuss their recently published studies and more current findings that demonstrate the value of rehabilitation care approaches in skilled nursing facility (SNF) settings. The interactive discussion session was attended by therapy clinicians, managers, and nursing home administrators interested in implementing modern best practices to improve or maintain a resident’s optimal functional abilities. This article provides highlights of the discussion.</p><h3>Variation in Employment of Therapy Assistants in SNFs Based on Organizational Factors</h3><p><em>Presented by Tracy M. Mroz, PhD, OTR/L, and Rachel Prusynski, DPT, PhD</em><br></p><p>Mroz and Prusynski discussed the findings of a research article published in 2021 that investigated the variation of employment of therapy assistants in SNFs and the impacts on quality measures.<sup>1</sup> Additionally, they discussed subsequent work in this area related to organizational characteristics of where therapy assistants appear to have the most impact and whether any changes have occurred with the implementation of the Medicare Part A SNF Patient-Driven Payment Model (PDPM), growth of managed care payment models, and the disruption of the COVID-19 public health emergency.<sup>2,3,4,5 </sup><br></p><p>The key takeaways were that therapy assistants are a critical part of the SNF rehabilitation team and represent approximately half of the therapy workforce in SNFs. However, therapy assistant staffing varies based on SNF organizational characteristics, such as Medicare volume, geographic location, and ownership status. Notably, therapy assistants are especially important in rural SNFs. Although the implementation of the PDPM in October 2019 and the onset of the COVID-19 pandemic in early 2020 resulted in overall reduced therapy staffing, the researchers emphasized that the “relationship between therapy assistant staffing and quality generally suggests little detriment to using therapy assistants for therapy provision in SNFs,” therefore, if used appropriately, “utilizing therapy assistants may be a cost-effective way to continue to provide services...without impacting quality of care.” </p><h3>Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in SNFs</h3><p><em>Presented by Rachel Prusynski, DPT, PhD, and Tracy M. Mroz, PhD, OTR/L </em><br></p><p>On implementation of the SNF PDPM in October 2019, the practice of multiparticipant therapy increased. Currently, group therapy includes from 2 to 6 patients conducting similar activities per clinician, while the clinician simultaneously oversees 2 patients who are performing different activities with concurrent therapy. However, little was known about how substituting multiparticipant therapy for individualized therapy may impact patient outcomes. The presenters discussed the findings of a research article published in 2022 that intended to establish baseline relationships between multiparticipant therapy and patient outcomes using pre-PDPM data.<sup>6</sup> Additionally, the researchers discussed subsequent work related to changes observed since the implementation of PDPM.<sup>7</sup> <br></p><p>The findings prior to PDPM implementation revealed that less than 1 percent of SNF stays included multiparticipant therapy. However, those patients receiving multiparticipant therapy for up to 25 percent of therapy minutes per stay were associated with slightly better outcomes related to functional improvement and successful community discharge. Potential benefits of multiparticipant therapy discussed included reduced social isolation, enhanced motivation to improve participation, peer feedback, and vicarious learning. Additionally, patients selected for multiparticipant therapy were less likely to have significant functional deficits, cognitive and communication impairments, behavioral issues, or neurological issues, including dementia. Those receiving multiparticipant therapy were also likely to receive intensive individual therapy, so multiparticipant therapy was a supplemental service. <br></p><p><img src="/Issues/2023/Winter/PublishingImages/Winter23_Medicare2.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:335px;height:256px;" />With the onset of PDPM and before the COVID-19 pandemic, the use of any multiparticipant therapy increased to about 30 percent of SNF stays, while the remaining 70 percent of patients continued to receive individualized therapy during their entire stay. Notably, example data for hip-fracture diagnoses demonstrated that the overall percentage of multiparticipant minutes per stay remained much lower than the 25 percent limit permitted. However, the presenters cautioned that the increase in multiparticipant therapy use was aligned more with organizational factors than clinical characteristics, which is being further explored. <br>The session concluded with evidence-based examples where multiparticipant therapy can complement best practices. Short-duration high-intensity training has been shown to be more effective with specific patient populations than traditional low-intensity longer-duration approaches. Other applications of effective multiparticipant therapy include education-based groups for goals and expectation setting, strategies for problem solving and safety, fall risk/prevention, and health promotion and wellness, particularly in preparation for discharge to the community. </p><h3>Experiences of Social Distancing During COVID-19 as a Catalyst for Changing Long Term Care Culture </h3><p><em>Presented by Marion C. Leaman, PhD, CCC-SLP</em><br></p><p>Leaman expanded upon concepts from a paper published in 2021 where a parallel was made between the experience of social isolation that occurred during the COVID-19 pandemic and similar experiences occurring in everyday life for people with communication disorders living in long term care (LTC) facilities.8 For example, the COVID-19 pandemic, infection-control protocols included SNF visitation restrictions, social distancing, and masking/gowning that created an environment in which staff and residents alike experienced various degrees of social isolation. The presenter highlighted that such commonly experienced feelings of a sense of deprivation, emotional instability, social or emotional loneliness, anxiety, depression, and others are quite like the social isolation often experienced every day for years by persons with aphasia living in LTC facilities when they reside in a suboptimal communication environment.<br></p><p>Persons with aphasia have difficulty with speaking, understanding, reading, and writing to various degrees, but their intelligence remains intact. Adding a communication disorder on top of existing factors, such as a reduced social network, chronic disease, frailty, and vision or hearing loss, magnifies the risk for increased social isolation unless the LTC environment, including all staff, is supportive. For people with aphasia, social isolation is brought on by a lack of people who know how to communicate with them. As exemplified in a presentation slide <em>“Living amongst a sea of people … yet I’m completely alone.” </em><br></p><p>The presenter discussed evidence and opportunities for SLPs and the rehabilitation team to leverage the lessons learned from the pandemic as a catalyst in the effort to overcome institutional and training barriers to shift the LTC culture to one that more highly values a communicative environment that is accessible to all, thereby reducing the risk of social isolation for those with communication disorders and improving overall resident and staff satisfaction. This change will require administrative support and a nominal amount of training resources to build an action plan for creating a culture valuing communication and relationships. <br>The article discussed included a chart detailing immediate-, near-, and long term actions that can be taken including:<br></p><ul><li>Learning and using the names of staff and residents.</li><li>Making friendly comments.</li><li>Sharing stories about everyday life, events, and activities.</li><li>Showing genuine interest in others’ lives and well-being.</li><li>Adding to or expanding upon staff communication training.</li><li>Leveraging knowledge of staff SLPs for techniques that can be used within the course of care and do not take additional time to apply.</li><li>Tracking outcomes of improvements resulting from a changed communication culture, including relevant clinical outcomes, resident/staff satisfaction, and even staff turnover.</li></ul><h3>Mixed-Methods Approach to Understanding Determinants of Practice Change in SNF Rehabilitation: Adapting to and Sustaining Value With Post-Acute Reform </h3><p><em>Presented by Allison M. Gustavson, PT, DPT, PhD </em><br></p><p>Health care trends incorporating value-based payment and incentive models impacting SNF providers are driving therapists to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. Gustavson discussed the findings of a research article published in 2021 that sought to identify various organizational and team characteristics that increase the likelihood of successful and sustainable implementation, as an organization implements disruptive changes in care delivery approaches.<sup>9</sup> The key question asked in this research was <em>“What makes SNFs successful at implementing changes that positively impact outcomes?”</em> The study compared the characteristics of the therapists’ attitudes toward evidence-based practice and aspects of intervention implementation in the context of the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions between SNFs that were able to successfully implement an evidence-based high-intensity rehabilitation program versus SNFs that were unsuccessful.<br></p><p>The results were that successful SNFs saw improvements in the short physical performance battery, gait speed, community discharge rates, reduced lengths of stay, and reduced costs of ~$1500 per stay. This was achieved without increasing treatment time or reducing therapist productivity. A root-cause analysis of low-performing SNFs showed that performance was driven by multiple factors. For example, SNFs that were unsuccessful implementing a high-intensity rehabilitation program had the following characteristics:<br></p><ul><li>They were more likely to have therapists with low self-efficacy and preconceived notions that act as barriers. </li><li>The organizations prioritize productivity/profit rather than patient-centered care. </li><li>There is no consistency in which therapist a patient sees or the treatment approaches of the different therapists. </li><li>Team dynamics are poor, with no good processes for communication within the rehab team and across departments. </li><li>There is little self-reflection or focus on results that could be tracked by using good-outcomes metrics. </li><li>They have nursing staff shortages. </li></ul><p>In other words, even <em>“good therapists are no match for a bad system.” </em></p><p>Suggestions were discussed highlighting management characteristics of high-performing SNFs that can foster successful implementation of new evidence-based clinical rehab programs. First and foremost is management and staff buy-in, which may require an assessment of patient-centeredness of the organizational system, the team dynamics, the degree of disruptive preconceptions such as ageism that may need to be overcome, and the therapist, facility staff, and patient belief that the new approach will be feasible and effective. Once a plan to implement is made, the clinicians must have time and space recognized to improve, which includes offering the following:<br></p><ul><li>Champions to mentor and support.</li><li>In-clinic practice and time for reflection.</li><li>Multi-faceted approaches to individualize needs/preferences.</li><li>Strategies to reduce cognitive load when making practice change.</li><li>Adequate resources to learn and apply as well as measure the success of the new practices. </li></ul><div><em>Daniel Ciolek is associate vice president, therapy advocacy, for the American Health Care Association.<br></em></div><div><em><br></em></div><div><span id="ms-rterangepaste-end"><br></span></div><div><span class="ms-rteStyle-Normal">References</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">1. Mroz TM, Dahal A, Prusynski R, Skillman SM, Frogner BK. Variation in Employment of Therapy Assistants in Skilled Nursing Facilities Based on Organizational Factors. Med Care Res Rev. 2021;78(1_suppl):40S-46S. doi:10.1177/1077558720952570.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">2. Prusynski RA, Frogner BK, Skillman SM, Dahal A, Mroz TM. Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities. J Appl Gerontol. 2022;41(2):352-362. doi:10.1177/07334648211033417.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">3. Mroz TM, Dahal A, Skillman S, Frogner B. The Occupational Therapy Assistant Workforce in Skilled Nursing Facilities. American Occupational Therapy Association. August 2002. <a href="https://www.aota.org/-/media/corporate/files/advocacy/federal/otaworkforceinsnfsfinalreport922.pdf" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://www.aota.org/-/media/corporate/files/advocacy/federal/otaworkforceinsnfsfinalreport922.pdf</a>.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">4. Prusynski RA, Leland NE, Frogner BK, Leibbrand C, Mroz TM. Therapy Staffing in Skilled Nursing Facilities Declined after Implementation of the Patient-Driven Payment Model. JAMDA. 2021;22(10):2201-2206. doi:10.1016/j.jamda.2021.04.005.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">5. Prusynski RA, Humbert A, Leland NE, Frogner BK, Saliba D, Mroz TM. Dual Impacts of Medicare Payment Reform and the COVID-19 Pandemic on Therapy Staffing in Skilled Nursing Facilities. J Am Geriatr Soc. 2023;71(2):609-619. doi: 10.1111/jgs.18208.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">6. Prusynski RA, Rundell SD, Pradhan S, Mroz, TM. Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in Skilled Nursing Facilities. J Geriatr Phys Ther. 2023;46(4):185-195. doi:10.1519/JPT.0000000000000363.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">7. Prusynski RA, Pradhan S, Mroz TM. Skilled Nursing Facility Organizational Characteristics Are More Strongly Associated With Multiparticipant Therapy Provision Than Patient Characteristics. Phys Ther. 2022;102(3):pzab292. doi: 10.1093/ptj/pzab292.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">8. Leaman MC and Azios JH. Experiences of Social Distancing During Coronavirus Disease 2019 as a Catalyst for Changing Long-Term Care Culture. Am J Speech Lang Pathol. 2021;30:318-323. doi:10.1044/2020_AJSLP-20-00176.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">9. Gustavson AM, LeDoux CV, Stutzbach JA, Miller MJ, Seidler KJ, Stevens-Lapsley JE. Mixed-Methods Approach to Understanding Determinants of Practice Change in Skilled Nursing Facility Rehabilitation: Adapting to and Sustaining Value With Postacute Reform. J Geriatr Phys Ther. 2021;44(2):108-118. doi:10.1519/JPT.0000000000000288.</span><br></div>	Research shows that innovative rehabilitation programs reduce costs, improve outcomes, and achieve patient satisfaction.	2023-11-06T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_Medicare.jpg" style="BORDER:0px solid;" />	Medicare	Medicare
Unveiling the October 2023 ICD-10-CM Updates	https://www.providermagazine.com/Issues/2023/Winter/Pages/Unveiling-the-October-2023-ICD-10-CM-Updates.aspx	Unveiling the October 2023 ICD-10-CM Updates	<p><img src="/Issues/2023/Winter/PublishingImages/Winter23_caregiving.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />On October 1, 2023, the health care industry welcomed a fresh set of updates to the <em>International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).</em> These updates are vital for health care providers, coders, and payers as they ensure both excellent resident care and accurate documentation and billing. This article reviews the ICD-10-CM changes pertaining to Parkinson’s disease, parkinsonism, chronic obstructive pulmonary disease (COPD), and osteoporosis with pathological fracture of the pelvis. Understanding these updates is crucial for delivering optimal health care services and maintaining compliance with coding standards.</p><h3>Parkinson’s Disease (G20)</h3><p>Parkinson’s disease is a progressive neurodegenerative disorder that affects millions of individuals worldwide. Accurate coding is essential to track and treat this condition effectively. In line with the updated guidelines, facility coders must now distinguish whether a resident’s G20 Parkinson’s disease code corresponds to Parkinson’s disease or parkinsonism. As per the new coding system, these two conditions, previously classified under the ICD-10-CM code G20, now have separate designations. For Parkinson’s disease, coders should use G20.A- and G20.B-. For parkinsonism, G20.C is the correct code. <br></p><p>This change may require a comprehensive review of the patient’s medical records. If the documentation is unclear, facility coders must query physicians and nonphysician practitioners (NPPs) to provide a precise description of the actual condition. If parkinsonism is determined to be the correct diagnosis, further clarification is required to identify its underlying cause. If the resident is diagnosed with Parkinson’s disease, facility coders need to seek information from the provider regarding the presence or absence of dyskinesia and fluctuations to ensure the assignment of the most specific diagnosis code.<br></p><p>Here is further clarification on how to differentiate these two conditions:<br></p><p>Parkinson’s disease is a neurologic disorder characterized by involuntary and uncontrollable movements, such as tremors, rigidity, and difficulties in maintaining balance and coordination. These symptoms typically develop gradually and worsen over time. As the disease progresses, individuals may face challenges related to mobility and communication. Additionally, they may experience changes in mental and behavioral states, sleep disturbances, feelings of depression, memory problems, and increased fatigue.<sup>1</sup><br></p><p>Parkinsonism, a broad term encompassing various neurologic conditions that share movement difficulties akin to those seen in Parkinson’s disease, is characterized by symptoms such as tremors, limited mobility, and muscle rigidity.<sup>2</sup><br></p><h3>Chronic Obstructive Pulmonary Disease (J44)</h3><p>COPD is a prevalent respiratory condition characterized by persistent airflow limitation. ICD-10-CM updates related to COPD aim to improve accuracy in diagnosis and documentation related to COPD combined with asthma and bronchitis. The additional code of J44.89 was added to indicate when COPD includes asthmatic bronchitis or emphysematous bronchitis. A medical record review or provider inquiry is needed to ensure the medical record documentation supports this code. Note that “Not otherwise specified (unspecified) COPD” continues to be coded as J44.9.</p><h3>Osteoporosis with Current Pathological Fracture of Pelvis (M80.0B- and M80.8B-)</h3><p>Osteoporosis is a common condition characterized by weakening of bones that make them more susceptible to fractures. The ICD-10-CM updates for osteoporosis with current pathological fracture of the pelvis aim to enhance coding accuracy for the fracture location. Before the FY 2024 updates, a pathological fracture of the pelvis was identified by the “Other specified site” code of M80.0A-. This code included several fractures that were not represented by an individual code in the coding set. The addition of M80.0B-, Age-related osteoporosis with current pathological fracture, pelvis, and M80.8B-, Other osteoporosis with current pathological fracture, pelvis, adds a more specific site code. Medical record review and physician query are necessary to determine if the current “Other specified site” code is referring to the pelvis. Only if the site of the fracture is the pelvis can the new code be applied.</p><h3>Next Steps for FY2024 Codes</h3><p>To ensure the accuracy of diagnosis coding within the health care team, staff need the essential tools. They must have access to up-to-date ICD-10-CM coding manuals that should be renewed every October to incorporate the latest coding guidelines. It is also imperative to discuss with the medical director the importance of precise and specific diagnoses. This open dialogue will help underscore the significance of accurate coding practices in the long term care setting.<br></p><p>It’s also crucial to inform physicians that they may receive queries related to their diagnoses. This proactive communication ensures that the medical staff is prepared to address any inquiries and maintain the quality of patient records.<br></p><p>Every new fiscal year, a series of crucial steps should be taken to ensure the accuracy of diagnosis coding within the facility. To begin, diagnostic reports must be generated from the electronic health record (EHR) to pinpoint records that contain either deleted or updated codes. This initial review serves as the foundation to maintain the integrity of the coding system. Codes that require update as of October 1 can be found in the Conversion Table at <a href="https://www.cms.gov/medicare/coding-billing/icd-10-codes/2024-icd-10-cm" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://www.cms.gov/medicare/coding-billing/icd-10-codes/2024-icd-10-cm</a>.<sup>3</sup><br></p><p>Subsequently, a detailed examination of the physician documentation within each flagged medical record will determine which updated code would best suit the condition of the resident. This process guarantees that the code aligns with the most current and relevant clinical information.<br></p><p>In cases where more specific details are required for accurate coding, staff must reach out to the physician or NPP. This collaborative communication ensures the coding process is as precise as possible, benefiting both patient care and health care data management.<br></p><p>By diligently following these steps each new fiscal year, facilities can maintain the quality and accuracy of their coding practices.</p><h3>Conclusion</h3><p><img src="/Issues/2023/Winter/PublishingImages/JenniferLabay.jpg" alt="Jennifer Labay" class="ms-rtePosition-2" style="margin:5px;" />The October 1, 2023, ICD-10-CM updates are critical for health care professionals, ensuring accurate documentation, diagnosis, and treatment of patients. Staying informed about these changes is essential for providing high-quality health care services while maintaining compliance with coding standards. Health care organizations, coders, and providers should invest the time and effort to understand and implement these updates and thus improve patient care and billing accuracy. </p><p><em>Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).</em><br></p><p><br></p><p><span class="ms-rteStyle-Normal">References</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">1. National Institute on Aging. (2022, April 14). Parkinson’s disease: Causes, symptoms, and treatments. <a href="https://www.nia.nih.gov/health/parkinsons-disease#:~:text=Parkinson%E2%80%99s%20disease%20is%20a%20brain%2chave%20difficulty%20walking%20and%20talking" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://www.nia.nih.gov/health/parkinsons-disease#:~:text=Parkinson’s%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking</a></span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">2. Parkinson’s Foundation. (2018). Parkinson’s disease vs. parkinsonism. <a href="https://www.parkinson.org/library/fact-sheets/parkinsonism" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://www.parkinson.org/library/fact-sheets/parkinsonism</a></span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">3. Centers for Medicare & Medicaid Services. (2023). 2024 ICD-10-CM. <a href="https://www.cms.gov/medicare/coding-billing/icd-10-codes/2024-icd-10-cm" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">https://www.cms.gov/medicare/coding-billing/icd-10-codes/2024-icd-10-cm</a></span><br></p>	A look at changes in Parkinson’s disease, parkinsonism, COPD, and osteoporosis with current pathological fracture of pelvis.	2023-11-13T05:00:00Z	<img alt="" src="/Issues/2023/Winter/PublishingImages/Winter23_caregiving.jpg" style="BORDER:0px solid;" />	Caregiving	Focus on Caregiving

Interim President	https://www.providermagazine.com/Lists/People On The Move/DispForm.aspx?ID=115	Interim President	<img alt="" src="/PublishingImages/People%20on%20the%20Move/POTM%202023/Winter23_POTM-RubyJp.jpg" style="BORDER:0px solid;" />	Ruby Jo Lubarsky	Kentucky Association of Health Care Facilities/Kentucky Center for Assisted Living
Director	https://www.providermagazine.com/Lists/People On The Move/DispForm.aspx?ID=116	Director	<img alt="" src="/PublishingImages/People%20on%20the%20Move/POTM%202023/Winter23_POTM-YoungKim.jpg" style="BORDER:0px solid;" />	Young Kim	Laurel Brook Rehabilitation & Healthcare Center
Senior Director of Finance	https://www.providermagazine.com/Lists/People On The Move/DispForm.aspx?ID=117	Senior Director of Finance	<img alt="" src="/PublishingImages/People%20on%20the%20Move/POTM%202023/Winter23_POTM-MelissaZygarlicke.jpg" style="BORDER:0px solid;" />	Melissa Zygarlicke	Health Dimensions Group

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