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State Makes Universal Transfer Form Mandatoryhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/State-Makes-Universal-Transfer-Form-Mandatory.aspxState Makes Universal Transfer Form Mandatory<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p>​In New Jersey, transferring patients across the continuum of care has seen its share of problems regarding continuity and relaying accurate patient information. Developing and implementing a common transfer form to alleviate these issues was sorely needed to improve quality of care and reduce medical errors. </p> <div>To address this need, health care facilities, home care providers, health care professionals, and other stakeholders worked with the state Department of Health and Senior Services (DHSS) to create and implement a mandatory <a href="/Monthly-Issue/2012/Documents/NJUTF.pdf">Universal Transfer Form (UTF</a>).</div> <h3 class="ms-rteElement-H3">Getting Started</h3> <div>In late 2006, the UTF Task Force was launched with the New Jersey Hospital Association and the Health Care Association of New Jersey coordinating this statewide effort (see box, below).</div> <div> <img class="ms-rteImage-2 ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0112/Caregiving.gif" alt="" style="margin:10px;" /><br>The task force defined transfer as the handing off of responsibility for a patient from one facility or agency licensed by DHSS to another. The task force determined that it would be in the best interest of the patient if the receiving facility/agency had an up-to-date summary of essential information that was documented clearly on a standardized form to preserve continuity of care upon transfer. </div> <div> </div> <div>This approach offered three advantages: All facilities would adjust their protocols for paper or electronic record systems to support the efficient capture of information needed to populate the mandatory form. Professionals receiving the new patient would know exactly where to look for the information needed to ensure continuity of care upon transfer. There would be a clear standard defining their duty to send accurate and complete information with patients upon transfer.</div> <div> </div> <div>Exclusions included transfers between emergency departments; the return of an emergency department patient (who was not admitted to the hospital) back to his or her long term care facility; and special care needs patients, such as premature infants, newborns, and maternity care patients. </div> <div> </div> <div>Voluntary compliance had failed in the past, so all stakeholders committed to using the UTF with the knowledge that the form would be mandated via state regulation.</div> <div> </div> <div>All participants received numerous sample forms and transfer-of-care articles for review. The initial work concentrated on discussing and deciding what information was essential to include, as well as the degree of detail.</div> <h3 class="ms-rteElement-H3">Keeping It Manageable</h3> <div>From the beginning, stakeholders were mindful of the concept that less is more. Too much information invited greater opportunities for errors of commission and omission. The task force decided to develop a form that captured essential information for continuity of care at the time of transfer and to encourage the sending provider to attach copies of relevant source documents appropriate to the needs of each patient.</div> <div> </div> <div>Determining the best way to communicate medication information was especially challenging. Some stakeholders wanted a written list of current medications, while others wanted a copy of the physicians’ orders and medication administration records. Still others suggested that in accordance with The Joint Commission standards, a medication reconciliation document should be used. </div> <div> </div> <div>Ultimately, the task force decided that the sending facility must include accurate information about current medications in a self-defined manner. </div> <div> </div> <div>The initial draft was a two-page form. Page one contained essential information, and desired information was listed on page two. This allowed the sending facility to complete only the first page if the transfer out was an emergency, such as a nursing facility resident in need of immediate hospitalization. </div> <div><span id="__publishingReusableFragment"></span> </div> <h3 class="ms-rteElement-H3">Testing The Product</h3> <div>The draft form was pilot-tested in two phases. Phase one was a nonscientific, real-world mini pilot involving 10 facilities to determine if the draft form had major faults. The results of the pilot rendered minor suggestions to improve the form, which were adopted prior to the phase two trial.</div> <div> </div> <div>Rutgers University was contracted to provide an objective, statewide phase two pilot test of the UTF. </div> <div> </div> <div>The purposes of the phase two pilot were to gauge the acceptance of a UTF, identify ways to improve the form, highlight opportunities to effectively train staff in use of the UTF, and determine if the UTF was appropriate for a variety of facilities. </div> <div> </div> <div>Five hospital systems and their referring and aftercare facilities participated in the phase two pilot. </div> <div> </div> <div>The hospitals selected were in the northern, central, and southern areas of the state and were in both urban and suburban areas. The goal was to represent broadly the types of facilities that would be required to implement the UTF. Thirty-five facilities from these hospital systems participated in the pilot. This included assisted living facilities, home health care agencies, nursing homes, and rehabilitation hospitals. Some of these facilities offered multiple levels of care and specialized units, including mental health. </div> <div> </div> <div>The 11-month field test yielded 546 UTF forms, 218 sender’s evaluation forms, and 10 receiver’s evaluation forms. Due to the low volume of receiver’s evaluations, Rutgers followed up by interviewing staff at receiving facilities. </div> <div> </div> <div>In parallel during phase two, IGI Health created and pilot-tested an electronic version of the UTF with one hospital system and some of its post-acute partners. This was in anticipation of the expected development of and investment in more electronic health record applications in all care settings.</div> <h3 class="ms-rteElement-H3">Form Still Too Long </h3> <div>Four themes emerged from the senders’ feedback: The form took too much time to fill out, the form was too long, staff members did not always have the information required, and there were various suggestions to omit or reduce specific areas. Receivers were pleased to have accurate and timely information on one form and offered ideas to reduce the length of the form. </div> <div> </div> <div>Most importantly, the overwhelming majority of senders and receivers in the field were quick to recognize the inherent advantages of a standardized transfer form.</div> <div> </div> <div>Based on their evaluation of the pilot, Rutgers made several recommendations that were adopted by the task force: </div> <ul><li>Shorten the form while including the necessary information to ensure a safe and effective transfer;</li> <li>Include more staff members at future training sessions, incorporating a team approach rather than train-the-trainer;</li> <li>Address the individual organizational process needs of each specific facility and network, including the types of electronic or traditional medical filing systems; and</li> <li>Ensure that specialized facilities’ unique circumstances are addressed in the implementation of the UTF. </li></ul> <div>As a result, the form was reduced to a one-page document that captured the information needed at the time of transfer to ensure continuity of care. In addition, a comprehensive instruction sheet was developed to accompany the revised form.</div> <h3 class="ms-rteElement-H3">The Final Transfer Document</h3> <div>In its final incarnation, information on page one included:</div> <ul><li>Name and telephone number for physician and sending facility contact person in the event that the receiving professionals have questions</li> <li>Reason(s) for transfer</li> <li>Code status</li> <li>Pain along with other vital signs</li> <li>At-risk alerts</li> <li>Under-skin condition, identify if no wounds or the type of wounds</li> <li>Identify attached documents</li> <li>Require that the sending facility attach current medication information</li></ul> <div>In 2009, the final version of the UTF form and instructions were presented to DHSS. Following the administrative process for adopting regulations, in August 2011 the department finalized the rules for all 1,900 licensed health care providers and made the form and instructions available. </div> <div> </div> <div>Electronic or paper completion of the UTF is permitted; considerable emphasis is being placed on electronic use of the form as a method to facilitate care transitions in concert with the goals of health care reform and the move toward health information exchanges. </div> <div> </div> <div><em>Theresa Edelstein, MPH, LNHA, is vice president, post-acute care policy & special initiatives, for the New Jersey Hospital Association. She can be reached at <a href="mailto:%20tedelstein@njha.com">tedelstein@njha.com</a>. Daniel Moles, RN, BBA, MPS, LNHA, is president of TRANSITION HealthCare Consultants and Nursing Home Expert Opinion Services, Monroe Township, N.J. He can be reached at <a href="mailto:NHConsultant@comcast.net">NHConsultant@comcast.net</a>. </em></div> In New Jersey, transferring patients across the continuum of care has seen its share of problems regarding continuity and relaying accurate patient information. Developing and implementing a common transfer form to alleviate these issues was sorely needed to improve quality of care and reduce medical errors. 2012-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0112/Caregiving0112_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn1
Florida Nursing Facilities Rise Above Challenging Timeshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Florida-Nursing-Facilities-Rise-Above-Challenging-Times-.aspxFlorida Nursing Facilities Rise Above Challenging Times<div><div><img class="ms-rtePosition-1" src="/archives/archives-2011/PublishingImages/POTR_logo_rollup.jpg" alt="" style="margin:5px 15px;" />Florida has suffered deeply from the effects of the Great Recession and its aftermath, with once booming housing and construction markets gone bust and even the 12-month-a-year tourism trade unable to prop up an otherwise weak economy that has left nearly 1 million without work. </div> <div> </div> <div>In a state known for its older-skewing populace, along with Disney World, space launches, and the beach, the economy has left another mark on Florida. The Sunshine State is now thought of as a leading foreclosure market in a country full of depressing stories about lost real estate dreams.</div> <div> </div> <div>The gloomy economic scene has put intense pressure on state lawmakers to find ways to eliminate huge budget deficits. Fiscal year (FY) 2011-2012 saw the need to bridge a $4.6 billion deficit, and FY 2012-2013 could see a $2 billion hole. As Provider went to press, Florida Gov. Rick Scott (R) was preparing to release his 2012-2013 budget recommendations, which long term care providers anticipate will include another round of Medicaid reimbursement reductions.</div> <div> </div> <div>Medicaid costs rose to $20.3 billion projected for this fiscal year in Florida, from about $19.8 billion in 2011, with the state’s share surging 23 percent, to $9.48 billion, from $7.7 billion, Florida legislature reports said. The state’s share of Medicaid is forecast to rise 2.7 percent, to $9.74 billion, in 2013, and total costs may rise 15 percent by 2015.</div> <div> </div> <div>Florida’s legislature last year also passed a proposal to shift almost all Medicaid beneficiaries into managed care plans to reduce costs, but the state has not received a waiver from the federal government to start the process of making the change.</div> <div> </div> <div>Overall, the short-term picture is clear in Florida: Medicaid reimbursement dollars will decline while beneficiary rolls rise and the economy lags behind in keeping up with rising costs. </div> <h3 class="ms-rteElement-H3">Medicaid Under The Spotlight</h3> <div>Gov. Scott specifically pointed to the growing costs of the Medicaid program as a main drag on the rosier state income picture for 2011. </div> <div> </div> <div>The governor told the media in late November that when he releases his proposed budget, it will have recommendations to deal with rising Medicaid costs. Beyond immediate measures to help balance the budget, Scott would like the federal government to let states run the Medicaid program, a popular notion among many in his party who call for “block granting” Medicaid dollars as opposed to managing the federal-state partnership that currently exists.</div> <div> </div> <div>Talk of what could be in the offing for next year has J. Emmett Reed, executive director of the Florida Health Care Association (FHCA), working hard to limit what will certainly be another reduction in reimbursement dollars for long term care providers.</div> <div> </div> <div>“It was bad last year, but then you’re dealing with a $4.6 billion budget hole. We weren’t happy but it could have been worse, and it was worse for other providers,” Reed says.</div> <div> </div> <div>Things didn’t look so bleak for FY 2012 about six months ago, he says, but things took a turn for the worse by end of summer, and now the negative reports project the aforementioned $2 billion budget hole.</div> <h3 class="ms-rteElement-H3">Double Whammy</h3> <div>At the same time the state has hit health care providers hard in the Medicaid program, the federal government has reduced Medicare reimbursement for nursing care providers, a virtual tsunami of cuts, as Reed puts it.</div> <div> </div> <div>“Seventy percent of our costs are our people [staff], and the residual effects go to the vendor level,” he says.</div> <div> </div> <div>A lot of FHCA members are assessing their bottom lines anew with the reimbursement uncertainty now a seemingly constant reality, with some likely in line to reduce staffing while many more try to figure out ways to avoid such steps, Reed says.</div> <div> </div> <div>“We have a lot of members who are not cutting. They are working with frontline caregivers to manage hours,” he says. “Caregivers working at facilities have knowledge of the residents, they work with residents.”</div> <div> </div> <div>Reed notes that all the work being done to creatively work around the 2011-2012 reductions could be a mere footnote to what lies ahead. “If there is another round of cuts, all bets are off,” Reed says. “But providers are bending over backwards to make it work and keep caregivers there to serve residents.”</div> <h3 class="ms-rteElement-H3">Greek For Caring</h3> <div>Against this backdrop of mostly negative economic news, nursing and assisted living facilities conduct the day-in day-out work of caring for the state’s frail and elderly, a job Marilyn Wood, president and chief executive officer (CEO) of Opis Management Resources, Tampa, Fla., has embraced for 40 years. She worked first as a nurse and rose through the ranks to lead Opis, a word that comes from the Greek language and translates to “caring.”</div> <div> </div> <div>Opis was founded in 2003, assuming control of properties owned by Kennett Square, Pa.-based Genesis HealthCare, which departed the state because of concerns about the business climate. Florida is not an easy state to do business in, with its high litigation costs tied to a friendly environment for trial lawyers.</div> <div> <img width="147" height="441" class="ms-rtePosition-2 ms-rteImage-2" alt="Opis resident" src="/Monthly-Issue/2012/PublishingImages/0112/OTR_6.jpg" style="margin:15px 5px;height:222px;" /><br>Opis runs 10 skilled nursing and one assisted living facility across the state and prides itself on strict attention to quality, having won top honors from the state of Florida four times for its efforts to make a positive difference in elder care.</div> <div> </div> <div>Wood sees long term care as a business prone to defined cycles, with the current one being as challenging as any one that has presented itself in the past. She has also seen how the acuity level of residents has shifted, transforming the work to a higher level of care at all settings.</div> <h3 class="ms-rteElement-H3">Florida A Tough Market</h3> <div>As providers across the country face the challenges of reimbursement reductions and marketing their services in a down economy, Wood says Florida remains a unique case with its plentiful number of seniors and other factors.</div> <div> </div> <div>“The litigation we have in our state is still a problem for us,” she notes. Also a challenge is the fact that Florida is a pacesetter in regulation. “I think this comes because of the scrutiny generated by the large population of seniors in our state,” Wood says.</div> <div> </div> <div>The Medicaid issue is, of course, a leading challenge as well, but one she grasps. “The reality is the government has only so many resources; there are pressures to fund education and transportation beyond health care, for example,” Wood says.</div> <div> </div> <div>All sectors have had to sacrifice, but the goal for long term care is to do so without compromising quality care. The jobs inside her facilities are all tied to making residents safe and as healthy as possible, so each is valuable to the overall operation.</div> <div> </div> <div>Opis employs 2,300 people, and these workers are part of a family as well, putting food on their own tables and paying mortgages. “That’s what people have to understand. We take our staffing issues seriously and care for them passionately. Legislators need to understand that,” Wood says.</div> <h3 class="ms-rteElement-H3">CCRC Attracts Residents Despite Economy</h3> <div>Tom Kelly, CEO of Village On The Isle in Venice, Fla., thinks his operation is getting it right in how to care for every long term care need within his continuing care retirement community (CCRC) just a few minutes from the Gulf of Mexico. Located south of Sarasota, the CCRC offers seniors skilled nursing, assisted living, and independent living options in a high-tech community wired with the latest technology to improve care quality and make living as comfortable as possible for residents.</div> <div> <img width="497" height="368" class="ms-rteImage-2 ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0112/OTR_5.jpg" alt="" style="margin:15px 10px;width:382px;height:287px;" /></div> <div>A not-for-profit, faith-based provider, Village On The Isle is affiliated with the Evangelical Lutheran Church in America and strives to meets its commitments beyond the daily care of residents in a 100 percent ecumenical fashion, Kelly says. This effort includes catering a Meals on Wheels program to the local community, serving 180 meals per day all week.</div> <div> </div> <div>“All of it is done out of our own pocket with volunteers,” Kelly says.</div> <div> </div> <div>With a staff of 275 serving the 415 seniors in the CCRC, the breakdown of the living options are 210 residential apartment homes, 100 assisted living accommodations, and a 60-bed skilled nursing facility. Again, as part of the faith-based effort, 10 percent of the 100 assisted living spots are reserved for a special program for those who cannot afford to pay full freight. The maximum cost is $1,500 a month for the affordable care program, compared with the regular rate of $3,695, he says.</div> <div> </div> <div>“There are no Medicaid waiver dollars involved,” Kelly says.</div> <h3 class="ms-rteElement-H3">Technology Vital To The Mission</h3> <div>Village On The Isle takes technology seriously. The entire complex is wired for Wi-Fi, which is free for residents and guests as well as mobile Skype videophones that residents can use to video chat with their families and loved ones. Dining areas are equipped with digital signage for easy representation of daily menus, and health care facilities employ Electronic Medication Observation Systems to reduce medication errors.</div> <div> </div> <div>Other tools include the Nurse Rosie system, which provides state-of-the-art equipment for gathering vital signs such as pulse oximetry, blood pressure, temperature, and blood glucose levels. The system interfaces with CareTracker to eliminate human error in the recording and transcription of vital signs.</div> <div> </div> <div>Kelly praises the CCRC’s staff for devising new ways to make technology more than just software and hardware, but part of the resident’s experience and part of the staff’s care plan. The move to keep abreast of the latest tools for pleasing residents and their families is a strategy to maintain quality care and attract business even in the rough economy.</div> <h3 class="ms-rteElement-H3">Jobs, Jobs, Jobs</h3> <div>Over the years, Kelly has built up a strong business that had a 20 percent vacancy rate when he took over. Now, the facilities have added and saved jobs with an attention to detail and made staff more capable with the use of technology.</div> <div> </div> <div>With the high occupancy rate near 100 percent, Village On The Isle is a job beacon for the Venice community. “We have very high staff retention, and that is good because long-term employees are your best assets. This translates to consistent quality care, no lawsuits, and few worker comp issues,” Kelly says.</div> <div> </div> <div>Kelly’s staff have 80 percent of their health insurance paid for, and there is a 20 percent employer match in a retirement plan with no vesting.</div> <div> </div> <div>Village On The Isle also works with the local high school to attract young workers who often make the care community their first job. </div> <div> </div> <div>“It’s $8.75 to start, and they can eat whatever they want,” Kelly says.</div> <div> </div> <div>Some of the younger workers stay on for years to come, he says, noting his director of food services came out of the high school recruitment effort.</div> <div> </div> <div>When the state Medicaid reimbursement reductions took effect July 1, 2011, and were followed in October by the federal cutbacks of more than 11 percent in Medicare payments, assessments had to take place on how to deal with the loss of funding, Kelly says.</div> <div> </div> <div>“We expected the problem to occur, and we built operational budgets accordingly,” he says. This preparation resulted in no wage cuts or a job freeze for employees, even though the final Medicare percent rollback was on the high end of expectations coming in one fell swoop.</div> <div> </div> <div>To combat the effect of the governmental reductions, Village On The Isle has sought to bolster its outpatient business, diversifying its services by providing potential clients with the latest low-gravity treadmill system for rehabilitation purposes.</div> <div> </div> <div>By getting away in some respects from the unpredictable nature of Medicaid and Medicare reimbursement, the system of overall care across the CCRC can flourish, starting with the core mission of serving others, both the ones paying for care and the entire community surrounding the site.</div></div> Florida has suffered deeply from the effects of the Great Recession and its aftermath, with once booming housing and construction markets gone bust and even the 12-month-a-year tourism trade unable to prop up an otherwise weak economy that has left nearly 1 million without work. 2012-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0112/POTR0112_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ManagementColumn1
Providers Claim Victory After Tax Repeal Votehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Providers-Claim-Victory-After-Tax-Repeal-Vote.aspxProviders Claim Victory After Tax Repeal VoteLong term care providers got a victory in November when Congress repealed the 3 percent withholding tax mandate to allow businesses, including skilled nursing facilities, to utilize all payments on products and services made by government units. <br><br>“The repeal of this burdensome tax policy is a victory for patients and providers alike, who require timely products and services in order to ensure high-quality care in America’s skilled nursing facilities,” said Gov. Mark Parkinson, president and chief executive officer of the American Health Care Association (AHCA).<br><br>“Without this so-called interest-free loan, providers can better facilitate daily resources to care for patients. As Congress begins to turn more of its focus on finding ways to reduce costs, it is critical that we protect these resources that ensure our seniors and individuals with disabilities are able to access the care they require.” <br><br>The 3 percent withholding tax would have required all businesses receiving federal, state, and local government funding for products and services to have 3 percent of that payment withheld beginning Jan. 1, 2013. <br><br>This requirement would have impacted payment under general government contracts, as well as Medicare payments.Long term care providers got a victory in November when Congress repealed the 3 percent withholding tax mandate to allow businesses, including skilled nursing facilities, to utilize all payments on products and services made by government units. 2012-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0112/3percent.jpg" style="BORDER:0px solid;" />PolicyColumn1
Standing Outhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Standing_Out.aspxStanding Out<div>Mention Flint, Mich., to most anyone inside the “rust belt” and the responses could range from “sad and empty” to “crime-ridden and hopeless.” The city that gave birth to General Motors and the United Auto Workers now evokes images of blocks of boarded-up homes, parades of for-sale signs, and abandoned strip malls. </div> <div> </div> <div>Not surprisingly, the statistics behind these images are bleak: double-digit unemployment rates that are higher than the national average, a poverty level of 34 percent (more than twice the national average of 14.3 percent), and a crime rate that ranks among the highest in the nation. </div> <div> </div> <div>According to the Federal Bureau of Investigation, Flint now holds the dubious distinction of being No. 4 on its list of the most crime-ridden cities in the United States.</div> <div><br>Making matters worse, thousands of denizens have fled the city in recent years, causing the population to drop by 18 percent between 2000 and 2010, according to the U.S. Census Bureau. </div> <div><h3 class="ms-rteElement-H3">A Bright Spot</h3> <div>This story is not about Flint alone, however. This story is about a bright spot in the city: Willowbrook Manor, an award-winning 102-bed skilled nursing center located a few miles west of the city’s center.</div></div> <div>Willowbrook shines as an example of how the human spirit, along with some persistence and hard work, can endure economic hardship and adversity. </div> <div> </div> <div>On a cool day shortly after Thanksgiving, its lobby is festooned with a Christmas tree, festive lights, and sparkling decor. In contrast to the surrounding blight, staff members at Willowbrook emit cheerful, positive attitudes. </div> <div> <img class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0112/CS_Table1.gif" alt="" style="margin:15px 5px;" /></div> <div>“I know everyone is down on Flint, but I think it’s making a comeback,” says Ryan Michelson, Willowbrook’s administrator, who was born and raised near Flint and attended the University of Michigan-Flint.</div> <div> </div> <div>He says his experience with the embattled city has been mostly positive. “I went to school in downtown Flint, and I never had any brushes with crime,” he says. </div> <div> </div> <div>Michelson brings this sanguine attitude to his job, which likely contributed to his facility’s success in receiving a Silver National Quality Award from the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) last year. </div> <div> </div> <div>Based on the Malcolm Baldrige Performance Excellence Program, a public-private partnership housed at the National Institute of Standards and Technology within the U.S. Department of Commerce, the AHCA/NCAL Silver Award is not an easy feat to achieve.</div> <div><h3 class="ms-rteElement-H3">Therapy Program, Staff Longevity Help Cause</h3> <div>According to the Silver Award application, criteria “focus on results and the conditions and processes that lead to results.” </div> <div> </div></div> <div>For Willowbrook, successful rehabilitation programs, staff longevity, and customer satisfaction are some of the accomplishments that helped them garner the Silver Award. </div> <div> </div> <div>The facility’s rehabilitation program, dubbed Home Express, sends more than 80 percent of its skilled therapy residents home or to less acute care settings.</div> <div> </div> <div>Also noteworthy is the longevity of its staff (<em>see Table 2, below</em>). The director of nursing, assistant director of nursing, and Michelson have been with Willowbrook for 13 years. The minimum data set coordinator is a 14-year veteran of the facility, as is the environmental services director. Turnover is also low among Willowbrook’s 120 employees (<em>see Table 3, below</em>). Compared with Willowbrook’s owner, Ciena Healthcare Management, turnover is dramatically lower. In 2010, the rate for Willowbrook was 13 percent, while the Ciena turnover rate was at 40 percent.</div> <div> <img class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0112/CS_Table2.gif" alt="" style="margin:20px 10px;" /><br><img src="/Monthly-Issue/2012/PublishingImages/0112/CS_Table3.gif" alt="" style="margin:5px;" /><br><br>Keeping the facility humming at such a high level, says Michelson, means constantly evaluating and analyzing data, which come from several sources. Customer surveys, discussions with family members and employees, concern forms, and suggestion boxes are some of the methods employed. </div> <div> </div> <div>In addition, SWOT (strengths, weaknesses, opportunities, and threats) and environmental analyses are utilized. “Analysis of data sources helps us plan and prepare to meet the needs and expectations of future customers and to ensure their satisfaction,” says Michelson. </div> <div> </div> <div>He also credits the facility’s commitment to its mission, its code of ethics, and code of conduct for its success. </div> <div> </div> <div>“These things have helped us keep employee turnover low and create a successful rehabilitation program,” he says. </div> <div><h3 class="ms-rteElement-H3">Union Challenges Present But Minimal</h3> <div>Michelson also points to Willowbrook’s “aesthetically appealing environment” and high quality of care as reasons for its recognition as a provider of choice in Michigan, “despite the disadvantage of location and unionization,” he says. Aside from location, being a “union shop” presents a challenge to Willowbrook’s management. All employees, except management and licensed nurses, are unionized at Willowbrook. Given that Flint has been dominated by the auto industry for decades, unionization has become part of the fabric of the city’s culture. </div> <div> </div></div> <div>“Unions present unique challenges to employers,” says Michelson. “Willowbrook’s union contract dictates equal pay for equal work, which prevents us from rewarding employees with bonuses or raises based on performance.”</div> <div> </div> <div>Michelson says this policy also prevents the promotion of unionized employees to management levels while maintaining their union status.</div> <div> </div> <div>“Health care facilities need to remain focused on the care of customers, and unionization tends to divert that focus in alternate directions, which has the potential to decrease effectiveness,” he says. </div> <div>Despite these challenges, Willowbrook has scored consistently high marks on its employee satisfaction surveys, and union-filed grievances have declined steadily over the past decade. </div> <div> </div> <div>The secret ingredient to this success, says Michelson, is that “we are fair and consistent with all staff members.”</div> <div> </div> <div><h3 class="ms-rteElement-H3">A Positive Outlook</h3> <div>Ciena Healthcare Management, headquartered in Southfield, Mich., owns and operates Willowbrook in addition to a stable of 35 long term care properties in Michigan and Connecticut. Kristine Halsey, chief operating officer for Ciena, notes that the company is expanding. “While others are retreating, we see the coming years as a time of opportunity for expansion,” she says.</div> <div> </div></div> <div>Halsey reports that although the Medicare and Medicaid funding climate is poor, Ciena has not made any staff changes.</div> <div> </div> <div>Expansion for Ciena means that it is building skilled nursing centers throughout lower Michigan, as well as hiring staff to oversee a new dining program that will eventually be implemented throughout the entire company.</div> <div> <img class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0112/CS_Table4.gif" alt="" style="margin:5px;" /></div> <div>Ciena recently broke ground on a new skilled nursing community in Grand Blanc Township, just east of Flint. The 68,000-square-foot facility, known as the Grand Blanc Care Center, will be a “state-of-the-art facility with 74 short-term rehabilitation and long term care suites with private baths in each,” says Halsey.</div> <div> </div> <div>At a cost of more than $8.5 million and expected to create more than 120 full-time and part-time jobs, Grand Blanc Care Center is slated to open next summer. </div> <div> </div> <div>In addition to six bariatric rooms, a rehabilitative therapy room, and a spa, the community will feature several dining venues, including a main dining room, a restorative dining room, a private dining room, and an a la carte 24-hour room service menu created by an executive chef.</div> <div> </div> <div>Ciena will open a new skilled nursing community in Ann Arbor, Mich., this fall. Regency at Bluffs Park, was renovated at a cost of more than $5 million.The 71-bed facility will feature 37 private rooms and 17 semi-private rooms, all with in-room showers and baths. </div> <div> </div> <div>According to Ciena’s website, the new center is “designed to have the look and feel of a boutique hotel.” In addition to other amenities, each resident bed will have its own flat screen TV.</div> <div> </div> <div>The 37,000-square-foot building is also expected to receive a Silver LEED Certification, as granted by the U.S. Green Building Council.</div> <div> </div> <div>Also part of this project, Ciena donated more than one acre of land to the city of Ann Arbor to be used as a public access point to Bluffs Park. </div> <div> </div> <div>A third Ciena community will open soon in Canton, Mich. The Regency at Canton will offer short-term rehabilitation and long term care, which includes 40 private rooms and 80 semi-private rooms.</div> <div>dining next on list for upgrade.</div> <div> </div> <div>Next on Ciena’s list of priorities is fine dining. Halsey says the company is revamping its entire dining program so that residents can enjoy better food and a more pleasant dining atmosphere. </div> <div> </div> <div>“We hired a corporate chef from a well-known Detroit restaurant to train the cooks in all of our communities,” says Halsey, who notes that they will start with basic sauces and work their way up.</div> <div> </div> <div>Many of the facilities will keep their existing cooks and take classes with the corporate chef. The overhaul includes menu planning and dietary requirements for all Ciena chefs.</div> <div> </div> <div>A “quality dashboard” created in-house by Ciena enables facility staff to see, on a daily basis, how the residents are doing on a number of indicators. </div> <div> </div> <div>“It’s really about data,” says Halsey, “and giving them the information and tools to provider the best quality of care possible.”</div> <div> </div> <div>This support is evident in the fact that eight of Ciena’s care centers, including Willowbrook, recently received five-star ratings from the Centers for Medicare & Medicaid Services’ quality rating system.</div> <div>In addition, Willowbrook was recognized by U.S. News & World Report as one of America’s best nursing homes in 2011.</div> <div> </div> <div>What’s more, Ciena selected Willowbrook as Facility of the Year three times over the past five years.</div> <div><h3 class="ms-rteElement-H3">Don’t Count Flint Out</h3> <div>At press time, Flint’s troubles continued as Michigan Gov. Rick Snyder (R) appointed an emergency manager to oversee the city’s shaky finances. Although the move appears to be the latest indicator of Flint’s downward spiral, the city still has many supporters.</div> <div> </div></div> <div>Richard Karp, a developer who specializes in historic preservation, is bullish on Flint’s prospects for a successful revitalization. He was instrumental in rebuilding the Durant, a once-legendary downtown hotel named for the founder of General Motors, William C. Durant, a grandson of Henry Crapo, the 14th governor of Michigan.</div> <div> </div> <div>Built in 1920, the Durant thrived for nearly 50 years as a symbol of the city’s success. After sitting empty for more than 30 years, Karp began refurbishing the hotel in 2008.</div> <div> </div> <div>Since its reopening as an apartment and commercial leasing space last January, interest in the project has exceeded Karp’s expectations. </div> <div> </div> <div>“The apartments are 100 percent leased, and we have one commercial suite left,” he says. In addition, the project has won five awards thus far, including the Governor’s Award for Historic Preservation. </div> <div> </div> <div>Karp says he was attracted to the Durant project for several reasons. “The expansion of the University of Michigan campus, a strong revitalization effort in the downtown area, and the lack of housing for students” pointed to its potential for success, he says.</div> <div> </div> <div>Karp confirmed that he is eyeing two more projects for development in the downtown area in the near future. </div> <div> </div> <div>In the meantime, Michelson remains upbeat about Flint’s comeback. He points to the city’s cultural establishments as examples of endurance: The Flint Institute of Music, the Institute of Arts, and several colleges and universities with campuses downtown are all thriving amid the city’s turmoil.</div> <div> </div> <div>Flint has weathered much hardship over the years, and it could get worse before it gets better, but Flintoids are an enduring lot. </div> <div> </div> <div>After all, it was built on steel and grit by the largest automobile manufacturer in the world.</div> <div> </div> <div>And so, as the city wrestles with its ghosts, Willowbrook hums along efficiently, business as usual. </div>Mention Flint, Mich., to most anyone inside the “rust belt” and the responses could range from “sad and empty” to “crime-ridden and hopeless.” 2012-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0112/CS_thumb.jpg" style="BORDER:0px solid;" />Management;Quality ImprovementCover Story1
Survey: Docs Face Stress, Burnouthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Survey-Docs-Face-Stress-Burnout.aspxSurvey: Docs Face Stress, Burnout​Doctors are stressed out, according to a recent national survey of U.S. physicians. Conducted by Cejka Search, the survey found that the majority of U.S. physicians are moderately to severely stressed or burned out on an average day, with nearly 63 percent of respondents saying their stress has risen moderately to dramatically in the past three years.<br><br>Despite such a strain on this sector of the nation’s caregivers, only 15 percent of the survey respondents said their organizations have done anything to help them deal more effectively with their stress or burnout.<br><br>The survey, conducted in September 2011, also measured actions that hospitals, clinics, and health care organizations take to support and reduce physicians’ stress and burnout. <br><br>“[These] data show that physician stress and burnout is prevalent and increasing,” said Mitchell Best, chief operating officer of Physician Wellness Services, a sponsor of the survey. “Until now, little research has been done that delves into why physicians feel stress, the impact it has on their lives, and the impact physician stress has on patients.” <br><br>Medicare and Medicaid policies were among the top four causes of doctors’ stress and burnout, according to the survey. In addition, the economy, health care reform, and unemployed and uninsured patients were among the top stress factors.<br><br>The top four work-related stress factors were cited as administrative demands of the job, long work hours, on-call schedules, and concerns about medical malpractice lawsuits. <br><br>The stress has taken a toll on doctors’ personal lives, according to the survey. Fourteen percent of respondents indicated they had left their practice as a result of stress, while many cited fatigue, sleeplessness, irritability, and moodiness as consequences.<br><br>“Physicians are human beings with physical and emotional limitations,” said a survey respondent. “In order to perform better, we need better physical and emotional health and [a better] work environment.”<br><br>Nearly one-third of respondents said that better work hours/less on-call time and better work/life balance would help to reduce their stress. <br><br>For more information about the survey, go to: <a href="http://www.physicianwellnessservices.com/news/stresssurvey.php">http://www.physicianwellnessservices.com/news/stresssurvey.php</a>.   Doctors are stressed out, according to a recent national survey of U.S. physicians. 2012-01-01T05:00:00Z<img alt="" height="740" src="/PublishingImages/default-article-image.png" width="740" style="BORDER:0px solid;" />Management;Workforce;Clinical;CaregivingColumn1
Commission Certifies First EHRs For Long Term Carehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Commission-Certifies-First-EHRs-For-Long-Term-Care.aspxCommission Certifies First EHRs For Long Term CareA big second step has been taken in the movement to accelerate the use of electronic health records (EHRs) in the long term and post-acute care setting (LTPAC) with the announcement by the Certification Commission for Health Information Technology (CCHIT) that the first two software products for use in the LTPAC sector received certification, according to a leading expert in the field.<br><br><img alt="Cynthia Morton" class="ms-rteImage-2 ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/Headshots/CynthiaMorton_thumb.jpg" style="margin:5px 10px;" />Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care, told Provider that the CCHIT-Certified 2011 LTPAC program sets the groundwork for assuring providers that the time and money they plan for EHRs is being well spent on quality and usable products.<br><br>“This is especially important for providers wading through the EHR/HIT issue who are not super familiar with the area, might not have a high-ranking CIO [chief information officer] in the company, and are smaller ‘mom and pop’ operations,” Morton says.<br><br>The second reason for the importance of the CCHIT certification process is interoperability. Now more than ever, LTPAC providers need to work with partners across the health care continuum, and the certification process helps that happen with its stamp of approval, she says.<br><br>LTPAC providers “are working more with hospitals and have to exchange records back and forth to ensure patient safety,” Morton says. The goal for LTPAC providers and all providers is to avoid rehospitalizations, an issue made even more key with the federal government’s agenda to improve quality care and reduce costs, rewarding providers who do well and penalizing those who do not in reducing rehospitalizations.<br><br>The products certified under the CCHIT program for 2011 were AOD Software of Ft. Lauderdale, Fla., with its Answers EHR version Autumn 2011, and HealthMEDX Vision of Ozark, Mo., with its HealthMEDX Vision version 7.1.10.<br><br>LTPAC providers are not currently eligible for EHR adoption incentives under the American Recovery and Reinvestment Act (ARRA) HITECH program. The ARRA incentives are based, in part, on hospitals showing electronically that they meet quality measures and share patient information with other providers.<br><br>“It’s an advantage to LTPAC providers who want to form partnerships with hospitals to adopt CCHIT-certified LTPAC EHRs,” says John Derr, leader of strategic clinical technology for Golden Living and a member of CCHIT’s board of trustees.<br><br>“CCHIT’s certification of an EHR’s integrated interoperability and security features will prove invaluable as providers seek to participate in community health care organizations designed to foster coordination across the spectrum of care.” <br><br>In addition, LTPAC EHRs may be certified in the federal Office of the National Coordinator EHR certification program for eligible providers and hospitals if they meet certain criteria.<br><br>CCHIT also offers special EHR certification programs for cardiovascular medicine, child health, emergency departments, behavioral health, dermatology, oncology, and clinical research.<br><br>More information on the CCHIT program and how to apply for certification is at <a href="http://www.cchit.org/">www.cchit.org</a>.<br>A big second step has been taken in the movement to accelerate the use of electronic health records (EHRs) in the long term and post-acute care setting (LTPAC) with the announcement by the Certification Commission for Health Information Technology (CCHIT) that the first two software products for use in the LTPAC sector received certification, according to a leading expert in the field.2012-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/Headshots/CynthiaMorton_thumb.jpg" style="BORDER:0px solid;" />Survey and Certification;QualityColumn1
Facility Residents With Dementia See Decline Slowed Without Drugs: Studyhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Facility-Residents-With-Dementia-See-Decline-.aspxFacility Residents With Dementia See Decline Slowed Without Drugs: StudyNursing facility residents suffering from dementia and living in a group of Bavarian facilities in Germany were able to postpone their decline in cognitive function through nonpharmacological means, according to a new study released in the journal BMC Medicine. <br><br>The study, “Non-pharmacological, Multicomponent Group Therapy in Patients with Degenerative Dementia: A 12-month Randomised, Controlled Trial,” found a prolonged, intensive program of motor stimulation and other means worked better than the regular drug routine. <br><br>The reason for the study is that currently available pharmacological and nonpharmacological treatments have shown only modest effects in slowing the progression of dementia. The study’s objective was to assess the impact of a long-term nonpharmacological group intervention on cognitive function in patients with dementia and on their ability to carry out activities of daily living (ADLs) compared with a control group receiving the usual care.<br><br>The trial involved 98 patients with primary degenerative dementia in five nursing homes in Bavaria. The intervention consisted of motor stimulation, practice in ADLs (like going to the bathroom), and cognitive stimulation (acronym MAKS). The care was conducted in groups of 10 residents led by two therapists for two hours, six days a week for 12 months.  <br><br>Cognitive function was assessed using the cognitive subscale of the Alzheimer’s Disease Assessment Scale and the ability to carry out ADLs using the Erlangen Test of Activities of Daily Living at baseline and after 12 months. <br><br>Report authors said after 12 months, the results showed that cognitive function and the ability to carry out ADLs had remained stable in the intervention group but had decreased in the control patients.<br><br>This result led to the conclusion that a highly standardized, nonpharmacological, multicomponent group intervention conducted in a nursing facility setting was able to postpone a decline in cognitive function in dementia patients and in their ability to carry out ADLs for at least 12 months. The reason for the study is that currently available pharmacological and nonpharmacological treatments have shown only modest effects in slowing the progression of dementia. 2012-01-01T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/senior_man_daughter.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalColumn1
Four Drugs Cause Most Emergency Hospital Visitshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Four-Drugs-Cause-Most-Emergency-Hospital-Visits.aspxFour Drugs Cause Most Emergency Hospital VisitsAdverse drug events (ADEs) cause an estimated 100,000 emergency hospitalizations for seniors every year, yet two-thirds involve just a handful of anticoagulants and diabetes medications, according to a new study in the New England Journal of Medicine.<br><br>Researchers from the Centers for Disease Control and Prevention (CDC) conducted the study and singled out four drugs and drug classes as the cause of most emergency visits. They are warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Alone or together, they account for 67 percent of emergency ADE hospitalizations of adults 65 years and older. Warfarin was implicated in 33 percent of cases, lead author Daniel Budnitz, MD, director of CDC’s medication safety program, said.<br><br>In contrast, medications red-flagged as high risk or inappropriate by health authorities explained only 1.2 percent and 6.6 percent, respectively, of such hospital admissions.<br><br>“These data suggest that focusing safety initiatives on a few medicines that commonly cause serious, measurable harm can improve care for many older Americans,” Budnitz said. <br><br>“Doctors and patients should continue to use these medications but remember to work together to safely manage them.”Researchers from the Centers for Disease Control and Prevention (CDC) conducted the study and singled out four drugs and drug classes as the cause of most emergency visits. 2012-01-01T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/medications_4.jpg" style="BORDER:0px solid;" />ClinicalColumn1
Nursing Facility Margins Could Go Negative If Further Cuts Happen: Studyhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Nursing-Facility-Margins-Could-Go-Negative.aspxNursing Facility Margins Could Go Negative If Further Cuts Happen: StudyAn independent analysis projects nursing home margins will slide into negative territory if Congress makes further reimbursement cuts to the Medicare and Medicaid programs, underpinning the argument of long term care advocates that enough is enough in the way of reductions to providers serving the nation’s frail and elderly.<br><br>The American Health Care Association commissioned The Moran Co. to perform an independent analysis of national nursing facility margins to show the most recent performance of the nursing home industry. The analysis is based on the most recent Medicare cost reports for fiscal years ending in 2009 filed by nursing facilities that participate in the Medicare program and includes revenue from all payers for nursing facility services and total expenses.<br><br>The data show slight 0.75 percent overall aggregate margins in 2009 for nursing facilities, which is a lower number than those published by the Medicare Payment Advisory Commission (MedPAC), although within MedPAC’s margin of error. The commission has backed a market basket freeze for nursing homes, assuming margins for freestanding facilities for 2009 to be 3.5 percent.<br><br>Moran’s analysis projecting into 2012 and beyond shows a bleaker outlook. When factoring in a two-year zero market basket update and a possible new requirement for nursing homes to limit bad debt to 25 percent, among other factors, margins would dip into negative ground in 2012 at minus 0.1 percent and deflate further to a negative 2.9 percent in 2013, the report said.<br><br>“Our baseline suggests that going forward from 2009, nursing facility operating margins would be mildly positive, holding current payment policies constant,” the report said. However, if reimbursement policy changes, then the slide to negative margins would be impacted, Moran said. These changes include the aforementioned two-year suspension of market basket adjustments and limiting bad debt to 25 percent, as well as imposing 5 percent coinsurance on days one through 20 of skilled nursing facility care and capping Medicaid provider taxes at 3.5 percent of total payments.<br><br>“If reimbursement policy changes of the magnitude of those now under discussion are implemented, our point of estimate of the outcome suggests that nursing facility overall margins would turn consistently negative,” the report said.The American Health Care Association commissioned The Moran Co. to perform an independent analysis of national nursing facility margins to show the most recent performance of the nursing home industry. 2012-01-01T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/capitol_full_night.jpg" style="BORDER:0px solid;" />PolicyColumn1
Nursing Shortage No More? New Report detects Nursing Boomlethttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/Nursing-Shortage-No-More.aspxNursing Shortage No More? New Report detects Nursing BoomletA new report in Health Affairs outlines how a surge in young women in their twenties entering the nursing field has put a dent in the long-discussed nursing shortage, a boomlet fueled by a weak economy that may ease concerns about an aging workforce of registered nurses (RNs) in the nation’s hospitals and long term care facilities.<br><br>“Between 2002 and 2009 ... the number of full-time RNs ages 23-26 increased by 62 percent. If these young nurses follow the same life-cycle employment patterns as those who preceded them, as they appear to be so far, they will be the largest cohort of registered nurses ever observed,” the article said.<br><br>Nurses, like teachers, are less likely to change professions or move locales as is the case in other sectors, leading to the projection for more stability in nursing numbers because of the recent influx of young people in the field.<br><br>The report noted that because of the surge in the number of young people entering nursing, the RN workforce is projected to grow faster during the next two decades than previously anticipated.<br><br>“However, it is uncertain whether interest in nursing will continue to grow in the future,” the article said.<br><br>The number of RNs between 23 and 26 years old reached a high of 190,000 in 1979, but fell sharply to below 110,00 in the early 1990s. The report said the level hit a low of 102,000 in 2002 before the recent climb higher.<br><br>The authors from RAND Health, Vanderbilt University, and Dartmouth College said the downturn in the economy in recent years was an obvious first reason for the uptick in nurses. There is also the factor of federal spending for nursing workforce employment that rose to $240 million in 2010.<br><br>If the trend holds, the RN supply is now projected to keep pace with the growth in population through the year 2030. Previous estimates projected a massive 250,000-plus shortage in RNs over the next two decades.<br><br>What could hold back the positive trend is the lack of capacity in the nation’s nursing schools to teach all potential applicants, the report said.A new report in Health Affairs outlines how a surge in young women in their twenties entering the nursing field has put a dent in the long-discussed nursing shortage.2012-01-01T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/nurse_4.jpg" style="BORDER:0px solid;" />WorkforceHuman Resources1
OSHA Targeting High-Injury Workplaceshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0112/OSHA-Targeting-High-Injury-Workplaces.aspxOSHA Targeting High-Injury WorkplacesThe Occupational Safety and Health Administration (OSHA) recently announced its Site-Specific Targeting 2011 plan, which includes about 300 nursing and personal care communities among sites being singled out for inspections. These communities have high rates of employee injury or illness. <br><br>The 300 communities have reported employee Days Away, Restricted, and Transfer (DART) case rates from between 13 to 16 days annually; or a Days Away From Work rate of 11 or 12 days annually. <br><br>Inspections will focus specifically on ergonomic stressors; exposure to blood and other potentially infectious materials; exposure to tuberculosis; and slips, trips, and falls. <br><br>If OSHA’s compliance officer finds additional hazards during the inspection, they will be cited as well. Assisted living communities categorized as residential care facilities by OSHA will be inspected for the same types of violations as nursing and personal care facilities. If OSHA’s compliance officer finds additional hazards during the inspection, they will be cited as well. Assisted living communities categorized as residential care facilities by OSHA will be inspected for the same types of violations as nursing and personal care facilities. 2012-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0112/crowd_bridge_thumb.jpg" style="BORDER:0px solid;" />WorkforceColumn1

February


 

 

Smooth Transitions Reduce Hospital Visitshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Smooth-Transitions-Reduce-Hospital-Visits.aspxSmooth Transitions Reduce Hospital Visits<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><img class="ms-rteImage-2 ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0212/Caregiving1.jpg" alt="" style="margin:15px 5px;width:360px;height:239px;" /><br>Reducing <a href="/Monthly-Issue/2012/Pages/0212/Discharge-Summaries-Factor-Into-Readmissions.aspx">hospital readmissions</a> from nursing centers starts with analyzing the continuum of care—from the hospital setting to the nursing facility transfer, through any events and decisions that may lead to readmission. </div> <div> </div> <div>Health care associations, policy institutes, and think tanks have already taken the initiative and are creating tools to help hospitals and nursing homes reduce rehospitalizations. A program called Interventions to Reduce Acute Care Transfers (INTERACT) II, created at the Georgia Medical Care Foundation under a special study contract with the Centers for Medicare & Medicaid Services, offers a comprehensive array of communication tools and checklists for nursing home staff members.</div> <div> </div> <div>The INTERACT II tools include questionnaires and guidelines to help staff members make informed decisions at every step of the care continuum and help staff:</div> <div> </div> <div>■ Better identify acute changes of condition and elevated risk levels; </div> <div>■ Identify residents with the highest risk for developing acute change of condition;</div> <div>■ Identify the causes of an acute change of condition and the feasibility of managing the resident within the nursing home setting; and</div> <div>■ Effectively manage acute changes in condition.</div> <div> </div> <div>The goal is to address one of the fundamental reasons why patients are needlessly transferred to hospitals—the assumption that certain status changes automatically require that a patient be rehospitalized.</div> <div> </div> <div>In reality, there are many medical scenarios that skilled nursing centers can address competently and successfully. If a facility is prepared with the right equipment, if staff have the right training, and if the right procedures are followed, then many nursing home-to-hospital transfers could be avoided.</div> <div> </div> <div>A rehospitalization reduction program at the University of Minnesota focused on identifying risk factors and designing a protocol around an interdisciplinary team approach for high-risk patients. In this approach, there are many medical scenarios that nursing centers like Revera Health Systems, Meriden, Conn., can address competently and successfully. </div> <div> </div> <div>Testing this approach at a Minnesota nursing home, researchers were able to lower rehospitalization rates by 20 percent—33 percent lower than the national average.</div> <div> </div> <div>Revera has taken the publicly available INTERACT II tools and adapted them to meet the needs of Revera facilities. The goals of Revera’s program are to improve bedside nursing assessment, improve communication to the physician about changes of condition, reduce off-hour calls to the physician for nonemergent issues, improve communication with interfacility transfers, and conduct quality reviews after each hospital/emergency room transfer to determine appropriateness of a transfer.</div> <h3 class="ms-rteElement-H3">The Tools</h3> <div>Revera’s INTERACT program includes procedures and checklists that allow facility staff to identify patients at risk and make timely interventions to prevent the kinds of problems that can lead to a hospital admission.<br></div> <div><br>Among the key tools employed by Revera’s program are Care Paths and Change in Condition File Cards.<br><br> The purpose of this color-coded (red for immediate action required and blue for reporting the next business day) system is to help guide the assessment and management of common changes in resident status that could result in acute-care transfers. </div> <div><br>There are six Care Paths in the Revera INTERACT toolkit for conditions that commonly result in acute-care transfers: dehydration, urinary tract infection, lower respiratory infection, mental status change, fever, and chronic heart failure. <br></div> <div><br>The file cards enable a nurse to conduct a quick snapshot of potential scenarios, thus saving time on assessment and the next steps for each patient.</div> <div><br>Color-coded envelopes that include checklists are completed for every patient who is transferred to the emergency room for evaluation and treatment. The purpose of this system is to provide a single envelope with all the necessary forms needed to provide continuity of care.</div> <div><br>Revera’s Quality Improvement Tool is used to review acute-care (nonelective) transfers of residents to the emergency room or direct admission into the hospital. It is used to identify patterns among acute-care transfers and possible ways to reduce avoidable transfers.</div> <div><br>The Early Warning Tool is aimed at identifying changes in the resident’s condition, communicating changes to nursing staff, and identifying possible opportunities to prevent sending residents to the hospital.<br><span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><span><img class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0212/caregiving3.gif" alt="" style="margin:5px 10px;" /></span>Role Of Health Care Reform</h3> <div>The impending implementation of health care reform’s numerous provisions has prompted Revera to take a proactive approach to change.<br></div> <div><br>With that in mind, Revera’s nursing centers have launched several initiatives designed to reduce readmissions, such as additional quality improvement programs, more specialists on staff, more nurse practitioners on staff to perform higher-level assessments, and expanded on-site specialty services such as including pulmonology and dialysis units in selected markets.<br><br></div> <div>In-house specialty services and specialists on staff—at least in certain strategic areas—is one key to reducing rehospitalizations. </div> <div><br>Some physicians and hospitals have approached Revera to inquire about its centers’ ability to provide more specialized care services, particularly pulmonary care. Since many patients today have chronic obstructive pulmonary disease, or COPD, as a secondary diagnosis, but don’t meet the criteria to be admitted to a hospital unit, nursing centers could be the ideal solution.</div> <div><br>In addition to offering more specialty staff and services, the company also launched a pilot program in which a consulting hospitalist works with the patients in one of its centers.</div> <div><br>The hospitalist’s main responsibility is to ensure the continuity of care for the patients, from hospital discharge and transfer through their recovery and discharge from a center. The hospitalist also consults with and educates the facility’s nursing staff so that they can make better assessments and care decisions. </div> <div><br>A team effort is probably the single most important factor in reducing hospital readmission rates from nursing homes. </div> <div> </div> <div><em>Stuart Lindeman is senior vice president of operations and JP Lyke, RN, MPS, LNHA, FACHCA, is director of case management services at Revera Health Systems, Meriden, Conn.</em></div>Reducing hospital readmissions from nursing centers starts with analyzing the continuum of care—from the hospital setting to the nursing facility transfer, through any events and decisions that may lead to readmission. 2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0212/Caregiving2_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn2
Provider Gets In The Loophttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Provider-Gets-In-The-Loop.aspxProvider Gets In The Loop<div><img src="/Monthly-Issue/2012/PublishingImages/0212/Management3.jpg" class="ms-rteImage-2 ms-rtePosition-2" alt="" style="margin:10px 5px;width:239px;height:359px;" /><br>About one-third of Americans 64 and older suffer from hearing loss, and more than half of those 85-plus do as well. That amounts to millions of older individuals struggling with the frustrations and disappointments of hearing loss every day. </div> <div> </div> <div>Whether talking with a friend or loved one on the phone, listening to announcements in a public space, or simply watching a movie, the effects of hearing loss are profound. Many seniors with hearing loss become embarrassed by their limitation and withdraw from social interaction, which can cause loneliness and depression.</div> <h3 class="ms-rteElement-H3">Leading The Way</h3> <div>At one assisted living community in Massachusetts, officials have been working on changing that for residents and guests. <br><br></div> <div>In June, EPOCH Assisted Living at Boylston Place in Chestnut Hill became the first such community in the state to install a technology growing rapidly in popularity: a hearing loop.</div> <div><br>The hearing loop system involves a copper wire, called a loop, installed around the perimeter of a room. </div> <div>EPOCH has installed the loop in its cinema room, where guest speakers, performers, and others entertain residents and guests. Residents with hearing aids enter the space and simply push a button on their own hearing device to pick up the loop’s signal. Their hearing aid becomes a wireless, convenient, and personal amplification device, allowing them to hear clearly.</div> <div><br>The hearing loop is found across Europe and is just starting to gain popularity in the United States. In Europe, it is used in public places of all types, from churches to airports to museums. When Julie Bolt, director of marketing at EPOCH Assisted Living at Boylston Place, first heard of the system, she thought it would be a great way to help residents with hearing loss regain some of their independence.</div> <h3 class="ms-rteElement-H3">Residents Respond</h3> <div>“One gentleman was having a particularly hard time because he not only was hard of hearing, but he was losing his eyesight as well,” Bolt says. “The hearing loop let him become more integrated and engaged.”<br></div> <div><br>Life Enrichment Director Brizida Koci agreed. “He said to me, ‘You gave me my hearing back,’” Koci says.</div> <div><br>“One of the great things about this system is that it’s private, it’s innocuous,” Bolt says. </div> <div><br>“As a private organization, we’re not required to be ADA [American’s with Disabilities Act] compliant, but wewant to take the initiative because we have multiple residents who benefitfrom it.” </div> <h3 class="ms-rteElement-H3">Multiple Uses</h3> <div>EPOCH uses the system regularly when performers and speakers visit the community, and when screening films. The majority of those who use a hearing aid—about 80 percent—use the type of hearing aid that connects to the loop with the push of a button. Those who do not have a loop-compatible hearing aid are able to <a href="/Monthly-Issue/2012/Pages/0212/Cost-And-Installation-Facts.aspx">install the piece of equipment</a> needed directly into their hearing aid in order to make it compatible. A headset can also be used by residents who do not have a hearing aid. <br></div> <div><br>Gilbert Chudnow, a resident at EPOCH Assisted Living at Boylston Place, has used his hearing aid and the loop system several times and had high praise for it.</div> <div><br>“It’s relieving,” he says. “For the first time, I can enjoy watching a movie because I can hear it without distraction. When you’re hard of hearing, thereare side things going on and you have to concentrate so hard. Now I canrelax.”</div> <h3 class="ms-rteElement-H3">Further Implementation Planned</h3> <div>Encouraged by the success and popularity of the system, EPOCH officials plan to eventually broaden it to other spaces in the community. They also hope to add additional microphones to the system so multiple speakers and performers can be heard using the loop.<br><br></div> <div>Kristine Tilton, executive director at EPOCH Assisted Living at Boylston Place, says she is excited and proud to be the first senior living community in the state of Massachusetts to offer the hearing loop system to residents and guests.<br><br></div> <div>“Their faces just lit up,” Tilton says. “Many of them have a very hard time hearing speakers, and this new system lets them enjoy events and interact as well.”<br><br><span><img src="/Monthly-Issue/2012/PublishingImages/0212/Hearing-Loop.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 15px;" /></span>According to HearingLoop.org, this logo incorporates, with the permission of the National Association of the Deaf, the universal symbol for hearing assistance. <br><br>Explanatory text was added to the logo along with a “T,” which signifies an available telecoil-compatible system. <br><br>When placed at entrances, the sign informs people that the venue is looped. It also serves as publicity for loop systems and the usefulness of telecoils—thus serving to promote both, the website notes.<br><br></div> <div>For more information on hearing loops, go to: <a href="http://www.hearingloop.org/">www.hearingloop.org</a>.</div> <div> </div> <div><em>Kayleigh Karutis is a freelance writer based in Boulder, Colo. She can be reached at <a href="mailto:%20kkarutis@pivotcomm.com">kkarutis@pivotcomm.com</a>.</em></div>About one-third of Americans 64 and older suffer from hearing loss, and more than half of those 85-plus do as well. That amounts to millions of older individuals struggling with the frustrations and disappointments of hearing loss every day. 2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0212/Management2_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn2
Laundry & Long Term Carehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Laundry-And-Long-Term-Care.aspxLaundry & Long Term Care<div><img class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0212/Laundry1.jpg" alt="" style="margin:10px 15px;" /><br>While laundry might not be the first thing that comes to mind when thinking about the quality of care at a long term care facility, it does play an important role. How clean and fresh-smelling linens, towels, and garments are impacts the comfort level of patients, residents, and visitors. <br></div> <div> </div> <h3 class="ms-rteElement-H3">Familiar Sights And Smells </h3> <div> </div> <div>Being in a long term care facility is typically not the first choice for most residents, so anything that can put their minds at ease and help them feel at home is incredibly important. Linens, towels, and garments washed in highly effective products that are also commonly used within the home can be comforting and reassuring to guests who may be dealing with serious health issues. In a recent poll of more than 500 professionals working in long term care facilities across the country, 85 percent of those surveyed agreed that residents who are surrounded by familiar sensory experiences, such as softness or fragrances, say they feel more comfortable and at home in their living environment. <br><br></div> <div> </div> <div>Similarly, 82 percent of respondents reported that residents say they feel more at home in their facility when they use brands they know and trust. <br></div> <div> </div> <h3 class="ms-rteElement-H3">Hygienic Laundering A Must</h3> <div> </div> <div>To achieve the proper level of hygiene in laundry procedures, it is imperative that cleaning professionals follow Centers for Disease Control and Prevention guidelines for laundry. Temperatures above 140º Fahrenheit are recommended for either the wash cycle and/or the dryer cycle. <br><br></div> <div> </div> <div>As a supplement to the temperature level, chlorine bleach may be used to meet hygienic criteria. <br><br></div> <div> </div> <div>However, when laundry is colored, bleach may not be appropriate, as the heat generated during the drying cycle can be used to achieve the necessary level of hygiene. <br><br></div> <div> </div> <div>There are two major types of detergents—alkaline and near-neutral. Alkaline detergents have a high pH formulation, which is effective in removing body soils, grease, and the like; however, linens require multiple rinses or the use of an acid rinse to return the pH as close to neutral as possible. <br><br>Alkaline detergents are also corrosive, cause safety concerns in handling among employees, and cause linens to retain mineral encrustation, creating stiff, rough-feeling fabrics resulting in greater wear and tear, which leads to more frequent linen replacement needs and costs. </div> <div> </div> <div><br>Cleaning products that are phosphate-free with a near-neutral pH formula extend linen life and make fabrics noticeably softer to the touch. With a near-neutral pH detergent, there is no need for pH correction through use of an acid, there’s less wear and tear on fabrics, and it is noncorrosive and safer for employees to handle. </div> <div> </div> <div><br>Extending linen life also results in greater cost savings as linen replacement needs decrease. </div> <div> </div> <div><br>The quality of care in a long term care facility is always the first priority, of course, but the need to manage costs is a reality as well. In one example, testing has shown that a leading detergent with a near-neutral pH helped reduce <a href="/Monthly-Issue/2012/Pages/0212/Quick-Tips-For-Reducing-Operational-Costs.aspx">operational costs</a> by providing up to 55 percent savings in linen replacement costs due to worn fabrics. </div> <div> </div> <h3 class="ms-rteElement-H3"></h3> <h3 class="ms-rteElement-H3">Sustainable Cleaning</h3> <div> </div> <div>It is important to note that doing things right the first time reduces rework and repeated use of products for cleaning the same linens, which is important for having a sustainable laundry care program. In fact, source reduction is usually the most cost-effective approach to sustainable cleaning.</div> <div> </div> <div><br>Facility managers purchasing laundry care products should also ensure that products do not contain phosphates, known carcinogens, or other reproductive toxins and that they meet the California Code of Regulations maximum allowable volatile organic compounds levels.</div> <div> </div> <div><br><img class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0212/Laundry2.jpg" alt="" style="margin:5px 10px;width:178px;height:272px;" />While it can be easily overlooked in the grand scheme of concerns managing a long term care facility, it’s worth taking time out to consider just how crucial a role clean, sanitary, and fresh-smelling laundry can play in the comfort level of residents and visitors. </div> <div> </div> <div><br>At the same time, it’s also often a significant contributor to operational costs and impacts sustainability initiatives and worker safety. </div> <div> </div> <div><br>For all of these reasons, facility managers must take a good, hard look at their on-premise laundry systems and work with their suppliers and product manufacturers to ensure the best results for their patients and guests. </div> <div> </div> <div><em> </em></div> <div><em></em> </div> <div><em>Steve Kovacs is research and development section head at Procter & Gamble Professional, where he leads product development and customer understanding for cleaning product solutions provided for the hospitality; health care; and building, cleaning, and maintenance businesses.</em></div>While laundry might not be the first thing that comes to mind when thinking about the quality of care at a long term care facility, it does play an important role. How clean and fresh-smelling linens, towels, and garments are impacts the comfort level of patients, residents, and visitors. 2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0212/Laundry2_thumb.jpg" style="BORDER:0px solid;" />Management;QualityColumn2
Medicaid Funding Shortfall To Reach All-Time High: Studyhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Medicaid-Funding-Shortfall.aspxMedicaid Funding Shortfall To Reach All-Time High: StudyNew research paints a negative picture for nursing facility reimbursement under the Medicaid program for this year and next, with fresh projections calling for the average shortfall in reimbursement for 2011 to hit $19.55 per Medicaid patient day, an unprecedented high $3 wider than actual average shortfalls recorded in 2009.<br><br>“Between 2009 and 2011, Medicaid rates increased only 2.9 percent—the lowest two-year increase in the 10-year history of the report. As such, the projected Medicaid shortfall is at an unprecedented high, and the percentage of Medicaid allowable costs covered by the Medicaid rates is at its lowest point since 2003,” according to Eljay consultants, who wrote the study on commission for the American Health Care Association.<br><br>The actual shortfall for 2011 will likely be even higher than the $19.55 figure, report authors said, noting that “real” cost increases historically outpace projected inflationary rises for nursing facilities.<br><br>In raw terms, the unreimbursed nursing facility Medicaid allowable costs are projected to exceed $6.3 billion in 2011, another historically high mark.<br><br>The actual daily reimbursement shortfall for 2009, the latest year data are available, was estimated at $16.54 per Medicaid patient day, slightly less than the 2008 actual shortfall of $16.79. “The shortfall has increased by almost 83 percent between 1999 and 2009,” the report said.<br><br>To make matters worse, Eljay does not foresee a rebound in Medicaid rates coming any time soon, with even wider funding gaps coming as a result.<br><br>“Medicaid rate increases rebounded nicely after the 2002-2005 recession. Unfortunately, there will not be a repeat performance for nursing home rate increases in 2012 and beyond. <a href="/Monthly-Issue/2012/Pages/0212/States-Caught-In-Funding-Vise.aspx">State budget deficits</a> in this latest recession were more than double compared to the last recession from 2002-2005,” the report said.<br>Also, only 20 states had nursing facility provider tax programs in 2003, most of which imposed taxes far below the federal maximum, making provider taxes a significant avenue for tax relief.<br><br>“Today, 40 states have nursing facility tax programs, many of which impose taxes at, or close to, the maximum tax allowed under federal law. In addition, provider taxes are a target for federal deficit reduction in future years, and state finances are too weak to replace those funds,” the report said.<br><br>Eljay said total tax collections reached $4.5 billion, and, overall, provider taxes on nursing facilities generate more than $6 billion in matching federal funds. In states with such programs, these taxes are used to reimburse an average of $21 per patient day in Medicaid nursing facility costs.<br><br>The final piece of negative news is that the current recovery from the recession has been slow at best, leaving states to grapple with major deficits, a situation made more challenging following the loss of enhanced FMAP (federal medical assistance percentage) funds under the now-expired Federal Recovery Act. Eljay sees 2012 as worse than 2011 due to all of the economic and budgetary pressure on states.<br><br>“With negligible rate increases across the country, and conservatively assuming costs increase at the same pace as the forecasted annual market basket, the 2012 projected Medicaid shortfall will climb to almost $25 per Medicaid day. Under this scenario, nursing homes will experience negative Medicaid margins averaging almost 14 percent,” the report said.<br><br>And there will not be enough help coming from the Medicare side of the ledger to balance the Medicaid gap, the report said, noting federal Medicare reductions have hit providers hard.<br><br>“With 2012 Medicare revenue reductions averaging $58 per Medicare day, it does not appear that future Medicare margins will be enough to subsidize the accelerating Medicaid shortfalls,” Eljay said.<br><br>“We estimate a negative Medicaid margin approaching 14 percent for 2012; assuming Medicare margins continue to average 18 percent, the 2012 shortfall from the two programs combined would exceed $2 billion,” Eljay said.<br>“Between 2009 and 2011, Medicaid rates increased only 2.9 percent—the lowest two-year increase in the 10-year history of the report.” 2012-02-01T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/staff_laptop_2.jpg" style="BORDER:0px solid;" />Column2
Physicians Moving Inhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Physicians-Moving-In.aspxPhysicians Moving In<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>The health care industry is buzzing about Life Care Centers of America’s (LCCA’s) success in reducing rehospitalizations from 40 percent to 15 percent in one year among facilities participating in their latest effort to improve quality care, says Beecher Hunter, LCCA president. <br><br></div> <div>Rehospitalization reduction efforts are taking center stage as hospitals will start to be penalized, beginning this year, if one of their Medicare patients returns to the hospital within 30 days.</div> <div><br>LCCA’s size is part of what has made its new initiative—to place a full-time doctor in every nursing facility—possible. LCCA has 225 skilled nursing facilities in 28 states and employs more than 35,000 people. </div> <h3 class="ms-rteElement-H3">Assessing Benefits</h3> <div>This program goes far beyond what most long term care facilities are able to do on their own, and, if Hunter and Kenneth Scott, DO, LCCA’s chief medical officer and corporate medical director, have anything to say about it, the move will dramatically improve the quality of care and quality of life for thousands of LCCA residents across the country. The initiative is changing the clinical operations of LCCA nursing facilities in many ways, from measures that reduce antipsychotic use to those that improve cardiac care, but it is also changing the resident makeup in the facilities as hospitals turn to them with greater certainty that their more critically ill patients will be well taken care of and won’t wind up back in the hospital within a month, incurring penalties for the hospital. <br><br></div> <div>Further benefits LCCA has noted since the program’s inception in September 2010 include reduced staff turnover, greater resident and family satisfaction, and improved clinical outcomes.</div> <h3 class="ms-rteElement-H3"><div><span><span><img class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0212/CS1.gif" alt="" style="margin:5px 10px;" /></span></span>Steps For The Future</div></h3> <div><span></span>The increasing focus by health care policymakers on ways to reduce rehospitalizations may have consequences for the vast majority of nursing facilities, and while not all facilities have the wherewithal to hire full-time physicians, other studies laud the beneficial effect of having a nurse practitioner or physician’s assistant on staff. <br><br></div> <div>And, of course, nursing facilities across the nation—including LCCA—are embracing the well-known INTERACT II program, which provides care paths, communication tools, and advance care planning tools with the goal of reducing hospitalizations by improving the identification, evaluations, and communication about changes in resident status.<br><br><br>Whatever approach is taken, nursing facilities will increasingly confront the need to care for even sicker patients with a team of staff who will require a higher level of training to care for them, catch conditions early, and intervene promptly.<br><br><br><br><span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3"><span></span>Just The Facts</h3> <div>The rate of Medicare rehospitalization industry-wide has significantly increased over the past three decades (see graph).<br><img class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0212/CS2.gif" alt="" style="margin:10px 15px;" /><br></div> <div>But the government is taking the issue on. This year, hospitals with high readmission rates will have to absorb a 1 percent penalty under the Hospital Readmissions Reduction Program, which places emphasis on three readmission-prone conditions: acute myocardial infarction, heart failure, and pneumonia. In the following two years, that penalty will go up to 2 percent and then 3 percent.<br><br></div> <div>One out of every five Medicare beneficiaries discharged from the hospital is readmitted within 30 days at a cost to Medicare of over $17 billion annually, according to MedPAC, which also estimated that as many as 75 percent of readmissions are preventable.<br><br></div> <div>According to a 2010 study, if potentially preventable rehospitalizations dropped by only 25 percent, Medicare could save more than $25 billion per year—a tidbit unlikely to escape the notice of federal budget slashers. <br></div> <div><br>About 40 percent of hospitalized Medicare beneficiaries are discharged to a post-acute setting like a nursing facility, Alliance for Quality Nursing Home Care President Alan Rosenbloom said in a statement late last year. Information about the patient’s care lost during the transfer from hospital to nursing facility puts the patient at significantly higher risk for readmission, he added. <br><br></div> <div>The New England Journal of Medicine published an influential study in 2009 that analyzed rehospitalization data from almost 12 million fee-for-service Medicare beneficiaries. Nearly 20 percent of those discharged from a hospital were rehospitalized within 30 days, 34 percent within 90 days, and 54 percent within a year. Of those who were discharged with a medical condition, 69 percent were readmitted or died within a year. If the beneficiary had surgery, the rate of readmission was 53 percent.</div> <h3 class="ms-rteElement-H3">Motives Are Unselfish</h3> <div>Even though reducing rehospitalizations may not save nursing facilities any money—in fact, it may cost more—long term care providers are increasingly pursuing that goal anyway, some believing that higher quality care will bring its own rewards, like increased referrals. </div> <div><br>That seems to prove true, judging by anecdotal evidence, but because those referrals will likely be of sicker residents, facilities may well be forced to staff up to meet those residents’ needs. <br><br></div> <div>Rather, long term care providers are increasingly focused on reducing rehospitalizations not for financial gain but to improve the quality of life and quality of care for their residents by removing as much of the turmoil and discomfort of repeated hospital visits as they can, providers almost universally say.</div> <div><br>To help manage this potentially dramatic change, as well as address the most pressing quality issues of the day, the American Health Care Association (AHCA) will unveil a new quality initiative near the end of this month. One of the “prongs” of that initiative will be reducing rehospitalizations.</div> <div><br>AHCA will launch the new quality improvement initiative at its Quality Symposium in Houston Feb. 23 and 24. (For more information on the symposium or to register, visit <a href="http://www.ahcancal.org/events/calendar/Lists/Events%20Calendar/DispForm.aspx?ID=549" target="_blank">www.ahcancal.org and click on Events</a>.)<br></div> <div>The initiative builds on the past decade or more of AHCA efforts, from Quality First to Advancing Excellence, says David Gifford, AHCA’s senior vice president of quality and regulatory </div> <div>affairs.</div> <div><br>Gifford expects a positive reaction from members, once the initiative is made public. “AHCA and its members have said loud and clear that they really want to improve quality,” he says, “and we want to do it in a systematic way that really has an impact on organizations as a whole.”</div> <h3 class="ms-rteElement-H3">Rehospitalization Triggers</h3> <div>The New England Journal of Medicine study found that five medical conditions were the most frequent causes of rehospitalizations: heart failure (27 percent return to the hospital within one month), pneumonia (21 percent), chronic obstructive pulmonary disease (23 percent), psychoses (25 percent), and gastrointestinal problems (19 percent).<br><br></div> <div><img class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0212/CS3.gif" alt="" style="margin:5px 15px;" />In a study of more than 10,000 hospital admissions published in the Journal of Hospital Medicine, unplanned readmission within 30 days was 24 percent to 33 percent more likely for people on high-risk medications such as narcotics or steroids. </div> <div><br>A second, smaller study published in the same journal found that depression predicted a threefold risk of multiple readmissions, while being underweight raised the risk more than 12-fold. </div> <div><br>A study published last year in the Journal of the American Medical Directors Association analyzed more than 10,000 hospital discharges of people aged 75 and over. The researchers found that patients with genitourinary disorders had the highest rate of readmission within seven days of initial discharge (30 percent). </div> <div><br>The seven-day readmission rates for cardiovascular disorders (25 percent), urinary tract infection (28 percent), renal failure (27 percent), and infection (36 percent) were also high. <br><br></div> <div>Other risk factors identified by various studies include cancer with metastasis and heart attack.</div> <div>With so many risk factors, how does one design or choose a rehospitalization reduction program?</div> <h3 class="ms-rteElement-H3">How To Develop A Program</h3> <div>The conditions that most frequently account for rehospitalizations vary from one facility to another, so any reduction program must be tailored, says Beecher. </div> <div><br>The first step is to determine the facility’s rehospitalization rate. To do this:</div> <div>■ Specify a time period, like 30 days;</div> <div>■ Count the number of rehospitalizations during that period;</div> <div>■ Divide that number by the facility’s average census during the 30-day period; and</div> <div>■ Multiply by 100. </div> <div><br>Not all of these rehospitalizations will be avoidable, of course; the director of nursing (DON) or administrator will need to review each rehospitalization to identify those that were potentially avoidable and flag any conditions that crop up again and again as good prospects for initial efforts.</div> <div><br>Next, set up a task force to develop the rehospitalization prevention program, involving the DON, nurse supervisors and leaders, and certified nurse assistants (CNAs) from all three shifts. This team assesses facility resources to identify which resident conditions can be managed at the facility and which need an acute care setting.</div> <div><br>The team develops or acquires systems, protocols, and clinical pathways to assist nursing staff with clinical decision making (check out the INTERACT II tools or “How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations,” available from the Institute for Healthcare Improvement, based in Cambridge, Mass., and free on its website, <a href="http://www.ihi.org/">www.ihi.org</a>).<br><br></div> <div>An emphasis on improved communication between nursing facility and hospital, especially through the transfer process, is crucial. Also, don’t forget to address advance planning. Without it, residents will be sent to the hospital even if their preference would be for less invasive care at the end of life.</div> <div><br>After that, the team will be able to determine what training, supplies, or other tools will be necessary to make the program work.</div> <div><br>Finally, set up a system for measuring the program’s success rate. Consider having debriefing sessions following each rehospitalization to identify glitches, potential problems, or ways to make the process flow more smoothly. </div> <div><br>And, if the company is able, it can do all of the above plus hire a full-time physician for each facility.<br></div> <div> <span id="__publishingReusableFragment"></span></div> <h3 class="ms-rteElement-H3">How The LCCA Idea Originated</h3> <div>The events setting in motion what would one day be the buzz of the health care industry started long ago when Forrest Preston, LCCA’s founder and chief executive officer, met Scott, then a hospitalist caring for a member of Preston’s family, who came to the hospital with atrial fibrillation. <br><br></div> <div>As Scott worked to stabilize his patient, the two men discussed her care, of course, but also Scott’s 16 years as a hospitalist and his success in building new hospitalist programs while carrying a full case load. </div> <div><br>By the time the patient was ready to leave the hospital, Scott had made an enduring impression on Preston. He remembered Scott when he needed a corporate medical director who knew how to design and implement programs to improve quality of care.</div> <div><br>“Life Care had been planning this approach” for some time, says Hunter. </div> <div><br>But efforts to bring DONs and medical directors into gatherings where they could both earn continuing education credits and talk shop with their peers to get ideas on how to handle various clinical issues back at the facility still weren’t enough to get the outstanding results Preston was looking for. </div> <div><img class="ms-rtePosition-2 ms-rteImage-2" alt="Beecher Hunter" src="/Monthly-Issue/2012/PublishingImages/0212/Beecher-Hunter_E.jpg" style="margin:10px;width:176px;height:220px;" /><br>Four or five years ago, Preston started talking with greater determination about finding new ways to improve clinical outcomes, says Beecher.</div> <div><br>In 2009, “Preston approached me about the whole concept of having a larger physician presence in the [facilities] and having full-time physicians for each nursing home,” says Scott. “When we began, the whole thrust was simply to improve the quality of care.”</div> <div><br>“During the formative process of trying to figure out how we were going to do this,” Scott says, he and Hunter were influenced by the New England Journal of Medicine study that reported a 20 percent rehospitalization rate for Medicare patients across the nation, “and that the cost of those rehospitalized within 30 days was exorbitant.” </div> <div><br>“I brought it to Forrest and Beecher, [saying] ‘if we put a doctor in each nursing home [rehospitalizations are] something we could impact,’” says Scott.</div> <div><br>For the past 15 months, Scott has been hunting down the best doctors possible who have what it takes to be a long term care physician, placing them in LCCA facilities, and watching the rehospitalization rates plummet.<span></span></div> <h3 class="ms-rteElement-H3"><span><span></span></span>Common Conditions</h3> <div>Nearly 6 million Americans live with congestive heart failure, according to the American Heart Association. It’s the fasted growing cardiac disease in the United States. More than half a million new cases of congestive heart failure are diagnosed and 300,000 people die from the condition each year.</div> <div><span><span><br><img class="ms-rteImage-2 ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0212/Ken-Scott.jpg" alt="" style="margin:0px 10px;width:176px;height:220px;" /></span></span><span></span>“If you look at some of the data just on congestive heart failure, the return to hospital from a nursing facility is about 32 percent across the nation,” says Scott.</div> <div><br>Ten years ago, a patient with congestive heart failure stayed in the hospital an average of eight days, says Scott. Today that average is four days, “and the way we [treat] congestive heart failure hasn’t changed that much” over the past decade, he says. So patients with congestive heart failure are being transferred to a nursing facility when the patient is sicker and more frail than in the past.</div> <div><br>A hospital can stabilize an acute congestive heart failure patient in four days. Based on the DRG that Medicare pays, it is difficult financially for a hospital to keep a patient with congestive heart failure much longer than four days. The thing is, what hospitals in the recent past did for the patient on those next four days was adjust medications so that all the dosages were working at peak efficiency. </div> <div><br>Because these patients are being transferred to nursing facilities before dosages are worked out to their best benefit, problems can arise, often due to incomplete information received from the hospital during the transfer. </div> <div><br>For example, if a patient is on a diuretic but the dosage is too high, he or she may dehydrate and get dizzy, fall, and come back to the hospital with a broken hip. If a doctor were on staff who had been treating that patient, he or she may have known from past experience that this patient has a strong reaction to a diuretic, or at the very least would be able to monitor the patient’s reaction to dosages closely and adjust them accordingly—and quickly.</div> <div><br>Another illustrative issue with congestive heart failure patients who are transferred early to a nursing facility is that the facility’s direct care staff are responsible for picking up on any indications of returning congestive heart failure. But that’s a complicated thing to diagnose, says Scott. </div> <div><br>“If it were as simple as monitoring weight,” that would be one thing, he says, “but it’s more complicated than that in many patients. So the very fact that we have our on-site, full-time physician to monitor these patients means more symptoms will be caught early enough for the nursing facility to manage the patient without a rehospitalization in many cases,” Scott says.</div> <div><br>At one LCCA facility, rehospitalization rates overall have dropped from about 40 percent to a startling 8 percent within four months of hiring a full-time doctor, and that rate has been sustained at between 8 and 10 percent for several months.</div> <h3 class="ms-rteElement-H3">Other Benefits</h3> <div>Having a full-time doctor on site also eliminates the rehospitalizations that occur because the regular on-call physician isn’t available. </div> <div><br>Say a patient presents with fever, and the medical director, before going off-call, ordered a bunch of laboratory tests. The labs, arriving after the doctor is no longer available, indicate to the nurse that the resident has a urinary tract infection (UTI). She calls the doctor, but since he’s not available, she calls the doctor who’s filling in. That fill-in doctor has no relationship with the resident, hasn’t seen the resident, and doesn’t know the nurse or how accurate her reading of the labs is. </div> <div><br>Worried about both the patient and his own legal risk, the doctor instructs the nurse to send the patient to the emergency room. An on-staff physician, on the other hand, is familiar with the nurse, the facility’s capabilities, and the resident’s medical history and is more likely to instruct the nurse on how to manage the UTI at the facility. </div> <div><br>Another benefit of the on-site doctor is that he or she can improve many other aspects of nursing facility care. They lift the quality of care for all patients, of course, but they also provide superior education to nurses and CNAs, and, anecdotally, their mere presence results in higher satisfaction rates with patients, families, and staff. </div> <div><br>“We’re hearing how excited [families] are that they can walk into the building on a given day of the week, and talk to the doctor about their loved one,” says Scott. LCCA is about to launch a customer satisfaction survey to quantify the effect that on-site doctors are having on satisfaction.</div> <div> <span id="__publishingReusableFragment"></span><br></div> <h3 class="ms-rteElement-H3">Effects On Staff</h3> <div>Staff turnover also appears to be dropping in facilities that employ a physician, says Scott. The information is purely anecdotal at this point, but some LCCA facility administrators have told Scott that they’re seeing greater retention of nurses and CNAs and reduced overtime. <br><br></div> <div>Another big benefit is the speed with which a decision on whether the resident should go to the hospital can be reached. In a nursing facility without a doctor, the nurse, in the event of a potentially serious condition with a patient, will call the on-call doctor, leave a message, and wait hours for a response. </div> <div><br>“By the time the doctor gets back [to them] and they finish their paperwork, they’re late in leaving,” says Scott. “Now, with a doctor on site full-time, they’re [not only] getting their orders on time and finishing their paperwork on time,” but have the satisfaction of seeing that the residents they’re concerned about are getting immediate attention. That improves their job satisfaction. </div> <div><br>“It’s an extra level of motivation for all of us: having an impact on residents’ personal and physical lives,” says Hunter.</div> <div><br>Another reason staff satisfaction appears to be improving is just the mere fact that the doctor is working with them. “Part of the problem over the years with nursing home work is the lack of respect for what we do from the rest of the health care industry,” says Scott. Once a doctor is on staff full-time, direct-care staff seem to feel that if the work is important enough for a doctor to be there with them all day because patients are coming in sicker, their own work must be getting more important, too. Plus, the doctor can come up to a CNA and say, “Great job!” and that means all the world to them, Scott says.</div> <div><br>“The other aspect that I’m seeing glimpses of, and it will take a little longer to produce the data, but one of the big concerns with the state Medicaid programs is the cost of long term care patients in a nursing home. And the bottom line is that with a full-time doctor, the long term care census is starting to go down. <br><br>Patients come in and either get better and go home or get worse and go back to the hospital or don’t progress and stay on the long term care side. </div> <div><br>“With the doctor there, more are getting better and going home. Before the intervention, every time a resident came back from a hospital he or she was weaker and worse off. Now they’re continuing to get better and reentering society. So, it’s reducing the cost of the Medicaid as well as Medicare program.”</div> <div><br>Having full-time doctors has also resulted in reduced use of antipsychotics, says Scott. LCCA is still in the midst of collecting further data about the rehospitalization rates by a number of factors, but anecdotally the doctors appear to be making a huge difference. </div> <h3 class="ms-rteElement-H3">Finding The Right Doctor</h3> <div>Finding a physician just to make rounds at the facility periodically can be difficult because Medicare reimbursement rates for seeing a patient in the nursing facility is lower than treating that same patient in his or her office. Outpatient reimbursement is much better. Even doctors who do visit nursing facilities must have a high enough volume to cover costs, and so they don’t spend all their time in one building but visit several. It’s great that the residents get to see a doctor periodically, but it doesn’t compare to having a doctor right there the moment something goes south. </div> <div><br>Just getting a doctor into all of LCCA’s 225 buildings appropriate for the intervention is consuming most of Scott’s time right now. He must not only locate doctors interested, but “you have to have a doctor who really understands long term care,” says Scott. “Even for full-time geriatricians, there’s an adjustment to being full-time in a nursing home. It can be hard to predict.”</div> <div><br>Getting the right doctor into each facility will “take a little time,” Hunter says. “We’re really focusing our energy on that.”</div> <div><br>The newly hired physicians aren’t given special training on how to operate within a nursing facility environment, but LCCA does bring them to the company’s headquarters in Cleveland, Tenn., for orientation and discussion of what goals the company is trying to achieve.</div> <h3 class="ms-rteElement-H3">Increased Referrals</h3> <div>The LCCA facilities that have demonstrated tremendous reduction in rehospitalizations are seeing increases in hospitals discharging to them more compromised residents in hopes that they will help protect the hospital from being financially penalized by returns within 30 days.</div> <div><br>Despite hospitals sending sicker patients to LCCA facilities, “for the most part we’re still managing to keep those rehospitalization rates down,” says Scott, “but it’s becoming much more work for our doctor. I’m sure there’ll be a point where that’s maxed.”</div> <div><br>“In a Florida LCCA building, our doctor’s return-to-hospital rate has remained 6.8 percent to 8 percent for about six months, and in November that rate was 5.8 percent,” says Scott. “In December, his rate was 10 percent, and he says it’s truly because of the patients he’s getting. But the hospital is going to push the boundaries.”</div> <div><br> “Once we put a doctor in a building it even broadens the scope of what we can do,” says Scott. “We can take much more critically ill patients. It allows us to develop new programs, such as a cardiac care program in one of our Florida buildings.” </div> <h3 class="ms-rteElement-H3">What’s Next?</h3> <div>Scott, focused as he is on getting top-notch doctors into LCCA’s facilities, already looks to the future. “I think this next year will be a banner year for us,” he says. “It took me about a year of working with Forrest, Beecher, and the team here to come up with a plan that we thought would work. In the past 15 months we’ve hired 33 doctors for 33 buildings, and at some point you start to get into a rhythm, and I think we’re there.” Scott expects 2012 to see LCCA “bust this open and hire at a more rapid pace, with the end effect of better quality of care and cost savings to the overall health care system.”</div> <div><br>Once LCCA achieves a “critical mass of doctors in an area, camaraderie springs up among those doctors,” Scott says. “All the Arizona doctors get together once a month and talk about what’s working in their building, what issues [must be addressed] to improve quality of care,” among other related topics, Scott says. </div> <div><br>“I think that process is the next step,” says Scott. “We have committed physicians in this process. I learn from them. We take those gains, and we use that to improve what we’re doing across the nation.</div> <div><br>“Next is a physician-led program that results in the quality-of-care outcomes [that the company has seen in its efforts to reduce rehospitalizations], which not only improves the care but also reduces the cost to the federal government,” Scott says. “We’re seeing that on the bounce-backs, but I think we’re going to see it in other areas, and those doctors” will be leading the charge.</div> <div><br>“We hope that other companies will follow suit on this,” says Hunter. “The more companies that do that, [the] greater the positive impact on the residents we all service, and good for all is good individually.” </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em></div>The health care industry is buzzing about Life Care Centers of America’s (LCCA’s) success in reducing rehospitalizations from 40 percent to 15 percent in one year among facilities participating in their latest effort to improve quality care, says Beecher Hunter, LCCA president. 2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0212/CS_allenj0040r_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn2
HHS Releases Final Set Of 26 Quality Measures For Medicaid Beneficiarieshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Quality-Measures-For-Beneficiaries.aspxHHS Releases Final Set Of 26 Quality Measures For Medicaid BeneficiariesThe Department of Health and Human Services (HHS) has published its final set of 26 core quality measures for adult Medicaid beneficiaries that states, providers, and insurers can use on a voluntary basis to manage care delivery and improve quality, according to a recent posting in the Federal Register.<br><br>“Identification of the initial core set of measures for Medicaid-eligible adults is an important first step in an overall strategy to encourage and enhance quality improvement,” the HHS posting said.<br><br>“States that choose to collect the initial core set will be better positioned to measure their performance and develop action plans to achieve the three-part aims of better care, healthier people, and affordable care.”<br>Through an evaluation process, an original listing of more than 1,000 measures was narrowed down to 51 when a draft rule came out in December 2010. What remains are slightly more than two dozen measures set across six major categories.<br><br>The six are prevention and health promotion, management of acute conditions, management of chronic conditions, family experience of care, care coordination, and availability. Examples of measure names include annual HIV/AIDS medical visits, controlling high blood pressure, diabetes screenings, antidepressant medication management, and annual monitoring for patients on persistent medications. All of those measures come under the management of chronic conditions category.<br><br>The final rule for core measures is just part of a process spelled out in the health care reform law, HHS said. Over the next year, the Centers for Medicare & Medicaid Services (CMS) will phase in parts of the Medicaid Adult Quality Measures Program that will help to further identify measurement gap areas.The Department of Health and Human Services (HHS) has published its final set of 26 core quality measures for adult Medicaid beneficiaries that states, providers, and insurers can use on a voluntary basis to manage care delivery and improve quality, according to a recent posting in the Federal Register.2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/Misc/check.jpg" style="BORDER:0px solid;" />Column2
ACO Process Moving Along, But Number Of Players Limited: Experthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/ACO-Process.aspxACO Process Moving Along, But Number Of Players Limited: Expert<br>A leading health care law and policy expert sees the implementation of accountable care organizations (ACOs) progressing, but suspects that ACOs are getting more attention than they deserve considering the relatively small number of provider groups expected to play in the space and more ambitious efforts being taken in bundled care and other government-led initiatives in the Medicare program.<br><br>David Harlow, founder and principal of The Harlow Group, and author of health care blog, HealthBlawg, <a href="http://healthblawg.com/">http://healthblawg.com</a>, says long term care providers should prepare for the changes coming to the Medicare world no matter if ACOs are involved or not.<br><br>“Especially with the thinner margins being seen today, it is important for providers to recognize no matter what it is called, ACO or otherwise, there is a movement underway away from fee-for-service to bundled payment and global payment systems,” Harlow says.<br><br>He said the sense is that many long term care providers are concerned about joining ACO-like groups out of fear of losing their independence, but those concerns need to be weighed against the changing tides in the health care business. Cementing ties between acute care and post-acute care providers would be good for both entities, Harlow says, with long term care providers being able to work with one or many hospital groups. “There is a real need for mom and pop [nursing homes] to get more sophisticated by moving to invest more in IT. To do this they will need some sort of infusion of funds from a larger organization,” he says.<br><br>“And at the same time, ACOs would do well to include various long term care providers.”<br><br>ACOs are part of a government effort under the health care reform law to allow Medicare beneficiaries to benefit from coordinated care, which is expected to improve care and save money by affiliating primary care doctors, specialists, hospitals, and other health care providers in patient care.<br><br>The final ACO rule that came out from the Centers for Medicare & Medicaid Services (CMS) in October answered a lot of stakeholder concerns about a draft proposal, but even with the changes in the final rule the footprint of organizations getting into ACOs is going to be small when compared to those involved in the Medicare program, he says.<br><br>“The final rule did a good job of making it easier for organizations to clear the regulatory hurdles,” Harlow says. Easier qualification rules, answers to anti-trust issues, and recognition of the progress being made in the private sector on ACOs were positives.<br><br>He said CMS projects that up to 250 organizations will be getting into ACOs over the next four years covering 2 million Medicare lives. That compares to the roughly 50 million covered under Medicare as a whole. The first wave of ACOs will come soon with those who qualified for the Pioneer ACO program, which is meant for provider groups that had already taken steps to form ACO-like structures before CMS acted.<br><br>A total of 32 groups were greenlighted by CMS in December to go live under the Pioneer program, Harlow says.<br><br>He said there is no number out yet on how many organizations are ready to form ACOs under the broader CMS ACO program.A leading health care law and policy expert sees the implementation of accountable care organizations (ACOs) progressing, but suspects that ACOs are getting more attention than they deserve considering the relatively small number of provider groups expected to play in the space and more ambitious efforts being taken in bundled care and other government-led initiatives in the Medicare program.2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0112/crowd_bridge_thumb.jpg" style="BORDER:0px solid;" />Column2
Cost And Installation Factshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Cost-And-Installation-Facts.aspxCost And Installation Facts<div style="text-align:center;"><img src="/Monthly-Issue/2012/PublishingImages/0212/Management1.jpg" alt="" style="margin:45px 5px;width:495px;height:327px;" /> </div> <div> </div> <div><a href="http://www.hearingloop.org/">HearingLoop.org</a>, a website dedicated to educating consumers and businesses about the loop technology, notes that equipment ranges in size, from small portable and commercial window-counter installations to systems for home TV rooms, and larger-area systems. </div> <div> </div> <div>Portable receiving units, akin to those for infrared and FM systems, can be purchased for those without telecoil-equipped aids.</div> <div> </div> <div>According to the website, some installations, such as those for older wooden structures, may be easier to install and therefore be cost-saving. But for optimal performance in institutional settings, the site recommends the following: “Professional installation (and design, if needed) is highly recommended. Metal in the floor, walls, and ceilings, for example, may necessitate special system design and extra amplification. Adjacent rooms may require systems designed to prevent spillover of sound from one room to the next.” The technology’s wires are typically installed not at ear level but rather either below the listener, such as under a carpet edge, a baseboard, or a floor, or above the listener. </div> <div> </div> <div>The cost of hearing loop technologies range from $2,000 to $8,000 for small- to medium-sized worship centers, but more for very large facilities.</div>HearingLoop.org, a website dedicated to educating consumers and businesses about the loop technology, notes that equipment ranges in size, from small portable and commercial window-counter installations to systems for home TV rooms, and larger-area systems. 2012-02-01T05:00:00ZColumn2
Discharge Summaries Factor Into Readmissionshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Discharge-Summaries-Factor-Into-Readmissions.aspxDischarge Summaries Factor Into Readmissions<div><br>Discharge summaries play a key role in the transitional care of patients to nursing facilities, according to a new study published in the Journal of General Internal Medicine by University of Wisconsin researchers, who detailed how the completeness of documentation varied from patient to patient.  </div> <div> </div> <div>The best way to make the process work better is to improve the information in summaries and have them done in a more timely fashion, the report said. </div> <div><img class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0212/Caregiving2.jpg" alt="" style="margin:15px;" /> <br></div> <div>The objective of the work was to examine the relationship among clinical-work processes, provider characteristics, and discharge summary content to identify approaches that promote high-quality discharge documentation. </div> <div> </div> <div>What researchers discovered was that critical component omissions were common in discharge summaries “and were associated with delayed document creation and less experienced providers.”</div> <div> </div> <div>Study authors said more research is needed to understand the impact of discharge documentation quality on patient and system outcomes, but it was clear that more work needs to be done on the process of thoroughly documenting transitions to nursing facilities. </div> <div> </div> <div>The study looked at all (a total of 489) hip fracture and stroke patients discharged to sub-acute care facilities from 2003 to 2005 from a large Midwestern academic medical center. Patients on hospice/comfort care were excluded.</div> <div> </div> <div>Researchers said they studied 32 expert-recommended components in four categories: patient’s medical course, functional/cognitive ability at discharge, future plan of care, and name/contact information from summaries of sample patients.</div> <div> </div> <div>The results showed that historical components, like a patient’s medical course, were included more often than components that directly inform the admission orders in the nursing facility, like future plan of care. In the latter category, most summaries included a discharge medication list (99 percent), disposition (90 percent), and instructions for follow-up (91 percent), but less frequently included diet (68 percent), activity instructions (58 percent), therapy orders (56 percent), code status (7 percent), and pending studies (6 percent).</div> <div style="text-align:right;">—Patrick Connole</div> Discharge summaries play a key role in the transitional care of patients to nursing facilities, according to a new study published in the Journal of General Internal Medicine by University of Wisconsin researchers, who detailed how the completeness of documentation varied from patient to patient. 2012-02-01T05:00:00ZColumn2
Feds Release First National Assisted Living Survey Findingshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Feds-Release-First-National-Assisted-Living-Survey-Findings.aspxFeds Release First National Assisted Living Survey Findings<br>Recently, federal researchers released initial findings of the first-ever nationally representative study of assisted living/residential care facilities and residents—officially titled the “2010 National Survey of Residential Care Facilities.” This is the largest study of the assisted living profession ever done by the federal government. <br><br>The Centers for Disease Control and Prevention’s National Health Care Statistics conducted the data collection in an effort to gather information about the characteristics of residential care buildings and their residents.<br><br>Perhaps most significant was evidence of the growth of Medicaid’s role in assisted living. The study found that 19 percent of residents received Medicaid funding, and 43 percent of facilities had at least one resident receiving Medicaid assistance. Key findings also include the following:<br><ul><li>In 2010, there were 31,100 residential care facilities (RCFs—the study’s term for assisted living) with 971,900 beds nationwide. Facilities exclusively serving adults with severe mental illness or developmental disabilities were excluded from the survey.</li> <li>About one-half of RCFs were small facilities with four to 10 beds. The remainder comprised medium facilities with 11 to 25 beds (16 percent), large facilities with 26 to 100 beds (28 percent), and extra-large facilities with more than 100 beds (7 percent).</li> <li>One-tenth of all RCF residents lived in small RCFs, and a comparable 9 percent lived in medium facilities, while the majority resided in large (52 percent) or extra-large (29 percent) RCFs.</li> <li>Larger RCFs were more likely than small RCFs to be chain-affiliated and to provide occupational therapy, physical therapy, social services counseling, and case management. <br></li></ul> The study found that RCFs were most commonly located in the Western region of the country (42 percent of all RCFs) and least commonly located in the Northeast (8 percent). In the West, there were 245 beds per 1,000 persons aged 85 and older, compared with 131 beds in the Northeast, 164 beds in the South, and 177 beds in the Midwest. <br><br>Thirty-seven percent of residents were receiving assistance with three or more activities of daily living. The study also found the following prevalence of common chronic conditions among residents, with half having at least three chronic conditions.<br><ul><li>High blood pressure—57 percent</li> <li>Alzheimer’s disease or other dementias—42 percent</li> <li>Heart disease—34 percent</li> <li>Depression—28 percent</li> <li>Arthritis—27 percent</li> <li>Osteoporosis—21 percent</li> <li>Diabetes—17 percent<br></li></ul> Thirty-nine percent of facilities provided skilled nursing services by registered nurses or licensed practical nurses for 13 percent of all residents. The provision of skilled nursing services did not vary by facility size, while the provision of occupational and physical therapy increased with facility size. Recently, federal researchers released initial findings of the first-ever nationally representative study of assisted living/residential care facilities and residents—officially titled the “2010 National Survey of Residential Care Facilities.” This is the largest study of the assisted living profession ever done by the federal government. 2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0212/ALapartment.jpg" style="BORDER:0px solid;" />Column2
Financial Scams, Swindles Against Seniors Increasing, Council Sayshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0212/Financial-Scams.aspxFinancial Scams, Swindles Against Seniors Increasing, Council Says<br>An Otsego Place resident was in a rush to get to the grocery store in Storm Lake, Iowa. When stopped by a community staffer, he said he needed to wire $25 in order to get his $25,000 cash winnings.<br><br>Another time, a credit card company called a female resident asking for her Social Security number. The caller told her there were suspicious charges to her credit card. <br><br>Debbie Klatt, administrator of Otsego Place, received several of these reports from her residents when she realized that scammers were systematically calling the telephone numbers of her residents with various scam scenarios and asking for money. She immediately issued a community-wide memo warning residents not to talk to the scammers. <br><br>“We instructed them to hang up, then contact me or their son or daughter,” Klatt says. “It was truly amazing. The residents have their own individual telephone numbers through two different phone companies. It was like the scammers had a list of numbers. We don’t publish a directory. We do have a list of their names and apartment numbers for the security system in the front entrance,” she says. <br><br>Whether the scammers used the security list or not, scams against the elderly are on the rise in the United States. More than 7. 3 million older Americans—one out of five adults over the age of 67—have been victimized by a financial swindle, according to a recent survey completed by the Investor Protection Trust, a Washington, D.C.-based nonprofit. <br><br>Older adults comprise 12 percent of the U.S. population but represent 35 percent of all fraud victims, according to USBoomers.com. Seniors above the age of 85 are at the highest risk for financial abuse, according to the National Council on Aging (NCOA). Residents of assisted living communities can be targeted since the average age of a resident is 86.9 years old. Financial abuse is committed by both <br>strangers and family members through common and, in many cases, age-old scenarios. <br><br>Seniors are particularly vulnerable, and the con artists know it, NCOA says. Seniors are more likely to have savings, own their own home, and have good credit. In addition, people who grew up during the 1930s, 1940s, and 1950s were taught to be polite so they have a hard time saying “no” or hanging up the phone. These seniors are also less likely to report the crime, according to the Federal Bureau of Investigation. In addition, seniors’ cognitive capabilities can be diminished by medications or dementia. <br><br>Awareness is the main form of protecting seniors from these types of crime. Recently, NCOA developed “Steps to Avoiding Scams,” a toolkit designed to educate seniors about how to protect themselves from financial abuse and scams.<br><br>The toolkit was developed so that a 60-minute presentation could be delivered by a facilitator. The toolkit consists of a training guide and fully scripted Power Point presentation for workshop facilitators. <br><br>Assisted living providers should consider reviewing the presentation slides and the script because it is written for seniors living in their own homes. Information in the kit includes the top 10 scams, tips to avoid scams, and resources for reporting scams. <br><br><span><strong>Top 10 Scams Targeting Seniors</strong><br><br>1. Health care/Medicare/health insurance fraud<br>2. Counterfeit prescription drugs<br>3. Funeral and cemetery scams<br>4. Fraudulent anti-aging products<br>5. Telemarketing<br>6. Internet fraud<br>7. Investment schemes<br>8. Homeowner/reverse mortgage scams<br>9. Sweepstakes and lottery scams<br>10. The grandparent scam<em><br>Source NCOA</em><span style="display:inline-block;"><br><br><br></span></span><br><br>There is also a handbook for distribution to seniors or other workshop attendees.<br><br><strong></strong><strong>Resources</strong><br><br><ul><li><a href="http://bit.ly/vbfKkS">NCOA: “Steps To Avoiding Scams” toolkit on the Savvy Saving Seniors page</a> </li> <li><a href="http://www.donotcall.gov/">Stop Telemarketing Calls</a> (888) 382-1222</li> <li><a href="http://www.fbi.gov/scams-safety/fraud/seniors">FBI’s Task Force on Seniors</a></li> <li><a href="http://www.stopmedicarefraud.gov/reportfraud.html">Stop Medicare Fraud</a><br></li></ul> <br>Debbie Klatt, administrator of Otsego Place, received several of these reports from her residents when she realized that scammers were systematically calling the telephone numbers of her residents with various scam scenarios and asking for money. She immediately issued a community-wide memo warning residents not to talk to the scammers. 2012-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0212/News_con-artist_thumb.jpg" style="BORDER:0px solid;" />Column2

March



 

 

Palazzo Favors Competition To Help Cure Health Care Woeshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/Palazzo-Favors-Competition.aspxPalazzo Favors Competition To Help Cure Health Care Woes<p>​<img width="150" height="150" class="ms-rteImage-2 ms-rtePosition-1" alt="Palazzo" src="/Monthly-Issue/2012/PublishingImages/0312/Palazzo.jpg" style="margin:5px 10px;" />As far as Rep. Steven Palazzo (R-Miss.) sees it, the time to do something about the tough issues facing the country and Congress is now, notably by acting forcefully on the ballooning deficit and the underlying issues causing the problem.</p> <p>In an interview with <em>Provider</em>, the first-term congressman representing Mississippi’s Fourth District said he’d like this and the next Congress to work on solving problems and not put them off for the future.<br>For instance, the current system does not allow a good way to pay for the Medicare and Medicaid programs, Palazzo says, and that must be addressed for the good of the nation and all seniors.</p> <p>“I’d like to see us get to a point where Congress can take up some of these tough issues—like Medicare and Medicaid. These are some of the biggest drivers of our debt. We have an aging population, more and more who are going to need care in the future, and fewer and fewer people paying into the system,” he says.</p> <p>Continuing a “kick-the-can-down-the-road” approach just won’t do. “There’s no question we need to control costs. But the best way is by focusing more on the patient and having health care providers compete for their business,” Palazzo says.</p> <p>Like many conservatives in the House, he also favors a larger state role in the health care system, especially as the federal government combats tough budget choices.</p> <p>“So many rely on Medicaid to care for the Greatest Generation. We can find a responsible way to do that without bankrupting the program. The only way to ensure that all Americans have access to quality health care is to confront these rising costs and the market distortions that created them,” Palazzo says.</p> <p>Caring for the nation’s older generations is extremely important, Palazzo says, noting that this is the generation of World War II and Korean War veterans that did so much for protecting national interests and freedom across the globe.  </p> <p>“Thousands of South Mississippians rely on these long-term health care services, and we will continue to work to keep these services affordable. Not only do they deserve our assistance, they have paid for it through their taxes over the course of their careers. As the average lifespan of Americans continues to increase, addressing the challenges to long term care will only increase, for the individual as well for the caregivers. Fortunately, seniors today have more and more choices,” he says. </p> <p>His district is home to many veterans, and for that matter active duty military personnel, who take advantage of the area’s naturally mild temperatures and access to medical and long term care facilities tied to military installations. </p> <p>“South Mississippi enjoys mild temperatures year-round, beautiful watersheds, rivers, islands, the Gulf of Mexico, and white sandy beaches. As such, it is a natural retirement destination,” Palazzo says. “The 4th Congressional District, particularly Harrison County, has one of the largest percentage populations of veterans, dependents, retirees, and active military personnel in the country. The largest portion of these veterans is from the World War II, Korean, and Vietnam War eras.”</p> <p>Just like elsewhere in the country as the baby boomer generation enters retirement age, access to long term care facilities will be an important factor in determining where they will live out their golden years.</p> <p>“South Mississippi is fortunate to be home to one of two Armed Forces Retirement Homes in the country and also home to the Veterans Affairs Medical Center adjacent to Keesler Air Force Base in Biloxi,” Palazzo says.    </p> <p>Palazzo’s personal experience with long term care involves an uncle who required care when the family could no longer meet his health needs.</p> <p>“When my uncle got so sick with Parkinson’s disease that my aunt could no longer care for him, the family decided it was best to put him in a long term care facility in Hattiesburg. That’s never an easy decision, but I can honestly say that the facility was clean and well-kept; he received quality care and was treated with dignity. </p> <p>“In a difficult time, it was a relief for the family to know that he was being well cared for in his last days,” the congressman says. </p> <p>As for broader health care issues, Palazzo has backed the repeal of pieces of the Obama reform law such as the Independent Payment Advisory Board, which in his view is another bureaucratic panel of unelected officials to control payment decisions and decide how patients’ services are paid for.</p> <p>“There’s a reason people are so upset about this board, and I’ll continue to work to repeal it,” he says. </p>As far as Rep. Steven Palazzo (R-Miss.) sees it, the time to do something about the tough issues facing the country and Congress is now, notably by acting forcefully on the ballooning deficit and the underlying issues causing the problem.2012-03-01T05:00:00Z<img alt="Palazzo" src="/Monthly-Issue/2012/PublishingImages/0312/Palazzo.jpg" style="BORDER:0px solid;" />PolicyColumn3
New Quality Cabinet Launches Therapy Outcomes Initiativehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/New-Quality-Cabinet.aspxNew Quality Cabinet Launches Therapy Outcomes Initiative<img alt="Mary Ousley, Quality Initiative" class="ms-rteImage-2 ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/Headshots/MaryOusley_thumb.jpg" style="margin:10px 15px;" /><br>The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) has created a Quality Cabinet, which is out of the starting gate with an ambitious five-point agenda that includes a groundbreaking effort to develop outcome measures for therapy provided to skilled nursing facility residents.<br><br>The cabinet was established by the AHCA Board of Governors to “coordinate and direct our collective efforts as we advance quality-of-care and quality-of-life issues on behalf of our members and those in our charge,” said a description from AHCA Chair Neil Pruitt Jr.<br><br>The Quality Cabinet is chaired by Mary Ousley, president of Ousley & Associates in Richmond, Ky., and former chair of AHCA. Howie Groff, former NCAL chair, serves as vice chair.<br><br>Ousley said the cabinet will address five strategic goals, which are part of the AHCA/NCAL Quality Initiative:<br><ul><li>Reduce the 30-day hospital readmission rate during a skilled nursing facility (SNF) stay by 15 percent over three years;</li> <li>Reduce the off-label use of antipsychotic drugs for the geriatric population by 15 percent by December 2012;Reduce facility turnover among clinical staff by at least 15 percent over three years; and</li> <li>Increase resident satisfaction so that more than 90 percent of residents, families, and other stakeholders are willing to recommend the facility to others.<br></li></ul> “A separate group will work on the fifth area: development of new therapy outcome measures,” Ousley says.<br><br>Currently, there “is no way to say that when you receive this level of therapy in a skilled nursing facility this would be the expected outcome,” she says. The therapy outcomes group, which will hold an organizational meeting early this year, will begin by researching existing outcome measures and scientific evidence of their value and explore measures that would be a good fit for a post-acute and long term care model, Ousley says.<img src="/Monthly-Issue/2012/Pages/0312/New-Quality-Cabinet.aspx" alt="" style="margin:5px;" /><br><br>The therapy outcomes group will include representatives from the National Association for the Support of Long Term Care and academic institutions that have conducted outcomes research. It will also reach out to the Medicare Payment Advisory Commission for input and has the support of the Centers for Medicare & Medicaid Services.<br><br>While the Quality Cabinet’s goals won’t be achieved overnight, “by the end of 2012 and 2013 we expect to have made a substantial difference in each of these areas across our membership,” Ousley says.The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) has created a Quality Cabinet, which is out of the starting gate with an ambitious five-point agenda that includes a groundbreaking effort to develop outcome measures for therapy provided to skilled nursing facility residents.2012-02-01T05:00:00Z<img alt="Quality Initiative" src="/Monthly-Issue/2012/PublishingImages/Logos/quality_init_logo_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality ImprovementColumn3
Providers Target Savings Through Rehospitalization Reduction Proposalhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/Providers-Target-Savings.aspxProviders Target Savings Through Rehospitalization Reduction Proposal<img src="/Monthly-Issue/2012/PublishingImages/Misc/Hospital%201.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="rehospitalization, bad debt, MedPAC" style="margin:5px 10px;width:368px;height:238px;" /><br>As lawmakers and federal agencies consider additional Medicare cuts to skilled nursing facilities, the American Health Care Association (AHCA) is countering with a proposal to encourage providers to reap savings for the program by reducing their hospital readmissions.<br><br>This approach would be more equitable, innovative, and care-focused than simply cutting provider rates through Medicare bad debt and other potential payment reductions, AHCA says.<br><br>The bad debt proposal “is a cut which threatens some of the most vulnerable individuals’ access to care, while achieving the needed savings by reducing hospital readmissions is an approach that meets fiscal goals through improvements in quality,” said Gov. Mark Parkinson, AHCA president and chief executive officer.<br><br>An AHCA overview of the hospital readmission issue points out that they “are not only a physical strain on patients, but a costly strain on the American taxpayer.” <br><br>One in five patients discharged from the hospital return within 30 days, costing Medicare $17.4 billion in 2010, AHCA says. Almost one-fourth of these beneficiaries are skilled nursing facility (SNF) patients receiving post-acute care.<br><br>While many providers have already begun making strides to reduce rehospitalizations, AHCA says its proposal would accelerate these efforts by giving providers incentives to achieve $2 billion in Medicare savings from 2014 to 2021.<br><br>Under the proposal, the secretary of Health and Human Services would set a targeted readmission reduction goal needed to hit the $2 billion mark, and SNFs would work toward that goal. If savings were not achieved, the SNF market basket update would be reduced to make up for the shortfall in expected savings. If providers met the savings goal, they would share in additional savings gained through lowered readmissions.<br><br>The proposal also gives AHCA some common ground with the Medicare Payment Advisory Commission (MedPAC). At a January meeting, MedPAC voted to recommend rebasing Medicare SNF payments and eliminating the market basket in 2013, policies that AHCA said it opposes. But at the same meeting, commissioners offered positive acknowledgment of AHCA’s readmissions proposal.<br>“AHCA is encouraged by MedPAC’s discussion of future rehospitalization policy,” Parkinson said<br>in a statement. “We were especially pleased MedPAC acknowledged AHCA’s proposals to reduce <br>rehospitalizations.”This approach would be more equitable, innovative, and care-focused than simply cutting provider rates through Medicare bad debt and other potential payment reductions, AHCA says.2012-03-01T05:00:00Z<img alt="rehospitalization, bad debt, MedPAC" src="/Monthly-Issue/2012/PublishingImages/Misc/Hospital-1_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalColumn3
Resident Activities: What Is Appropriate?https://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/Resident-Activities-What-Is-Appropriate.aspxResident Activities: What Is Appropriate?​​ <div>After a hard week at work, many adults look forward to a quiet dinner at a restaurant with a close friend or loved one. However, a peaceful evening can sometimes be interrupted by the crying of a child. Most anyone would be annoyed by this and ask, “Who would bring a child out at this hour of the night to a restaurant like this; it’s not like this is a ‘family restaurant’ where you would expect small children to accompany their parents, this is a formal restaurant!” </div> <div> </div> <div>Many in this situation find themselves wondering why parents would bring children to a formal dining experience, the expectations of which were clearly beyond the comprehension of the child as demonstrated by the child’s inability to behave in accordance with the expectations of the setting. <br>Although the above scenario sounds unpleasant, a similar experience is lived by many residents each day in nursing facilities and other settings. This article will explore an all-too-common scenario and discuss what needs to be done to ensure not only superior customer service for all residents but also how to avoid potential deficiencies resulting from this similar scenario.</div> <div><div><h2 class="ms-rteElement-H2">Enough Is Enough</h2></div> <div>Millie is an 81-year-old resident with severe cognitive impairment secondary to Alzheimer’s disease. Her most recent minimum data set (MDS) 3.0 assessment indicates that she has problems with both long-term and short-term memory. The Staff Assessment for Mental Status had to be conducted, as Millie lacked sufficient cognition to complete the Brief Interview for Mental Status (BIMS) instrument. </div> <div>In addition, section B of the MDS 3.0 indicates that Millie’s hearing is highly impaired, and although she has a hearing aide, Millie’s cognition results in her frequently taking the hearing aide out and losing it. </div> <div> </div> <div>In terms of making herself understood and her ability to understand others, Millie is rarely or never understood, and rarely or never understands others, due to her lack of linguistic abilities secondary to her diagnosis. However, Millie is quite lively in that she is generally into “everything” on the unit. Using her wheelchair for independent mobility, she often self-propels into the rooms of other residents, which generally causes considerable upset. Difficult to redirect, Millie sometimes strikes out at staff or other residents. </div> <div> </div> <div>One evening, Millie wheeled herself into the nurses’ station, which was unattended (staff were busy elsewhere on the unit). One of the charge nurses returned to the station to find Millie with two charts open and their contents strewn across the floor. </div> <div> </div> <div>“That’s it, I’ve had enough,” the nurse exclaimed and took Millie down the hall into the day room where the activity aide was holding a trivia game. </div> <div> </div> <div>“Millie wants to play,” the nurse says as she places Millie’s wheelchair next to members of the group and turns to leave. </div> <div> </div> <div>“But Millie isn’t supposed to attend this activity,” the activity aide explains. “It’s not an appropriate activity for her.” </div> <div> </div> <div>“Millie has the right to attend any activity that she wants to, that’s part of her resident rights,” the </div></div> <div>nurse says as she walks away.</div> <h2 class="ms-rteElement-H2">What Is Right? What Is Wrong?</h2> <div><div>Although the nurse is certainly correct that Millie has rights, what becomes abundantly clear is that the nurse’s citation of “resident rights” in this situation has less to do with the intent of the law and more to do with expecting the activity department to keep Millie out of trouble. </div> <div> </div></div> <div><img src="/Monthly-Issue/2012/PublishingImages/0312/0312-Caregiving1.gif" alt="Alzheimer's, behavior, dementia" class="ms-rtePosition-1 ms-rteImage-2" style="margin:5px 10px;width:193px;height:702px;" />Appendix PP of the “State Operations Manual” indicates that the resident “has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident.”</div> <div> </div> <div>The first thing missing in this situation has to do with self-determination. Millie didn’t tell the nurse, “I want to go to the day room and play trivia.” Also, would placing Millie in an activity that she lacks the ability to effectively participate in due to her cognitive status really support her dignity? In fact, if the activity is complicated, and results in frustration, a catastrophic reaction may result. This could put the safety and well-being of other residents at risk.</div> <div> </div> <div>The real issue here is that the activity that the nurse is attempting to encourage Millie’s participation in is inappropriate for Millie’s cognitive abilities. Recall that Millie has both long- and short-term memory problems, demonstrates an absence of useful hearing, is unable to make herself understood, and generally is unable to understand others.</div> <div> </div> <div>In fact, recall that the staff were unable to use the BIMS scale of the MDS 3.0 due to her poor cognition. The activity was appropriate for individuals who had higher cognitive functioning, were able to understand the verbal content of the activity, and were able to adequately express their ideas. </div> <div> </div> <div>The second point to consider is the potential negative effects of Millie’s presence on the activity and, ultimately, the enjoyment of other residents. If the activity is disturbed by the presence of residents who are inappropriate for the activity, it is likely that the residents’ enjoyment will be low—just as the individuals who attended a dinner had their time spoiled by the crying of a child.</div> <div> </div> <div>Although the circumstances are different, the end result is the same—individuals in both situations have a certain expectations, and because of the lack of thought of others, the expectation was not met. This resulted in both frustration and lack of enjoyment.</div> <div> </div> <div>However, in the scenario presented at the beginning of this article, the worst that could happen is that an expensive dinner was ruined. But when one considers the many thousands of dollars per month it costs for residents to stay in a long term care facility, the impact is significantly greater.</div> <div> </div> <div>In addition, in the above scenario individuals who were displeased with the annoying child could get up and leave. And since the nursing home is where these residents live, leaving is scarcely an option. </div> <h2 class="ms-rteElement-H2">Could This Really Result In A Deficiency?</h2> <div>Certainly! Recall that the regulations at F-248 require that “the facility involves the resident in an ongoing program of activities that is designed to appeal to his or her interests and to enhance the resident’s highest practicable level of physical, mental, and psychosocial well-being.” Clearly, the trivia activity is not designed to meet the needs of Millie.</div> <div> </div> <div>Recall that F-248 includes an investigative protocol. Part of the investigative protocol requires surveyors to interview residents regarding their satisfaction with the activity program in the facility. Residents will most likely be quite displeased that their activities are being interrupted by residents inappropriate to an activity, and often will share this with surveyors, when asked.</div> <div> </div> <div>Of course Millie does have the right to attend the activity. The facility’s activity director should be using MDS 3.0 section F (Preferences for Customary Routine and Activities), along with section C (Cognitive Patterns), to determine the range of activities that Millie can participate in. Using the MDS 3.0 data should result in program planning that results in a cross-section of activities available to all residents with varying cognitive abilities and activity interests.</div> <div> </div> <div>There should be an appropriate number of activities for high-functioning residents, low-functioning residents, and everyone in between. </div> <div> </div> <div>A comprehensive activity assessment should consider both cognitive and physical factors, such as hearing and vision, as well as activity preferences.</div> <div> </div> <div>Activities should be selected for individual residents based on the comprehensive assessment. This will result in activities that provide the appropriate level of challenge and interest, while at the same time avoiding frustration.</div> <div> </div> <div>If Millie’s cognitive and behavioral status results in her inability to effectively function in a group activity setting, then individualized activities to meet Millie’s unique needs should be developed. Consultation with a recreation therapist may be beneficial in developing individualized approaches.</div> <div> </div> <div>It is easy to understand how staff can become frustrated with residents who demonstrate challenging behaviors. It is essential that the administrator not permit the activities program to be turned into a glorified babysitting service.</div> <div> </div> <div>Activities should be selected commensurate with resident interest and resident abilities, not to serve as a panacea for frustrated staff. The facility’s activity director should engage in ongoing assessment of both resident interests and abilities and revise the facility’s comprehensive activity programming to meet the assessed needs of its residents. </div> <div> </div> <div><em>Linda Buettner, PhD, LRT, CTRS, is professor of recreation therapy and gerontology at the University of North Carolina at Greensboro and co-coordinator of the Geriatric Treatment Network for the American Therapeutic Recreation Association. Timothy Legg, PhD, CNHA, GNP-BC, CTRS, FACHCA, is professor of nursing and academic program chair at Kaplan University School of Nursing. He serves as a long term care consultant with Gerber Consulting Services, Clymer, Pa. </em></div> After a hard week at work, many adults look forward to a quiet dinner at a restaurant with a close friend or loved one. However, a peaceful evening can sometimes be interrupted by the crying of a child. Most anyone would be annoyed by this and ask, “Who would bring a child out at this hour of the night to a restaurant like this; it’s not like this is a ‘family restaurant’ where you would expect small children to accompany their parents, this is a formal restaurant!” 2012-03-01T05:00:00Z<img alt="seniors,Alzheimer's, dementia, activities" src="/Monthly-Issue/2012/PublishingImages/0312/caregiving.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalColumn3
A New Look At Online Staff Traininghttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/A-New-Look-At-Online-Staff-Training.aspxA New Look At Online Staff Training<p><img width="133" height="429" class="ms-rteImage-2 ms-rtePosition-2" alt="long term care, training, e-learning" src="/Monthly-Issue/2012/PublishingImages/0312/0312-HR.jpg" style="margin:5px 10px;width:258px;height:315px;" />The juxtaposition of new federal and state laws with current reimbursement and budget cuts has created a disparity for today’s providers. Federal regulations like the Affordable Care Act of 2010 will require nursing homes to institute a facility-wide compliance program by 2013, while mandating enhanced nurse aide training and a comprehensive quality assurance and performance improvement program not long after. </p> <p>State laws like the Part 1300 Nurse Practice Act in Illinois will now require licensed practical nurses, registered nurses, and all advanced practice nurses to complete dozens of hours of approved continuing education, all per each two-year license renewal cycle.</p> <p>These and other regulations will call for the allocation of more resources to staff development and training over the coming years, while the Centers for Medicare & Medicaid Services reimbursement cuts and tighter budgets challenge providers financially. </p> <div><h2 class="ms-rteElement-H2">Doing More With Less</h2> <div>Together, these forces have left administrators and human resources (HR) professionals searching for ways to do more with less, expanding their services using fewer resources.</div> <div> </div> <div>In the fall of 2011, LeadingAge conducted a study of 65 nonprofit HR professionals with anywhere from one to 31 facilities and 50 to 650 employees. When asked about staff education, 100 percent of respondents agreed that employee training is critical to meeting compliance requirements and survey readiness. But, at the same time, almost 75 percent of the same respondents said they will either reduce or just maintain their current training budget through 2012, no doubt a direct result of this inequity. </div> <div> </div> <div>One way to meet regulations, while cutting costs, is to create a standardized training program with consistent and targeted instruction across all shifts and employment levels. The first step in doing so is to dedicate at least one staff member exclusively to the task. </div> <div> </div> <div>The study found that almost half of the respondents have one or two employees dedicated to executing training, including teaching, scheduling, and reporting, while the same percentage of respondents reported that this employee is typically the facility’s HR director. </div> <div> </div> <div>With a dedicated professional or team of professionals, it will be possible to streamline training using multiple mediums of instruction. An effective training program will combine a variety of instruction methods, including in-service, written, and online courses. </div></div> <div><h2 class="ms-rteElement-H2">Online Training Can Help</h2> <div>While in-service instruction has traditionally comprised the bulk of staff training for many nursing homes, online learning is growing in popularity because of its ability to provide up-to-date information in real time and be regularly updated, with the capacity to reflect even the slightest change in regulation. </div> <div> </div> <div>About half of the respondents in the LeadingAge survey said they use online training to fulfill at least a portion of their employee education, with over 32 percent of respondents’ education courses conducted online. </div> <div> </div> <div>“Online learning has given us the ability to more efficiently and effectively prepare for surveys and try to attack a survey or complaint issue very quickly without having to create an in-service and get everyone into the facility to receive the training,” says Carly Saltis, director of human resources for Extended Care Consulting, Evanston, Ill. </div> <div> </div> <div>“Online learning allows us to get out of jams pretty quickly, and more courses are approved by the state and federal agencies, which helps. We don’t have to worry about missing a regulation with the online learning.”</div> <div> </div> <div>Beyond compliance, educating staff online can save time and money by providing nursing homes with flexibility. Over 52 percent of respondents in the survey said they witnessed cost savings as a result of online training.</div> <div> </div> <div>“Online training saves time in an environment that operates on a 24-7 basis and consists of taking care of people,” says Saltis.</div> <div> </div> <div>Online training saves time and money at the 25 nursing facilities Saltis consults for by training first-, second-, and third-shift employees online. No longer requiring these employees to come in before their shifts start, stay after a shift, or on their days off for an in-service seminar, online training allows them the time to complete their course work during their shifts. </div> <div> </div> <div>By allowing staff members to complete training whenever and wherever—both on the job and at their leisure, Saltis says employee satisfaction improves and the learning is more effective. </div> <div> </div> <div>“It provides flexibility for the user and ensures that the employee is understanding the message by asking them questions throughout the training, along with a post-test to verify that they’ve truly understood and absorbed the materials,” says Saltis. “That’s important because there are times in long term care that we’ve given an in-service and when you have someone up there talking for 45 minutes, typically you lose the attention of some employees part of the time. </div> <div> </div> <div>“If it’s at their leisure and they’re not coming in on their time off, then the employee is much more focused on the training material.” At some of Saltis’ facilities, headphones are provided to help employees focus on training modules, while minimizing noise for other staff members and patients. In some facilities, Saltis says, three or four employees may take an online course simultaneously, saving additional time and allowing for group discussion.</div> <h2 class="ms-rteElement-H2">Federal Requirements Met</h2> <div>For Robert Vardaman, online training manager at Indiana-based TLC Management, the goal is to be “proactive, not reactive in our training.” This means that the employees in TLC Management’s 17 nursing homes begin their training at orientation, continuing on to fulfill additional requirements as needed, in-house, during their workday. </div> <div> </div> <div>“The state of Indiana requires a certain amount of hours on dementia and resident’s rights, and we make sure they do those all up front,” says Vardaman. “We use it to fulfill the state requirements and then go beyond that to include care issues that we are interested in our staff learning about. Some employees will even ask if they can take courses that aren’t assigned. When they have the time, we provide the resources for them to do so.”</div> <div> </div> <div>As always, online courses are most effective when used in combination with other mediums of learning, like in-service training sessions. </div> <div> </div> <div>“Online learning works well when coupled with the traditional learning,” says Saltis. “We have to train them so much so you’ve got to have a good balance between online and in-person learning.”</div> <div> </div> <div>Regardless of which type of training is used, the sign of a successful program is its ability to interact with the trainee and include a follow-up that allows administrators or HR professionals to track whether its employees understood what was presented enough to put it into practice. </div> <div> </div> <div>Ric Henry, president of Pendulum, a risk management consulting firm based in Albuquerque, N.M., says in addition to meeting standards, training also helps nursing homes improve their consistency and effectiveness. </div> <div> </div> <div>“Training is not just what a facility needs to do to comply; it’s a best practice,” says Henry. “It’s going to minimize the risk of liability. Best practice to us means it covers the quality and risk components.” </div> <div> </div></div> <div><em>Tamar Abell, MA, CCC-SLP, is a third-generation nursing home owner and operator who managed 10 communities for over 15 years. In 2005, Abell founded Upstairs Solutions (<a href="http://www.upstairssolutions.com/">www.upstairssolutions.com</a>), now a leader in e-learning for senior care communities. Abell can be reached at: <a href="mailto:tabell@upstairssolutions.com">tabell@upstairssolutions.com</a>.</em> </div>The juxtaposition of new federal and state laws with current reimbursement and budget cuts has created a disparity for today’s providers. Federal regulations like the Affordable Care Act of 2010 will require nursing homes to institute a facility-wide compliance program by 2013, while mandating enhanced nurse aide training and a comprehensive quality assurance and performance improvement program not long after.2012-03-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0312/0312-HR_thumb.jpg" style="BORDER:0px solid;" />Workforce;ManagementColumn3
Facilities Tap Fresh Ideas, New Technologyhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/Facilities-Tap-Fresh-Ideas-New-Technology.aspxFacilities Tap Fresh Ideas, New Technology<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div>​ <div>Of the many reasons for the long term care sector to modernize, one stands out above the rest: Adapt or forego opportunities for growing the business in the dawning age of coordinated, patient-centered care, where quality improvement, outcomes, and meeting consumer needs dominate. </div> <div> </div> <div>That is the message from providers that are buying into high-technology options and innovative system changes to transform their service offerings, be it electronic health records (EHRs), sensor hardware, or low-tech operational tweaks. These changes also put facilities serving the nation’s frail and elderly in line to eventually reap the benefits of the nascent bundled payment and accountable care organization (ACO) programs unveiled recently by the Centers for Medicare & Medicaid Services (CMS).</div> <div> </div> <div>The goals of bringing high-tech and innovation to the nursing facility level are to make life better for residents, make work less arduous for staff, and provide facilities easier methods to report outcomes to state and federal governments that are radically shifting reimbursement payment by making accountability king.</div> <div> </div> <div>It has become a cliché to say long term care does not keep pace in a wired world. Mark Twain’s old quip about Cincinnati, Ohio, comes to mind: “When the end of the world comes, I want to be in Cincinnati because it’s always 20 years behind the times.” When it comes to the health care sector, all too often long term care has been “Cincinnati” in the way Twain intended.</div> <div> </div> <div>As with Cincinnati, the quip is no longer apt, but long term care providers say it takes new thinking and dollars to get started and an energy force within an organization to sustain fresh ways of doing business.</div> <div> </div> <div>Following are the ways some providers are innovating by meeting the needs of a growing elderly demographic and burgeoning rehab client base for “younger” seniors. The focus is on understanding consumer demand and getting nursing homes and assisted living centers in tune with the times. </div> <div>Innovation, Not Just Technology </div> <div> </div> <div>Bill Anderson, vice president for quality, innovation, and change engineering at the Sioux Falls, S.D.-based Evangelical Lutheran Good Samaritan Society, is as enthusiastic as they come when outlining the steps this nonprofit provider has taken to bring about change to its 240 locations and 27,000 residents.</div> <div> </div> <div>Part of his job is to harness a constant state of “brainstorming,” harvesting ideas from all corners of the company to make facilities better for residents, staff, and families. “We encourage innovation and incorporate these ideas to meet unmet needs,” Anderson says.</div> <div> </div> <div>“This might involve throwing out an old system, and it could mean adding new technology.”</div> <div> </div> <div>His work is manifested in the <a>Good Samaritan Vivo program</a>, with vivo meaning “I live” in Latin. A website for Vivo is just one sign of the importance the entire company puts on innovation.<br>For Good Sam, there are two pillars working for the same high-quality care goal: technology and innovation. It doesn’t mean a solution is always a new gadget, but it does mean fostering change.<br>“Technology is simply a means to an end,” Anderson says.</div> <div><h2 class="ms-rteElement-H2">Shiny Gadgets Just A Place To Start </h2> <div>Anderson notes that there are many “shiny objects out there” to assist in caring for residents now, like sensors from Honeywell and other manufacturers to track motion and health vitals, but that is just part of what Good Sam is exploring.</div> <div> </div> <div>It is looking into new services focused on the upstream side of the health and wellness trade for people not in need of full-blown skilled nursing care, who may need health care coaching at home, help to care for a pet, or small home repairs. </div> <div> </div> <div><img class="ms-rteImage-2 ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0312/0312-CoverStory3.jpg" alt="" style="margin:5px 10px;width:338px;height:285px;" />As the push for community-based care becomes more of a reality, the market for elder-care technology and service providers is expected to grow exponentially over the next decade.</div> <div> </div> <div>These ancillary services, not seen before in traditional long term care business models, are of course not reimbursable through government programs, but are in the plans for Good Sam. “We’re in an awkward position, where we try [new services] out first and then bring it to the attention of CMS and others,” Anderson says.</div> <div> </div> <div>As an example of the company’s interest in new concepts in long term care, Good Sam is taking part in the LivingWell@Home research study being conducted by the University of Minnesota. The study will include 1,600 people and focus on the use of sensors to monitor health and health outcomes.</div> <div> </div> <div>A three-year research study that began in 2010 and funded by an $8.1 million grant, LivingWell intends to evaluate the effectiveness of using sensor technology, telehealth services, and personal emergency response systems in helping seniors maintain their wellness before they are in need of nursing care.</div> <div> </div> <div>Information from projects such as LivingWell@Home, combined with information and research from the other consortium members, will provide an unprecedented amount of data about health care trends, habits, and wishes of seniors across the country, Anderson says.</div> <h2 class="ms-rteElement-H2">Sensors, Telehealth, Responses</h2></div> <div><div>In the program, participants and their living spaces will be outfitted with sensors to detect movement, monitor sleep quality, and collect other information about day-to-day activities.</div> <div> </div> <div>The information is transmitted via a secure Internet site to a registered nurse, who compares the data with a client’s usual patterns of daily living. Good Sam uses sensor technology developed through a partnership with WellAWARE Systems and Volunteers of America and began deployment of WellAWARE sensor technology in 2009.</div> <div> </div> <div>Also being employed in the study is telehealth, a remote care delivery system.</div> <div> </div> <div>With telehealth, a client measures his or her own vital signs such as blood pressure and heart rate using telehealth equipment. The information is then sent electronically to a collection point where it is analyzed by a nurse. And the last link is personal emergency response, which notifies family or professional caregivers in the event of an adverse event such as a fall or sudden illness.</div> <h2 class="ms-rteElement-H2">Casting A Wide Net</h2></div> <div><div>“If not now, when for innovation? If not now, when for connecting to other partners?” says Anderson. </div> <div>“It’s just an ideal time, and if we don’t do that, and organizations don’t do that, they’re just simply not going to be able to serve people down the road. We want to be in a position of being stronger five or 10 years from now, rather than struggling to figure out what’s next for us,” he says.</div> <div> </div> <div>Good Sam’s tag line, “Innovation for Well-Being” under the Vivo banner, reinforces the intention of the program.</div> <div> </div> <div><img width="927" height="716" class="ms-rteImage-2 ms-rtePosition-2" alt="Good Sam, brainstorm, Innovation for Well-Being" src="/Monthly-Issue/2012/PublishingImages/0312/0312-CoverStory2.jpg" style="margin:10px;width:329px;height:219px;" />The society’s board of directors and executive leadership team affirmed that resourcing an innovation program is one of the organization’s five strategic initiatives. </div> <div> </div> <div>This commitment is the first and most important step to building an innovation culture that advances new products and services, rapidly based on the voice of customers (residents, families, staff, and communities), and does so by placing small bets with little fear of failure, the company says.</div> <div> </div> <div>Anderson’s “if not when” thought is a calling card for the provider, with the goal of creating a culture of innovation and resourcing contained in the Vivo Innovation Center.</div> <div> </div> <div>Located at its Sioux Falls headquarters, the Good Sam innovation center hosts partners in innovation work as well as innovation training and collaborative workshops. </div> <div> </div> <div>Most of the innovation work will happen in the field at its nursing facilities, but the center is home for external partners and donors.</div></div> <div><h2 class="ms-rteElement-H2">A New Type Of Resident </h2> <div>Anderson’s role and those of many in the Good Sam innovation effort were created as part of a reorganization program in 2010, when the company decided to build the innovation center aligned with new organizational strategies to attract a new generation of seniors to its facilities. </div></div> <div><br>With the 10,000 or so baby boomers turning 65 on a daily basis this decade, it made sense to Good Sam to work at meeting the demands of this new type of nursing home or assisted living resident or rehabilitation-only consumer.</div> <div><br>“This coming generation [of seniors] has different expectations, so we are developing and have developed new rehab and skilled care options,” Anderson says.</div> <div><br>These different expectations include the desire to stay at home as long as possible, with custom-tailored care utilizing new technology for better care results. “For the long term care industry this has not been a thing we do,” Anderson notes.</div> <div> </div> <div>Kelly Soyland, Good Sam director of innovation and research, says there are five steps to the design process.</div> <div> </div> <div>The first may seem obvious, but is often overlooked or misunderstood, and that is to spend time with the customer, developing the deep empathy necessary to understand the challenges they face.</div> <div> </div> <div>“This is a deep dig, not just a survey. We have to ask, ‘What would they tell us they want done differently?’” Soyland says.</div> <div> </div> <div>The next steps are to identify the main problems and then create a solution. The final stages are to prototype and test the solution and know that even a failure will create an opportunity to learn. </div> <div> </div> <div>“Innovation has to meet with feasibility to offer us a chance to create a new service line,” he says. </div> <div><h2 class="ms-rteElement-H2">Asking The ‘Why’ Questions</h2> <div>As an example, Soyland highlights the work of the Good Sam innovation team with electronic company </div></div> <div>Royal Philip Electronics of the Netherlands on the topic of adherence to physician orders. </div> <div><br>The collaboration wants to learn why adherence was not higher and studied 100 Good Sam independent living residents at three Arizona campuses as part of the program.</div> <div> </div> <div>What they learned is that different people have different reasons for not acting on a physician’s order, which in the case of the study was to take medicine for high cholesterol. </div> <div><br>Soyland said one group of the cohort goes into a denial phase, while another refuses to take the medicine because they don’t think it will help them. Others are afraid of adverse effects of the medication, saying the risk of side effects outweighs the value of listening to a doctor’s orders.</div> <div> </div> <div>The bottom line is to know what the resident-clients and their families are thinking.</div> <div> </div> <div>“I think in all cases of innovation, it starts with the human need,” says Soyland. “Technology may be a part of the solution but rarely all of the solution,” he points out.</div> <div><span id="__publishingReusableFragment"></span> </div> <div><h2 class="ms-rteElement-H2">Making Labor Count</h2> <div>In its purest form, a type of innovation that works in any type of business is when a product or service comes along to fill a void that has never been previously addressed. This is what the Cleveland, Ohio-based OnShift software provider has accomplished with its tools to help long term care facilities manage labor costs and operations. </div> <div> </div> <div>OnShift Chief Executive Officer (CEO) Mark Woodka said the opportunity to fill a void was there; with labor costs a huge chunk of the cost of running a long term care facility, it was needed, especially with providers looking to save money in the face of Medicare and Medicaid funding cuts.</div> <div> </div> <div>“For skilled nursing facilities, 70 percent of costs are labor, and in assisted living facilities, 50 percent of costs are labor,” he says.</div> <div> </div> <div>OnShift’s software is built specifically for long term care providers, taking into account regulations and developments, like health care reform or reimbursement issues, and how staffing will be impacted.</div> <div> </div> <div>Providers no longer have to use the old way of looking to fill open shifts via laborious telephone calling, and they can now manage how many hours each employee accumulates each day and week to avoid costly overtime pay. </div> <div> </div> <div>Woodka says his software automatically communicates to employees on open shifts and any other messaging needs via text, plain text to speech, or e-mail. Staff respond to the message with a yes or no to being able to fill a shift, and then the director of nursing (in the case of nursing staff) decides which option makes the most sense. </div> <div> </div></div> <div>“The system avoids overtime, gives the ability to stick to a labor budget, and gives [administrators] a tool to manage labor costs and deal with census fluctuations,” he says. Required staffing levels are no longer difficult to measure, with upticks or downticks in resident numbers tied to the software’s staffing management function.</div> <div><h2 class="ms-rteElement-H2">Cost Savings Possible </h2> <div>Woodka believes the old thinking in nursing care circles that technology is too hard to teach to staff and costs too much is not applicable these days. OnShift claims its software saves $25,000 to $60,000 a year for an average 100-bed facility in decreased overtime outlay and other efficiencies. Staff satisfaction also has improved at his client’s facilities, making right-size staffing easier and giving staff an equal chance of picking up shifts through the software’s communication capabilities.</div> <div> </div></div> <div>A provider who uses OnShift, Janet Harris, CEO of Holland Management, says the need was there for software like the one Woodka markets and shows how a relatively simple piece of technology can create an innovation to the day-to-day work in facilities.</div> <div> </div> <div>“There was no software that could handle the scheduling needs of long term care. We knew right away it would be a winner,” Harris says.</div> <div> </div> <div>Holland Management oversees a number of facilities and includes Housing and Urban Development housing, home health care, assisted living services, and senior health care campuses as well as a country club and lodge in Colorado. Its four continuing care retirement communities are in Ashtabula, Mount Vernon, Dover, and Bellaire, all in Ohio.</div> <div> </div> <div>The Holland organization supports 800 residents and 650 employees.</div> <div> </div> <div>Harris says she uses OnShift not only for nursing staff needs, but for administrative staffing as well, such as human resources and housekeeping.</div> <div> </div> <div>“It’s a way we communicate with employees through the messaging system.</div> <div> </div> <div>It is added value to us. We don’t make calls out to employees, and the employees love it because it really puts the scheduling issue back in their hands,” she says.</div> <div> </div> <div>Overall, Holland uses a number of platforms and software systems, including SharePoint and PointClickCare, to electronically link company operations in a closed-network, centralized “cloud” environment.</div> <div> </div> <div>“Putting the paper away and using electronic means has been a great advance for the company, covering major issues like the aforementioned labor costs to more mundane items like updating policy books.</div> <div> </div> <div>“Paper trails seemed to never keep up with the changes, but now it’s all online for staff, making it easier to train and initiate them,” Harris says.</div> <div><h2 class="ms-rteElement-H2">Reasons To Embrace Technology</h2> <div>When a person says technology and health care to experts in the sector, it is important to differentiate between the in-facility methods used to operate more efficiently and the wider issue of government policy to give providers incentive to modernize. </div> <div> </div></div> <div>Erik Johnson, senior vice president at Washington, D.C.-based consultancy Avalere Health, says there certainly is reason for long term care providers to get active in moving to EHRs and other technology, but the timing is challenging for many, to say the least.</div> <div><br><img width="412" height="464" class="ms-rteImage-2 ms-rtePosition-2" alt="HHS, EHRs" src="/Monthly-Issue/2012/PublishingImages/0312/0312-CoverStory1.gif" style="margin:5px;width:417px;" />“I don’t know that nursing facilities have a lot of direct incentive to invest right now with margins getting hammered,” Johnson says.</div> <div> </div> <div>He notes that the stimulus spending law famously did not include long term care in its high-tech health care funding allotments, but he says the new CMS programs for ACOs and bundled care offer an indirect incentive for long term care providers to get up to speed on data-keeping by moving to EHRs and other systems for tracking outcomes and the care of residents.</div> <div> </div> <div>As coordinated care comes to fruition through ACOs or ACO-like structures, it will be highly important that the total continuum of care can communicate a patient or resident’s records among one another.</div> <div> </div> <div>“Acute care will be looking to the post-acute care world for the best partners available,” Johnson says.</div> <div> </div> <div>Investing in EHRs and other technology has been hampered in the past not only because of cost, but also of concerns that long term care workers would not use the new tools or would move out of the profession too quickly to benefit from the training, he says.</div> <div> </div> <div>There is also the impression that many skilled nursing residents don’t experience as many interventions or changes in health status as in acute care hospitals.</div> <div> </div> <div>But Johnson expects change will come about, noting the experiences being registered with the Kindred collaboration with the Cleveland Clinic on coordination of care as an example.</div> <div> </div> <div>Doctors also will play a role in bringing new technology to nursing facilities.</div> <div> </div> <div>“There is sort of a generational split happening with doctors,” Johnson says, noting that many young doctors have trained in the Veterans Affairs hospital system where digital records are prevalent. <br></div> <div>When they move on from their training days to other system settings, they expect and want to see the continued use of electronic means for better care, he says.</div> <div> </div> <a href="/Monthly-Issue/2012/Pages/0312/LTC-Groups-Tackle-HIT.aspx" target="_blank"><div><strong>LTC Groups Tackle HIT</strong></div> <div><span id="__publishingReusableFragment"></span> </div></a><div><h2 class="ms-rteElement-H2">Realizing The Benefits</h2> <div>Gary Kelso, president of Mission Health Services, based in Huntsville, Utah, puts a lot of faith in the computer technology his nonprofit utilizes on a daily basis. </div></div> <div><img class="ms-rteImage-2 ms-rtePosition-1" alt="Gary Kelso, Mission Health Services, long term care, facility" src="/Monthly-Issue/2012/PublishingImages/0312/GaryKelso.jpg" style="margin:10px;" /><br>EHRs have resulted in better collaboration and comprehensive care for residents, he says, and helped to further modernization efforts as part of the Eden Alternative culture change movement the company wanted to pursue.</div> <div> </div> <div>“Once we got more people without having paper in their hands, we started to realize the benefits,” Kelso says. It is a challenge to change people’s mindsets, with many staff and stakeholders not trusting technology and not wanting to give up the old ways.</div> <div><br>“But, I think I saw where we needed to go. Even though a lot of people around me had their heads in the sand, not believing we had to go [electronic]. I am a bit of a tech geek, and I saw when our workforce dwindled we needed to be able to do more with less manpower,” Kelso says.</div> <div><br>He also sees what the experts say is the coming revolution in care, the coordinated payment and delivery model, as an opportunity.</div> <div><br>“Small organizations will be able to compete with large organizations because of technology,” Kelso says. </div> <div><br>As an example of the good all this new data can do, he mentions a simple report Mission created last year to show the rate of hospital readmissions from its facilities. </div> <div><br>The majority of long term care providers see a 15 percent to 24 percent range for readmissions, Kelso says, and he knows that possessing low readmissions will be vital for payment adequacy. So when the report came in, Mission’s very low 1.53 percent readmission rate was very good news indeed.</div> <div><h2 class="ms-rteElement-H2">High-Tech, Low-Tech</h2> <div>In Kelso’s mind “high-tech meets low-tech” and provides for “high touch.” What this means is that the new tools being used to eliminate paper records and other time-consuming methods of doing things frees up caregiver time to spend on patient care.</div> <div> </div> <div>Simply put, “High-tech creates more time for staff to be with residents,” he says.</div> <div> </div> <div>Nurses are no longer tied to a nursing station, which offered a central gathering point but also offered less face time with residents. Now, a nurse toting around an iPad or other type of computer can interact with residents while charting, he says. All told, Kelso knows the times are changing in the health care sector, and for many providers like Mission and Good Samaritan and scores of others, that change is already taking place, one innovation at a time. </div></div>The goals of bringing high-tech and innovation to the nursing facility level are to make life better for residents, make work less arduous for staff, and provide facilities easier methods to report outcomes to state and federal governments that are radically shifting reimbursement payment by making accountability king.2012-03-01T05:00:00Z<img alt="long term care, LTC, technology, post-acute care" src="/Monthly-Issue/2012/PublishingImages/0312/0312-CoverStory5.jpg" style="BORDER:0px solid;" />TechnologyCover Story3
HHS Calls Medicare, Medicaid Fraud A Top Challengehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/Fraud-A-Top-Challenge.aspxHHS Calls Medicare, Medicaid Fraud A Top ChallengeThe Department of Health and Human Services (HHS) said solving Medicare and Medicaid fraud is a top management challenge, and despite recent success in cracking down on such fraud, there are many roadblocks to overcome in further reducing criminal activity in the programs.<br><br>HHS said a main challenge in fighting fraud is effectively using the Centers for Medicare & Medicaid Services’ (CMS’) provider enrollment and payment suspension authorities against those providers and suppliers that have exploited weaknesses to commit fraud rather than provide legitimate patient care. <br><br>Other challenges are managing HHS’ expanding use of data analysis and excluding individuals and entities from federal health care programs to protect beneficiaries.<br><br>The department said the Affordable Care Act (ACA) addressed many program vulnerabilities by authorizing rigorous enrollment and screening processes, enrollment moratoria, and payment suspension. <br><br>A year ago February, CMS published a final rule implementing the ACA provisions concerning screening of providers and suppliers based on fraud risk. <br><br>“Enhanced data analysis is made possible by the impressive enforcement results of the nine Medicare Fraud Strike Forces, which are part of the Health Care Fraud Prevention and Enforcement Action Team,” HHS said. <br><br>“The strike forces are interagency teams of prosecutors and federal and local law enforcement that focus enforcement resources on geographic areas at high risk for fraud.”<br><br>In June 2011, CMS implemented the Fraud Prevention System to risk-score Medicare Fee-for-Service claims prepayment and awarded a contract to IBM in July 2011 to develop and test new predictive <br>models.<br><br>HHS said although the CMS final rule on enrollment screening takes important steps toward preventing fraud, there are additional opportunities for CMS to strengthen the enrollment system, including adopting a more flexible screening approach, tailoring screening measures to fraud risks, and classifying re-enrolling home health providers as “high risk.” HHS said a main challenge in fighting fraud is effectively using the Centers for Medicare & Medicaid Services’ (CMS’) provider enrollment and payment suspension authorities against those providers and suppliers that have exploited weaknesses to commit fraud rather than provide legitimate patient care. 2012-03-01T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/architecture_1.jpg" style="BORDER:0px solid;" />PolicyColumn3
Knee Replacement Surgeries Soar For People Over 50, European Study Concurshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/Knee-Replacement-Surgeries-Soar.aspxKnee Replacement Surgeries Soar For People Over 50, European Study Concurs<img src="/Monthly-Issue/2012/PublishingImages/Misc/knee_therapy19306649.jpg" alt="knee replacement, seniors, osteoarthritis" class="ms-rteImage-2 ms-rtePosition-1" style="margin:10px 15px;width:303px;height:230px;" /><br>Finnish researchers found that incidences of knee replacement surgery rose rapidly over a 27-year period among 30- to 59-year-olds in that country, with the greatest increase occurring in patients aged 50 to 59 years. <br><br>According to the study published in <em>Arthritis & Rheumatism,</em> a peer-reviewed journal of the American College of Rheumatology, incidences were higher in women throughout the study period.<br><br>This type of research echoes a trend in the United States for more knee replacement surgeries, which has resulted in many long term care providers bolstering rehab services for “younger” short-term residents.<br><br>Osteoarthritis (OA), the cause of many knee replacement surgeries, is a highly disabling joint disease that, according to a 2002 report by the World Health Organization, is the fourth leading cause of years lived with a disability worldwide. In the United States, experts say more than 10 million adults are affected by OA, and for those with advanced disease, arthroplasty (knee replacement) may be the only treatment option to relieve the disabling pain and stiffness and improve quality of life.<br><br>The Agency for Healthcare Research and Quality said more than 600,000 total knee replacements were performed in the United States in 2009, and a previous study estimates that number could grow by 673 percent, to 3.48 million procedures, by the year 2030.<br><br>To advance understanding of the issue in Finland, researchers obtained data collected by the Finnish Arthroplasty Registry of all unicondylar (partial) and total knee replacements performed between 1980 and 2006. The team analyzed the effects of gender, age group, and hospital volume on incidence rates.<br><br>Findings indicate a 130-fold increase in incidence of total knee arthroplasty among those between the ages of 30 and 59 years during the study period. The incidence increased from 0.5 to 65 operations per 100,000 individuals, with the most rapid increase occurring from 2001 to 2006 (18 to 65 operations per 100,000). Increase in incidence of partial knee replacements was also observed, from 0.2 to 10 operations <br>per 100,000 inhabitants.<br><br>In the last 10 years of the study the incidence of total knee replacements was 1.6- to 2.4-fold higher in women than in men. Incidences of total and partial knee replacements were also higher in the oldest age group (50 to 59 years of age).Osteoarthritis (OA), the cause of many knee replacement surgeries, is a highly disabling joint disease that, according to a 2002 report by the World Health Organization, is the fourth leading cause of years lived with a disability worldwide. In the United States, experts say more than 10 million adults are affected by OA, and for those with advanced disease, arthroplasty (knee replacement) may be the only treatment option to relieve the disabling pain and stiffness and improve quality of life.2012-03-01T05:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/Misc/knee_therapy_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn3
LTC Groups Tackle HIThttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0312/LTC-Groups-Tackle-HIT.aspxLTC Groups Tackle HIT​ <div><img class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0312/0312-CoverStory5.jpg" alt="" style="margin:5px 15px;width:264px;height:264px;" />According to a road map produced by the LTPAC HIT Collaborative for health information technology (HIT) in long term and post-acute care (LTPAC), there is a growing recognition of LTPAC as an integral part of the overall health care spectrum.</div> <div> </div> <div>LTPAC providers are starting to participate in many health information exchange (HIE) initiatives, and there are significant calls being made to expand HIT meaningful-use incentives to LTPAC, the group said. In addition, health care reform includes consideration of the needs for person-centered funding for long-term services and supports.</div> <div> </div> <div>This expanded LTPAC vision encompasses a broad range of providers: home- and community-based services, nursing homes, long term acute care hospitals, rehabilitation and post-acute care facilities, PACE programs, hospice, chronic disease and co-morbidity management, medication therapy management and senior pharmacists, wellness providers, and others, the road map says.</div> <div> </div> <div>Of course, the LTPAC sector’s increased importance is being fueled by the aging population, along with a growing preference for personal choice and control in long term care decision making, the collaborative says. The emergence of technologies like remote monitoring and telehealth, along with electronic health records (EHRs), is also feeding a consumerism not seen in LTPAC previously.</div> <div><h2 class="ms-rteElement-H2">Group Recommendations</h2> <div>For the near term, the priorities and recommendations of the LTPAC HIT Collaborative are the following:</div> <ul><li>Leverage existing programs and policies by advocating for the inclusion of LTPAC in national and state HIT efforts designed to expand the adoption, use, and exchange of HIT for everyone.</li> <li>Adopt and use health IT and EHRs.</li> <li>Certify LTPAC vendor solutions by establishing and extending EHR certification criteria to LTPAC providers to adopt EHR adoption, coordinate care among health care settings to increase quality of care, and prepare for possible provider incentives.</li> <li>Foster the strongest inclusion and participation of LTPAC providers and vendors in emerging state HIEs and the national health information network.</li> <li>Promote care coordination and continuity of care through the use of HIT during transition-of-care periods and for electronic prescribing.</li> <li>Empower stakeholders, be they consumers, patients, or caregivers, to expect person-centered and person-directed outcomes as they participate in health care systems, processes, and activities.</li> <li>Move HIT in LTPAC from the phase of pilot testing and demonstrations of value to becoming a sustain-able part of operations that continuously result in improved quality care, increased efficiencies, and cost effectiveness.</li> <li>Define and advance an EHR research agenda that includes a focus on LTPAC and contains identified priorities.</li></ul></div> <div><h2 class="ms-rteElement-H2">A Federal Role</h2> <div>The American Health Care Association/National Center for Assisted Living (AHCA/NCAL), a member of the LTPAC Collaboration, said in a position paper that it is only when all health care providers adopt HIT that the true benefits of EHRs will be seen. These benefits include reduced medical errors and savings derived from more seamless care transitions.</div> <div> </div> <div>AHCA/NCAL is advocating that Congress provide HIT funding to the LTPAC setting comparable to the support that acute and ambulatory care settings receive. </div> <div> </div> <div>“Without HIT adoption among all providers, the federal government cannot expect to realize a robust return on its investment in HIT, including reduced administrative costs for claims processing and reimbursement; improved health care quality, efficiency, and care coordination; or enhanced patient safety and advancements in managing chronic conditions,” AHCA/NCAL said. </div> <div> </div> <div>More information on the collaborative is at <a href="http://www.ltpachealthit.org/">www.ltpachealthit.org/</a>.</div></div>According to a road map produced by the LTPAC HIT Collaborative for health information technology (HIT) in long term and post-acute care (LTPAC), there is a growing recognition of LTPAC as an integral part of the overall health care spectrum.2012-03-01T05:00:00ZColumn3

April


 

 

Assisted Living Spaces: Fostering Social Engagementhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/Assisted Living Spaces Fostering Social Engagement.aspxAssisted Living Spaces: Fostering Social Engagement<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div><img class="ms-rteImage-2 ms-rtePosition-2" alt="Dining arrangements can be altered to invite varied table mates." src="/Monthly-Issue/2012/PublishingImages/0412/0412Design1.jpg" style="margin:5px 15px;width:399px;height:282px;" />This senior generation is not coasting to the end. They are still on the journey, seeking new experiences and an expanded awareness. At this stage of life, today’s seniors have more time to indulge in areas of interest that they may have had to set aside in favor of work and family obligations. </div> <div> </div> <div>Notwithstanding age in years, the senior today has a more youthful self-identity and aspires to a more engaged and active lifestyle. </div> <div> </div> <div>Compared with the tastes of the emerging baby boomer population versus their predecessors, it is clear the design assumptions that were employed in the 1990s no longer work. In the ’90s, designers and residents favored traditional style, dark wood, and “vanilla” colors and textures. </div> <div> </div> <div>These created exterior and interior impressions that look old, sedentary, and tired. </div> <div> </div> <div>In contrast, baby boomers favor an environment that is lively and energetic. It needn’t be edgy, but it must be bright, with a measured degree of lightheartedness. </div> <div> </div> <div>There is no single design aesthetic employed; instead, it should be an activating expression appropriate to the local community’s local design vernacular and population. When strong regional or local community identities exist, the environment should reflect these.</div> <h2 class="ms-rteElement-H2">Landscaping Important To Feelings Of Contentment</h2> <div>A vibrant natural world brings energy. Rooms with great views, whether of nourished gardens or expansive vistas, engage the resident with the living world. Landscape, indoor and out, brings a healthy and enriching spirit to the community. Natural building materials and finishes offer a harmonious interface between space and place, advancing a fresh and integrated feel to the environment.</div> <div><br>Such spaces bring brightness and pleasure to the individual, which is reflected in the quality of spirit they share while in spaces that elevate their mood. Remember, a well-cared-for landscape is a very powerful communicator of overall “caring.” </div> <div><br>Plants don’t die: With proper care, they flourish. When residents and their families see well-tended grounds, they receive the message that staff care for residents as well.</div> <div><br>Furnishing comfort determines the length of stay, and the posture in it determines the level of relaxation versus engagement. The ergonomics of the furniture need not only respect the mobility limitations that may exist but should also strive to position the user to lean into the activity of the common area and not withdraw by virtue of a sedentary posture. </div> <div><br>Over-soft, reclining positions will advance fatigue and result in a drowsy manner, if not a tendency to sleep sitting. The more upright the seat (without sacrificing comfort), the more engaged and prolonged the interaction between individuals. Color and materials also communicate quality and cleanliness. Dusty and darker tones often create an impression that materials and finishes are soiled. Lighter, softer tones offer a more youthful feel even when applied to traditional interior décors. </div> <h2 class="ms-rteElement-H2">Lighting Choices Critical</h2> <div>Lighting is often seen as a utility and not as a theatrical tool. However, with creative applications of lighting, the character of rooms can be made energetic or relaxing, comfortable for large groups or comfortable for just two, socially engaging or transient. </div> <div><br>Lower levels of illumination are often used in large rooms to encourage small independent zones where a few might visit. The brighter the overall illumination, the more it is appropriate for a larger assembly of people who are interacting.</div> <div><br>Often, lighting is measured on brightness and not on clarity. Lights that are too bright or lamps that are exposed can cause glare. The glare produces early eye fatigue and limits the ability to see beyond the intrusive illumination. Indirect lighting, more softly and uniformly cast, produces a better level of visual acuity and invites visual connection with others. </div> <div><br>The avoidance of eye fatigue also invites a longer duration in areas where social interaction is encouraged.</div> <div><br>Composing the décor with the ingredients of indoor planting, proper furniture, brightened colors, and creative lighting will result in residents feeling more lively and interactive and acting accordingly.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Activate Outdoor Living</h2> <div>If viewing the outdoors inspires the resident with beauty of the living world, then being outdoors ensures that outcome. Much depends on the area’s climate, but even in the northern and southern reaches of the United States, there are times of the year that are temperate, providing a welcome opportunity to get outside the four walls of home. </div> <div><img class="ms-rteImage-2 ms-rtePosition-1" alt="A gazebo lends an additional neighborly feel to the property." src="/Monthly-Issue/2012/PublishingImages/0412/0412Design3.jpg" style="margin:15px 25px;" /><br>Yet, all too often, outdoor living spaces are designed for passive viewing, not active experience. This does little to further the goals of social interaction. Consider the following reflections.</div> <div><ul><li>The most successful outdoor living areas are freely accessible. That begins with transparency. The more the indoor environment presents the outdoors as an extension of the same domain, the more the outside invites engagement. The more the outside is furnished and shaded to feel like a living space, the more it becomes an enhanced and expanded community living area. The more it is appointed with groupings and common features such as fire pits or TV, the more people will enjoy the space for extended periods of time.</li></ul></div> <div><ul><li>Even in urban environments where open space is often at a premium, outdoor space in the form of a rooftop terrace can become extremely popular with residents. </li></ul></div> <div><ul><li>An outdoor experience can also be fostered by selecting certain indoor areas to be all-season rooms that advance greater engagement with the outdoors. Sunrooms, solariums, and conservatories are but a few examples of indoor spaces that allow for outdoor experience even in inclement conditions. </li></ul></div> <div>Artificial daylighting, as well, will project a sunny day even with gray and overcast conditions.</div> <div><ul><li>Gardening is the most popular outdoor activity in the country, regardless of age. Every senior living community should offer opportunities for residents to engage in the creative, spiritually fulfilling process of nurturing plants. </li></ul></div> <div>Raised planters provide easy access to gardening for people who cannot get down and up readily. A community garden can even provide food for the common kitchen, flowers for the table, and, most importantly, a common interest to share with others. </div> <div><ul><li>A pool with a “roll-in” edge, especially if the pool is partially shaded with a canopy, invites use by people with a wide range of physical abilities and use of the amenity for greater periods of time throughout the day. The longer they enjoy the feature, the more social interaction results.</li></ul></div> <div><ul><li>A pet park where residents can walk and play with their dogs provides regular physical activity and a chance to get to meet other animal lovers. </li></ul></div> <div><ul><li>Multipurpose outdoor pavilions that can be used for cooking and dining expand the dining venues and change the character and spirit of the occasion.</li></ul></div> <div><ul><li>Indoor areas suitable for crafts, hobbies, and learning venues bring together individuals who share a common interest. A common interest or purpose is the core of a lasting acquaintance.</li></ul></div> <div><ul><li>Finally, consider landscaping. Avoid just considering the planter and shrub border. An investment in trees creates communities that age with dignity and ever-increasing value. As trees mature, they provide seasonal interest and form a canopy that offers shelter and charm. Well-shaded outdoor spaces become destinations—rooms without walls—which encourage prolonged interaction and sociable encounters. <br></li></ul></div> <h2 class="ms-rteElement-H2"><img class="ms-rteImage-2 ms-rtePosition-2" alt="Small common areas provide communal living spaces where residents can gather." src="/Monthly-Issue/2012/PublishingImages/0412/0412Design2.jpg" style="margin:5px 10px;width:395px;height:277px;" />Integrate Safety, Security</h2> <div>For social interaction to flow freely, the resident must feel safe and secure. They generally are, when housed in a proper environment, but that reality may still not be perceived. <br></div> <div><br>The challenge in any planned community is to create an environment that feels protected without expressing it with hardened expressions like bars, gates, and obtrusive surveillance devices—an environment that suggests a home rather than a prison.</div> <div><br>A community planning theory that grew out of New Urbanism (see <a href="http://www.newurbanism.org/" target="_blank">www.newurbanism.org</a>) integrates safety and security measures that both function effectively and minimize the implication that a threat may prevail. </div> <div><br>In part, it focuses on visibility, avoidance of blind corners, translucent rather than solid outdoor enclosures, and lighting that avoids bright sources or “hot spots” in favor of uniform and often indirect lighting sources.</div> <div>At the front desk, use of a lower counter that provides for a fuller view of the attendant—better yet, a segmented desk that allows that attendant to move around the desk and greet a resident or visitor—projects a strong, friendly first impression.</div> <div><br>Corridors can be intimidating environments. The addition of windows and natural lighting, the appointment of each unit door as if it were the “front stoop” of a private dwelling, and the occasional use of art and furniture that convey an impression of permanence rather than transience are features that bring a safe, secure feeling to the community space.</div> <h2 class="ms-rteElement-H2">Return On Investment</h2> <div>For optimal benefit to residents and preferred return on investment to providers, designers must prioritize their focus on common areas that draw residents together in ways that cultivate connectivity. <br><br></div> <div>Even within existing facilities, many of the principles of social engagement can be advanced with attention to detail and awareness of the objective.</div> <div><br>As residents become active, engaged, and communicative, they invest in the place they call home. That investment generates durability in both their efforts to delay decline and their respective occupancy within the facility.</div> <div><br>Thoughtful planning and design and the encouraged use of amenities not only attract residents and their families to a senior-living community, they enable providers to weave a social fabric that activates and engages residents in their community life. </div> <div> </div> <div><em><img class="ms-rteImage-2 ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0412/0412Design_Koch.jpg" alt="" style="margin:5px;width:127px;height:171px;" /><br><br>Robert Koch, AIA, is a principal of Fugleberg Koch, an architecture, planning, urban design, and development consulting firm located in Winter Park, Fla. The firm’s residential portfolio includes mixed-use, urban infill, mid-rise, high-rise, direct-entry, senior living, workforce housing, and affordable-housing projects. Koch can be contacted at (800) 393-0595 or online at <a target="_blank">www.fugleberg koch.com/contact.php.</a></em></div> This senior generation is not coasting to the end. They are still on the journey, seeking new experiences and an expanded awareness. At this stage of life, today’s seniors have more time to indulge in areas of interest that they may have had to set aside in favor of work and family obligations. 2012-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0412/0412Design_thumb.jpg" style="BORDER:0px solid;" />Management;DesignColumn4
A Look At MDS 3.0 Psychosocial Changeshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/A-Look-At-MDS-3-0-Psychosocial-Changes.aspxA Look At MDS 3.0 Psychosocial Changes<div> </div> <div>In October 2010, the minimum data set (MDS) 3.0 changed the way in which nursing home residents’ needs were assessed. It created new psychosocial requirements, including direct resident interviews for cognition, mood, customary routine and preferences, pain, and return to the community. </div> <div> </div> <div>It also requires nursing home interdisciplinary staff to use standardized tools, including the Brief Interview for Mental Status (BIMS) and the Confusion Assessment Method (CAM) in Section C, the Patient Health Questionnaire (PHQ) 9 in Section D, a new Preference Assessment Tool (PAT) in Section F, and a Numeric Rating Scale (0-10) or a Verbal Descriptor Scale pain assessment tool in Section H. </div> <div> </div> <div>In Section Q, residents are asked about their desire to return to the community. If the answer is yes, there are procedures to follow with local contact agencies and support through Money Follows the Person or local contact agencies.</div> <div> </div> <div>This article is a follow-up to a <em>Provider</em> October 2010 focus group article that found MDS 3.0 psychosocial training was needed because social workers and interdisciplinary staff were not prepared for the new requirements. </div> <div> </div> <div>There were concerns about inconsistent levels of social work staff, qualifications, and caseloads. Given these results, a second set of focus groups was conducted in 2011 with social workers and nurses to learn how the implementation was going from the perspective of staff in the field. </div> <div> </div> <div>This article presents the results from these group sessions, which aimed to understand the impact of MDS 3.0 implementation on psychosocial assessment and care planning in nursing homes. </div> <h2 class="ms-rteElement-H2">Focus Group Findings</h2> <div>The second set of focus groups was conducted in two phases, each held with nursing home nurses and with both licensed and unlicensed social workers/social work designees. Twenty-four participants represented a range of for-profit and not-for-profit facilities, small and large facilities, and rural and urban areas. <br><br>During the teleconference, they responded to questions sent in advance regarding the positive and negative impacts of MDS 3.0 on both residents and staff, as well as on the care area assessments (CAAs). </div> <div><img class="ms-rtePosition-2 ms-rteImage-2" src="/Monthly-Issue/2012/PublishingImages/0412/0412Caregiving.gif" alt="" style="margin:5px 15px;width:426px;height:604px;" /><br>The results of the focus groups revealed consistency in responses to questions and concerns identified from nurses and social workers. MDS 3.0 positive findings included the insightful nature of resident interviews, which often resulted in new information for staff, and the identification of suicidal residents with the PHQ 9. </div> <div><br>Importantly, interdisciplinary roles were found to be better defined as different team members are now required to fill out different sections of the MDS 3.0. </div> <div><br>A stronger role for social work has now been created in terms of acting as interdisciplinary facilitator and leader. The most common MDS 3.0 role configuration involved social workers completing cognition, mood, and return-to-community items; nurses completing the pain and delirium items; and the activities therapist completing preferences.</div> <h2 class="ms-rteElement-H2">Redundancy, Time Management </h2> <div>The focus group participants identified the requirement to repeat multiple clinical interviews for the five-, 14-, 30-, 60-, and 90-day Medicare assessments; discharge assessments; and OBRA (Omibus Budget Reconciliation Act) assessments as their most significant concerns about MDS version 3.0. </div> <div><br>The redundant interviews were reported to be frustrating for residents and resulted in reduced quality time staff can spend with residents. The negative impact on overall quality of care as the result of more time being spent on documentation, repeated interviews, and CAAs was noted to be most concerning to both disciplines. </div> <div><br>The participants also noted the importance of interdisciplinary work, while also acknowledging a lack of formal training in how to function as a team. Those who believed their teams functioned well prior to MDS 3.0 expressed less role conflict and ambiguity. </div> <div><br>Several participants emphasized that the greater demands of the new system placed more stress on the teams and therefore more conflict.</div> <div><br>Ideally, staff members need to be trained to work as a unit, where members feel comfortable expressing themselves and decision making is shared. There needs to be role clarity where staff understand what is expected of them by the organization as it relates to MDS 3.0 completion, care plan development, and implementation. </div> <div><br>This is a problematic area in facilities, where staff have no training in teamwork and the training and credentials of staff vary.</div> <div><br>Interdisciplinary teamwork with appropriate understanding of each other’s roles is the gold standard; teams that do not have this seem to struggle more with the MDS 3.0. </div> <div><br>Both social workers and nurses were concerned because there was limited CAA training, especially around psychosocial issues.</div> <h2 class="ms-rteElement-H2">CAA Processes ‘Hard To Follow’</h2> <div>All focus group staff reported using CAAs developed by the Centers for Medicare & Medicaid Services (CMS), and none were using their own evidence method, as described in the “MDS 3.0 Manual” (Appendix C–84). Yet, they had major concerns: CAAs were described as “not easy to follow” and not providing step-by-step evidence-based approaches that would be suitable for staff with varying educational backgrounds, such as those from a social service designee with a high school education versus masters-trained social workers or nurses. </div> <div><br>In addition, multiple CAAs are triggered and keep staff so busy with documentation that there is less time for continued assessment, interventions, and interdisciplinary coordination of care. Documentation requirements must be understood in terms of the number of CAAs and total caseload. </div> <div><br>Finally, completion of Section Q creates problems because of inconsistencies across states regarding procedures, expectations, referral response times, and lack of clarity as to how this section should be completed.</div> <div><br>Engaging residents in the interview process is a positive step toward a person-centered approach, the focus groups agreed. If the MDS 3.0 is to be an effective tool, there need to be consistent standards of training done for an interdisciplinary group of qualified practitioners, participants concluded.</div> <div><br>This study confirmed the 2010 focus group findings that “clinical training beyond MDS 3.0 coding is required and should be offered by national nursing facility organizations and their affiliates.”</div> <div>The types of training needed include: team cohesion, using and interpreting scores on standardized scales, and testing issues.</div> <div><br>In addition, staff need more guidance on developing procedures for addressing differences in self-reporting versus clinical observations and guidelines for developing treatment responses, the focus group observed. </div> <div>Residents’ voices are critical to person-centered care; however, the frequency of the interviews needs to be addressed as it creates frustration for elders and staff. </div> <div><br>These focus groups provided critical feedback for improving both processes and practice.</div> <div>Go to: www.providermagazine.com for a case study example of how the MDS 3.0 has impacted a resident.</div> <div><em> </em></div> <em></em><div><em>Robert P. Connolly, LCSW-C, a consultant and retired from the Centers for Medicare & Medicaid Services, is based in Ellicott City, Md., Deirdre Downes, LCSW, is director of social work for Jewish Home Lifecare, New York, N.Y., and Jake Reuter, LSW, is director of the North Dakota Money Follows the Person program, Bismarck, N.D.</em></div>In October 2010, the minimum data set (MDS) 3.0 changed the way in which nursing home residents’ needs were assessed. It created new psychosocial requirements, including direct resident interviews for cognition, mood, customary routine and preferences, pain, and return to the community. 2012-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0412/0412Caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn4
Meehan Says He Understands Challenges For LTC Sectorhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/Meehan-Says-He-Understands-Challenges-For-LTC-Sector.aspxMeehan Says He Understands Challenges For LTC Sector<img src="/Monthly-Issue/2012/PublishingImages/0412/PatrickMeehan.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:15px 10px;" /><br>First-termer Rep. Patrick Meehan (R-Pa.) wants changes to the Medicare and Medicaid programs to give nursing home providers more certainty in their expectations for reimbursement levels, noting he gets the challenges facing the long term and post-acute care sectors at a time of restrained federal and state spending. <br><br>Meehan, in an interview with Provider, says he keeps long term care as a priority issue not only because of its importance to the nation, but also because his 7th congressional district outside of Philadelphia is home to many seniors. In fact, he says, Pennsylvania ranks third in the country for population of seniors and fourth for the number of residents 85 and older.<br><br>“Ensuring the best care for our seniors is a top priority of mine,” Meehan says.<br><br>To give providers some assistance in their business planning, he wants to start solving the quandary of how to maintain the Medicare and Medicaid programs by ending the way reimbursement is calculated.<br><br>“Medicare and Medicaid providers have been facing high uncertainty in providing care, often not knowing what level of reimbursement they may receive. I believe one way to better manage these programs is to provide certainty. We see the need for certainty with the need to permanently repeal the Sustainable Growth Rate formula that is used to calculate physician reimbursements for Medicare. Congress has no intention of allowing a 30 percent or 40 percent cut in reimbursement for services, and we should not continue to kick the can down the road with short-term patches, pretending that this may actually be the case,” Meehan says.<br><br>Moving forward, he thinks it is important to recognize that nursing facilities, hospitals, and other providers are sharing a significant burden in the effort to curb deficit spending. Meehan wants to pursue savings and reforms, but not at the cost of care.<br><br>“Congress needs to better understand the shoestring on which many hospitals and nursing facilities operate to ensure we are not putting seniors’ health care and quality of life in jeopardy. This is an issue I’ve been working closely on since coming to Congress last year, and I will remain committed to it,” Meehan says. <br><br>For Medicaid, Meehan echoes what many Republicans in Congress want, which is to give the states a larger role in administering and providing access for their beneficiaries. “I believe each state should have the ability to reform their Medicaid program to better serve their patient population,” he says.<br><br>Also in line with most from his party, Meehan does not agree with the part of President Obama’s health care plan that created the Independent Payment Advisory Board (IPAB), which will be charged with finding savings in Medicaid. He said it is actually a bipartisan issue concerning lawmakers from both parties on how much control the IPAB will have.<br><br>“Composed of unaccountable bureaucrats, it will make arbitrary decisions about what is covered and not based on the bottom line and not what contributes to quality of care for seniors, either in hospitals, doctors’ offices, or nursing facilities,” Meehan says.<br><br>Meehan said he supported HR 674, which repealed the 3 percent withholding requirement that would have allowed Medicare to withhold 3 percent of all payments to federal government contractors. <br><br>“While 3 percent may not sound like a significant amount, without repeal, this delayed reimbursement could have jeopardized vital services for seniors and people with disabilities at long term care facilities,” he says.<br><br>His broader view of the health care system reflects his feeling Obama’s health care law missed a chance to help lower skyrocketing costs, noting the reforms will actually boost costs by $311 billion over the next decade. “Instead, we need to take costs out of the system. One way to do that is through small business health plans, which will help bring down health care costs. Many individual small businesses want to provide health benefits to their employees, but find them too expensive to purchase on their own,” Meehan says.<br><br>“By passing a law to allow small business health plans to form, many individual businesses can join together and pool their risk, allowing them to get the same good deals that big corporations get.” <br><br>His duties on Capitol Hill include membership on the House Oversight and Government Reform, Transportation and Infrastructure, and Homeland Security committees. He is also chairman of the Homeland Security Subcommittee on Counterterrorism and Intelligence. <br><br>“In this role, I’ve had the opportunity to examine the changing nature of the threat to the homeland. On the Oversight Committee, I work on a wide range of issues including how we can make our government leaner, more efficient, and more accountable,” Meehan says.<br><br>For the near term, he is focused not only on health care, but on job creation and economic growth and the intersection of these two issues. “With one in six jobs in southeastern Pennsylvania related to the life sciences industry and a high population of seniors, I am making it a priority to work with my colleagues to ensure doctors do not continue to face devastating cuts over and over again.” First-termer Rep. Patrick Meehan (R-Pa.) wants changes to the Medicare and Medicaid programs to give nursing home providers more certainty in their expectations for reimbursement levels, noting he gets the challenges facing the long term and post-acute care sectors at a time of restrained federal and state spending. 2012-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0412/PatrickMeehan.jpg" style="BORDER:0px solid;" />PolicyColumn4
High Court Upholds Pre-Dispute Arbitration Agreementshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/High-Court-Upholds-Pre-Dispute-Arbitration-Agreements.aspxHigh Court Upholds Pre-Dispute Arbitration AgreementsA Feb. 21 opinion from the U.S. Supreme Court unanimously upheld the validity and enforceability of pre-dispute arbitration agreements between nursing facilities and their residents.<br><br>The American Health Care Association (AHCA), which supports the use of voluntary pre-dispute arbitration agreements, applauded the decision in the case of Clarksburg Nursing & Rehabilitation Care v. Marchio.<br><br>“The Supreme Court of the U.S. has made clear that it is both legal and appropriate for nursing homes and patients to use pre-dispute arbitration agreements,” said Gov. Mark Parkinson, AHCA president and chief executive officer, in a statement.<br><br>“It is affirming to us that the Supreme Court understands and enforces arbitration agreements to provide more timely and less adversarial conclusions, thus allowing facility staff to focus their time and effort on what is really important—quality patient care,” he said.<br><br>AHCA and the West Virginia Health Care Association  have both been involved with the case, whose central issue is whether the Federal Arbitration Act (FAA) protects pre-dispute arbitration when there are claims of personal injury or wrongful death.<br><br>AHCA submitted an amicus brief to the West Virginia Supreme Court, which decided last June that Congress “did not intend for the FAA to protect these types of arbitration agreements from state interference,” making them unenforceable, AHCA said in a statement on the Supreme Court opinion.A Feb. 21 opinion from the U.S. Supreme Court unanimously upheld the validity and enforceability of pre-dispute arbitration agreements between nursing facilities and their residents.2012-04-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/legal_2.jpg" style="BORDER:0px solid;" />Policy;LegalColumn4
LTC Jobs Critical To Economic Recovery, Labor Report Showshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/LTC-Jobs-Critical.aspxLTC Jobs Critical To Economic Recovery, Labor Report ShowsLong term and post-acute care jobs will rank among the nation’s top employment groups in the coming decade, according to an American Health Care Association (AHCA) analysis.<br><br>The report from the Bureau of Labor Statistics (BLS) projects that the health care and social assistance sector will gain the most new jobs—5.6 million, or more than a quarter of the total 20.5 million jobs that are expected to be created between 2010 and 2020. <br><br>The top four groups predicted to grow the most in that time are all in the health care field, according to an analysis of BLS data by AHCA’s Research Department. Furthermore, the eight occupational categories identified by BLS as either the largest or fastest growing are at the core of providing long term and post-acute care services: registered nurses; personal care aides; home health aides; nurse assistants, orderlies, and attendants; physical and occupational therapy assistants and aides; and physical therapists.<br><br>The Labor Department report shows “our sector is growing in both projected numbers and importance,” said Gov. Mark Parkinson, president and chief executive officer of AHCA. Long term and post-acute care jobs will rank among the nation’s top employment groups in the coming decade, according to an American Health Care Association (AHCA) analysis.2012-04-01T04:00:00ZWorkforceColumn4
N.Y. Law A Slippery Slope For Nursing Home Liabilityhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/NY-Law-A-Slippery-Slope-Nursing-Home-Liability.aspxN.Y. Law A Slippery Slope For Nursing Home Liability<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div><img class="ms-rteImage-2 ms-rtePosition-2" alt="legal" src="/Monthly-Issue/2012/PublishingImages/0412/0412Legal.jpg" style="margin:5px 15px;width:237px;height:361px;" />In a move that could be a harbinger for similar legislative changes across the country, the bellwether state of New York recently amended portions of its Public Health Law (PHL) in a way that seems to invite more litigation against nursing home providers. </div> <div> </div> <div>The statute governs the rights of patients to bring private actions against residential health care facilities when allegedly injured as a result of being deprived of any right or benefit established by contract or by state or federal statute, code, rule, or regulation. </div> <div> </div> <div>Subdivision 1 of the statute was amended to define injury to include emotional and physical harm, financial loss, and death, while subdivision 4 was modified to ensure that the statutory remedies available are in addition to, among other things, the ability to bring tort causes of action against nursing home providers. </div> <div> </div> <div>In addition, the statute was amended so that a violation of the specific rights set forth in PHL section 2803-c(3) is not a prerequisite for a statutory claim. </div> <div> </div> <div>At a time when there is more interest in looking to alternative dispute resolution than lawsuits as a way of resolving disputes, these amendments unfortunately lead the way for more liability claims against nursing homes.</div> <h2 class="ms-rteElement-H2">Remedies Are Cumulative </h2> <div>PHL section 2801-d(1) provides that a “residential health care facility that deprives any patient of any right or benefit…shall be liable to said patient for injuries suffered as a result of said deprivation.” The statute provides that “[a] ‘right or benefit’…[is]…created or established for the well-being of the patient by the terms of any contract; by any state statute, code, rule, or regulation; or by any…federal statute, code, rule, or regulation.” </div> <div><br>The statute also allows for all remedies to be “in addition to and cumulative with any other remedies available to a patient” that may exist in the courts or in any other state agency. “Rights,” according to section 2803-c of the PHL, include, but are not limited to, the following: not to have one’s civil and religious liberties infringed, to manage one’s own financial affairs, and to be fully informed of one’s medical condition and treatment. </div> <div><br>Before the statute was amended, courts were divided as to whether claims were limited only to those rights set forth in PHL section 2803-c. For example, in Begandy v. Richardson, the trial court held that a patient could not bring suit based on a violation of the statute. In this case, the plaintiff alleged that the defendant’s failure to lock, label, or prevent access to a cellar stairway and to light the stairway violated the relevant building codes and portions of her admission agreement by failing to provide adequate care to prevent her from wandering. </div> <div><br>But the appellate court disagreed with the plaintiff’s claim, having found that a statutory claim was limited to a deprivation of a “personal right or benefit contemplated by section 2803-c.” </div> <div><br>Prior to the amendment, the courts had ruled in a variety of ways that had left the issue unresolved as to whether a plaintiff could assert both a PHL section 2801-d claim and a common law tort claim using the same set of facts. </div> <div><br>The practical distinction between a common law tort claim and a claim under PHL section 2801-d is an important one. Among other things, as the burdens of proof vary, a plaintiff may succeed in one cause of action and not the other, as the common law and statutory claims are not duplicative. A patient’s attorney can thus win a tort claim but lose a statutory claim even though they arise out of the same facts.</div> <div>In other words, a plaintiff can win on one cause of action and lose on the other cause of action, based on the same facts, because the burden of proof differs. </div> <h2 class="ms-rteElement-H2">Definitions Broadened </h2> <div>The law was amended for the purpose of “clarify[ing] the grounds for liability claims against nursing homes.” Thus, subdivision 1 of section 2801-d was amended to clarify that “‘injury’ shall include…physical harm to a patient; emotional harm to a patient; death of a patient; and financial loss to a patient.” </div> <div><br>Subdivision 4, section 2801-d, which provided that statutory remedies were “in addition to and cumulative with” other remedies, also states that a violation of subdivision 3 of 2803-c “is not a prerequisite for a claim under this section.” Rather than merely “clarify” the statute, the legislature broadened access so that advocates can now assert: 1.) both personal injury claims and a PHL section 2801-c claim; 2.) a PHL section 2801-d claim that is not limited to the rights set forth in PHL section 2803-c; and 3.) claims under a broad definition of what constitutes a statutory injury. </div> <div><br>Using the facts in the Begandy case as an example, the landscape has clearly changed. In Begandy, the court denied the plaintiff’s motion to amend his personal injury complaint based on violations of both the building code and certain provisions of the defendant’s admissions agreement, as it found that PHL section 2801-d claims were limited to the violation of PHL section 2803-c rights. </div> <div>Post-amendment, however, such a plaintiff can now assert a claim that a facility violated the statute by failing to comply with the building code—the theory being that the plaintiff was deprived of a statutory “right or benefit” accorded to him. </div> <div>A provider may now face a whole new category of claims that do not implicate the rights set forth in PHL section 2803-c. What’s more, there is no limitation on the type of injury that may be asserted by the plaintiff.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Defense Strategies</h2> <div>A provider has an absolute affirmative defense if it can prove that it “exercised all care reasonably necessary to prevent and limit the deprivation and injury.”</div> <div><br>Does this mean that even if a provider violated a regulation that benefited a patient but thereafter exercised reasonable care to prevent injury to a patient, that the provider is not liable? What does the term “reasonably necessary” mean?</div> <div><br>A facility has a general duty to exercise reasonable care and diligence in safeguarding a patient, and that duty is based, in part, on the patient’s capacity to provide for his or her own safety. </div> <div><br>However, there is a clear analogy between the affirmative defense raised under PHL section 2801-d and the defenses a provider raises when facing an ordinary negligence or a medical malpractice claim. </div> <div><br>Accordingly, a provider should prepare a defense based on whether the statutory claim is based on a legal theory of medical malpractice or ordinary negligence. The distinction between the two turns on whether the acts and/or omissions at issue involve a medical matter that can only be assessed by medical professionals or whether the conduct and/or omission at issue can instead be assessed by using common knowledge and experience. </div> <div><br>In other words, is the provider liable because it failed to exercise proper medical care and supervision (medical malpractice) or because it failed to exercise the care or supervision that a nonprofessional would use in the situation at issue (ordinary negligence)? </div> <h2 class="ms-rteElement-H2">Recent Cases</h2> <div>Recent appellate cases have upheld dismissals of post-amendment PHL section 2801-d claims. </div> <div>The Gold v. Park Avenue Extended Care Center Corp. case provides a good illustration of a claim dismissed at the trial level. A provider may also examine Butler v. Shorefront Jewish Geriatric Center for guidance. </div> <div><br>In Gold, the plaintiff asserted both a section 2801-d violation and common law negligence. </div> <div><br>The plaintiff alleged that, as a result of the defendant’s failure to install side rails on the decedent’s bed, and because of its failure to provide her with proper supervision, she sustained numerous falls that led her to suffer a stroke, dementia, and eventually death.</div> <div><br>The provider, in support of its motion for summary judgment, submitted a doctor’s opinion establishing that: 1.) there were no supervision deficiencies given regarding the decedent’s health and status; 2.) the use of a restraint would have been inappropriate; and 3.) the absence of a restraint did not proximately cause any injury to the decedent because none of the falls were from the decedent’s bed. </div> <div><br>The plaintiff, in opposition, only relied on a registered nurse’s affidavit. The court found no merit to her assertion that the federal regulation providing that each resident must receive care to maintain his highest physical, mental, and psychosocial well-being was violated and that the decedent was injured thereby.  </div> <div> </div> <div><em>Andrew I. Bart is an attorney with Tenzer and Lunin, a New York City law firm. He may be reached at (212) 262-6699 or at <a href="mailto:andrewibart@gmail.com">andrewibart@gmail.com</a>.</em></div>In a move that could be a harbinger for similar legislative changes across the country, the bellwether state of New York recently amended portions of its Public Health Law (PHL) in a way that seems to invite more litigation against nursing home providers.2012-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0412/0412Legal_thumb.jpg" style="BORDER:0px solid;" />Policy;LegalColumn4
OIG: More Documentation Cuts Payment Error Ratehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/OIG-More-Documentation-Cuts-Payment-Error-Rate.aspxOIG: More Documentation Cuts Payment Error RateA new report by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) says a more vigorous effort by contractors working for the Comprehensive Error Rate Testing (CERT) program to find missing documentation could have cut the payment error rate in the Medicare program by $956 million in 2010.<br><br>OIG conducted a pilot project to obtain missing documentation identified in the fiscal year (FY) 2010 CERT program and published the report recently. It is available at <a href="http://oig.hhs.gov/">http://oig.hhs.gov</a>. <br><br>“Based on our results, the CERT statistical contractor estimated that additional documentation to overturn claim payment denials would have reduced the FY 2010 error rate estimate from 10.5 percent to 10.2 percent, which would have reduced the estimate of improper payments by approximately $956 million,” the report said.<br><br>OIG obtained additional documentation in its survey project that enabled the CERT review contractor to overturn, or partially overturn, its claim payment denials for 46 of 136 claims, amounting to around 34 percent. <br><br>The CERT review contractor overturned its claim payment denials for 46 claims because it determined that the additional medical records OIG obtained were proof enough to show that the health services or items billed to the Medicare program were medically necessary. <br><br>The CERT contractor did not initially get the added documentation because it did not always contact referring providers directly to obtain missing information, did not always redirect follow-up documentation requests to compliance or reimbursement personnel, or did not always seek proper signatures on clinicians’ notes when the signatures were  illegible, the report said.<br><br>To improve the program, OIG recommended that the Centers for Medicare & Medicaid Services (CMS) continue to educate providers on the issue. It also said CMS should assess the improper payments identified by the CERT review contractor and the overturned denials of claim payments to explore which claims may benefit from a deeper review.<br><br>Lastly, the report said, CMS should ensure that the CERT documentation contractor follow established rules in seeking signature attestations.<br><br>CMS disagreed with the final two recommendations, noting it has intensified efforts throughout 2011 to improve the claims documentation process and that contractors have been following procedures on signatures. A new report by HHS OIG says a more vigorous effort by contractors working for the Comprehensive Error Rate Testing program to find missing documentation could have cut the payment error rate in the Medicare program by $956 million in 2010.2012-04-01T04:00:00ZColumn4
Quality Symposium: CMS Pleased With Industry Initiativehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/Quality-Symposium-CMS-Pleased-With-Industry-Initiative-.aspxQuality Symposium: CMS Pleased With Industry Initiative<div><img class="ms-rtePosition-1" alt="Jonathan Blum" src="/news/PublishingImages/blum_jon2.gif" style="margin:5px 15px;" />The long term and post-acute care industry needs to hold the Centers for Medicare & Medicaid Services (CMS) accountable for its inconsistencies, Jonathan Blum, deputy administrator of the agency, told the 425 attendees at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) Quality Symposium in February. </div> <div> </div> <div>“Where we need your help, and where you need to come to us, is when you see one part of CMS not operating consistently with the others,” he said. </div> <div> </div> <div>“We are a large bureaucracy, so if you feel at any time the payment policies we are promoting are not consistent with what we’re trying to achieve on the quality side, on the survey and cert side, those are opportunities to come to us and say, ‘Hey guys, get this right.’”</div> <div> </div> <div>Blum addressed the two-day conference during its opening session, just after Gov. Mark Parkinson, AHCA/NCAL president and chief executive officer, and Neill Pruitt Jr., AHCA chair, had outlined its new Quality Initiative (see Provider’s March issue, page 38, for details) and its four measurable goals.</div> <div> </div> <div><div class="ms-rteElement-Callout3"><strong>Initiative Goals</strong><span><strong> AHCA/NCAL Quality</strong></span></div> <div class="ms-rteElement-Callout3">Safely Reduce Hospital Readmissions. By March 2, 2015, at 12:00 p.m., reduce the number of hospital readmissions within 30 days of a skilled nursing stay by 15 percent.</div> <div class="ms-rteElement-Callout3">Increase Staff Stability. By March 2, 2015, at 12:00 p.m., reduce turnover among clinical staff (registered nurse, licensed vocational nurse, licensed practical nurse, certified nurse assistant) by 15 percent.</div> <div class="ms-rteElement-Callout3">Safely Reduce the Off-Label Use of Antipsychotics. By Dec. 31, 2012, at 12:00 p.m., reduce the off-label use of antipsychotics by 15 percent.<span></span> <br></div> <div class="ms-rteElement-Callout3"><span>Increase Resident Satisfaction. By March 2, 2015, at 12:00 p.m., increase the number of customers who would recommend the facility to others up to 90 percent.<span></span></span></div></div> <div>As Blum took to the podium, he commended Parkinson and Pruitt for their leadership in recognizing CMS as a partner and “not an adversary,” as Parkinson noted in his opening statement. “It is inspiring at CMS that you see us as a trusted partner,” Blum said to attendees. “I’d like to thank you, to commend you. From our perspective, we couldn’t be more pleased and more proud of you. There will be no disagreement regarding the overall quality goals.”<br><br></div> <div>With that, Blum described the three-part aim that is guiding CMS’ work, as follows: better care, better health, and lower cost through improvement. In addition, he highlighted six “tangible, overarching goals” the agency hopes to achieve inside of the three-part aim, which he noted fit “very well” with <br><br><strong>AHCA/NCAL’s goals: </strong></div> <div>1. Reduce health care-acquired conditions. “We are trying to focus on reducing harm to patients while they are in facilities,” Blum said. “We also want to reduce the number of adverse medication events and reduce inappropriate antipsychotic use, which is why we are so pleased to see that this is one of your quality goals,” he said.</div> <div><br>2. Reduce fragmentation in the health care delivery system. Blum noted that the current health care delivery system has silos of care. “And sometimes that care is not very coordinated,” he said. “One of our key goals is to reduce fragmentation, which led to CMS focusing on reducing hospital readmissions.” In addition, CMS is focusing on bundled payments to create stronger incentives for providers to take a much more integrated approach to care. </div> <div><br>3. Create a health care system that has the capacity to capture and act on patient-reported information. “It is a fair observation that CMS tends to think of its world as payment, dollars, and survey information,” Blum said. </div> <div><br>“We’re trying to change that to what the patient needs. We are building payment structures and care structures that focus on what patients need, what patients want, and how they navigate through the health care system.” Blum noted that the goal is to change care structures to encourage a health care delivery system that focuses on “patient-centered, best-quality outcomes at the lowest possible cost.” </div> <div><br>4. Prevent and reduce harm to patients who have cardiovascular disease. This includes increasing blood pressure control, reducing high cholesterol, keeping patients healthier, and focusing on preventing chronic conditions, Blum said.</div> <div><br>5. Encourage and promote innovation in local communities. CMS is supporting and nurturing local initiatives and systems throughout the country, Blum said, noting that one policy example the agency is focused on is supporting sites that want to integrate dual-eligible populations. </div> <div>CMS’ new Center for Medicare and Medicaid Innovation is providing opportunities to spur local innovation, Blum added. </div> <div><br>6. Identify and define measures that can serve as indicators of cost reduction. “Part of the reason care is not coordinated is because of the financial payment system we have in place,” Blum said. </div> <div><br>“So, part of our goal, our mission, is also to focus on reducing costs, to lower costs through improvement.” <br><br>He noted that CMS would like “to prove to the world that lower cost, more trust fund solvency, if you will, will come not from just cutting market basket rates or cutting payments, but through better-managed care, better-coordinated care, and providing better transitions for our beneficiaries.” </div> <div><br>In conclusion, Blum noted that the six goals he outlined are “very consistent” with the goals that Parkinson had outlined in the organization’s Quality Initiative. “This is where our partnership can work really well together,” he said.</div> <div><br>The Quality Initiative goals that Blum commended were hashed out by board members and AHCA/NCAL staff during a two-day retreat, Pruitt told attendees during the opening session. </div> <div><br>“We spent the first two days of our meeting—we didn’t talk about policy, Washington politics, or elections—we sat down and discussed quality and how it can make a difference in the buildings and patients we serve,” Pruitt said. </div> <div><br>“We wanted quality to be an expectation, not just something we talk about. We wanted to think differently; we wanted to embrace the spectrum of services. We wanted to talk about technology and dashboards as a quality improvement tool. And we wanted it for all members regardless of size or profit or nonprofit status.” <br></div>The long term and post-acute care industry needs to hold the Centers for Medicare & Medicaid Services (CMS) accountable for its inconsistencies, Jonathan Blum, deputy administrator of the agency, told the 425 attendees at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) Quality Symposium in February. 2012-04-01T04:00:00Z<img alt="" height="150" src="/Monthly-Issue/2012/PublishingImages/0412/blum_jon2.gif" width="150" style="BORDER:0px solid;" />QualityColumn4
Staff Age Irrelevant When It Comes To Hearthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/Age-Irrelevant-When-It-Comes-To-Heart.aspxStaff Age Irrelevant When It Comes To Heart<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div><div style="text-align:center;"><img class="ms-rtePosition-4 ms-rteImage-3" src="/Monthly-Issue/2012/PublishingImages/0412/0412CoverStory.jpg" alt="" style="margin:5px;width:497px;height:318px;" /></div> <div> </div> <div>The graying of America is in full force, and the long term care facility workforce is not exempt. Instead of seeking a fountain of youth for staff, facilities are finding innovative ways to employ the experience and knowledge of older staff while keeping them safe and healthy, and they are encouraging intergenerational relationships that enhance quality care and teamwork. And in the process, they are finding that caring is ageless.</div></div> <div> </div> <div>As the country ages, it isn’t surprising that the health care workforce is getting older as well. A study published in a 2000 issue of the Journal of the American Medical Association projected that between 2010 and 2020, over 40 percent of the registered nurse (RN) workforce alone will be over age 50, according to researchers P. Buerhaus, D. Staiger, and D. Auerbach. Between 1994 and 2001, RNs 50 years old and over grew at an annual rate of 4.7 percent, said the same researchers in a study published in Health Affairs in 2004. Between 2002 and 2003, the rate shot up to 15.8 percent, the researchers said. </div> <div> </div> <div>At the same time, the number of RNs under age 35 is going down as part of a 20-year trend, they said.</div> <h2 class="ms-rteElement-H2">Ageism A Factor?</h2> <div>While the workforce in general is aging, it hasn’t stopped the influx of ageism in the workplace. According to one study published in the Journal of Gerontology: Psychological Sciences in 2011, there is evidence of bias against older workers. Older workers were thought to be “moderately less apt” in areas such as interpersonal skills and suitability to be selected for any given job, although they were rated higher in reliability, said authors A. Bal, A. Reiss, C. Rudolph, and B. Baltes.</div> <div> </div> <div>Nonetheless, in long term care, a profession that centers around aging, most facility leaders value older staff and work to keep them <a href="/Monthly-Issue/2012/Pages/0412/At-Any-Age,-Motivation-Makes-For-Happy-Staff.aspx">healthy and happy.</a> As J. Kenneth Brubaker, MD, CMD, a medical director in central Pennsylvania, says, “I have never seen an instance of ageism in long term care staffing. I’ve worked with some nurses who have been at their facility for 40 years.” He adds, “If you perform well, age isn’t an issue. I suspect that the lower the turnover, the higher the average age of staff.”</div> <div><br>Anne Marie Barnett, RN, president of Maryland NADONA/LTC, agrees that ageism isn’t an issue in a profession many workers have entered because “they had an older relative who inspired them to pursue this career. They have a passion for it.”</div> <div><br>A greater challenge for Barnett is blending cultures. “A large percentage of my nursing and caregiving staff are from different countries. Language barriers and other issues can impact their relationships with residents and other staff. We have to deal with that,” she says. However, she stresses, “It’s all about leadership and creating good staff relationships. You need to be fair across the board and treat all staff with respect.”</div> <div><br>Susan Persch, MBA, senior director of business systems at Brookdale Senior Living in Milwaukee, Wis., adds that “there is no ageism because there is so much important work to be done. We are always looking for good people who share our passion, and we are welcoming to all who share our mission and compassion for caring.”</div> <h2 class="ms-rteElement-H2">A Generation Gap?</h2> <div>It is important for facilities to address the needs and concerns of both younger and veteran staff members. </div> <div>To do this effectively, they need to understand their common concerns and different needs. “Most of the literature says that there are generational differences in the way people approach and value work, and there are generational differences between older and younger nurses,” says Linda Norman, DSN, RN, FAAN, senior associate dean for academics, Vanderbilt University School of Nursing in Nashville, Tenn.</div> <div>It is crucial to acknowledge and address these differences, says Henri Carlton, RN, BSN, director of nursing for Charlestown retirement community in Catonsville, Md.</div> <div><br><img class="ms-rteImage-2 ms-rtePosition-1" alt="Brookdale walkers for Alzheimer’s Association" src="/Monthly-Issue/2012/PublishingImages/0412/0412CoverStory2.jpg" style="margin:0px 15px;width:365px;height:253px;" />“As we are working alongside younger folks, it becomes difficult to relate sometimes. It can be hard to find common ground, but when we don’t, it can lead to conflict on the floor,” Carlton says. “We have nursing assistants who have been here for 20-plus years, and when a new nurse comes in, they tend to see things differently.”</div> <div><br>To understand the generational differences between nursing staff, it is useful to look at history. In the 1960s and 1970s, women had fewer career choices, and nursing was a popular traditional option. <br><br>However, as career opportunities for women opened up, Norman says, “We went through a period where it was considered ‘old school’ to be a nurse or teacher—as if you were settling for less if you went into these professions.” In recent years, she adds, there has been a resurgence of interest in nursing as a career choice. Part of this may be because of the nursing shortage and the perception that nursing offers job security, decent pay, and job flexibility. </div> <div><br>However, Norman stresses, “Much of the renewed interest in nursing has to do with the younger generation’s desire for altruistic work. These young people want to do something meaningful and see nursing as an opportunity to help people improve their health.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Meeting Staff Expectations</h2> <div>Norman and her colleagues studied generational differences and found that “the biggest thing was the amount of physical work and hours. Older nurses didn’t like the longer [12-hour] shifts as much as the younger nurses did.” In fact, she says, in facilities where only longer shifts were available, veteran nurses were more likely to retire or look for jobs where they could have 9:00 to 5:00 schedules. </div> <div><br>Norman suggests, “If you want to retain nurses, issues related to shift lengths become important to consider. That was borne out in our research.”</div> <div><br><img class="ms-rteImage-2 ms-rtePosition-2" alt="Brookdale resident, Innovative Senior Care therapist" src="/Monthly-Issue/2012/PublishingImages/0412/0412CoverStory4.jpg" style="margin:5px 15px;width:310px;height:465px;" />Younger staff are more likely to have been weaned on culture change and teamwork. As a result, they expect to be a valued and respected part of the health care team. “One reason a facility may have high turnover is that they have staff who don’t feel valued by practitioners,” says Brubaker. “Good interpersonal relationships between physicians and staff are more likely to create a happy work experience for everyone. It affects the quality of care when staff are afraid to talk to the physicians or feel that the doctors don’t listen to their suggestions.”</div> <div><br>However, just as younger staff have different learning experiences and expectations, he suggests that younger physicians are being taught teamwork and person-centered care as well.</div> <h2 class="ms-rteElement-H2">A Common Denominator</h2> <div>While younger and veteran nurses are different in many ways, they also share many values. For example, Norman says, “Younger and older nurses share an overwhelming desire to help people. They want to be able to feel that they can make a meaningful contribution. Both generations look at nursing as a stable field.” At the same time, younger nurses may come into the profession with a more tangible intention, Norman suggests, because they had many options and chose nursing.</div> <div><br>To identify and promote the common ground that nurses of all generations share, “you have to change the question,” Carlton says. She suggests that instead of asking nurses why they went into the field, it is more useful to ask them what nursing means to them.</div> <div><br>“When we asked this, we pretty much heard the same thing across the board—they wanted to make a difference in people’s lives. When we don’t get caught up in the holier-than-thou rhetoric, we find that we all are in this profession for the same reasons. The core of what we do and why we do it is the same,” Carlton says. “Once we talked to staff this way, everyone could relate, and you could see the passion coming out all over the place.”</div> <h2 class="ms-rteElement-H2">Tossing Out Stereotypes</h2> <div>Disposing of stereotypes about age is important to the success and satisfaction of older staff and good relationships between staff of all ages. For example, while some older workers may not be as adept at using technology as their younger counterparts, techno-phobia and age don’t necessarily go hand in hand.</div> <div><br>As 67-year-old Melanie Scalese, coordinator for performance improvement, risk management, safety, and infection control at Charlestown, says, “I do well with computers. Nowadays, most older people are comfortable with technology. Even a lot of our residents use computers easily.” The key is to have strong training programs for younger and older staff that ensure they are comfortable with all the job skills they need, she says.</div> <div><br>Brubaker adds, “For the most part, nurses’ interest in lifelong learning will make them want to work at a new skill.” </div> <div><br>Carlton agrees that many older nurses welcome the opportunity to learn something new. “The younger generation challenges us to do better and be more knowledgeable,” she says. “We need to encourage older nurses to take this opportunity to be even better at what they do.” She adds that older nurses need to realize that questioning decisions and seeking multiple opinions is common in the younger generation of nurses.</div> <div><br>“You can’t take this personally. This is how they have learned to seek and process information. It’s not an attack on your judgment,” she says.</div> <div><br>Persch agrees that such generational differences don’t have to mean a generation gap: The key is to understand younger people’s frame of reference. </div> <div><br>“People between the ages of 18 and 25 often are referred to as ‘generation digital.’ They grew up with the computer as a primary language. Rather than have to learn it, they are bilingual. It is a given that they know computers and technology,” she says. </div> <div><br>One way to get away from stereotypes is to get away from words and language that promote them. As Carlton says, “Words like ‘old’ become very inflammatory. We stopped using those kinds of words, and we were able to get down to the essence of what we do and find common ground. We have to constantly remind ourselves not to get sucked back into earlier ways of thinking.”</div> <h2 class="ms-rteElement-H2">Two-Way Learning</h2> <div>Bringing together younger and veteran nurses and nurse assistants can help make the most of the skills and strengths both bring to the table. </div> <div><br>For example, as Norman says, “You need to look at what contribution older staff can make in mentoring new staff. That is where decision-making experience and clinical expertise can really come into play.” </div> <div>She urges managers not to be short-sighted in their quest to lure younger nurses with a few years of experience versus new graduates. “It often is harder to recruit new nurses to come into long term care, and sometimes facilities are skeptical of nurses with no experience,” she says. “Matching up veterans with novices can help the newer nurses learn from the older nurses and really begin to appreciate the value of long term care.”</div> <div><br>This can help facilities attract and keep good young nurses, Norman says. As she explains, “Those who are interested in the field may get turned off when they are told that they need more experience. If they go into acute care to gain that experience, chances are that you won’t get them back.”</div> <div><br>By partnering newer nurses with more experienced nurses, the pool of practitioners from which to draw grows, and it can help older nurses handle the physical demands of the job.  <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Growing Awareness Of LTC</h2> <div>Younger nurses increasingly are seeing long term care as an appealing option, says Norman, partly because of a growing emphasis on geriatrics in the nursing school curriculum. </div> <div><br>“There has been a push within health care itself to increase the content and emphasis on geriatrics in professional education,” Norman says. “As a result, nursing students are seeing the attributes of the elderly and value of helping them.</div> <div><br>“When I went to school, the attitude was that you couldn’t do much for elders—just keep them comfortable. Now we know that we can do much more. That helps people see geriatrics and long term care as a more viable place for care delivery,” she says.</div> <div><br>The growing emphasis on geriatrics in educational curricula presents an opportunity for facilities to attract the best and brightest nursing staff. As Norman says, “Nursing homes can reach out and partner with schools of nursing to identify opportunities such as summer programs where students can come and work in the facility.”</div> <div><br>She also applauds the idea of facilities providing scholarships with a catch. “Nothing stimulates someone’s interest in a place like a scholarship with a work requirement,” Norman says. </div> <h2 class="ms-rteElement-H2">Safekeeping Treasures</h2> <div>As important as it is to attract young nurses, it is equally valuable to retain veteran nurses. One way to do this is to implement procedures and innovations to keep them physically healthy. </div> <div><br><img class="ms-rteImage-2 ms-rtePosition-1" alt="Brookdale staff at fundraising event." src="/Monthly-Issue/2012/PublishingImages/0412/0412CoverStory3.jpg" style="margin:5px 10px;width:373px;height:262px;" />“When I went into nursing, I heard seasoned practitioners complain about back pain. They worked through the pain proudly,” recalls Carlton. “When I came to my current facility, there was lots of talk about injuries. They no longer were a badge of honor. In fact, they were unacceptable.”</div> <div><br>The facility developed a campaign to encourage safe lifting and implemented the use of mechanical lifts. It purchased high-low beds that enable ergonomic-ally correct care, and they utilize simple solutions such as proper desk height, back-friendly chairs, and good lighting. </div> <div><br>Carlton says, “We constantly look at ways to better preserve the bodies of both residents and staff. We have a very comprehensive wellness program that includes prevention as well as reactionary components.”</div> <div><br>The results show. As Carlton says, “We have nurses in their 70s who are very effective bedside because we have provided things that assist them.”</div> <div><br>Maxine Roby, MS, NHA, administrator of Rowan Community, a senior care community in Denver, says that it is important to make older staff feel empowered about their health. “Someone in their 20s goes to the doctor for a knee problem and gets it fixed. But an older person might think he or she is stuck with the problem. We need to encourage people to get help for illnesses or injuries at any age,” she says.</div> <div><br>When older staff members feel good, the positive energy is reflected in their work. As Roby says, “We have a nurse who is in his 70s. He is standing all day long, bending, moving. In some ways, it keeps him young.”</div> <h2 class="ms-rteElement-H2">Saying Goodbye</h2> <div>While facilities may decide to implement initiatives to <a href="/Monthly-Issue/2012/Pages/0412/Helping-Hands.aspx">retain</a> older nurses, some aging practitioners simply will be unable or unwilling to handle the challenges of working on the floor in this setting. As Barnett says, “When staff get older, they may tend to slow down and look for less physically demanding challenges.” </div> <div> </div> <div>Even older nurses who love their jobs and can still perform them effectively may choose another path. For example, Scalese is retiring soon. While she hopes to continue working on an as-needed basis, she is ready for the next phase of her life.<br></div> <div>“I’m looking forward to retirement. I have goals for my life after retirement. I wouldn’t be comfortable sitting at home.”</div> <div><br>In the meantime, she loves her work. Some of her younger colleagues call her “mom” and are happy to answer call bells so that she doesn’t have to rush up and down the halls. She will miss her familial relationships with residents and staff, but—like many older nurses—she has left a legacy that she hopes will inspire younger practitioners to follow her example. </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div>The graying of America is in full force, and the long term care facility workforce is not exempt. Instead of seeking a fountain of youth for staff, facilities are finding innovative ways to employ the experience and knowledge of older staff while keeping them safe and healthy, and they are encouraging intergenerational relationships that enhance quality care and teamwork. And in the process, they are finding that caring is ageless.2012-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0412/0412CoverStory_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Management;WorkforceCover Story4
CMS Modifies MDS 3.0 To Ease Burdenshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/CMS Modifies MDS To Ease Burdens.aspxCMS Modifies MDS 3.0 To Ease Burdens<p>Nearly 18 months after implementation of the minimum data set (MDS) 3.0, changes and clarifications are being made to the assessment tool in an effort to ease concerns about the burden it has placed on providers and residents. The changes, which were announced March 7 by the Centers for Medicare & Medicaid Services (CMS) during a training conference in St. Louis, will take effect April 1, 2012. <br><br>The modifications include:<br>■ Section Q will now require fewer questions about a resident’s preference to avoid being asked repeatedly about return to the community, among other changes.<br>■ An unplanned discharge has been defined as an “acute-care transfer of the resident to a hospital or an emergency department in order to either stabilize a condition or determine if an acute-care admission is required, based on emergency department evaluation.” Unplanned discharges can also be defined as a resident who unexpectedly leaves the facility against medical advice.<br>■ Providers may now carry forward patient interview coding from scheduled PPS assessments to stand-alone unscheduled assessments (COT, SOT, and EOT), provided that the most recent scheduled assessment interviews were performed no more than 14 days prior.<br>■ The RAI manual and MDS changes will take place less frequently. CMS plans to release errata documents on only those pages where changes and modifications are made, making it easier for providers to maintain the manual. After the next release in October 2012, future updates will occur only once per year. <br><br>“We are pleased that CMS has taken these steps to reduce the burden of MDS on patients and care providers,” said David Gifford, MD, senior vice president of quality, regulatory affairs, and research at the American Health Care Association. <br><br>According to an MDS expert who attended the conference, “Providers are happy about some of the changes,” says Rena Shephard, MHA, RN, RAC-MT, C-NE, executive editor of the American Association of Nurse Assessment Coordination. She notes that among the most significant changes were those made to discharge assessments. <br><br>CMS has determined that if it is an unplanned discharge, then there is an abbreviated discharge assessment required, and it does not include the direct resident interview. “That’s the big thing,” Shephard says. <br><br>“They really did try to hear what providers were saying to them,” she says. <br><br>Changes related to the frequency of resident interviews were applauded, says Shephard. “The way it is now, any time you do an assessment, you have to redo the resident interview,” Shephard says.<br><br>To alleviate this burden, CMS said that as of April 1 when coding an unscheduled prospective payment system (PPS) assessment, the interview items can be coded using responses provided by the resident on a previous scheduled assessment, but only if those interview responses from the scheduled assessment were obtained no more than 14 days before the completion date of unscheduled assessment, Shephard says.<br><br>“That’s a really big deal, that’s a really big change,” she says.<br></p>Nearly 18 months after implementation of the minimum data set (MDS) 3.0, changes and clarifications are being made to the assessment tool in an effort to ease concerns about the burden it has placed on providers and residents. 2012-04-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/staff_laptop_1.jpg" style="BORDER:0px solid;" />PolicyColumn4
Four States Make Major Changes To Assisted Living Regs In 2011https://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/Four-States-Make-Major-Changes-To-Assisted-living-regs.aspxFour States Make Major Changes To Assisted Living Regs In 2011The National Center for Assisted Living (NCAL) recently released its 2012 edition of “Assisted Living State Regulatory Review,” finding that 16 states made changes to assisted living regulations, statutes, and policies during 2011.<br><br>Four states—Georgia, Nevada, North Carolina, and South Dakota—made major changes. Georgia created a second level of licensure for assisted living communities alongside the state’s existing licensure of personal care homes. “While the categories share many common requirements, assisted living community standards are more stringent or vary in a number of areas,” the report says. <br><br><span><img class="ms-rteImage-2 ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0412/iStock_000016730895Medium.jpg" alt="" style="margin:5px;width:272px;height:184px;" /></span>Facilities with 25 or more beds can opt for either type of licensure.<br><br>In South Dakota, assisted living centers are now regulated under new rules that further define restrictions on accepting and retaining residents, as well as conditions under which hospice care may be provided.<br><br>New regulations for assisted living residences adopted last year in Nevada centered mainly on medication administration, including increased medication administration training for caregivers, from eight initial hours to 16 initial hours, and new refresher training requirements, from three hours every three years to eight hours annually.<br><br>In addition, Nevada administrators must take the same initial medication administration training and the same refresher training as their caregivers, regardless of whether or not the administrator is a licensed medical professional. <br><br>In North Carolina, the legislature approved changes that impact adult and family care home licensure, including penalties and remedies for violations, discharge of adult care home residents, frequency of inspections based on quality ratings, infection control standards, and training and competency evaluation of medication aides.<br><br>“Florida and several other states are considering major changes for 2012,” says Karl Polzer, NCAL’s senior policy director and the report’s author. “As in previous years, this year’s report found many states actively refining and developing regulations.”<br><br>The report is published every March. It is the only annual resource that summarizes state assisted living regulations across 21 categories, which include life safety, physical plan requirements, medication management, and move-in/move-out criteria.<br><br>The report also found that six states added or revised education and training requirements. For instance, Washington began requiring most new direct-care workers to take 75 hours of training within 120 days of being hired and then become certified as home care aides within 150 days. <br><br>Other focal points of state regulatory changes include disclosure of information to consumers, infection control, discharge/transfer between sites, and move-in and move-out criteria, as well as medication management. The National Center for Assisted Living (NCAL) recently released its 2012 edition of “Assisted Living State Regulatory Review,” finding that 16 states made changes to assisted living regulations, statutes, and policies during 2011. 2012-04-01T04:00:00Z<img alt="" height="150" src="/Monthly-Issue/2012/PublishingImages/0412/iStock_000016730895Medium.jpg" width="225" style="BORDER:0px solid;" />PolicyColumn4
GAO Wants Upgrades To QIS Monitoring Processhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/GAO-Wants-Upgrades-To-QIS-Monitoring-Process.aspxGAO Wants Upgrades To QIS Monitoring ProcessIn a new report, the General Accountability Office (GAO) advised the Centers for Medicare & Medicaid Services (CMS) to improve the way it monitors implementation of the Quality Indication Survey (QIS) process for nursing homes.<br><br>The QIS is a revised long term care survey process that was developed under CMS oversight. It represents an effort to standardize how the survey process measures nursing home compliance with federal standards and the interpretive guidelines that define those standards.<br><br>The new review, GAO-12-214, follows earlier studies of the QIS-based survey process and builds on suggestions for changes that CMS has agreed need to be made. <br><br>“In 2009, CMS commissioned a third study that was completed in 2011 and identified aspects of the QIS process that could affect the consistency with which surveyors identify quality problems,” GAO said.<br>For example, the study found that during resident interviews, surveyors did not consistently probe for further information when provided with incomplete responses to interview questions. <br><br>“However, CMS does not have the means to routinely monitor the extent to which the QIS is helping improve the survey process as intended. Such routine, ongoing monitoring would be consistent with federal internal control standards and could include the use of performance goals and measures,” GAO said.<br><br>GAO said that CMS officials reported taking steps to address the study’s findings and recommendations and noted the agency does have access to some data, such as the amount of time surveyors have spent inspecting facilities, which could be used to help develop performance goals and measures.<br><br>“CMS has taken some steps to monitor and facilitate states’ implementation of the QIS-based routine survey, but CMS’ efforts are not systematic,” GAO said.<br><br>As part of the CMS effort to monitor states’ implementation, it primarily uses quarterly teleconferences with state survey agency officials to obtain information on the extent to which each state has completed training all its surveyors to use the QIS. However, states may not always participate in the teleconferences, and those that do may not provide complete information on their progress.<br><br>“As a result, the information CMS obtains through its monitoring of states’ progress may be incomplete,” GAO said. <br><br>To help facilitate states’ implementation of the QIS, CMS provides states with guidance, gives presentations, and offers states opportunities to share their implementation experiences through quarterly teleconferences. <br><br>However, CMS does not have a systematic method for obtaining, compiling, and sharing information on state experiences, especially information on approaches states have taken to help facilitate implementation of the QIS. Systematically sharing such information—for example, through CMS’ annual conference in which all state survey agencies participate—could help the agency facilitate implementation in states that have not begun QIS implementation, GAO said.In a new report, the General Accountability Office (GAO) advised the Centers for Medicare & Medicaid Services (CMS) to improve the way it monitors implementation of the Quality Indication Survey (QIS) process for nursing homes.2012-04-01T04:00:00Z<img alt="" height="150" src="/Monthly-Issue/2012/PublishingImages/0412/Inspect%20QIS%20thumb.jpg" width="150" style="BORDER:0px solid;" />QualityColumn4
Case Study: Minimum Data Set 3.0 Pyschosocial Changeshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0412/Case-Study-MDS-3-0-Pyschosocial-Changes-.aspxCase Study: Minimum Data Set 3.0 Pyschosocial Changes<p>​The following case example may help illustrate some of the complex and important issues identified regarding the use of the new minimum data set (MDS) 3.0 assessment tool, particularly around the psychosocial sections.<br><br>Mr. S, age 80, was admitted as a Medicare skilled nursing facility (SNF) resident after hip surgery because of a fall at his group home. Prior to his SNF admission, he lived in an adult home—he never managed to maintain an apartment as he went from job to job.  <br><br>His rehabilitation therapy progress was good, and yet his discharge was determined not to be feasible because his group home would not accept him due to his inability to manage the stairs independently. His nursing home social worker and community case manager were unable to find alternative housing. After a 15-day SNF stay, he was transferred from the SNF directly to the nursing facility.  <br><br>His OBRA annual assessment was completed on day 14. In the Mood Section of the MDS, Mr. S accurately indicates that he is not experiencing difficulty with eating, fatigue, sleep, concentration, or interest in extra-curricular activities. He scored a total severity of 5 on the PHQ 9 in contrast with the team’s assessment identifying depression. He expresses that he feels bad about himself and perseverates on thoughts that his medical condition is “evidence that God is punishing him” and his feelings of hopelessness.  <br><br>He was raised in foster care and has two siblings—one is deceased, and the other has Alzheimer’s disease and is in a facility. Extended family is caring toward him but overwhelmed by caring for the family member with dementia. He indicates in Section Q that he wants to return to the group home. He has a long history of psychiatric illness and has a case manager as his main contact. While he is able to walk around the facility independently, he becomes frustrated due to expressive aphasia, and his Brief Interview for Mental Status (BIMS) score was 14, which shows strong cognitive abilities. The nursing home team is addressing his depression through psychotropic medications, including visits by a psychologist, a social worker, and pastor.<br><br>In the case example, Mr. S is being interviewed for his 14-day OBRA admissions assessment. He has a history within the facility of becoming frustrated when attempting to communicate his needs due to expressive aphasia. Facility staff are now attempting to complete the BIMS, PHQ 9, and preference interviews with Mr. S for at least the third time in the past 30 days. It is highly likely that he will experience feelings of anger and frustration when being interviewed and further compromise his overall well-being. The validity of the interview may also be decreased as the result of Mr. S responding negatively to the interviewer. </p> <div>Social Workers and nurses indicated that the repeated interviews, especially for BIMS and PHQ 9, required for SNF and significant change assessments, result in residents refusing to answer the questions or elicit feelings of frustration that compromise the data being captured. </div> <div> </div> <div>In addition, the staff assessment has to be completed when a resident refuses to answer resulting in additional time spent on paperwork instead of providing clinical support to residents. [In this case, the self-report and staff report are likely to differ since he presents differently to clinical staff compared with his self-report.]</div> <h2 class="ms-rteElement-H2">Care Area Assessment</h2> <div>The following table illustrates Mr. S’s MDS 3.0 interdisciplinary CAA and care planning needs:</div> <p> </p> <table class="MsoNormalTable ms-rteTable-default" border="1" cellspacing="0" cellpadding="0" style="border-bottom:medium none;border-left:medium none;margin:auto auto auto -5.3pt;width:617px;border-collapse:collapse;height:261px;border-top:medium none;border-right:medium none;"><tbody><tr class="ms-rteTableHeaderRow-default"><th class="ms-rteTableHeaderFirstCol-default" colspan="7" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:6.65in;padding-right:5.4pt;border-top:windowtext 1pt solid;border-right:windowtext 1pt solid;padding-top:0in;"><div style="text-align:center;"><font face="Calibri">SNF Stay Issues</font></div></th></tr> <tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Problem</span></div></th> <td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Care Area Assessment Triggered</span></div></td> <td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">SW</span></div></td> <td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">RN</span></div> <div><span style="font-family:'times new roman', 'serif';font-size:10pt;">LPN</span></div></td> <td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">MD</span></div> <div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Psychiatrist</span></div></td> <td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">CNA</span></div></td> <td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Activities</span></div> <div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Other</span></div></td></tr> <tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Requests Discharge</span></div></th> <td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">#20 Return to Community Referral</span></div></td> <td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td> <td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;height:28px;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr> <tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" colspan="7" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:6.65in;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">NF Admission Assessment Issues</span></div></th></tr> <tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"><span> </span>High BIMS Score</span></div></th> <td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"># 2 Cognition Loss/Dementia</span></div></td> <td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td> <td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr> <tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Aphasia/Making self understood</span></div></th> <td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">#4 Communication</span></div></td> <td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td> <td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td></tr> <tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Normal PHQ 9 score & yet need for further depression<span>  </span>assessment</span></div></th> <td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">NONE</span></div></td> <td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td></tr> <tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Use of antipsychotic and antidepressant medications</span></div></th> <td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"># 17 Psychotropic Drug Use</span></div></td> <td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"><span> </span></span></div></td> <td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td> <td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr> <tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default" style="border-bottom:windowtext 1pt solid;border-left:windowtext 1pt solid;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:117.9pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">Requests Discharge</span></div></th> <td width="202" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:151.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">#20 Return to Community Referral</span></div></td> <td width="36" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:27pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="42" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.5pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="90" class="ms-rteTableEvenCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:67.4pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;">X</span></div></td> <td width="43" class="ms-rteTableOddCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:31.95pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td> <td width="69" class="ms-rteTableLastCol-default" valign="top" style="border-bottom:windowtext 1pt solid;border-left:#f0f0f0;padding-bottom:0in;background-color:transparent;padding-left:5.4pt;width:51.55pt;padding-right:5.4pt;border-top:#f0f0f0;border-right:windowtext 1pt solid;padding-top:0in;"><div><span style="font-family:'times new roman', 'serif';font-size:10pt;"> </span></div></td></tr></tbody></table> <p> </p> <p>Mr. S' case exemplifies many important care planning and CAA issues. First, the interdisciplinary care planning needs generated by his problems require clinical skills since his behavior is not consistent with his PHQ 9 score. Further, it is clear that his needs require the full complement of interdisciplinary staff, yet staff may be stretched by new MDS 3.0 documentation requirements or by lack of adequately trained mental health staff to assist Mr. S.<br><br>The social worker is a key team member to bring the care plan team together to address his needs and yet her/his priority is split between the SNF and the nursing facility (NF), with the NF often being the priority. It is estimated that it would take Mr. S’ social worker approximately three hours to complete the three CAAs, document depression needs in the medical record, and to coordinate with Mr. S’ case manager and the local contact agency regarding his desire to return to the community when it is unlikely that resources exist to support him.  </p> <p>This case study is relevant to Provider's April 2012 Caregiving column on the MDS 3.0 Pyschosoical changes: <a href="/Monthly-Issue/2012/Pages/0412/A-Look-At-MDS-3-0-Psychosocial-Changes.aspx">http://dev19.providermagazine.com/Monthly-Issue/2012/Pages/0412/A-Look-At-MDS-3-0-Psychosocial-Changes.aspx</a>. </p> <p> </p>This case study helps to illustrate some of the complex and important issues identified regarding the use of the MDS 3.0 assessment tool, particularly around the psychosocial sections. In this case study, Mr. S, age 80, was admitted as a Medicare SNF-stay resident after hip surgery because of a fall at his group home. 2012-04-06T04:00:00Z<img alt="" height="150" src="/Monthly-Issue/2012/PublishingImages/0412/April%2011%20case%20study%2016445232_thb.jpg" width="150" style="BORDER:0px solid;" />Caregiving;Clinical;ManagementColumn4

May


 

 

Med Reductions Boost Quality Of Lifehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0512/Med-Reductions-Boost-Quality-Of-Life-.aspxMed Reductions Boost Quality Of Life<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><img class="ms-rteImage-2 ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0512/Caregiving-PHOTO.jpg" alt="" style="margin:10px 15px;" /></div> <div>Examining how nursing staff time was allocated on the dementia unit of a skilled nursing facility in New Milford, Conn.––and wondering if a reallocation would benefit the residents and enhance the job satisfaction of those who care for them––has led to a dramatic drop in the average number of medications per resident: from 9.2 to 5.5. The national average is 9.7.<br><br></div> <div>The breakthrough can best be attributed to a partnership between the facility’s administrator, medical personnel, fellow nurses, and dietary staff, who were all encouraged to question traditional practices and consider change. <br></div> <h2 class="ms-rteElement-H2"><strong>What Nursing Home Staff Can Do </strong></h2> <div>The questions, which many in long term and post-acute care have pondered, included the following:<br></div> <div><span><span class="ms-rteFontSize-1">■<span style="display:inline-block;">  </span></span></span>Shouldn’t there be more to nursing care than medication administration?</div> <div><span class="ms-rteFontSize-1"><br>■</span> Can nutritious foods, sunshine, and moderate exercise take the place of vitamin and mineral supplements? Can doses of some medications be safely reduced or eliminated, and can others be given together?</div> <div><span><span class="ms-rteFontSize-1"><br>■<span style="display:inline-block;">  </span></span></span>Is it necessary to dispense medications at exact times, including early in the morning, when many older persons living at home vary the timing and suffer no ill effects?</div> <div><span><span class="ms-rteFontSize-1"><br>■<span style="display:inline-block;"></span></span></span> Can changing organizational culture and the approach to health care enable residents with dementia to attain a better quality of life? </div> <h2 class="ms-rteElement-H2"><strong>A Stunning Discovery</strong></h2> <div>Since the reduction in medications, staff members have observed a marked improvement in the overall well-being of residents––a change that has not been lost on family members.<br></div> <div>The son of one of the residents remarked, “Decreasing my father’s medications has been miraculous. He’s awake, he’s talking, and he is alive again.” </div> <div><br>A key partner in the undertaking was Primary Charge Nurse Jeff Hine, who analyzed the reason for every medication of every dementia unit resident. </div> <div><br>What he helped unearth did not shock staff on a medication-by-medication basis, but the totality of the discovery was stunning. </div> <div><br>The incidence of polypharmacy was widespread. For example, Claritin might have been ordered during allergy season and continued long after it was required. Often, when a laxative was ineffective, more laxatives were added rather than increasing the dose of the original medication, changing to a different medication, or trying natural alternatives. </div> <div><br>Other examples were more complicated: Omeprazole, added to a hospital patient’s medication regime as part of stress management, might be continued when the individual is discharged to the long term care facility. Then the pharmacist requests a diagnosis after doing a medication review, but the resident gets a diagnosis of gastroesophageal reflux disease, whether or not it is warranted, and the medication is continued indefinitely. </div> <div><br>A contributing factor on a dementia unit can be a resident’s inability to report symptoms. Fifty percent of the 1.6 million U.S. nursing home residents have a dementia diagnosis, and an estimated 760,000 preventable adverse drug events occur in nursing homes annually. So playing detective by analyzing facial clues and watching out for “guarding” and withdrawing from painful stimuli is essential in prudent medication reduction.</div> <h2 class="ms-rteElement-H2"><strong>Certain Meds Topped List</strong></h2> <div>As medications that could be cut back or eliminated were identified, heading the hit list were proton pump inhibitors, multivitamins, iron supplements, calcium supplements, statins, and vitamin D. Multivitamins were an especially salient example of a medication that should not escape scrutiny because they are often prescribed automatically and because a priority on preparing nutrient-dense foods can make them relatively superfluous. </div> <div><br>Moreover, studies have shown vitamin supplements to be harmful to the female elderly. According to reports in the Archives of Internal Medicine and Journal of the American Medical Association, vitamins, including multivitamins, B6, folic acid, iron, magnesium, zinc, and copper have all been linked with increased risk of death. </div> <div><br>The goals of reducing medications were met with particular success when it came to combating constipation, the leading reason for prescription drugs.</div> <div><br>Knowing that bulk-forming laxatives, stimulant laxatives, and stool softeners yield poor to fair results, the coordinator of clinical care and the director of nursing (DON) worked closely with the dietary staff to augment the number of meal choices that promote regularity through natural alternatives such as high-fiber cereals, waffles, and snack bars; whole grains; and highly effective fruits and vegetables. </div> <h2 class="ms-rteElement-H2"><span id="__publishingReusableFragment"></span><br><strong></strong></h2> <h2 class="ms-rteElement-H2"><div><strong>Team Effort Brings Results</strong></div></h2> <div>Meanwhile, the nursing staff ensured adequate fluid intake of 1,500 to 2,000 ml per day, encouraged regular exercise, bundled laxative passes, and, as much as possible, avoided waking residents to take laxatives. Now, almost no one on the facility’s dementia unit is awakened at 5:30 or 6:00 in the morning to take pills.</div> <div><br>Another dimension of the initiative was taking a step back to look at the life-and-death realities of some medication needs. One 96-year-old was on a lipid-lowering drug––which has an objectionable taste and is tough on the liver––even though the drug needs five years to reach efficacy. A particularly poignant example of blindly following protocol was a hospice patient receiving many meaningless medications, as his nurse commented, “three days before he left us.” </div> <div><br>In the eyes of Debbi Rossi-Stahl, the facility’s clinical care coordinator, “Observations like that one serve as a vivid reminder that Alzheimer’s disease is a terminal illness and that the emphasis for those afflicted with it should be on quality of life. Unfortunately, while that seems basic, our practices often belie common sense.”</div> <div><br>Affirming that view, one study of 323 nursing home residents with advanced dementia revealed that daily meds for chronic conditions were persistently prescribed even when the resident was in the final stages of illness. Up to 40 percent of residents were prescribed medications deemed inappropriate in palliative care of advanced dementia, and when medications of questionable benefit were finally discontinued, that typically occurred only when death was imminent. </div> <h2 class="ms-rteElement-H2"><strong>The Antipsychotics Issue</strong></h2> <div>According to Ahmed and Rossi-Stahl, another troubling and frequent instance of medication overuse concerns antipsychotic drugs. They point out that the three most common, Zyprexa, Seroquel, and Risperdal, all have black box warnings for the elderly that include increased risk of death. </div> <div><br>The medications, indicated for schizophrenia and bipolar disease only, are not approved by the U.S. Food and Drug Administration for dementia-related psychosis or agitation. </div> <div><br>“And yet,” DON Ahmed says, “residents with dementia suffer a range of side effects including high fevers, muscle rigidity, sedation, dry mouth, balance problems, tremors, and restlessness from unwarranted medications.”</div> <div><br>Ahmed and Rossi-Stahl believe nurses can play a leadership role in ensuring that each medication for each resident is truly beneficial and that the pursuit of quality of life is paramount. The pathways include education, advocacy, inquiry, team building, and monthly assessments of medications. The venues include interdisciplinary meetings and resident care plan meetings with families.</div> <div><br>As Hine puts it, “Less time tending to residents’ meds means more attention to providing direct patient care.” </div> <h2 class="ms-rteElement-H2"><strong>Residents, Family See Benefits</strong></h2> <div>Ahmed and Rossi-Stahl assert that their experience indicates a dementia unit does not have to be a place where nurses spend up to five hours per shift passing meds while residents’ quality of life is undermined by taking medications that do not deliver a significant benefit—and might even be causing harm. </div> <div>They imagine a different kind of dementia unit:</div> <div><br><span class="ms-rteFontSize-1">■</span> A place where residents can sleep through the night, uninterrupted by a medication pass, and have breakfast when they choose. <br></div> <div><span class="ms-rteFontSize-1">■</span> A place where staff members know their residents’ behaviors and can manage those behaviors without pyschotropic medications.</div> <div><span class="ms-rteFontSize-1"><br>■ </span>A place where nurses have the time to interact meaningfully with their residents and their residents’ families.</div> <div><span class="ms-rteFontSize-1"><br> ■</span> A place where each resident, to the extent he or she is able, can live comfortably and happily.</div> <div> </div> <div><em>Debbi Rossi-Stahl, a registered nurse with more than 30 years of experience, has been director of nursing for 11 years with TransCon Long Term Care at Candlewood Valley Health & Rehabilitation Center in New Milford, Conn., in which she oversees a 148-bed skilled nursing facility with a 44-bed dementia unit. Judie Ahmed, RN-BC, a registered nurse with more than 30 years of experience, has been working with dementia residents since 1986. Ahmed, who is certified in gerontological nursing and has worked as a director of nursing for more than 10 years, currently serves as coordinator of clinical services for TransCon, a member of the Connecticut Health Care Association. In this role, Ahmed has clinical oversight of four skilled nursing facilities, all of which contain a specialty dementia unit.</em></div> As medications that could be cut back or eliminated were identified, heading the hit list were proton pump inhibitors, multivitamins, iron supplements, calcium supplements, statins, and vitamin D. Multivitamins were an especially salient example of a medication that should not escape scrutiny because they are often prescribed automatically and because a priority on preparing nutrient-dense foods can make them relatively superfluous. 2012-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0512/Caregiving_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalColumn5
Nature & Nurture Unitehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0512/Nature-Nurture-Unite.aspxNature & Nurture Unite<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><img class="ms-rteImage-2 ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0512/Hill-Country-Retreat.jpg" alt="" style="margin:10px 20px;width:291px;height:239px;" />It would be difficult to argue that most people would not be happier and healthier if they could begin each day with a quiet, relaxed breakfast where there was a view of the ocean or the mountains. A peaceful stroll through the woods or a nice garden between the door of a home and the door of a car each day before work would better prepare everyone psychologically and physically for the day’s events. </div> <div> </div> <div>What is it about these connections with nature that make people happier and healthier? Perhaps if this connection was better understood, individuals might be more inclined to strengthen their relationship with nature. </div> <div> </div> <div>First is a clarification of the terms “nature” and “happier and healthier,” as used in this discussion. “Nature” refers to an organic environment capable of maintaining the processes necessary for survival (birth, growth, death, and interaction). This could be a solitary tree in a back yard or an entire rainforest in South America. “Healthier and happier” is limited to research where studies have measured heart rates, hormone production, cell growth, recovery rates, and other quantifiable reactions. </div> <div> <br>Most long term care professionals are familiar with the idea of evidenced-based design, or EBD. Simply put, EBD is the creation of environments that promote a higher quality of life or care through the use of credible research. The idea of EBD surfaced in 1984 when Roger Ulrich conducted a study of patients recovering from surgery, in which patients who enjoyed a view of a small grove of trees recovered faster and endured less pain and fewer complications than patients that had a view of a brick wall. </div> <div> </div> <div>In the years since Ulrich’s groundbreaking work, there have been thousands of studies related to improving the design of hospitals and long term care environments. All of these studies measure the positive effects of particular elements of the physical environment, those elements most frequently studied being plants and nature.</div> <h2 class="ms-rteElement-H2">The Physiology Involved</h2> <div>So, what is going on inside the human body when it is in nature? As humans grow and age, cells divide to produce more cells to account for growth and to replace worn out cells. As cells divide, the chromosomes within the cell split and replicate.</div> <div><br>At the end of each of these chromosomes are stretches of DNA called telomeres that protect the genetic data stored in the chromosomes. Each time a cell divides and the chromosomes split, the telomeres get a little bit shorter. Over a lifespan, they become so short that they can no longer protect the chromosomes, so cells die or become diseased. Therefore, the aging process eventually results in fewer healthy cells, and the telomeres on chromosomes are helpful indicators of age and disease.</div> <div><br>In 2009, a biological researcher discovered an enzyme called telomerase. When telomerase is released, it helps to replenish telomeres, which, in turn, help humans stay healthier and live longer. Subsequent research has demonstrated how relaxation and reduction of stress increase levels of telomerase, thereby keeping chromosomes intact a little longer.<br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2"><img class="ms-rteImage-1 ms-rtePosition-2" alt="Eden Home Courtyard" src="/Monthly-Issue/2012/PublishingImages/0512/Eden-Home-Courtyard-Renovation.gif" style="margin:5px 10px;width:398px;height:783px;" /><span><span style="display:inline-block;"></span></span>The Forest’s Healing Powers </h2> <div>The Japanese practice of Shinrin-yoku, a word that roughly translates to “forest bathing,” is the experience of taking a walk in the woods and simply breathing in the fresh air. The most important aspect of this experience is the quality of that air.</div> <div><br>Quing Li, a researcher who has been studying the effects of forest bathing for the past two decades, has found that inhalation of phytoncides, organic chemicals given off by plants, has many positive effects on the human body. Primary benefits include increasing the production of NK cells, which boost the immune system, and the reduction of stress levels. </div> <div><br>In one study, a group of nurses were taken from the city to a forested area where they participated in three two-hour walks in two days. Blood and urine tests before, after, and several days later revealed a significant increase in NK cell production and activity and decreased levels of adrenaline and noradrenaline (indicators of stress levels) not only immediately after the trip, but seven days later.<span></span></div> <h2 class="ms-rteElement-H2">Outdoors Vital</h2> <div>In 2005, the Centers for Medicare & Medicaid Services (CMS) conducted a study of 1,988 residents from 40 nursing homes in five states. In that study, CMS found that 40 percent of the residents surveyed said they did not get outside as much as they wanted. As one considers the nearly 800 people who said they could not get outside as much as they would like to, one can’t help but reflect on their inability to respond to a request that their bodies are making to them on a molecular level. </div> <div><br>A more immediate factor to consider is that some of the newer F-Tags put in place by CMS may be interpreted as addressing this unmet need. F-Tag F240, which states: “an environment that promotes maintenance or enhancement of each resident’s quality of life;” F242: “make choices about aspects of his or her life in the facility that are significant;” and F246: “reasonable accom-modation of individual needs andpreferences” are some examples of this. </div> <div><br>It seems like such a basic freedom, to step outside and take in a little fresh air. It is difficult to comprehend living a long life, free to spend time outside as desired, only to pass the final years of your life unable to leave the confines of a building.</div> <div><br>Approximately one in seven people will spend the end years of their lives in long term care. If 40 percent of that number claim insufficient access to fresh air, the odds are that many reading this magazine will experience this deprivation. <br></div> <h2 class="ms-rteElement-H2">Nature As Elixir </h2> <div>Fortunately this is a problem that is easily solved. In Japan, Shinrin-yoku is meant to be a quiet, relaxing time in nature. A person need not hike to the top of the mountain, but only to sit quietly under a tree and breathe deeply. <br></div> <div><br>One manner is to begin by following the lead of the Japanese government, which promotes 42 forest therapy bases<span></span><span><span></span></span> throughout Japan, thereby encouraging residents and tourists to improve their health. <br></div> <div>What is a forest therapy base? For those in the United States it could be a trip to an arboretum, botanical garden, or even a nearby park. </div> <div><br>Short outings for residents provide many of the benefits and require nothing more than sitting on a bench under a tree.</div> <div><br>If trips are not feasible, then start small by providing manageable outdoor areas, readily accessible to residents and highly visible to staff from the inside. Well-planned small areas can provide tremendous benefits and when properly designed can be safe and cost-effective.</div> <div><br>Most people instinctively understand the benefits of exposure to nature. For many it may be comforting to know that research has legitimized these instincts with science. Quantifiable studies show improvements on a broad scale, as in pain reduction, to small scale, such as cell health. </div> <div> </div> <div><em><img class="ms-rtePosition-1" alt="Patrick Smith" src="/Monthly-Issue/2012/PublishingImages/0512/Patrick-Smith.jpg" style="margin:5px;width:88px;height:135px;" /><br>Patrick Smith, vice president, Pi Architects (www.piarch.com), is Council of Landscape Architectural Registration Board-certified, a member of the American Society of Landscape Architects, a LEED Accredited Professional, and a member of the Society for the Advancement of Gerontological Environments. He can be reached at (512) 231-1910.</em></div>It would be difficult to argue that most people would not be happier and healthier if they could begin each day with a quiet, relaxed breakfast where there was a view of the ocean or the mountains. A peaceful stroll through the woods or a nice garden between the door of a home and the door of a car each day before work would better prepare everyone psychologically and physically for the day’s events. 2012-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0512/design_thumb.jpg" style="BORDER:0px solid;" />Quality;DesignColumn5
Budget Deficits Spur Quality Measurementhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0512/Budget-Deficits-Spur-Quality-Measurement.aspxBudget Deficits Spur Quality Measurement<div>Pay for Performance (P4P) has been an active topic within the health policy community for more than a decade and continues to move, quietly but inexorably, from background to forefront.</div> <div> </div> <div>Despite, or perhaps because of, the swirl of macro-level concerns and headwinds brought on by recession-driven budget deficits and the Accountable Care Act, interest among major payers in the utility of financial incentives to align quality and value in health care purchasing refuses to recede. Sooner or later, nursing home providers will encounter this phenomenon from one or all payers.</div> <div> </div> <div>The evidence to date suggests that under both current and future health financing, performance-based incentives will be featured among all types of purchasing and payment strategies. Thus, it is plainly important that providers actively participate in this issue.</div> <h2 class="ms-rteElement-H2">P4P In The Cards</h2> <div>Even if they plausibly conclude that P4P incentives may not represent either great peril or great promise for them in purely economic terms, providers will likely agree that the use of payment practices to support updated concepts of quality and performance is a worthwhile goal.<br><br></div> <div>The same can be said for the proposition that payers would buy in (literally) to an agenda that acknowledges their responsibility to ensure that payment practices not only provide adequate rates but motivate and support outcomes that meet or exceed minimum standards.</div> <div><br>Traditionally, public policies have relied chiefly on regulatory systems to promote quality or, more precisely, to deter poor quality in long term care. </div> <div><br>Most observers now agree that regulatory prescription and enforcement, while necessary as a safety net enabling public health agencies to discourage or respond to the most egregious examples of non-performance, are not well suited to the broader task of supporting high performance and continuous <br>improvement.</div> <div><br>Hence, there is a growing interest in leveraging the potential of positive incentives, along with transparent public reporting, to motivate and reward better results, viewed from both a quality and value perspective. </div><h2>Emerging State Medicaid Practices </h2><div>My InnerView has monitored P4P developments, specifically in connection with skilled nursing facility payment policy across state Medicaid programs for several years. <br><br>It also has published a series of annual papers tracing those developments while probing important issues related to the design of such programs, how performance is defined and measured, and how financial rewards are structured.</div> <div><br>The most recent analysis is featured in the white paper, “Value Based Purchasing in Skilled Nursing: Current Trends and Initiatives,” published in November 2011. </div> <div><br>The findings that follow are among those addressed in more detail in that paper, which is available from My InnerView.</div> <h2 class="ms-rteElement-H2">How Common Is Nursing Facility P4P Among State Medicaid Programs?</h2> <div>Ten state Medicaid programs have implemented some form of P4P component in connection with their purchase of nursing facility services—Colorado, Georgia, Indiana, Iowa, Kansas, Maryland, Minnesota, Ohio, Oklahoma, and Utah. In this group of programs, several have been temporarily interrupted either to enable design changes or due to budgetary exigencies, but all remain active or set to resume.</div> <div><br>Six additional states have received legislative authorization or have undertaken early-stage developments pointing to adoption of P4P features in the foreseeable future—California, Massachusetts, New York, Texas, Virginia, and Washington.</div> <div><br>If implemented in all 16 states, these programs would impact approximately half of all nursing facilities in the nation, and some 40 percent of nursing home residents. </div><h2>What Are States Measuring As Performance?</h2> <div>State Medicaid P4P schemes include dozens of different metrics organized to include outcomes, structures, and processes. Experimentation and evolution remain the norm. More importantly, there has been coalescence around core performance metrics across these state programs, indicating a response to stakeholder consensus on what matters most as indicators or drivers of quality. <br><br></div> <div>The five most frequently used measures, though differently defined from state to state, are:<br><br></div> <div><strong>1. Staff stability;</strong></div> <strong> </strong><div><strong>2. Customer satisfaction;</strong></div> <strong> </strong><div><strong>3. Regulatory compliance (in terms of prerequisites to participation);</strong></div> <strong> </strong><div><strong>4. Employee satisfaction; and</strong></div> <strong> </strong><div><strong>5. Culture change/person-centered care practices.</strong></div> <div><br>Only five of the 10 active state programs include clinical outcome measures, though most all of them originally did so.</div> <div><br>More recent state P4P designs have included specific support for adoption of nursing home culture change programs, along with frontline staff training and development, including distance learning and peer mentoring programs for certified nurse assistants. These emerging emphases reflect a growing understanding that organizational culture and frontline staff engagement and competencies are key accompaniments of virtually all important outcomes. <br></div> <h2 class="ms-rteElement-H2">What Are Key Considerations For An Effective Program?</h2> <div>The body of experience at the state level yields a number of salient conclusions. In general, P4P is likely to be most effective when linked to measures of performance that are multidimensional; seen as important by payers, providers, and consumers alike; and mutually reinforcing. These attributes can be attained with a fairly economical selection of measures—likely 10 or fewer.</div> <div><br>Whatever the number, each must be succinctly defined, broadly applicable to the universe of facilities covered by the program, and reasonably within their span of control. </div> <div><br>Additionally, performance measurement requires efficient and timely data exchange structures that not only yield information for determining payment awards on a frequent basis (for example, quarterly), but also provide continuous feedback to facilities to inform improvement efforts.</div> <div><br>Where the same or some portion of the performance data are used for public reporting to consumers, a robust information system will enable that important application as well. <br></div> <h2 class="ms-rteElement-H2">What Is the Best Approach To Developing An Effective P4P Program?</h2> <div>There is clear evidence for the wisdom of pre-planning and testing assumptions about how to best align financial incentives with desired outcomes.<br><br></div> <div>First, deciding what to define as significant performance is a proper function of broad stakeholder engagement from the outset.</div> <div><br>Secondly, data resources must be identified and a system of collection, reporting, and analysis created. Current public-domain data are generally insufficient and must be accreted or replaced with new information. This is not difficult or particularly costly, but it is necessary.</div> <div><br>Thirdly, a period of data collection and evaluation should be undertaken prior to linking provider payments to their performance on the selected metrics. If needed, metrics can be altered or targets reset before proceeding.</div> <div><br>Providers and their payers can learn much from what states are doing in the Medicaid realm, lessons that will likely prove valuable in a rapidly changing environment where performance and competitive advantage will be at a premium.</div> <div><br>To receive a free copy of the white paper, “Value Based Purchasing in Skilled Nursing: Current Trends and Initiatives,” which provides more in-depth detail on the topic of pay-for-performance in nursing homes, please visit <a href="http://www.myinnerview.com/">www.myinnerview.com</a>.</div> <div> </div> <div><div>Bruce Thevenot is the founder and principal of Thevenot/ARC Consulting based in Austin, Texas. The firm advises private and public clients on health policy and program issues. He formerly served as Senior Vice President, Strategic Relationships, for My InnerView and continues to serve as a Senior Consultant for the My InnerView and OCS products of National Research Corporation. He can be reached at <a href="mailto:%20bruce@thevenotarc.com">bruce@thevenotarc.com</a>.</div> <div> </div> <div style="text-align:center;"><img src="/Monthly-Issue/2012/PublishingImages/Logos/MIV_logo.gif" alt="" style="margin:5px;width:392px;height:98px;" /> </div> <div> </div></div> <em>This article was written by My InnerView (www.myinnerview.com), a product of National Research Corporation. My InnerView promotes evidence-based management practices in U.S. senior care organizations.</em>Despite, or perhaps because of, the swirl of macro-level concerns and headwinds brought on by recession-driven budget deficits and the Accountable Care Act, interest among major payers in the utility of financial incentives to align quality and value in health care purchasing refuses to recede. 2012-05-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/medical_staff.jpg" style="BORDER:0px solid;" />PolicyColumn5
Fraud Fighters Mine Datahttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0512/Fraud-Fighters-Mine-Data.aspxFraud Fighters Mine Data<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><img class="ms-rteImage-2 ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0512/CS1.jpg" alt="" style="margin:15px;width:241px;height:392px;" /><br>In the federal government’s war on <a href="/Monthly-Issue/2012/Pages/0512/Reform-Law-Arms-Feds-In-War-On-Health-Care-Fraud-And-Abuse.aspx" target="_blank">health care fraud and abuse,</a> the strategy of “pay and chase” is history, according to the Centers for Medicare & Medicaid Services (CMS). The new front on fraud deploys a more proactive approach that officials say will screen out would-be bilkers and streamline the process so that honest providers can better navigate the system.</div> <div><br>But in the wake of the agency’s fraud-fighting fervor, some skilled nursing facility (SNF) providers have been subjected to unprecedented tactics that have frightened staff members and, in some cases, put providers in a state of limbo that has stunted cash flow indefinitely. </div> <div> </div> <div>The new National Fraud Prevention Program is based on a data-mining tool known as predictive modeling, which, according to Peter Budetti, director of CMS’ Center for Program Integrity, utilizes a “twin pillars” approach: On the one side is a largely claims-based analytic system that incorporates a wide range of information for the purpose of identifying unusual patterns, while on the other side it screens providers in “a very efficient manner.”</div> <h2 class="ms-rteElement-H2"><div><strong>Real-Time Analysis, Screening</strong></div></h2> <div>Speaking recently at a briefing in Washington, D.C., Budetti described CMS’ new strategy as “a new generation of activity in which [CMS] is continuing to partner with law enforcement and take administrative action that will interrupt the ability of people to steal from the program.” </div> <div> </div> <div>The purpose of the new approach, he said, is to “make it harder for the bad guys to commit fraud and easier for the good guys to participate.” </div> <div> </div> <div>Launched nearly one year ago, the predictive analytics side of the program, known as the Fraud Prevention System (FPS), processes and monitors 4.5 million claims from Medicare Part A, Part B, and durable medical equipment providers each day using “a complicated and sophisticated set of algorithms to highlight problem areas, to generate alerts that enable the agency to direct its resources accordingly, and to take administrative action,” says Budetti.</div> <div> </div> <div>The system is designed to help investigators identify and analyze billing patterns in real time, in order to stop potentially fraudulent claims before they’re paid, investigate them, and take action quickly. </div> <div> </div> <div>In a <em>Los Angeles Times </em>op ed last year, Budetti outlined how the new approach is working. “First, we’re paying closer attention to who is signing up in the first place,” he said. “Now, before you can become a Medicare provider, you have to go through a rigorous third-party review process that will make sure you have the correct licenses and meet all the requirements to bill Medicare.”</div> <div> </div> <div>The days when you could just “hang a shingle and start billing Medicare are over,” he said. If criminals do get into the system, he added, “they’re now a lot more likely to get caught.”</div> <h2 class="ms-rteElement-H2"><strong>CMS Contractors Take Aggressive Stance </strong></h2> <div>It is amid this backdrop that CMS contractors have been given their marching orders. Among the groups charged with implementing the new agenda is one that has gained a great deal of attention from providers and the attorneys representing them—they are the <a href="/Monthly-Issue/2012/Pages/0512/All-About-ZPICs.aspx" target="_blank">Zone Program Integrity Contractors</a>, or ZPICs. </div> <div> </div> <div>Unfortunately for some providers, ZPIC auditors have been known to use aggressive tactics in their investigations by arriving at facilities unannounced and asking to speak to staff members in the middle of their shifts, for example. </div> <div><img class="ms-rtePosition-1 ms-rteImage-2" alt="Scot Hasselman" src="/Monthly-Issue/2012/PublishingImages/0512/ScotHasselman.jpg" style="margin:10px 15px;width:153px;height:224px;" /></div> <div>“ZPICs are carving out a role for themselves that is perhaps broader than what we would expect from the government itself,” says Scot Hasselman, a partner with Reed Smith, Washington, D.C., and member of the American Health Care Association (AHCA) Legal Committee. </div> <div><br>Hasselman and his colleagues have seen this activity in nursing facilities recently, “where the ZPIC auditors have shown up at a nursing home unannounced and said, ‘Let us see your records.’” This is not typical of a Medicare contractor, he says. </div> <div><br>“Normally, when there is an audit, the company will get a written notification in the mail, they pull the records together, they send them off, and then there’s a response.”</div> <div> </div> <div>Hasselman stresses that the unusual nature of these activities is unprecedented, even for the government. “When we have clients who are investigated, even under the federal False Claims Act, we’ll get a subpoena from the Office of Inspector General [OIG] or the Department of Justice [DOJ], and we’ll have 30 days or more to respond,” he says. </div> <div> </div> <div>“In contrast, we have reports of ZPIC auditors who have shown up in facilities unannounced, asked to see records, and interviewed employees and who have threatened various sanctions against providers if they refuse such requests.”</div> <div> </div> <div>Another tool being aggressively utilized by ZPICs is statistical sampling, in which the auditor reviews a sample of claims, representing perhaps several thousand dollars, and extrapolates that analysis into an assertion that the provider owes the government hundreds of thousands of dollars. </div> <div> </div> <div>“We are aware of companies that have had $8,000 in claims reviewed, and the ZPIC came back and determined that the disallowance is over $1 million,” Hasselman says.</div> <div> </div> <div>Other ZPICs have put providers under a pre-payment review that prevents the facility from billing to Medicare until the ZPIC has reviewed the claims. </div> <div> </div> <div>Pre-payment reviews are a key exercise of ZPICs’ audit authority, Hasselman says. “It means they can suspend payment to you and prevent you from billing in the first place. The problem with this is you don’t have any administrative appeal rights at this point in the process. In contrast, if you have a claim that has been disallowed, then you can go and appeal.</div> <div> </div> <div>“Instead, under a pre-payment review, the ZPIC will say, ‘we’re going to temporarily suspend you from being able to bill until we can review your claims.’” </div> <div> </div> <div>Halting the billing process can damage a provider’s cash flow. “In addition, you’re at their mercy because you’re waiting for them to analyze and make decisions about your claims,” says Hasselman. “So it can be a real challenge because you’re not in a position where you can go before an administrative law judge or a Medicare Administrative Contractor. There’s no remedy until you have a claim that’s disallowed.”</div> <h2 class="ms-rteElement-H2"><strong>What Are ZPICs Looking For?</strong></h2> <div>Attorneys representing SNF providers say the private ZPICs are in hot pursuit of perceived fraud, including the over utilization of therapy, based on what Hasselman describes as “the government’s mistaken belief” that only a very limited percentage of a SNF’s patient population could benefit from high-intensity therapy.</div> <div> </div> <div>“This is a big controversy,” he says, “where a number of providers are being targeted and audited for their provision of therapy services in Medicare skilled nursing facilities.”</div> <div> </div> <div>Hasselman says that ZPICs are zeroing in on SNFs’ use of resource utilization group (RUG) classifications, particularly ultra-high RUGs, “and some will say that if your utilization is over 15 percent or 20 percent it’s a presumption, on the part of the government and the ZPICS, that you’re doing something improper, that it’s fraud.”</div> <div> </div> <div>Most likely at the root of ZPICs’ ardor is a December 2010 OIG report that found “questionable billing practices” on the part of SNFs. In it, OIG asserts that some 26 percent of claims submitted by SNFs were not supported by the medical record and represented some $500 million in “potential overpayments.” </div> <div> </div> <div>Billing by SNFs for ultra-high therapy increased substantially from 2006 to 2008, with 17 percent of all RUGs in 2006 being ultra-high therapy, compared with 28 percent in 2008, the report found. At the same time, SNFs’ use of high therapy (as opposed to ultra-high therapy) dropped from 16 percent in 2006 to 11 percent in 2008. </div> <div><br>Most notable in the report is OIG’s assertion that the jump in higher-paying RUGs was not the result of a change in beneficiary characteristics. In the two-year period studied for the report, OIG claims that the beneficiaries’ ages and diagnoses at admission were “largely unchanged from 2006 to 2008.” </div> <div> </div> <div>Some SNFs also were found to have unusually long average lengths of stay, compared with those of other SNFs, the report said, indicating that “certain SNFs may be routinely placing beneficiaries in higher-paying RUGs regardless of the beneficiaries’ care and resource needs or keeping beneficiaries in Part A stays longer than necessary.”</div> <div><br>Having identified 348 SNFs that were in the top 1 percent, and using at least one of the measures discussed in the report, OIG asserted that for-profit SNFs owned by large chains are most likely to be inappropriately billing.<br><br><a href="/Monthly-Issue/2012/Pages/0512/What-Medicare-Contractors-Are-Looking-For.aspx" target="_blank">What Medicare Contractors Are Looking For</a><br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"><strong>OIG Sniffs Out RUG Outliers</strong></h2> <div>Given their findings, OIG recommended a number of steps that both CMS and SNF providers should take to ease overbilling. Among them: CMS should monitor payments and adjust rates, if necessary; strengthen monitoring of SNFs that are billing for higher-paying RUGs; and follow up on SNFs identified as having questionable billing. </div> <div> </div> <div>In addition, SNFs should consider utilizing “therapists with no financial relationship to the SNF to determine the amount of therapy needed throughout a beneficiary’s stay,” OIG advised. </div> <div> <br>In essence, OIG recommended that CMS look for outliers—providers that are putting what CMS deems to be a high number of patients in ultra-high RUG categories. The problem is, however, that many providers, by virtue of being good at providing rehabilitation therapy, could fit into this category. </div> <div><br><img class="ms-rtePosition-2 ms-rteImage-2" alt="Michael Cook" src="/Monthly-Issue/2012/PublishingImages/0512/MichaelCook.jpg" style="margin:5px;" />Michael Cook, an attorney who specializes in SNF compliance at Liles Parker, a law firm based in Washington, D.C., has seen what appears to be a major push to identify facilities that use ultra-high RUGs in post-acute care. “You have a lot of facilities that focus on these folks, so they may or may not show up as an outlier, but ultra-high RUGs is where they are focusing, so you better have your ducks in a row,” he says.</div> <div><br>“They can slice and dice data in so many different ways that practically any provider can appear to be an outlier,” says Robert Liles with Liles Parker. “Ultimately, they are statistics, and statistics may or may not mean anything. Nevertheless, contractors are heavily relying on data mining to identify providers who are billing differently than they would typically expect.”</div> <div><br>Liles, who specializes in physician practices, uses oncologists as an example. Although there are undoubtedly cases of fraud that will be identified using data mining, Liles is concerned that some providers may inadvertently be targeted, based solely on the fact that the provider has been identified as an outlier. <br><br>“You could have one [oncologist] who is recognized as the best of the best.  His peers may regularly refer him the most complicated cases. In such a situation, you would likely have a provider who is often billing at the highest levels of complexity. The oncologist isn’t necessarily committing fraud, but he would still appear as an outlier when data mining is conducted,” he says.</div> <div><br>The same is true for SNFs, according to Cook. “Since the advent of the sub-acute era in the 1990s and the corrections made to the initial RUGs calculations under the prospective payment system [PPS], many skilled nursing facilities have found that they can create a win/win situation by focusing upon serving patients in the SNF who previously would have been cared for in the hospital setting. Thus, the fact that a facility accepts a substantial number of patients who have ultra-high RUGs may simply be a reflection of rationalizing the best use of the setting.”  </div> <div><br>Nevertheless, it is important that providers fully understand their obligations when choosing to serve as a participating provider. According to Cook, “There are literally hundreds of thousands of pages of laws, regulations, and guidance, which cover the Medicare and Medicaid programs alone.”</div> <div> <br>Moreover, say Liles and Cook, new guidance is issued every day. “As a participating provider, you are obligated to follow each of these rules. Providers who are unwilling to take on these important responsibilities really shouldn’t join the program.” </div> <h2 class="ms-rteElement-H2"><strong>Clinical Decisions Second Guessed</strong></h2> <div>Singling out a facility for a fraud audit based solely on its rate of ultra-high therapy patients is a sign that fraud enforcement is out of sync with CMS policy purposes, Hasselman suggests. “The last decade has seen significant changes in post-acute sites of service,” he says. Imposition of Medicare controls like the 75 percent rule for inpatient rehabilitation facilities has pushed many inpatients needing rehabilitation back to SNFs.</div> <div><br>“At the same time many providers have invested capital into expanding rehabilitation facilities and developed clinical capabilities to service those patients,” says Hasselman. “In addition, there is an increasing body of clinical literature that supports the benefit of high-intensity rehabilitation for long term care patients. Stated otherwise, there is significant evidence that the patient population has, in fact, changed over the time period in the OIG report,” says Hasselman.</div> <div> <br>In spite of these improvements in the standard of care, CMS is concerned about the resulting additional costs, because reimbursement under the SNF PPS is a per diem payment based upon acuity, where acuity is driven in part by resources provided by the facility, to include minutes of therapy, he adds. Given this dynamic, ZPIC, OIG, and DOJ auditors are second guessing the clinical determinations of the facility staff and the independent attending physicians. </div> <div> </div> <div>“Although the government is prohibited from interfering with the practice of medicine, it is commonplace for auditors to substitute the hands-on clinical decision making of the facility’s professionals with that of their own,” Hasselman says, pointing to the Social Security Act, which contains a provision that prohibits the federal government from asserting any control over the practice of medicine.</div> <div> <br>Section 1801 of the act is clear on this point: “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.”</div> <div> <br>“I think it’s a little capricious for [CMS] to say ‘any facility that has more than 50 percent ultra-high RUGs is going to get audited,’” says Karl Steinberg, MD, a long term care physician and multifacility medical director based in San Diego, Calif. “But that’s exactly what they do. The outliers are the ones who will get audited. I’m all for people getting a lot of therapy because usually the more therapy they get, the quicker they get better.”</div> <div> <br>Steinberg, who is vice chair of the American Medical Directors Association Public Policy Committee, calls himself a full-time “SNFologist” because he does not have an office practice and sees patients in 12 nursing homes in San Diego. He points out that SNFs are still saving Medicare money when compared with the cost of therapy in acute rehab facilities. </div> <div> <br>“We’re keeping these people out of acute rehab, basically, which is way more expensive than even the highest RUG rate,” he says. “And I don’t think two hours of therapy a day is excessive for most of the patients I care for.</div> <div><br>“In general, physicians are going to support their patients getting as much therapy as is reasonable,” Steinberg says. “I don’t think there is any big outcry from us as to overbilling or providing unnecessarily rigorous services to our patients.”</div> <h2 class="ms-rteElement-H2"><strong>Preventing Nursing Home Audits</strong></h2> <div>Given the authority that ZPICs appear to have wielded, it is unlikely they will relent in their efforts anytime soon, say Cook and Liles. In addition to ensuring appropriate documentation, they advise clients, including SNFs, to take several steps to ward off an audit or, in some cases, avoid adverse results in an audit. Most important among them, they say, is to conduct a “gap analysis.”</div> <div><br><img width="132" height="142" class="ms-rtePosition-1 ms-rteImage-2" alt="Robert Liles" src="/Monthly-Issue/2012/PublishingImages/0512/RobertLiles.jpg" style="margin:15px;width:143px;" />“Go in, turn the lights on, do a sample of your claims, look at your operations. Are you meeting the current requirements? Yes or no? You’d be shocked at how many organizations have not taken this fundamental initial step,” says Liles. “Notably, those providers who fail to conduct a gap analysis are likely to continue moving down the wrong path—with deficient documentation, coding, and billing practices to show for it.”</div> <div><br>The next step is implementing an effective compliance program, he notes. “Once you have a clear picture of your risk areas, you will be better able to design an effective compliance program. Unfortunately, some providers have chosen to merely copy a template or something they found on the Internet, without conducting a full analysis of the organization,” says Liles. “This approach is likely destined to fail. An effective compliance program must take the provider-specific risks into consideration so that these risks can be avoided.”</div> <div><br>Cook advises providers to have a “well-functioning compliance program” that accounts for the OIG guidance for nursing facilities, especially the areas of risk noted in the guidance. Also, nursing facilities should consider areas of guidance that are specific to other types of providers with which they may interact significantly, such as hospice providers.</div> <div><br>Although the importance of good documentation is not a revelation for SNF providers, he advises clients to make it a priority now more than ever. “At the billing end, if you’re doing high or ultra-high therapy, it’s vitally important that your MDS [minimum data set] matches your care plan, which matches your progress notes, which matches what the therapists are recording in their charts, and that you have appropriate physician orders,” Cook says. <br></div> <div>Staff training is another important aspect of a compliance program, Cook and Liles add. “In addition to the normal training that accompanies a compliance program, staff should be trained about what to do if, and when, auditors arrive at the facility. It is important to keep in mind that you are obligated to cooperate if your organization is audited. While your organization doesn’t have Fifth Amendment rights, the individuals within the organization do,” Liles says.</div> <div><br>“Take care when dealing with government auditors; never lie or make a misleading statement. It is a crime to make a false statement to an OIG agent. Should you feel uncomfortable with the questioning, call your attorney.”</div> <div><br>Moreover, Cook says, it is important to minimize staff anxiety that may occur when auditors arrive, especially as they attempt to question staff. It is crucial to provide advance training to staff and management on how to appropriately handle the situation.</div> <div><br>Additionally, Cook explains that it is important for the facility to ensure that while it provides auditors with the records that they are seeking, the facility should also maintain control of the records that it provides and, to the extent feasible, the records that the auditors copy. “This is critical, among other things, to enable the facility to respond timely and intelligently both at exit and in any review process,” he says.</div> <div> </div> <div>For the purpose of the audit, it is important to designate a point person who is trained on how to handle questions and to ensure that the facility maintains control and knowledge over the records that are reviewed, Cook adds. </div> <div> </div> <div>ZPIC audits are similar to other contractor investigations in that providers have the same administrative appeals available to them as any other Medicare claims audit, Hasselman says. “Just like a Recovery Auditor, you get a regular disallowance and a five-level administrative appeals process. But one of the issues in the appeal can be the statistical analysis,” he says. </div> <div><br>“In other words, if you appeal a determination you appeal the underlying claim, but it is in your best interest to also appeal the statistical extrapolation.” </div> <div><br>Also worth noting is the fact that ZPICs are fraud auditors, he adds. “That’s their only role—to conduct fraud audits, to disallow claims, and to refer matters to DOJ or OIG. If you are the subject of a ZPIC audit, you should assume that they are reviewing your records to evaluate whether you are engaged in fraud,” says Hasselmen. </div> <div><br>“Although providers should treat all audits with seriousness, we recommend that ZPIC audits receive a company’s utmost attention.” </div> <h2 class="ms-rteElement-H2"><strong>Nursing Homes Should Prepare</strong></h2> <div>According to Cook, providers are best advised to be proactive in their efforts to respond to an audit. In addition to an effective compliance plan, providers need to ensure that each patient’s care plan is person-centered and tailored to the beneficiary. </div> <div> <br>“To belabor the obvious, providers should ensure that all care plans created for beneficiaries, especially those areas that address therapy, are tailored to the beneficiary’s individual needs and designed to address the beneficiary’s functional deficits,” he says, “and that the MDS, which drives the RUG assignment, is consistent with these factors. Contractors will be on the lookout for RUG assignments that they believe do not match the resident’s condition.”  </div> <div> <br>In the end, say Cook and Liles, it comes down to quality assurance and compliance plans. “If you put an effective compliance plan in place, you can reduce your risk significantly. The only way to eliminate all risk is to not bill at all,” they say. </div> <div><br>“It’s like a flu shot,” Liles says, “Having a good compliance program doesn’t mean you won’t get the flu, but if you do get the flu, hopefully it won’t be as bad as if you didn’t get a shot.” </div> ​The new National Fraud Prevention Program is based on a data-mining tool known as predictive modeling, which, according to Peter Budetti, director of CMS’ Center for Program Integrity, utilizes a “twin pillars” approach: On the one side is a largely claims-based analytic system that incorporates a wide range of information for the purpose of identifying unusual patterns, while on the other side it screens providers in “a very efficient manner.”2012-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0512/CS1_thumb.jpg" style="BORDER:0px solid;" />Policy;Management;LegalColumn5
Right-Size Staff A Good Bethttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0512/Right-Size-Staff-A-Good-Bet.aspxRight-Size Staff A Good Bet<div>Significant reimbursement cuts, regulatory reform, and an uncertain economy are forcing long term care providers to make the most of every dollar that they possibly can. Controlling labor costs—a provider’s largest operating expense—is a critical priority, now more than ever before. Instead of reducing staff, smart executives are driving efficiencies and cutting unnecessary costs in order to thrive during these challenging times. </div> <div> </div> <div>One of the most effective ways to squeeze costs without reducing head count is right-sizing staff. </div> <div>This means that facility or community management makes sure that they have the right number of people, in the right place, at the right time, all the time. Right-sizing staff day in and day out delivers the savings and efficiencies that can get a long term care organization running at top speed, at the right cost, while maintaining the high-quality care residents deserve.</div> <div> </div> <div>Overstaffing is much more common than one might think. Overstaffing in long term care organizations happens on a daily basis, but often the administrators and executive directors do not believe they are overstaffed. That’s because overstaffing commonly occurs just a little bit at a time—one shift here, one shift there—and it is very hard to see if the provider is using a paper schedule. </div> <div> </div> <div>Many providers overstaff on purpose, in preparation for call-offs, but then rarely cancel shifts if the call-offs do not occur.<img src="/Monthly-Issue/2012/PublishingImages/0512/OnShift-Staffing-article-chart.gif" alt="Overstaffing Adds Up" class="ms-rteImage-1 ms-rtePosition-2" style="margin:30px 10px;width:375px;height:196px;" /></div> <div> </div> <div>While it may seem like nickels and dimes, overstaffing adds up very quickly (<em>see right</em>). Even a minor variance in a provider’s labor budget versus actuals can be significant. For example, if a 100-bed facility is running at 0.1 HPPD (hours per patient day) over budget among direct care staff, reducing it can save approximately $75,000 annually. </div> <h2 class="ms-rteElement-H2">Step By Step</h2> <div>Explore the following steps to identify overstaffing and how to staff appropriately to avoid it in the future. The odds are high that overstaffing is driving up costs in a big way.<br><br></div> <div>Get transparency into staffing levels by understanding supply (staff) and demand (census) in each and every building and location. For skilled nursing providers, HPPD is a good method for identifying staffing levels. For assisted living providers, determine the level of service residents want or need, and roll this up to a summary of required labor hours. <br><br></div> <div>Next, use these measures to compare staffing actuals with a targeted labor budget for each department and position. Identify areas where hours were greater than the target by reviewing historical payroll data by day for a 30-day time frame. Nurses are expensive resources. If the majority of overstaffing is happening with nursing staff, it could be costing significant unnecessary expense. </div> <div><br>Consider acuity among residents when making this determination. A larger number of high-acuity cases may have driven the need for higher staffing levels. Hitting staffing targets is important, but not at the expense of care.</div> <h2 class="ms-rteElement-H2">Study The Odds</h2> <div>Providers need to identify how they became overstaffed. Pull past schedules and see how much overstaffing was built into the schedules at the start of a scheduling period. Review staffing levels at each shift. What patterns can be identified? Is overstaffing common during particular shifts or days of the week?<br> </div> <div><br>With schedules in hand, dig into the processes surrounding scheduling. What census level is the organization staffing to on a regular basis, and how does it correlate to reality? Many providers have experienced a decrease in census in the past several years yet continue to staff at maximum levels.</div> <div>How does the scheduler respond when there is a change in census? It’s common for providers to schedule staff based on a natural census, but oftentimes they do not adjust as the census fluctuates. This alone can lead to additional employees who are not necessarily required.</div> <div><br>Providers increase their chances for success by viewing staffing as a proactive practice and preparing for change at each and every shift. Proper scheduling is key to running a right-sized organization.</div> <div>Modify processes so that schedulers use an estimated future census in order to plan for the right number of staff, with the right qualifications, to stay on target.</div> <h2 class="ms-rteElement-H2">Check Over Established Time Period </h2> <div>Evaluate staffing plans based on a week or pay period, and make decisions based on a projected census and acuity or service levels for that time period. Consider any overstaffing patterns that were identified, and avoid those when building out schedules. <br></div> <div><br>In addition, review the process for filling call-offs. It’s common for schedulers to “plug the hole” left by a call-off, but in looking at the current census, that shift may not have needed to be filled. Establish guidelines that require the census to be reviewed whenever a call-off or unplanned open shift occurs.</div> <div>One of the most important practices to right-sizing an organization is to remain active and involved. Staffing is dynamic and requires day-in and day-out management. Establish a policy that requires staffing levels to be reviewed at the start of each and every shift. <br><br></div> <div>Incorporate a review of the daily and future staffing plan in daily meetings. Review the resident census throughout the course of the day, and make adjustments to scheduled staff based on these requirements. If resident releases are expected in the next shift or day, this presents an opportunity to reduce staff without sacrificing care or resident satisfaction. <br><br></div> <div>What’s great about a right-sized staffing strategy is that it can go beyond nursing into additional departments. Efficiencies and savings can grow significantly through proper staffing across departments.</div> <div>One provider company unknowingly found itself overstaffed by 0.24 HPPD across multiple facilities. This variance represented $3 million in excess costs in one year alone. </div> <div> </div> <div><em>Mark Woodka is chief executive officer of OnShift, a provider of Web-based staff scheduling and shift management software. He can be reached at <a href="mailto:%20mwoodka@onshift.com">mwoodka@onshift.com</a>.</em></div>Overstaffing is much more common than one might think. Overstaffing in long term care organizations happens on a daily basis, but often the administrators and executive directors do not believe they are overstaffed. That’s because overstaffing commonly occurs just a little bit at a time—one shift here, one shift there—and it is very hard to see if the provider is using a paper schedule. 2012-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0512/HR1_thumb.jpg" style="BORDER:0px solid;" />Management;WorkforceColumn5

June


 

 

A Virtual Roundtablehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/A-Virtual-Roundtable.aspxA Virtual Roundtable<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><img src="/Monthly-Issue/2012/PublishingImages/0612/CS1.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:5px 10px;" /><br>For this month’s issue, <em>Provider</em> posed a series of questions to long term care leaders from a number of backgrounds for their views on the state of the sector and how changes in reimbursement, government programs for accountable care organizations and bundled care, and other issues are impacting the way they operate. <br><br>In addition to long term care facility owners and operators, <em>Provider</em> talked to a manufacturer tied to long term care to get a unique perspective on its business prospects in providing goods and services to nursing homes, assisted living centers, and other seniors-centered businesses.<br><br>This “virtual” roundtable gives a snapshot of where the profession stands now and where it looks to be moving in the near term.<br><br>Participants include: Tom Coble—president and chief executive officer (CEO), Elmbrook Management Co.; Charles “Tripp” Francis—administrator, West Markham Sub Acute & Rehab; Robin Hillier—owner, Lake Pointe Rehab and Nursing Center; Shawn Scott—senior vice president for health care corporate sales, Medline HealthCare; and Chris Wright—president and CEO, iCare Management. <br><br><em class="ms-rteForeColor-8">Provider</em>—Have you made any changes to your operations since Medicare cuts went into effect last October?<br><span class="ms-rteForeColor-2"><br><img src="/Monthly-Issue/2012/PublishingImages/0612/Hillier.gif" alt="Robin Hillier" class="ms-rteImage-2 ms-rtePosition-2" style="margin:5px;" />Hillier</span>—My facility is in Ohio, where we saw dramatic Medicaid cuts in the same fiscal year as the Medicare cuts, so we have had to make drastic changes to our operations. <br><br>We had to make the gut-wrenching decision to reduce staffing and employee benefits, we have delayed some investments in new equipment and facility improvements that we were hoping to make, and have tried to identify new revenue opportunities. We continue close monitoring of overtime and routine purchases.<br><br><span class="ms-rteForeColor-2">Scott</span>—As a manufacturer that distributes directly to our customers, we are well-positioned to help our customers in these uncertain economic times. Our mission—no matter what the economic climate—is to provide innovative ways to help our customers drive more efficiencies in their business and reduce costs with new, innovative programs and products. We’ve introduced new programs like abaqis that help facilities manage their risk with QA and readmission, as well as clinical programs to help facilities improve their outcomes, provide education to their staff, and ultimately reduce their costs.<br><br><span class="ms-rteForeColor-2">Francis</span>—I have put more emphasis on vendor relationships and pricing. When looking for vendors for service, we look for those who are associate members of our state and/or national associations because they also have a vested interest in our success as a profession.<br><br><span class="ms-rteForeColor-2">Wright</span>—Besides restructuring our management overhead and cost structures throughout our organization more efficiently, we have developed new clinical programs, focused on clinical staff development initiatives, and made significant capital improvements to several of our nursing facilities to meet the demands of providing care to higher-acuity short-term stay patients and residents.<br><br>Our new clinical program initiatives are partly due to the hospitals’ need to collaborate and work with post-acute care providers in reducing hospital readmissions. <br><br>Organizations, such as ours at iCare, that have the ability to service all aspects of the nursing home residents, including behavioral/chemical abuse, short term, dementia, and clinically complex, will sustain better outcomes overall provided the high-quality initiatives we have implemented are <br>successful.<br><span class="ms-rteForeColor-2"><br>Coble</span>—Yes. We restructured nursing administration and used resident assessment coordinator training to educate our nursing staff on minimum data set changes, proper assessment, and coding of activities of daily living.<br><br><em class="ms-rteForeColor-8">Provider</em>—What is your view on the general state of the long term care industry? Is it strong or extremely challenging, and what ways have you worked to make your business grow in the current climate?<br><br><span class="ms-rteForeColor-2">Hillier</span>—I have worked in long term care since 1986, and this is the most challenging environment that I have experienced. I feel that I am not able to operate my facility the way I want to due to reimbursement constraints and find myself frequently having to choose between options that I would have never considered in the past in order to keep my doors open. <br><br>It is very difficult to choose between providing care at a level that is not up to the standard of quality that I would prefer or closing my doors and depriving the community of the health care services they need. I think there is great opportunity in the future for those of us who can survive the current environment, which is what keeps me going each day. <br><br>Our facility has delved into providing a higher acuity level, focusing on pulmonary services and ventilator care in order to attract a new market and take advantage of the [resource utilization group] RUG IV categories that provide additional reimbursement over what has been available previously. <br><br>This is helping us strengthen our census and increase our average reimbursement rate. This has been especially successful since Ohio is a case-mix state for Medicaid reimbursement. <br><br><span class="ms-rteForeColor-2">Francis</span>—I think the state of long term care has been and will be forever changing, both in regulation oversight and funding. But the overwhelming need for the specialized services of long term care is steadily growing and changing as well. <br><br>We have come to a time when those that we serve are looking for individualized care and services that meet their expectations. We have and will continue changing to meet our customers’ quality-of-life expectations on things such as wireless Internet, dietary fine dining, state-of-the-art rehab services, state-of-the-art nurse call system, and, in the case of our West Markham facility in Little Rock, Ark., we will be providing iPads at bedside for our residents to serve a variety of individual needs.<br><br><span class="ms-rteForeColor-2">Wright</span>—The need for 24-hour skilled nursing care will continue to be essential in the post-acute settings. The extreme challenge for the long term care industry is securing sustainable reimbursement levels in order to provide quality care and generate positive clinical outcomes. The operators of skilled nursing facilities will need to continue to increase their capability to care for the most fragile, medically complex patient. <br><br>The focus for all providers will be to deliver high-quality care that allows patients/residents to remain in the nursing home versus hospitalization. In order to achieve reduced hospital readmissions, we have enhanced our partnerships with APRNs [advanced practice registered nurses], physicians, and physician extender groups and purchased state-of-the-art therapy modalities to achieve better clinical and functional outcomes. <br><br>For instance, our new therapy modalities include a virtual rehab system and cardiac monitoring equipment. The critical need for us at iCare is to remain focused on the ongoing training and education of a workforce comprised of mostly licensed practical nurses, who are now entrusted to provide high-level medical care, with fewer registered nurses in the nursing home environment.<br><br>Our corporate director of education role is more necessary than ever, to ensure all nursing staff attains clinical competencies to provide the level of care that is—and once was—provided in the acute hospital setting. <br><br><span class="ms-rteForeColor-2">Coble</span>—The general state of the long term care industry is extremely challenging. The uncertainty of federal and state budgets, as well as the many new proposed demonstrations generated by the Affordable Care Act, make it very difficult to decide what is the right long term care business model for the future. <br><br>We have focused on post-acute care and have been proactively working with our local hospitals to reduce rehospitalizations.<br><span id="__publishingReusableFragment"></span><br><em class="ms-rteForeColor-8">Provider</em>—Can you describe your quality initiatives and how you are working on possible new goals, like, for instance, from the American Health Care Association’s (AHCA’s) new Quality Initiative* or your own independent efforts?<br><br><span class="ms-rteForeColor-2">Hillier</span>—Prior to the establishment of the AHCA quality agenda, our facility was mindful of trying to control hospital readmissions but did not formally track our rates nor have an actual plan in place to reduce them.<br><br>I appreciate the AHCA agenda for giving us firm goals to achieve, the mechanism to track our progress, and tools to help us be successful. It is exciting to be working toward improving our quality of care, even during these challenging financial times. AHCA has helped me realize that I need to be very specific in my quality goals. Up until now, we have had vague goals to improve quality, but we lacked specific targets and specific time frames to which we were going to hold ourselves accountable. <br><br><span class="ms-rteForeColor-2"><img src="/Monthly-Issue/2012/PublishingImages/0612/francis.gif" alt="Tripp Francis" class="ms-rteImage-2 ms-rtePosition-1" style="margin:5px;" />Francis</span>—Our quality initiatives include pain, consistency of care, falls, wounds, weight loss, and 14 other clinical metrics we track weekly to maintain a high quality of care. Unplanned hospital discharge is also a focus, and we utilize the Interact II** program for that. Our goal is to address these issues weekly and develop action plans as needed to maintain low percentages.<br><br><span class="ms-rteForeColor-2">Scott</span>—Yes, we are excited that AHCA is moving forward with an innovative quality program tied to the four goals released at AHCA’s Quality Symposium in February. We think it’s important our industry sets a high standard of care that is attainable to help improve our image among the general population.<br><br>It’s equally important to have our leaders at the table with CMS [the Centers for Medicare & Medicaid Services] to help set the benchmarks for these quality standards that will one day reflect our reimbursement levels. At Medline, we are working hard to develop programs based on the four quality goals. <br><br>As a vendor, we have an obligation to the long term care industry to help meet these challenges by developing programs to help staff become more efficient so they can spend more time at the bedside with the residents, help provide clinical support to help meet the oversight of their quality goals, and introduce new products to help improve the quality of life for those residents we care for. <br><br><span class="ms-rteForeColor-2">Wright</span>—Our facilities at iCare have focused on interdisciplinary continuous quality initiatives that have surfaced based on our customers’ feedback. The satisfaction surveys we obtain through My InnerView establish the framework for our ongoing CQI [continuous quality improvement] process. This enables our teams to evaluate all aspects of our care delivery and create opportunities for change and improvement. <br><br>The strong emphasis on homelike environments has given us the chance to take a hard look at the once very institutional environments that now need to service the baby boomer generation. Thus, the need for significant capital expenditures, including major facility face-lifts and renovations to our aging nursing homes, is also part of the efforts to improve quality. The enhancement of dining, activities, and treating each patient as an individual to meet their specific needs and expectations is more prevalent than ever in providing good customer satisfaction.<br><br><span class="ms-rteForeColor-2">Coble</span>—We have adopted the AHCA Quality Initiative as our organization’s quality goals. We have used Interact II in our facilities for the past couple of years as a tool not only for avoiding rehospitalizations but also for avoidable hospitalizations. We have both nurse practitioners and physician assistants deployed in our facilities and will use them to assist in the reduction of the use of off-label antipsychotics.<br><br><span class="ms-rteForeColor-8"><em>Provider</em></span>—Have you seen an impact on your business from new government programs under the health care reform act? Are you looking at taking part in an accountable care organization (ACO) or any other new initiative in the near future?<br><br><span class="ms-rteForeColor-2">Francis</span>—Health care services are continuing to evolve in both how they are delivered and how providers work together on the best outcomes for those who need a wide range of services from end-of-life care, to short-term rehab, to home or work. <br><br>So, as we continue to provide services in our communities, we are aligning ourselves with other health care providers so that we have the networking in place to meet the needs of our customers.<br><br><span class="ms-rteForeColor-2"><img src="/Monthly-Issue/2012/PublishingImages/0612/wright.gif" alt="Chris Wright" class="ms-rteImage-2 ms-rtePosition-2" style="margin:5px 10px;" />W</span><span class="ms-rteForeColor-2">right</span>—The federal government has done a poor job of clearly demonstrating the steps nursing home providers must take to be successful. In my opinion, this is due to continued gridlock by Congress and the executive branch, which has done nothing but politicize issues. Therefore, this inaction and uncertainty have made it very complicated for nursing home providers to foster real change that will assure us sustainable reimbursement levels as we improve quality care for our residents and patients.<br><br>The government needs to set out clear, achievable steps that allow providers to better plan their business and have clear strategic objectives for success. <br><br>Regarding ACOs, yes, we are developing partnerships and alliances with our medical community, such as hospitals, physician groups, home care, etc., that are considering being an ACO. We have been working hard to ensure our facilities are part of any ACO networks in our market service areas. <br><br><span class="ms-rteForeColor-2">Coble</span>—The only impact we have currently seen from the new government programs is the large amount of time required to try to understand and evaluate them. We operate in a rural area. Most of the programs currently under development will happen in urban settings, but we understand the future payment models will change, and we look forward to participating.<br> <br><span class="ms-rteForeColor-8"><em>Provider</em></span>—What are your staff retention and hiring programs like? Have you had success in finding and keeping qualified nurses and other staff?<br><br><span class="ms-rteForeColor-2">Hillier</span>—This has been a real challenge for us in the past year due to the reductions we have had to make in staffing and benefits. But I am extremely grateful to the staff who have stayed with us and continue to be loyal to our residents. I look forward to the day when the environment improves and I can provide the staffing, benefits, and retention incentives that my staff deserve.<br><br><span class="ms-rteForeColor-2">Francis</span>—I think the key to retaining staff is to create a culture in the workplace that promotes positive outcomes for our residents and gives our staff a sense of pride in their work. Most all of the special and caring individuals that work in health care are called to do this work and really take pride in outcomes and patient and family satisfaction results. <br><br><span class="ms-rteForeColor-2">Wright</span>—We at iCare have very low staff turnover due to paying and providing better benefits to our employees than the national average for nursing home staff. Our new clinical program initiatives, staff development programs, and physical plant renovations have also made it more attractive to recruit quality staff.<br><br><span class="ms-rteForeColor-2">Coble</span>—Our staff is the most valuable asset of our organization. We face the same challenges other rural health care providers do but have been fortunate that we have been able to hire and retain not only qualified but also very caring and compassionate staff.<br><span id="__publishingReusableFragment"></span><br><span class="ms-rteForeColor-8"><em>Provider</em></span>—What is the best part of running your company? <br><br><span class="ms-rteForeColor-2">Hillier</span>—The reason why I love working in long term care is that I have the opportunity to make a difference in someone’s life every single day.<br><br>Some days I can contribute to a positive outcome with a resident, some days I can provide emotional support or information to a distraught family member, some days I can help a staff member deal with a challenge in their life, and some days I can provide support or comfort to a fellow owner who is frustrated or overwhelmed. But every night when I go to bed, I know that in some small way I made a difference in someone’s life that day. I cannot imagine anything more rewarding.<br><br><span class="ms-rteForeColor-2">Francis</span>—Certainly, taking care of the elderly is our top priority. The rehabilitation aspect of the care is important, too, as it promotes independence and quality of life for any elderly person that is able to return home after an illness. Being able to meet or exceed our residents’ and families’ expectations is what drives me. <br><br>“Making every day of life count” is what my goal is each and every day for those that I have the pleasure of serving. I would focus a bit on people that work in this industry since they have to have a love or a “calling” to work in the long term care setting.<br><br><span class="ms-rteForeColor-2">Wright</span>—The best part is leading and being a part of a great team of senior management staff that is caring, creative, and knows how to implement change and make operational decisions, whether it is due to reimbursement constraints or meeting the needs and improving quality of care to our patients and residents. The balance between reimbursement reductions and quality outcomes is a delicate issue. <br><br>Therefore, iCare’s 2012 company motto is “Great people deliver great quality, which results in great sustainability and great financial performance.” So building and being a part of a group of great people is very rewarding to me.<br><br><span class="ms-rteForeColor-2">Coble</span>—The best part of running our company is the interaction with our staff, residents, and their families. Our base of operations is the community where I was born, raised, and have lived all my life. I have the honor and privileged to help take care of those who helped me grow into who I am.<br><br><span class="ms-rteForeColor-8"><em>Provider</em></span>—Name one thing that you would change, be it a reimbursement program cut or a regulation, that would improve your ability to take care of residents and run your operations.<br><br><span class="ms-rteForeColor-2">Hillier</span>—I would love to see the introduction of Boren-type language back into the federal regulations that would require the Medicaid program to cover the costs of efficiently run facilities, with a reasonable definition of who is efficient. Many Medicaid reimbursement programs throughout the country have been either constrained or cut for so many years in a row that it has become almost impossible to provide care at any reasonable level of quality. <br><br>If CMS is going to continue to consider the profit margin being earned on the skilled nursing facility PPS [prospective payment system] as a reason to restrict or reduce Medicare rates, there needs to be some requirement on the other hand for Medicaid to pay its fair share.<br><br><span class="ms-rteForeColor-2">Francis</span>—We continue to work closely with our associations to carry the torch, if you will, on getting the word out to our legislators and our communities on the value of our services to the country’s most frail and elderly and those that got us where we are today.<br><br><span class="ms-rteForeColor-2">Wright</span>—Stop the constant bureaucratic review. Change the regulatory system to one that assumes compliance and innovation rather than one that checks providers every step of the way. There is far too much overhead at both the Medicaid and Medicare offices. Resizing these two areas of government will save money to taxpayers and allow these agencies to properly reimburse providers. A possible solution is that these agencies should regulate in an IRS-style method—very few providers audited and reviewed—with severe penalties for egregious offenses. <br><br><span class="ms-rteForeColor-2">Coble</span>—Remove the three-day stay requirement for a qualifying skilled nursing stay.<br> <br><span class="ms-rteForeColor-8"><em>Provider</em></span>—How have new technologies affected your care programs?<br><br><span class="ms-rteForeColor-2">Hillier</span>—New technology has been beneficial in helping us be more efficient in the assessment process, as well as monitoring and creating efficiencies in our purchases. I think there is tremendous opportunity for technology to improve our operations, but often this requires a significant investment, which is getting harder and harder to find.<br><br><span class="ms-rteForeColor-2">Francis</span>—Moving toward an EMR [electronic medical record] allows the nursing staff more time with the resident. It also enhances communication to internal caregivers and external health care providers that work with us in providing continuity of care. I think technology is the tipping point in service provided by any provider. Our ability to meet the customers’ demands and expectation in a setting that they require, and on their time schedule, is crucial. <br><br>As an example, how many of our families communicate through the Internet? For a family who has to place a loved one in a skilled facility, how nice would it be to Face Time them at any time during the day or night? This will not only give the family a sense of peace but also give our residents the security and confidence they need to focus their attention on what they need to do for recovery.<br><br><span class="ms-rteForeColor-2">Wright</span>—New technologies are great! However, as of yet, the federal government has not provided clear programming and file formatting criteria to allow these technologies to integrate well. <br><br><span class="ms-rteForeColor-2">Coble</span>—Telemedicine in rural areas has had many false starts over the years. We look forward to embracing any opportunity to improve the quality of care we can provide.<br><span id="__publishingReusableFragment"></span><br><span><span class="ms-rteForeColor-2"><img src="/Monthly-Issue/2012/PublishingImages/0612/Scott.gif" alt="Shawn Scott" class="ms-rteImage-2 ms-rtePosition-2" style="margin:5px 10px;" /></span></span><em class="ms-rteForeColor-8">Provider</em>—How would you describe the business climate for long term care heading into the summer of 2012?<br><br><span class="ms-rteForeColor-2">Scott</span>—Between now and the end of the election, I don’t think we’ll see any major changes in the business climate. But we are seeing our customers adapting to the reimbursement changes that occurred in the fall of last year and the beginning of this year.<br> <br><em class="ms-rteForeColor-8">Provider</em>—How do you think long term care can become a more prominent issue for the upcoming election season?<br><br><span class="ms-rteForeColor-2">Scott</span>—With health care being such a significant part of the federal and state budgets, and health care reform so top of mind, health care will remain a prominent issue before, during, and after the election.<br><br>Also, with thousands of baby boomers entering our marketplace every day, health care, and especially long term care, will become a priority with our elected officials, if it hasn’t already. It is imperative for the leadership of AHCA to bring CMS creative ways to look at reducing these deficits without financially hurting our segment. By working alongside CMS as a partner to attain common goals, we can help assure ourselves of a sound financial future. <br><br>These five stakeholders in the business of caring for, and providing goods and services to, the country’s elderly and frail and those with disabilities have given their views during what is not only a crucial time for the long term care sector, but also for the country as the nation ages and people seek new ways to live in their later years.<br><br>The numbers of Americans becoming senior citizens and much older is staggering, and from the opinions expressed above there is a cautious optimism, a steadfastness offered by the providers and vendor Provider talked to about being able to get the job done, and done right. <br><br><em>Patrick Connole is a Provider contributing editor.</em> Provider posed a series of questions to long term care leaders from a number of backgrounds for their views on the state of the sector and how changes in reimbursement, government programs for accountable care organizations and bundled care, and other issues are impacting the way they operate. 2012-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0612/CS1_thumb.jpg" style="BORDER:0px solid;" />Quality;Management;WorkforceColumn6
Senate Aging Explores LTC Financing Solutionshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/Senate-Aging-Explores-LTC-Financing-Solutions.aspxSenate Aging Explores LTC Financing SolutionsThe U.S. Senate Special Committee on Aging held a recent hearing to explore how to balance the long term care needs of Americans with the country’s need to reduce debt and deficits. <br><br>In his opening statement, Committee Chair Herb Kohl (D-Wis.) said in an era of debt reduction, a rapidly aging population, and Medicare and Medicaid paying for the bulk of long term care, how could these programs become more efficient?<br><br>“As we look ahead, we’re going to have to do more with less,” he said, pointing to improving the efficiency of the government programs through reducing unnecessary hospitalizations, delaying or avoiding the use of institutional long term care services, and expanding home- and community-based services. <br><br>In a written statement submitted to the committee, the National Center for Assisted Living (NCAL) explained that a Centers for Medicare & Medicaid Services proposed rule has the potential to significantly increase long term care costs by eliminating assisted living providers from state Medicaid waiver programs. NCAL explained that the proposed rule’s impact “would significantly reduce long term care options for Medicaid beneficiaries, while potentially raising the cost of providing Medicaid coverage for the federal and state governments.”<br><br>Panelists also discussed encouraging the purchase of long term care insurance. The U.S. Senate Special Committee on Aging held a recent hearing to explore how to balance the long term care needs of Americans with the country’s need to reduce debt and deficits. 2012-06-01T04:00:00ZFinanceColumn6
SNFs To See 2013 Medicare Hike In Market Baskethttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/SNFs-To-See-2013-Medicare-Hike-In-Market-Basket.aspxSNFs To See 2013 Medicare Hike In Market BasketSkilled nursing facilities (SNFs) are expected to get a reprieve from the Centers for Medicare & Medicaid Services’ (CMS’) annual rulemaking on Medicare payment changes for the coming fiscal year. <br><br>Sources at the agency have said that instead of publishing a proposed rule for fiscal year 2013, CMS will issue an Update Notice for the SNF Prospective Payment System. The notice, which will be published by July 31, is expected to include a SNF market basket update of about 1.8 percent, with no other policy changes. <br><br>“CMS recognizes the struggles we have undergone and the importance of returning stability to the profession,” said Gov. Mark Parkinson, American Health Care Association (AHCA) president and chief executive officer.<br><br>AHCA has been working closely with CMS on the 2013 payment rule since last fall, explaining the financial predicament of members and seeking a greater level of understanding between the agency and the long term care profession. ​​Skilled nursing facilities (SNFs) are expected to get a reprieve from the Centers for Medicare & Medicaid Services’ (CMS’) annual rulemaking on Medicare payment changes for the coming fiscal year. 2012-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/Headshots/Parkinson.jpg" style="BORDER:0px solid;" />PolicyColumn6
The QIS Experthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/Tracking-Use-Of-Antipsychotics.aspxThe QIS ExpertQ. How does QIS address the use of psychoactive medications?<br><br>A. QIS has included investigations related to the use of antipsychotic medications since it was first implemented in 2007. <br><br>During Stage 1 of QIS, quality-of-care and quality-of-life indicators (QCLIs) measure use of benzodiazepines and antipsychotics. <br><br>These two QCLIs, which are contained in the Census Sample Record Review, include “Benzodiazepine Use” and “Antipsychotic Use without a Supporting Diagnosis.” The latter is consistent with the recently announced American Health Care Association Quality Initiative goal to safely reduce the off-label use of <br>antipsychotics.<br><br>The first QCLI, QP066, calculates the rate of Census Sample residents who are receiving benzodiazepines. This QCLI is a screen to identify facilities that have a high rate of sedative/hypnotic use so that further review in the second stage is targeted on facilities with high use rates. If the rate of benzodiazepine use exceeds the Stage 1 threshold, then benzodiazepine use is more fully reviewed using the Stage 2 psychoactive medications pathway. <br><br>The second QCLI, QP063, is not based on all census sample residents, but instead selects only those who are receiving one or more antipsychotic medications (the denominator). For those residents in the census sample who are receiving an antipsychotic medication, the QCLI calculates the proportion of residents who do not have a documented diagnosis reflecting psychoses based on a specific list of diagnoses (schizophrenia, psychotic mood disorder, acute psychotic episodes). Thus, the focus of this QCLI is to identify the rate of off-label use of antipsychotics. <br><br>If the threshold is exceeded, then antipsychotic use is more thoroughly investigated using the Critical Element Pathway in Stage 2 for Psychoactive Medications.<br><br>The Critical Element Pathway investigation for Psychoactive Medications is comprised of resident observations, resident/family interviews, and staff interviews. These investigations yield an evaluation of the Critical Elements: Assessment, Care Planning, Care Plan Implementation, Care Plan Revision, and Provision of Care and Services related to psychoactive medication use. In addition to application of the F-Tag determinations relating to the critical elements (F272, F279, F282, and F280), the determination of whether staff provided care to prevent adverse effects and use only necessary antipsychotic, anti-anxiety, and/or hypnotic drugs is made for F329. <br><br>Physician care is addressed through F385 and F386 as well as F501 because of the critical role of physicians in use of psychoactive medications. Pharmacy review is also included in this CE pathway, F428. The inclusion of all these F-Tags acknowledges that this is a multidisciplinary issue. <br><br><em>Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).</em>These two QCLIs, which are contained in the Census Sample Record Review, include “Benzodiazepine Use” and “Antipsychotic Use without a Supporting Diagnosis.” The latter is consistent with the recently announced American Health Care Association Quality Initiative goal to safely reduce the off-label use of antipsychotics.2012-06-01T04:00:00Z<img alt="Andy Kramer, MD" src="/Breaking-News/PublishingImages/headshots/AndyKramer.jpg" width="1248" style="BORDER:0px solid;" />QualityColumn6
2012 Top 40 Assisted Living Companieshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/2012-Top-40.aspx2012 Top 40 Assisted Living Companies<div>Landing the No. 1 spot this year on<em> Provider’s </em><a target="_blank" href="/reports/Documents/2012/0612_Top40.pdf">Top 40 Largest Assisted Living Companies </a>list is Brentwood, Tenn.-based Brookdale Senior Living, replacing Emeritus, which occupied the top spot last year for the first time. </div> <div> </div> <div>Emeritus Senior Living, Seattle, moved down just one place to No. 2 this year, while Sunrise Senior Living, McLean, Va., made the No. 3 slot and is followed by Atria Senior Living, Louisville, Ky. </div> <div><br>The remaining Top 10 contenders are largely the same as last year, with the exception of Dallas-based Capitol Senior Living, which jumped up from No. 14 last year to push out Life Care Services, The Woodlands, Texas, for No. 10 this year.</div> <div><h2 class="ms-rteElement-H2">Optimism Continues</h2> <div>The expansion of ancillary services and specialty care among assisted living providers continues at a steady pace this year, with companies citing, as they did last year, an optimistic outlook for the sector. <br></div> <div><br>Emeritus’ 2011 annual report is once again bullish on assisted living. The company believes that the sector will continue to benefit from several trends, including changing family dynamics, in which “the geographical separation of senior family members from their adult children correlates with the geographic mobility of the U.S. population. As a result, many families that may have provided care to senior family members in their homes are now unable to do so,” says the report.</div> <div> </div> <div>Also cited is a “supply/demand imbalance.” The senior population, Emeritus contends, continues to grow significantly, while the supply of assisted living units is not growing at a similarly rapid rate.<br></div> <div><br>“We believe that high construction costs, costs and availability of capital and credit, and the cost of liability insurance for smaller operators have constrained the growth in the supply of assisted living facilities,” the report says. </div></div> <div><h2 class="ms-rteElement-H2">Innovation Still In Play</h2> <div>Integral Senior Living, Carlsbad, Calif., will continue to implement Generations, a program based on person-centered care, while providing engaging and stimulating environments through dining and activity programs for those with memory loss.</div> <div> </div> <div>Both Capitol Senior Living and Ridgeline Management, Eugene, Ore., are implementing elder-directed care “inspired by the Eden Alternative.”</div> <div> </div> <div>Among the 40 providers on this list, 24 also offer nursing home care and 15 provide post-acute care. Not surprisingly, the bulk of the companies on this year’s Top 40 also offer memory or dementia care services. </div> <div> </div> <div>For 35 of this year’s Top 40 largest companies, independent living is an ancillary business option, compared with 33 last year. In addition, 15 companies this year offer pharmacy services, while that number was 12 last year. Up from 17 last year, 21 companies now offer hospice care to residents, while 16 offer home care.</div> <div> </div> <div>This year’s lineup represents a resident capacity of more than 208,000 and more than 2,340 buildings. <br></div></div>The remaining Top 10 contenders are largely the same as last year, with the exception of Dallas-based Capitol Senior Living, which jumped up from No. 14 last year to push out Life Care Services, The Woodlands, Texas, for No. 10 this year.2012-06-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Management;FinanceFinance6
2012 Top 50 Largest Nursing Facility Companieshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/2012-Top-50.aspx2012 Top 50 Largest Nursing Facility Companies<div><br>The reimbursement outlook may still be a bit shaky for nursing home providers, but this year’s Top 50 kept up a steady pace in the ranking of the <a href="/reports/Documents/2012/0612_Top50.pdf" target="_blank">2012 Largest Nursing Facility Companies</a>. Among the top 10 contenders this year are the same companies as last year, with one exception: The Ensign Group, based in Mission Viejo, Calif. A newcomer to the Top 10, Ensign gained a bed count of 1,351, knocking out another California provider, Skilled Healthcare Group, from Foothill Ranch to take over the No. 10 spot.<br><br></div> <div>Among the top nine slots this year were two changes: Atlanta-based SavaSeniorCare switched places with Sun Healthcare Group, Irvine, Calif., which slid down to No. 7 while Sun moved up to No. 6.<br><br>Skilled Healthcare landed in the No. 12 spot this year, just behind No. 11, Murfreesboro, Tenn.-based National HealthCare Corp.</div> <div> </div> <div>Making their debuts in the Top 50 this year are No. 30, AdCare Health Systems, Springfield, Ohio, and Tampa-based Opis Management Resources, at No. 44. </div> <div><h2 class="ms-rteElement-H2">Rehab Still Popular</h2> <div>Just as the addition of business such as assisted living has gained a foothold in the skilled nursing sector, so has rehabilitation therapy. And this year is no exception, as providers continue to report the addition or renovation of facilities for the purpose of adding or expanding rehab suites in order to keep up with baby boomer demand. </div></div> <div> </div> <div>At least 18 providers are planning to add rehab suites to their business lines. No. 17, Alisa Viejo, Calif.-based Covenant Care, will add rehab suites, remove nurses’ stations, and add Wi-Fi and private suites as part of its renovation plans.</div> <div> </div> <div>Miller’s Health Systems, No. 34, Warsaw, Ind., will add rehab suites and home care services to its services.</div> <div> </div> <div>Culture change initiatives continue to take hold in the sector, with at least a dozen providers reporting that they are incorporating such endeavors. No. 29, Duluth, Minn.-based Benedictine Health System, for example, is adding “more collaborative programs to help residents stay independent and engaged as they age,” while the Evangelical Lutheran Good Samaritan Society, No. 9, Sioux Falls, S.D., is implementing consistent assignment staffing in its facilities.</div> <div> </div> <div>In addition, many companies have plans to remove nurse stations and revamp dining programs.</div> <div><h2 class="ms-rteElement-H2">Ancillary Services Steady</h2> <div>The list of this year’s Top 50 nursing facility companies represents more than 400,000 beds and some 3,500 facilities, and the Top 10 providers alone represent 235,000 beds. </div> <div> </div> <div>The expansion of ancillary services, which has become a mainstay of the profession, continues. Bariatric care, which was offered by 23 companies last year, is now on the menu of services for 26 providers. </div> <div> </div></div> <div>Twenty-three companies provide ventilator care in their facilities this year, compared with 20 last year. Dialysis, offered by 19 on last year’s list, compares with 18 this year.</div> <div><br>Provider’s annual list of the Top 50 Largest Nursing Facility Companies is ranked by bed count as of Dec. 31, 2011. </div>The reimbursement outlook may still be a bit shaky for nursing home providers, but this year’s Top 50 kept up a steady pace in the ranking.2012-06-01T04:00:00ZManagement;FinanceFinance6
Chianese Plays Tough Guy, But Has Soft Touch In Real Lifehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/Chianese-Plays-Tough-Guy.aspxChianese Plays Tough Guy, But Has Soft Touch In Real Life<img class="ms-rteImage-1 ms-rtePosition-1" alt="Dominic Chianese" src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/Dominic.jpg" style="margin:5px 10px;width:190px;height:206px;" />Dominic Chianese, an actor whose long line of movie and television credits include Junior Soprano in the hit show, “The Sopranos,” visited the American Health Care Association on April 18 to discuss his foundation, Joy Through Art, which brings music and theater arts to nursing facility residents.<br><br>“It’s what I call a social mission to bring joy into their lives,” said Chianese, in an interview with Provider magazine’s Meg LaPorte. Chianese has been appearing in television roles since 1964. His big screen credits include “Godfather Part II,” “Dog Day Afternoon,” and “All the President’s Men.” He has been performing in nursing facilities for more than 30 years, singing and playing guitar. Collections of his music include the CDs “Ungrateful Heart” (2003) and “Hits” (2001).<br><br>Joy Through Art “hires professional artists to visit residents,” says the program’s website. “Like Dominic, the artists are more than entertainers, they become family.” The artists “become a social support system that helps to fulfill the emotional needs of the patients on a personal level,” the website says. “Art and entertainment, friendship and bonding, help residents to maintain better health.”<br><br>To learn more about Joy Through Art, visit <a href="http://www.joythroughart.org/" target="_blank">www.joythroughart.org</a>. <em>Provider’s</em> interview with Chianese is available on <a href="http://www.youtube.com/watch?v=q2oYJq50oW8&feature=channel&list=UL">You Tube</a> or can be viewed in the video section of the magazine’s website, <a href="/">www.providermagazine.com</a>.Dominic Chianese, an actor whose long line of movie and television credits include Junior Soprano in the hit show, “The Sopranos,” visited the American Health Care Association on April 18 to discuss his foundation, Joy Through Art, which brings music and theater arts to nursing facility residents.2012-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/Dominic_thumb.jpg" style="BORDER:0px solid;" />Quality;Culture Change;Quality ImprovementColumn6
Leadership Strategies That Stickhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/Leadership-Strategies-That-Stick.aspxLeadership Strategies That Stick<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div>Be Willing To Collaborate<h2></h2> <div>Before presenting the strategies, it is important to identify the attributes required to successfully usher an organization through change. Because it is important for leaders to invite and integrate the insights of multiple stakeholders, collaboration is key in charting the course. <br></div> <div><br>Yet, this can be very difficult for many. Keith Knapp, PhD, chief executive officer of a long term and post-acute care company, sums it up very well when he says, “The key element in culture change is getting people who are accustomed to being at the helm to get over it, to get over being in charge.” <br></div> <div><br>His company uses a novel approach to help leaders become more humble. Administrators and senior managers have to serve as certified nurse assistants (CNAs). They have to actually go through the CNA training. And during CNA Appreciation Week, executives, including the chief executive officer, switched roles with the assistants for a shift. </div> <div><br>Knapp says this honored the assistants, provided comic relief, and humbled many executives. It also allowed executives to experience life from another perspective. It reminded them of what it is humanly possible to accomplish when it comes to providing quality care.</div> <div><br>They now know it is about far more than mandated staffing ratios. Knapp says the experience gave decision makers valuable information for resource allocation during the budgeting process.</div> <h2 class="ms-rteElement-H2">Persuasion, Accountability</h2> <div>The second attribute of a good leader is the ability to inspire people to want to change their behavior and their thoughts. Leaders able to convince and persuade others have a significant advantage when working to transform their organizations. They can build a critical mass of like-minded innovators much more quickly than less compelling leaders. <br></div> <div><br>This inspiration happens through deeds, not rhetoric or elegant calls to action. <br><br></div> <div>The third attribute is what Michael Mankins and Richard Steele describe as “the ability to demonstrate ethics, integrity, and compliance.” In an era where playing fast and loose with rules has become the norm, employees easily become disheartened when they discover that their leaders have questionable ethical standards. </div> <div><br>In order to be credible as a change leader, it is important to uphold the highest standards. This means taking the high road even when it is difficult. Compliance is of critical importance in a profession such as long term care. </div> <div><br>The fourth and final attribute also comes from the work of Mankins and Steele. They suggest that leaders must be able to innovate resourcefully.  </div> <div><br>Few companies have limitless resources so it is vital that the scarce assets available be used with care. Note that a scarcity of resources does not have to translate into a scarcity of innovations. Creative executives can work within the confines presented to develop advancements.</div> <h2 class="ms-rteElement-H2">Sustainable Change</h2> <div>An excellent starting point for creating sustainable change includes building realistic plans with realistic expectations. <br></div> <div><br>Reality-based planning begins with the analysis of available resources—financial, human, and technological—and then devises strategies based on what is accessible. </div> <div><br>This reduces frustration because everyone involved in the change initiative is clear on what they have to work with. They can also begin a quest for identifying additional resources, such as tapping into networks of vendors, professional associations, and academics to help garner additional resources.</div> <div><br>The next strategy is to utilize a comprehensive approach to change. A string of disconnected, one-shot improvements that are not linked to larger initiatives do not produce lasting change at the core of the organization. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Tie Changes To Results</h2> <div>A comprehensive change initiative is one that clearly reflects the organization’s strategy, mission, and core values. It involves a well-developed multi-year, multi-level approach to altering services, systems, and structures. It also includes methods for measuring success and for recalibrating as needed.<br></div> <div><br>Knapp says that measurement is critical. He contends that people are caught up in describing activities but have not connected the dots in terms of key metrics like retention, employee engagement, and resident and family satisfaction. Any change effort should positively impact these important measures. According to Knapp, the follow through and fortitude to circle back and track whether it sticks or whether there has been backsliding is often a missing link. <br></div> <div><br>Additionally, the best comprehensive approaches involve multiple stakeholders. Their insights are blended and thoroughly integrated into the entire change effort. The involvement of stakeholders is an important consideration when launching large-scale change initiatives such as the culture changes currently touted in long term care. It is essential that stakeholders’ voices be heard. The change must have meaning to multiple constituencies if it is to be widely adopted. </div> <div><br>It is tempting to allow a visionary with a forceful personality to lead the charge. But if that visionary lacks the capacity to connect with the people on the receiving end of the change and the people responsible for day-to-day execution, the change will be short lived.</div> <h2 class="ms-rteElement-H2">Grow Your Leaders</h2> <div>Building leaders at all levels is an essential strategy in creating sustainability in any change initiative. Tampa-based Opis Management Resources operates 10 skilled nursing facilities and one assisted living center throughout the state of Florida. They have built multiple levels of leadership by launching a multi-year Managing in the Middle program to build the competence of middle managers and supervisors. The customized sessions were designed to reinforce the corporate mission, establish sound management principles, and create a service-oriented culture characterized by coaching. </div> <div><br>Recognizing the continuing need to build leadership, the company utilizes Leadership Learning Circles to build the strengths of the executive team. Each executive participates in in-depth learning of the principles required to advance the corporate culture. </div> <h2 class="ms-rteElement-H2">Discern And Pursue </h2> <div>The final strategy for developing real culture change is exercising discernment. While it is tempting to follow every trend that emerges in the profession, the most successful organizations determine what is best for them. By having a keen understanding of the organization’s strengths, weaknesses, and peculiarities, leaders are able to divine which innovations are really suitable for their company. Resist the temptation to adopt a flavor-of-the-month approach to culture change. </div> <div><span><span><img src="/Monthly-Issue/2012/PublishingImages/0612/JoanneSmikle.jpg" alt="Joanne Smikle" class="ms-rteImage-2 ms-rtePosition-1" style="margin:15px 5px;width:133px;height:161px;" /></span></span><br>Discern which approach is best for the situation and then faithfully pursue that course. Better still, draw on the innovators within the organization and craft ingenious approaches. If the strategies are developed from within, they are more likely to take root and blossom. </div> <div> <br><br></div> <div><em>Joanne L. Smikle provides insightful consulting and leadership education to long term care companies across the country. Visit <a href="http://www.smiklespeaks.com/">www.smiklespeaks.com</a> or reach her at <a target="_blank" href="mailto:joanne@smiklespeaks.com">joanne@smiklespeaks.com</a> or (301) 596-3140.</em></div> Business models must change. In order for that to happen, leaders have to develop practical approaches for launching sustainable change. 2012-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0612/mgmt_thumb.jpg" style="BORDER:0px solid;" />Management;WorkforceColumn6
The MDS 3.0 And Its Impact On Bladder And Bowel Carehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/MDS-3-0-And-Its-Impact-On-Bladder-And-Bowel-Care.aspxThe MDS 3.0 And Its Impact On Bladder And Bowel Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Resident care in the areas of bladder and bowel care require clinical and operational professionals to consider the impact of the minimum data set (MDS) 3.0 and its recent April 2012 changes, including updates to the resident assessment instrument (RAI) manual. These are very important treatment and regulatory areas, as they impact the treatment of nursing home residents for incontinence, urinary tract infections, toileting programs, and related skin issues.</div> <div> </div> <div>The current MDS 3.0 collects a significant amount of data related to all of these areas of care.  Facility management needs to be very aware of the changes in the data collection processes, as well as the focus on outcomes of care that the data now represent, as they manage this very costly and complicated clinical issue.</div> <div> </div> <div>The care and treatment of incontinence is a central part of clinical services to elders in skilled nursing facilities. </div> <div> </div> <div>Even though incontinence is not a normal part of the aging process, many elders experience incontinence after hospitalization. Elders that experience debility or weakness due to complex medical problems also have a higher incidence of incontinence. </div> <div> </div> <div>This can be a complex and costly issue for the facility and its clinical staff. The regulatory risks are higher, and as the data from assessments become more detailed and outcome-focused, attention to database content and tracking of the source of the data are much more important.</div> <h2 class="ms-rteElement-H2">MDS Offers A Complete Picture</h2> <div>The new MDS 3.0 database is very rich with regard to toileting programs, continence, and changes in continence status, as well as the outcomes of planned programs and care. The data are complemented by specific numerical reporting of cognitive status, mood, and activities of daily living (ADL) functional status and ADL scores, which include toileting.</div> <div> </div> <div>The current MDS database will report a much more complete picture of a resident’s status regarding the level of incontinence, progress being made with toileting or management programs, if strength or balance is improving, staff support for the toileting ADL, cognitive ability, and depression. Another important aspect of the MDS 3.0 database are overall skin issues, thanks to the new item in Section M 1040, Moisture Associated Skin Damage.</div> <div> </div> <div>This is very integrated and specific coding that will create the data picture of the clinical situation and interventions that are being used.</div> <div> </div> <div>Providers must be focused on this issue and discuss each component of the data, the definitions in the revised RAI Manual, and the data collection process in place in order to create the most accurate and complete picture of residents’ conditions and issues at the time of the Assessment Reference Period. </div> <div>Complicating these is the Centers for Medicare & Medicaid Services’ (CMS’) focus on payment processes, medical necessity of rehabilitation therapy and other services, rehospitalizations, and outcomes-based reporting for accountable care organizations (ACOs) and other payment processes. </div> <div><br>Given these facts, it is important to note that incontinence care is one of the highest cost centers and urinary tract infections are a very common reason for readmissions from home or institutional settings. </div> <h2 class="ms-rteElement-H2">Processes And Data Collection </h2> <div>The first step to keeping up with incontinence care is to become familiar with the MDS and to look for the changes so that staff and management can be focused on the data being collected. Providers should review the facility process for completing the Brief Interview for Mental Status and Resident Mood interviews so that issues related to either of these areas that impact the assessment and care planning for incontinence are identified early in the stay.<br></div> <div>ADL coding for transfers and toileting should be reviewed, and direct care staff must be very careful to accurately code the levels of functional decline the resident has at each assessment. The therapy plan for the resident must include building balance, strength, and skills for toileting. The test for balance in Section G of the MDS is very important, and the scores should be reviewed over time. </div> <div><br>Clinical staff should discuss any previous incontinence issues with the resident and identify any interventions used prior to admission, as well as any interaction with specialty medical services related to the issue. Coding for the assessment needs to come from specific information in the record related to voiding, plans that include toileting programs, and outcomes data.</div> <div><br>To correctly code Section H-200 of the MDS, the clinical team should review the definitions and intent information in chapter three of the RAI Manual, Section H, page H-3 to H-7. The steps for assessment are specific and must be addressed. </div> <div><br>Current toileting programs do contribute to restorative program documentation, but these codes will also be used by the surveyors to identify residents in active programs during survey process. Therefore, coding must always be current and accurate. The related section (page H-3) of the RAI Manual states: “Research has shown one-quarter to one-third of residents will have a decrease or resolution of incontinence in response to toileting programs.” <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Care Planning Steps Vital</h2> <div>The steps listed in this section related to planning for care are also very important and should be referenced as caregivers structure their approach, as follows: Determine the resident’s current continence status or risk, perform an accurate and thorough assessment, and take steps to implement appropriate individualized interventions. <br></div> <div>The RAI Manual also references the information related to incontinence in the Care Area Resource #6 in Appendix C. Additional information about toileting programs or planning incontinence care programs can be found in the book, “Managing and Treating Urinary Incontinence,” by Diane Kaschak Newman and Alan Wein.</div> <div><br>Coding for the level of urinary continence begins with the definitions of continence and incontinence, on page H-7 of the RAI Manual. Next, issues related to care planning, which include identification and treatment of underlying potentially reversible causes of the incontinence, must be addressed.</div> <div><br>Be sure to look at the coding, as it is an excellent way to track outcomes of toileting programs. If the resident does not or cannot respond to the toileting program, then a plan to maintain skin dryness and minimize exposure to urine must be implemented. </div> <div><br>To that end, a program of this type should focus not only on the times and types of incontinence, but the appropriate products and sizes needed to protect the skin while taking into consideration the resident’s dignity and comfort, as well as sleep hygiene. </div> <div><br>Diagnostic documentation of the case is very important so the team can consider not only possible metabolic and functional issues, but also the impact of medications on the resident’s status of continence, and risk factors that will impact the total plan of care. This includes the history or risks of falls. </div> <div><br>Incontinence and falls frequently are associated so this connects the ADL score, balance testing and coding, therapy programs, and goals, as well as the resident’s changes in cognition during the day.</div> <h2 class="ms-rteElement-H2">Educate Staff About Skin Issues</h2> <div>Skin issues are always important, and facilities have been doing a good job of tracking the presence of pressure ulcers and their characteristics on the MDS 3.0, Section M. The April 1, 2012, changes to the MDS 3.0 include two new items that have impact on the status of continence. Section M of 1040 now includes G. Skin Tears and H. Moisture Associated Skin Damage (MASD) from incontinence-association dermatitis, perspiration, drainage.<br></div> <div>The coding instructions in the RAI Manual for this section say: “Moisture-associated skin damage is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture, which can be caused, for example, by incontinence, wound exudate, and perspiration. MASD is also referred to as incontinence dermatitis.” <br></div> <div>All staff must be educated about these new coding items and the risk they present to residents and the facility. All coded MASD should be investigated and acted on as soon as possible. Incontinence products should be evaluated for their efficiency to keep the skin dry, and the importance of proper sizing of product must be emphasized.<br></div> <div>Coding of these items also needs to be communicated to the wound nurse and the clinical leadership of the unit. </div> <h2 class="ms-rteElement-H2">Track Meds </h2> <div>Now that the MDS 3.0 dataset includes the frequency of medication use by residents, it is also important to track the use of diuretics and the frequency of administration, as it impacts the level of incontinence and related risk. A consultant pharmacist, as well as the therapy department, may be good sources for a discussion about the frequency and amount of incontinence at various times of the day that may be stimulated by medication use.<br><br>Another issue that the interdisciplinary team must focus on is the change to the Care Area Assessment (CAA) resources that are part of the care planning process and completion of Section V of the MDS. Many of the CAAs have an impact on the incontinence care plan. Therefore, members of the care planning team that are involved with the related CAAs should review the new CAA resources and look for the April 1 changes both in Chapter 4, where the CAAs are individually described, and in Appendix C, where the specific CAA resources are located. </div> <div> </div> <div>There are many changes and significant information about toileting programs as well as related interventions. </div> <div><br>The CAA notes need to be very specific about interventions and planning related to incontinence from many different CAA areas, such as cognition, ADL Functional Rehab, Urinary Incontinence, Psychosocial Well-Being, Dehydration and Fluid Maintenance, Pressure Ulcer, and Return to the Community. </div> <div><br>The issues with the current MDS 3.0 and its database are very complex and have significant impact on reporting of clinical and behavioral data. The management of incontinence is very complex and requires much interdisciplinary support so the resident can reverse the condition, if possible, and have the best supportive care to protect their skin during the process. </div> <div><br>For residents who cannot reverse the situation, there should be highly individualized plans and products to keep them out of risk and with as much dignity as possible. The changes in the assessment process and definitions and processes for care delivery will assist caregivers to establish the best policies and procedures to meet residents’ needs and keep them as functional as possible. </div> <div> </div> <div><em>Leah Klusch, RN, BSN, FACHCA, is a nurse educator, consultant, speaker, and executive director of the Alliance Training Center, an educational foundation that focuses on issues related to the care of the frail elderly. She can be reached at LeahKlusch@sbcglobal.net.</em></div> The current MDS 3.0 collects a significant amount of data related to all of these areas of care. Facility management needs to be very aware of the changes in the data collection processes, as well as the focus on outcomes of care that the data now represent, as they manage this very costly and complicated clinical issue.2012-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0612/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn6
New Federal Agency Promotes Community Livinghttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/New-Federal-Agency-Promotes-Community-Living.aspxNew Federal Agency Promotes Community LivingA newly created agency within the Department of Health and Human Services (HHS) has been established to promote community living among seniors and people with disabilities.<br><br>The Administration for Community Living (ACL) will bring existing federal agencies related to aging and disabilities under its umbrella and “seek to enhance and improve the broad range of supports that individuals may need to live with respect and dignity as full members of their communities,” said Secretary Kathleen Sebelius, in a statement announcing ACL. “These support needs go well beyond health care and include the availability of appropriate housing, employment, education, meaningful relationships, and social participation.”<br><br>ACL is a product of the Obama administration’s commitment to helping people remain in their homes, “rather than in nursing homes or other institutions,” Sebelius said. <br><br>The Administration on Aging (AOA), the Office on Disability, and the Administration on Developmental Disabilities (ADD) will be moved within ACL, creating a “single agency that supports both cross-cutting initiatives and efforts focused on the unique needs of individual groups, such as children with developmental disabilities or seniors with dementia,” Sebelius said. <br><br>The reorganization will “establish a formal infrastructure to ensure consistency and coordination in community living policy across the federal government,” said a description of ACL on its website. The new agency will also work with the Centers for Medicare & Medicaid Services to “develop, refine, and strengthen policies that promote independent living among all populations, especially those served by Medicaid.” <br><br>No legislation is needed to establish ACL, as the HHS secretary has the authority to organize the department and its functions, according to the agency’s website. Kathy Greenlee, assistant secretary for aging, will serve as ACL administrator without relinquishing her current position. <br><br>While staff, resources, and management of the AoA and ADD will remain “relatively unchanged,” the reorganization will “reduce the fragmentation” among federal programs that address community service and support needs for seniors and people with disabilities, the ACL description said.The Administration for Community Living will bring existing federal agencies related to aging and disabilities under its umbrella and “seek to enhance and improve the broad range of supports that individuals may need to live with respect and dignity as full members of their communities.” 2012-06-01T04:00:00ZManagementColumn6
Policies And Procedures Promote Safe Operation Of Scootershttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/Policies-And-Procedures-promote-Safe-Operation-Of-Scooters-.aspxPolicies And Procedures Promote Safe Operation Of Scooters<div><img src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/indepthreport.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;" /></div> <div> <br><br></div> <div> </div> <div>Scooters and electric wheelchairs are used by slightly more than 5 percent of the assisted living population, according to the National Center for Health Statistics’ 2010 National Survey of Residential Care Facilities. While this may constitute a small number of residents, their use of scooters and wheelchairs is a complex issue to deal with because of two overlapping federal laws: the Americans with Disabilities Act and the Fair Housing Act.</div> <div> </div> <div>From a risk management standpoint, developing policies and procedures regarding scooters requires balancing the resident’s need for the scooter with the safety of everyone else who enters the assisted living building, says Sheila Salisbury, an insurance specialist and consultant with RCM&D in Baltimore. </div> <div>Salisbury has recently developed a policy for one of her clients—a continuing care retirement community—that can be adapted for assisted living buildings. </div> <div> </div> <div><img class="ms-rteImage-0 ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/chart.gif" alt="" style="margin:5px 10px;" />“The community had its fair share of accidents that resulted in damage to the building or injuries to other residents, visitors, and staff,” Salisbury says. “Since the policy was implemented there are still accidents, but the number and severity of accidents have decreased.”</div> <div> </div> <div>She attributes the success to a policy that makes the entire community aware of the rules for the safe operation of motorized scooters or wheelchairs. Salisbury recommends that communities should present four handouts to residents who either have motor scooters or are about to get one. </div> <div> </div> <div>The forms are Steps for Safely Acquiring and Operating an Electronic Motorized Vehicle (EMV), Rules of the Road, Safety and Enforcement, and Receipt of EMV Policy Handouts.</div> <div> </div> <div>Salisbury recommends that someone other than the administrator be designated the EMV staff point person. This person will spend time with residents, explaining the policies and procedures contained in the forms. Salisbury advises suggesting to residents that EMVs should not exceed the federal guideline for a common wheelchair—30 inches wide x 48 inches long. Vehicles larger than 30 inches wide may prohibit safe operation in hallways and cannot be safely transported on community shuttles. If the resident already has an EMV, review all of the policies with the person, pointing out safety features.</div> <h2 class="ms-rteElement-H2">Steps For Safely Acquiring And Operating Policy</h2> <div>1. Suggest residents meet with their primary care physicians so the physician can give the resident advice on what type of motorized vehicle best meets the resident’s needs. In addition, a physician’s examination and recommendation is required by Medicare to cover the costs of the EMV. </div> <div>2. Ask a local medical center to recommend a vendor who can provide good service and value to the resident. Functionality of the EMV should be the most important consideration in choosing a model. </div> <div>3. A staff person should review the Rules of the Road for safe operation with the resident. </div> <div>4. Require residents to complete a registration form, and keep the form on file. </div> <h2 class="ms-rteElement-H2"><img src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/man_scooter.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 10px;width:147px;height:222px;" />Form Three: Safety and Enforcement of EMVs</h2> <div>Explain that the EMV staff point person will issue warnings to any EMV operator who is in violation of the rules of the road. If a complaint is filed, the community should keep the complaint confidential, then investigate to determine who is at fault. If no one is at fault, then no further action is necessary. If the operator is at fault, the operator will be issued a warning.</div> <h2 class="ms-rteElement-H2">Enforcement/Warning Process</h2> <div>The enforcement process follows three violations. All violations should be issued to the EMV operator in writing. <br><br></div> <div>On the second warning, include all of the steps included in the first warning and add that a third violation within 12 months may result in more serious consequences, such as a $50 service fee. Follow the first two phases and then submit the case to the community’s EMV Safety Review Board. The board will review past violations with the resident and make a determination as to whether operating privileges should be suspended or an exception granted. <br></div> <h2 class="ms-rteElement-H2">Acknowledgement of Receipt and Review By Resident </h2> <div>This form should have the resident’s signature acknowledging receipt and that staff had reviewed the handouts for the safe operation of EMVs with the resident. </div> <br>Scooters and electric wheelchairs are used by slightly more than 5 percent of the assisted living population, according to the National Center for Health Statistics’ 2010 National Survey of Residential Care Facilities. While this may constitute a small number of residents, their use of scooters and wheelchairs is a complex issue to deal with because of two overlapping federal laws: the Americans with Disabilities Act and the Fair Housing Act.2012-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/man_scooter_thumb.jpg" style="BORDER:0px solid;" />Management;CaregivingColumn6
Sector Advocates Seek Shorter Lookback Period For Overpaymentshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0612/Sector-Advocates-Seek-Shorter-Lookback-Period-For-Overpayments.aspxSector Advocates Seek Shorter Lookback Period For Overpayments <p>​<img src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/capitalnews.jpg" alt="" style="margin:5px;" /><br>Advocates of the long term and post-acute care profession have raised “grave concerns” about a 10-year lookback period for identifying Medicare overpayments, which the Centers for Medicare & Medicaid Services (CMS) proposed as part of a rule implementing a provision of the Accountable Care Act (ACA).</p> <p>The ACA established new requirements for reporting and returning Medicare overpayments, but made no mention of a lookback period. CMS’ proposed rule would require the reporting and return of overpayments identified within 10 years of their receipt and allow contractors to reopen overpayment determinations as far back as 10 years. </p> <p>The imposition of such a lengthy lookback period “expands the already burdensome web of reporting requirements providers and suppliers face today,” said AHCA in formal 18-page comments. Furthermore, CMS’ proposal “escalates the complexity of various, inconsistent time periods providers have to retain records and report situations that could be considered an ‘overpayment,’ creates duplicative reporting obligations and processes, and further muddles how a Medicare provider or supplier is to proceed when faced with a situation that could be an overpayment,” AHCA said.</p> <p>The CMS proposed rule, published Feb. 16 in the Federal Register, implements an ACA provision that requires the return of Medicare overpayments within 60 days of their discovery, or by the date of their corresponding cost report. Repayments that are not made within that time frame become “obligations” under the federal False Claims Act.</p> <p>AHCA made nine recommendations for modifying CMS’ proposal in a way that balances the agency’s concerns and “the reality of the enormously burdensome nature of its proposals,” the comments said.<br>At the top of AHCA’s recommendations is a three-year lookback period, in place of the agency’s proposed 10-year window. </p> <p>AHCA’s comments pointed out that the ACA doesn’t suggest a lookback period, and that the time frame proposed by CMS correlates to the “outer limit of the False Claims Act statute of limitations,” inappropriately associating “simple overpayments” with false or fraudulent claims.<br></p> <p>AHCA’s recommendations included: <br>■ Allowing existing protocol for self-disclosure and self-referral disclosure to fulfill reporting obligations;<br>■ Imposing reporting and repayment obligations only when an overpayment cannot be addressed in the normal course of business; and<br>■ Establishing that identification of an overpayment does not occur until a provider has determined all information required by CMS, including the amount of the overpayment.</p>Advocates of the long term and post-acute care profession have raised “grave concerns” about a 10-year lookback period for identifying Medicare overpayments, which the Centers for Medicare & Medicaid Services (CMS) proposed as part of a rule implementing a provision of the Accountable Care Act (ACA).2012-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/8293_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ManagementColumn6

July


 

 

CBO Sounds Alarm on Long-Term Health Of Medicare, Medicaidhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/CBO-Sounds-Alarm.aspxCBO Sounds Alarm on Long-Term Health Of Medicare, MedicaidThe United States will have to rethink its priorities as aging baby boomers fill the Social Security, Medicare, and Medicaid safety nets, the Congressional Budget Office (CBO) said in a dire warning as part of a summary of its annual budget forecast. <br><br>“The aging of the baby boom generation portends a significant and sustained increase in the share of the population receiving benefits from Social Security and Medicare, as well as long term care services financed by Medicaid,” CBO said in its report, released June 5. <br><br>But health care costs will probably increase in any case, budget officials concluded. “Without significant changes in government policy, those factors will boost federal outlays relative to GDP [Gross Domestic Product] well above their average of the past several decades—a conclusion that holds under any plausible assumption about future trends in demographics, economic conditions, and health care costs,” the summary said. <br><br>Others have sounded similar alarms in the past, but CBO is generally considered to be the most even-keeled of Washington’s many budget shops. Its findings are stark.<br><br>If the nation’s current laws stay in place, CBO found, “spending on the major federal health care programs alone would grow from more than 5 percent of GDP today to almost 10 percent in 2037 and would continue to increase thereafter,” the summary said. “Altogether, the aging of the population and the rising cost of health care would cause spending on the major health care programs and Social Security to grow from more than 10 percent of the GDP today to almost 16 percent” 25 years from now.<br><br>“Absent substantial increases in federal revenue, such growth in outlays would result in greater debt burdens than the United States has ever experienced.”<br><br>The agency refrained from offering any solutions to the problems, but urged the nation’s leaders to proceed cautiously. <br><br>“Policymakers face difficult trade-offs,” CBO said. “On the one hand, cutting spending or increasing taxes slowly would lead to a greater accumulation of government debt and might raise doubts about whether longer-term deficit reduction would ultimately take effect. On the other hand, abruptly implementing spending cuts or tax increases would give families, businesses, and state and local governments little time to plan and adjust and would require more sacrifices sooner from current older workers and retirees for the benefit of younger workers and future generations. If the nation’s current laws stay in place, CBO found, “spending on the major federal health care programs alone would grow from more than 5 percent of GDP today to almost 10 percent in 2037 and would continue to increase thereafter,” the summary said. “Altogether, the aging of the population and the rising cost of health care would cause spending on the major health care programs and Social Security to grow from more than 10 percent of the GDP today to almost 16 percent” 25 years from now.2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0712/alarm.jpg" style="BORDER:0px solid;" />PolicyColumn7
Five-Star Ratings Show Significant Quality Improvementhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Five-Star-Ratings-Show-Significant-Quality-Improvement.aspxFive-Star Ratings Show Significant Quality Improvement<img src="/Monthly-Issue/2012/PublishingImages/0612/News%200612/capitalnews.jpg" alt="" style="margin:5px;" /><br>Nursing facilities have made dramatic improvements in their Five-Star ratings in recent years, according to government data compiled and analyzed by Abt Associates and released at a May 16 Centers for Medicare & Medicaid Services (CMS) stakeholders meeting.<br><br>The data, which came from CMS, found that the proportion of facilities with overall five-star performance ratings increased by 34.7 percent, from 11.8 to 15.9 percent over the three years from January 2009, when Five-Star began, through December 2011. <br><br>During the same three years, the number of four-star centers rose 17 percent, from 23.4 percent of all facilities to 27.4 percent, the data showed. The number of one-star facilities, meanwhile, diminished substantially from 22.7 to 15.7 percent, a 44.5 percent decline.<br><br>“The long term and post-acute care profession has improved in nearly all meaningful quality measures in recent years, including staff and customer satisfaction,” said Gov. Mark Parkinson, president and chief executive officer of the American Health Care Association. While quality is a “continuous journey,” Parkinson said he was “excited about this positive trend.”<br><br>Each facility’s overall Five-Star rating is a composite based on separate scores in three domains: staffing, quality measures, and health inspections. The CMS data found that in the area of staffing, the proportion of five-star-rated facilities rose 23.6 percent, from 7.2 percent of all centers nationwide to 8.9 percent as of December 2011. The number of those with four-star staffing ratings jumped from 30 to 39 percent of all nursing facilities, a 30 percent shift. The number of one-star-rated facilities in this domain, meanwhile, dropped sharply, from 23 to 14 percent, a 64.2 percent decline.<br><br>Improvements in the quality measures domain were also striking, with the number of five-star ratings rising 60 percent, from 10 to 16 percent of all facilities. Centers with one star dropped from 20 percent of all facilities nationwide to 11 percent, a 45 percent decline.<br><br>According to Abt, the largest component of the overall rating is the health inspection (survey), which is designed to remain fixed in its distribution from month to month. As a result, the three-year change to the overall rating is due to the growing number of five-star-rated facilities in the quality measures domain; the increase in four- and five-star nursing centers in the staffing domain; and/or the decline in one-star facilities in each of these areas.Nursing facilities have made dramatic improvements in their Five-Star ratings in recent years, according to government data compiled and analyzed by Abt Associates and released at a May 16 Centers for Medicare & Medicaid Services (CMS) stakeholders meeting.2012-07-01T04:00:00Z<img alt="" height="134" src="/Monthly-Issue/2012/PublishingImages/0712/star.jpg" width="140" style="BORDER:0px solid;" />Quality;CaregivingColumn7
Antipsychotics Resources Aboundhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Antipsychotics-Resources-Abound.aspxAntipsychotics Resources Abound<span>Staff and practitioner education and training regarding antipsychotic medications are key to any efforts to reduce these drugs’ use in long term care. Fortunately, there are many tools and materials already in existence. These include:<br>■ “Dementia Beyond Drugs: Changing the Culture of Care,” G. Allen Power, MD<br>■ Long Term Care Prescribing of Antipsychotic Medications: <a target="_blank" href="http://www.amda.com/governance/resolutions/E12.cfm">www.amda.com/governance/resolutions/E12.cfm</a><br>■ Clinical Practice Guideline: Dementia: <a target="_blank" href="http://www.amda.com/tools/guidelines.cfm#dementia">www.amda.com/tools/guidelines.cfm#dementia</a><br>■ Clinical Practice Guideline: Delirium and Acute Problematic Behavior: <a target="_blank" href="http://www.amda.com/tools/guidelines.cfm#dapb">www.amda.com/tools/guidelines.cfm#dapb</a><br>■ The Use of Antipsychotic Medications in Nursing Home Residents—Questions and Answers: <a target="_blank" href="http://www.ascp.com/sites/default/files/ASCP-QnA-AntipsychoticsFinal.pdf">www.ascp.com/sites/default/files/ASCP-QnA-AntipsychoticsFinal.pdf</a><br>■ A Systematic Evidence Review of Non-pharmacological Interventions for Behavioral Symptoms of Dementia: <a target="_blank" href="http://www.ncbi.nlm.nih.gov/books/NBK54971/">http://www.ncbi.nlm.nih.gov/books/NBK54971/</a><br>■ Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Homes Residents (Handouts): <a target="_blank" href="http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1098">http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1098</a><br>■ What You Should Know to Fight the Misuse of Psychoactive Drugs in California Nursing Homes: <a target="_blank" href="http://www.canhr.org/reports/2010/Toxic_Medicine.pdf">http://www.canhr.org/reports/2010/Toxic_Medicine.pdf</a><br>■ Off-Label Use of Atypical Antipsychotics: An Update: <a target="_blank" href="http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=786">http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=786</a><br>■ Guide to the Management of Psychotic Disorders and Neuropsychiatric Symptoms of Dementia in Older Adults: <a target="_blank" href="http://dementia.americangeriatrics.org/ASGGeriPsychConsult.pdf">http://dementia.americangeriatrics.org/ASGGeriPsychConsult.pdf</a><br>■ Implementation Guide: Reducing the Use of Daily Physical Restraints: <a target="_blank" href="http://www.nhqualitycampaign.org/files/impguides/3_PhysicalRestraints_TAW_Guide.pdf">www.nhqualitycampaign.org/files/impguides/3_PhysicalRestraints_TAW_Guide.pdf</a><br>■ Talking Points: Appropriate Prescribing of Antipsychotics: <a target="_blank" href="http://www.amda.com/advocacy/AMDA_Antipsychotics_Tlkg_Pts.pdf">www.amda.com/advocacy/AMDA_Antipsychotics_Tlkg_Pts.pdf</a><span style="display:inline-block;"></span></span>Staff and practitioner education and training regarding antipsychotic medications are key to any efforts to reduce these drugs’ use in long term care.2012-07-01T04:00:00ZColumn7
Cleanliness Critical In Feeding Tube Managementhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Cleanliness-Critical-In-Feeding-Tube-Management.aspxCleanliness Critical In Feeding Tube Management<div> </div> <div>Nearly 79,000 residents (5.68 percent) have feeding tubes in the long term care setting, according to March 2012 data from the Online Survey, Certification, and Reporting (OSCAR) data. In fact, a majority of elderly patients undergoing feeding tube placements are discharged to nursing homes after the procedure. <img width="150" height="150" class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0712/tube2_thumb.jpg" alt="" style="margin:15px;" /><br><br>For many residents, these tubes become a long-term condition, requiring continued diligence by the nursing home staff for assessment, maintenance, and documentation beyond the time frame of the skilled stay.</div> <div> </div> <div>Feeding tube placement provides an open tract to internal organs, and preventing deterioration of this chronic surgical site is crucial to the health and well-being of the individual.</div> <h2 class="ms-rteElement-H2">Optimum Conditions </h2> <div>A normal tube site should have a moist, red stoma with intact surrounding skin. However, with time and the persistent presence of the feeding tube, issues may arise that lead to complications such as leakage; infection and/or cellulitis; hypergranulation; bleeding; or peritubular skin that is denuded, excoriated, erythematous, macerated, ulcerated, or dry and crusty. <br><br>These issues may be brought on by trauma or aggravation. For example, a confused resident may pull on the tube or clothing could repeatedly catch on the tube. In addition, the tube could be positioned incorrectly or the resident could have gained or lost weight, which can impact the fit of the tube. Leakage can become very problematic to a person due to the discomfort caused by the combination of fluids irritating the skin, such as gastric, feeding formula, medications, and water from flushes. </div> <div><br>Dignity issues are also important. The embarrassment of soiled or odorous clothing inhibits residents from participating in social activities and even the pleasure of wearing favorite clothing. </div> <div><br>Leakage may occur due to local fungal or bacterial skin infections, caustic agents used to cleanse the surrounding skin or tube, tube failure, and stoma dilation with time.</div> <div><br>Suggested treatment for leakage includes correcting comorbidities, such as blood sugar or malnutrition, and local measures that address skin breakdown.</div> <div><br>Tube stabilization is also important to decrease leakage. However, it is a misconception that placement of a larger-size tube through the same feeding tube tract will resolve the leakage problem.</div> <h2 class="ms-rteElement-H2">Watch The Dressings</h2> <div>Traditionally, feeding tube sites have been covered with gauze. Fluids drawn into the gauze dressing evaporate, leaving dried particulate matter such as blood and protein behind, forming an impermeable layer. <br></div> <div><br>In the course of a dressing change, the dried proteins or scab pull at the surrounding tissue, creating inflammation and irritation that may result in drainage from the surrounding tissues or further tissue damage. </div> <div><br>Gauze also traps gastric leakage against the skin, resulting in local irritation, while foam dressings can lift the drainage away from the skin, and calcium alginates are known to trap or sequester drainage away from the skin. </div> <div><br>With the incidence of dementia and incontinence in today’s nursing home population, it is not uncommon to come across a confused resident who, being uncomfortable after an incontinent episode, reaches down for hygienic purposes and then tugs on the feeding tube area, using the hand contaminated with feces. <br>With a gauze-and-tape-only dressing (or a tube left open to air) there is no bacterial barrier to prevent the entry of this contamination into the body via the stoma. Thus, the use of gauze dressings may lead to resident discomfort, prolonged healing of the incision site, or peritubular skin loss and an increased risk of infection. </div> <div><br>To help maintain each person’s dignity and quality of life with the least amount of pain possible, while adhering to federal regulations regarding quality of care, skilled evaluations are indicated for the peritubular skin defects or wounds in residents with feeding tube complications. </div> <div><br>Also, local measures to address the skin breakdown are necessary, including nursing assessment of the feeding tube site and peritubular area.</div> <h2 class="ms-rteElement-H2">Peritubular Skin Assessment</h2> <div>Maintenance of healthy peritubular skin is paramount for resident comfort and to prevent tissue erosion, which may lead to more significant feeding tube site complications. Likewise, the peritubular skin assessment provides information that may provide the first indication of complications. </div> <div><br>A daily skin assessment should include inspection of the site for any signs and symptoms of infection, which could include erythema, induration, or pain. Additionally, presence of gastric drainage or leakage around the tube should be noted. A small amount of clear liquid drainage is normal; however, any increased amounts that saturate dressings or soil clothing indicate possible complications. </div> <div><br>Drainage that is odorous, green or yellow in color, or purulent should be included in the assessment as well. Observing for excess tissue (hypergranulation) growing around the tube is another component of the assessment. Hypergranulation may be a result of the body’s response to the foreign object (tube appliance) and may be uncomfortable to the resident, as it is commonly friable, bleeds easily, or has excess exudate. </div> <div><br>The peritubular area should be assessed to determine if skin tissue is intact or exhibits signs of maceration, excoriation, denudement, erythema, ulceration, or buildup or layering of dry/crusty drainage. </div> <h2 class="ms-rteElement-H2">Document Assessment Data</h2> <div>The information gathered from this assessment is an essential component of feeding tube management and should be documented in the resident’s medical record. </div> <div><br>The documentation communicates information that may indicate the need for interventions and collaboration with health care providers addressing the possible complications. </div> <div><br>Additionally, documentation regarding the resident’s overall condition such as dementia, agitation, confusion, incontinence, and pulling at the tube site or tube stabilization/positioning difficulties may further indicate a need for advanced wound products, with more frequent dressing changes such as daily, for an unspecified amount of time in order to appropriately manage the resident’s care. </div> <div> </div> <div><em>Rebekah Grigsby, MSN, RN, CWCN, CCCN, is education liaison and clinical specialist, American Medical Technologies, Irvine, Calif. Holly Korzendorfer, PT, PhD, CWS, FACCWS, is vice president of clinical development, Dermarite, Paterson, N.J.</em></div>Nearly 79,000 residents (5.68 percent) have feeding tubes in the long term care setting, according to March 2012 data from the Online Survey, Certification, and Reporting (OSCAR) data. In fact, a majority of elderly patients undergoing feeding tube placements are discharged to nursing homes after the procedure. 2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0712/tube2_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn7
Disaster Preparedness Refresherhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Disaster-Preparedness-Refresher.aspxDisaster Preparedness Refresher<div>It’s hurricane season again, and the fear of such weather-related disasters typically raises concerns about <a href="/Monthly-Issue/2012/Pages/0712/Three-Types-Of-Emergency-Preparedness-Drills.aspx">emergency preparedness plans and drills</a>, especially among long term care administrators. But being prepared for reality starts with knowing what the threats are. And hurricanes and fires are not the only threats to facilities.</div> <div> </div> <div>Each facility is unique, and each should arrange for a hazard analysis performed by a qualified health care disaster preparedness professional to identify the threats that are unique to it.</div> <div> </div> <div>In doing so, many administrators may be shocked at the number of unique threats that a long term care center faces and must prepare for.</div> <h2 class="ms-rteElement-H2">Determine Potential Hazards</h2> <div>A hazard analysis incorporates both identification of the potential hazard and the likelihood of such an event. Depending on a facility’s geographical location, the type of threats may include the following: natural, technological, human, and chemical, just to name a few.</div> <div> </div> <div>Because of a center’s location, it is important to note that boilerplate programs seldom work; what may be a hazard in Vermont may not be a hazard in Arizona. The facility has to prepare for the threats and potential perils that are common to its location and operations if the plan is going to work.</div> <div> </div> <div>In addition, for every hazard identified, a written Emergency Operations Plan (EOP) must address the threat and how the facility will respond, mitigate, and recover from the event.</div> <div> </div> <div>A nursing home’s response to a fire emergency will be much different than its response to an armed intruder or a swollen river a block away.</div> <div> </div> <div>Keep in mind as well both the fiduciary obligation and risk management implications associated with being the keeper and the caregiver of residents: There must be plans in place for all possibilities, and they must be specific to the facility’s risks.</div> <h2 class="ms-rteElement-H2">Drills Versus Exercises</h2> <div>A drill differs from an exercise in that a drill focuses on a single operation, while an exercise focuses on an entire sequence of events. Emergency preparedness drills draw their life blood from what is called the preparedness cycle, which is the process of “planning, training, equipping, exercising, evaluating, and taking action to correct and mitigate flaws in the plan.” What’s more, contrary to popular belief, one per shift per quarter is not the end-all answer. For the hazards that are identified in a facility’s assessment, an administrator must not only develop a plan around the hazard, but also test the plan and train staff.</div> <div> </div> <div>Drills serve a variety of purposes, including testing the plans, training and testing staff, training residents and family members, and identifying where a plan is weak and needs improvement. Administrators must realize that a plan is always a “work in progress” that continually needs to be updated and maintained.</div> <div> </div> <div>Drills help to identify where the updates are needed, or more simply stated, where they need to be tweaked in order to make it work the way it needs to work. And drills, to be successful, should be broken down into steps that can later be put together to create an exercise.</div> <div> </div> <div>Drills should also involve community emergency response/public safety agencies whenever possible. For example, when drilling for a potential workplace violence incident, consider inviting the police to participate in planning the drill, executing the drill, and the post-event review.</div> <div> </div> <div>Local community agencies can serve as excellent resources in developing an effective plan that creates a state of readiness for virtually all of the hazards a facility may face.</div> <div> </div> <div>There can be no dispute that drills require planning.</div> <h2 class="ms-rteElement-H2">Prepare, Prepare, Prepare</h2> <div>All EOPs should be drilled in four critical areas: planning, response, mitigation, and recovery. All four are critical components of a plan, yet most drills typically focus only on response.</div> <div> </div> <div>No matter the geographic location, every long term care facility is vulnerable to some type of equally harrowing event and must be prepared for it.</div> <div> </div> <div>The importance of identifying, planning, drilling, and readying for all hazards a facility can face cannot be over-emphasized. Not only is it prudent from a risk management perspective, but it is something residents and their families trust and count on the facility to do.</div> <div> </div> <div>Steve Wilder, CHSP, STS, is president and chief operating officer of Sorensen, Wilder & Associates, a Bourbonnais, Ill.-based health care safety/security/risk management consulting group. Wilder can be reached at (800) 568-2931 or at swilder@swa4safety.com. Stan Szpytek is president of Fire and Life Safety, based in Mesa, Ariz., and a consultant for Magnolia LTC Management, a firm that provides loss control, fire and life safety compliance, and emergency preparedness consultation. Szpytek can be reached at Firemarshal10@aol.com or (708) 707-6363. Calvin Groeneweg, RN, C-AL, is director of the Risk Management Department of Northern California Presbyterian Homes & Services, a company that operates and manages facilities for seniors in Northern California. Groeneweg can be reached at cgroeneweg@ncphs.org or (415) 351-3640.</div> <div> </div>It’s hurricane season again, and the fear of such weather-related disasters typically raises concerns about emergency preparedness plans and drills, especially among long term care administrators. But being prepared for reality starts with knowing what the threats are. And hurricanes and fires are not the only threats to facilities. Each facility is unique, and each should arrange for a hazard analysis performed by a qualified health care disaster preparedness professional to identify the threats that are unique to it. 2012-07-01T04:00:00Z<img alt="Disaster planning" height="150" src="/Monthly-Issue/2012/PublishingImages/0712/Disaster%20Preparedness%20Feature.jpg" width="150" style="BORDER:0px solid;" />Management;CaregivingColumn7
Getting Ready For QAPIhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Getting-Ready-For-QAPI.aspxGetting Ready For QAPI<div>The Centers for Medicare & Medicaid Services (CMS) will soon be rolling out early prototypes of tools and resources in response to a requirement under the Affordable Care Act to establish Quality Assurance and Performance Improvement (QAPI) regulations for nursing homes. <img width="150" height="150" class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0712/mgmt_thumb.jpg" alt="" style="margin:15px 10px;width:171px;height:171px;" /><br><br>The legislation requires CMS to provide quality assurance technical support to facility leaders on the development of “best practices” for continuous improvement of care outcomes. At the same time, the minimum data set (MDS) 3.0–based quality measure (QM) system is up and running, and providers can benefit greatly by linking these two programs together and enhancing their Quality Assurance (QA) Committee processes. </div> <div> </div> <div>In order to be prepared and to create a coordinated response to these initiatives, facility leaders can focus on staying informed, evaluating their QA committee’s organization, boosting data management, tracking outcomes, and developing enhanced subcommittees.</div> <h2 class="ms-rteElement-H2">Elements Of QAPI</h2> <div>Information about QAPI is posted on CMS’ QAPI website. It outlines the purpose, elements, and process of QAPI to assist facility staff in “developing and implementing appropriate plans of action to correct identified quality deficiencies.” </div> <div><br>The focus of the regulation is to assist nursing home staff in improving their QA committee functions using the following five key elements:</div> <div><br><strong>Element 1:</strong> Design and Scope, which looks at an ongoing, comprehensive program that includes all facility departments, coupled with resident-driven care. <br></div> <div><strong><br>Element 2:</strong> Governance and Leadership, which focuses on facilitating input from staff, residents, and families, as well as providing adequate resources for quality initiatives. </div> <div><strong><br>Element 3:</strong> Feedback, Data Systems, and Monitoring, which draws data from all available resources and formalizes outcomes monitoring. </div> <div><strong><br>Element 4:</strong> Performance Improvement Projects, which utilizes enhanced subcommittee work groups to accomplish goals. </div> <div><strong><br>Element 5:</strong> Systematic Analysis and Systematic Action, which includes a process for in-depth identification and analysis of actual and potential care-system problems.</div> <h2 class="ms-rteElement-H2">Stay Informed</h2> <div>CMS’ detailed instructions and data specifications for QMs are located on the CMS website. In order to stay informed about nursing facility-level data, access Certification and Survey Provider Enhanced Reporting (CASPER) online reports through the CMS welcome screen on the facility’s Quality Improvement and Evaluation Service (QIES) assessment submission process system for the MDS. </div> <div><br>These reports can help staff track and trend outcomes and provide focus for the QA performance improvement processes. Useful reports include the Facility Quality Measure Report, Resident Level Quality Measure Report, and Monthly Comparison Report. Staying informed about national QMs as well as facility-specific data is essential to effective quality management. </div> <h2 class="ms-rteElement-H2">Range Of Tools Available</h2> <div>In order to be well prepared for the QAPI rollout, staff should evaluate the QA committee process. An element often missing from committee function is representation from the MDS department. Many MDS coordinators do not provide reporting to the committee, or if they do, they rarely hear about the outcomes of the QA committee activities for MDS system improvement. </div> <div><br>Since the MDS processes are vital to quality outcomes, it is important to take time to review the MDS processes and ensure accuracy and teamwork. Having a well-functioning MDS system and interdisciplinary team is crucial to positive outcomes. </div> <div><br>When reviewing MDS systems, include supporting documentation, scheduled accuracy audits, validation and error messages, resource utilization group (RUG) trending data, and barriers to interdisciplinary teamwork for care area assessments and care planning.</div> <div><br>When preparing for QAPI, facilities should consider how the data are tracked and trended and plan to boost data management. </div> <div><br>Not everyone is a statistician, but a range of tools, from simple to advanced, is available to assist staff. Options include developing simple Excel spreadsheets or clinical software reports, or investing in QA Web-based tools that can help monitor facility outcomes. </div> <div><br>A vivid example of tracking and trending was the drop in mood-enhanced RUGs at many nursing homes during the transition from the MDS 2.0 to the MDS 3.0. The MDS 2.0 utilized staff input for resident mood on 16 different coding items. In contrast, the MDS 3.0 employs the Patient Health Questionnaire (PHQ-9), the gold standard for gaining resident information. However, facility staff have not connected the decreased mood-enhanced RUG levels to the change in the MDS coding methodology. </div> <div><br>If facilities experienced a decrease in mood-related RUGs, it may be due to not following prescribed interview practices. Sometimes clinicians can fall into one of two extremes, either not using the interview script and cue cards, or not using the resident assessment instrument (RAI) user manual-approved therapeutic interview techniques. When a facility has no mood-enhanced RUGs, it may be helpful to ask if there is a break in the facility system when it comes to adequately identifying mood. The data should be reviewed at the facility’s next QA committee meeting. </div> <h2 class="ms-rteElement-H2">Be Proactive </h2> <div>Subcommittees and ad hoc workgroups are a dynamic, essential part of a QA committee’s actions. Outcomes-based care suffers when workgroups, such as a Restraint Committee, Falls Risk Review Team, or Psychotropic Use Committee, are not functioning well. It is vital to have strong, supportive leadership to move committee activities along and make necessary changes in facility practices. </div> <div><br>At the end of every meeting ask, “What are we going to do?” “Who is going to do what?” and “When are we going to do it?” The most effective system improvements come from those closest to the issue, such as nurse assistants, dietary staff, and housekeepers. Think about the synergy that would be created if every staff member were involved in a QA subcommittee in some form or fashion.</div> <div><br>Being proactive is always preferable to being reactive, so utilize the full breadth of the quality-improvement tools and processes.<br><br>The Centers for Medicare & Medicaid Services QAPI website resources:<br><ul><li>CMS Nursing Home Quality Assurance & Performance Improvement: <a href="https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/QAPI.html">https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/QAPI.html</a></li> <li>CMS Nursing Home Quality Measures: <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html">https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html </a><br></li></ul></div> <div><em>Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.  <br></em><em> <br><img src="/Monthly-Issue/2012/PublishingImages/0712/AANAC.gif" alt="" style="margin:5px;" /><br></em></div>The Centers for Medicare & Medicaid Services (CMS) will soon be rolling out early prototypes of tools and resources in response to a requirement under the Affordable Care Act to establish Quality Assurance and Performance Improvement (QAPI) regulations for nursing homes. 2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0712/mgmt_thumb.jpg" style="BORDER:0px solid;" />Management;QualityColumn7
HHS, VA Set Aside $52 Million For Home-Based Care Centershttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Home-Based-Care-Centers.aspxHHS, VA Set Aside $52 Million For Home-Based Care CentersThe Obama administration has set aside $25 million over the next three years to help the elderly and those with disabilities to obtain home- and community-based long term care, the Department of Health and Human Services (HHS) announced in early June.<br><br>But some critics worry that the goal of home-based care, while well-intentioned, doesn’t match the realities facing the nation’s seniors and those with disabilities. <br><br>The HHS grants, along with another $27 million from Veterans Affairs, are designed to “make it easier for Americans to get the care and support they need where they need,” HHS Secretary Kathleen Sebelius said in a statement. <br><br>The money will be funneled to the states’ Aging and Disability Resource Centers (ADRCs) over the next three years, Sebelius said. States will also compete to be selected for an “accelerated” move to single-entry-point models, “which provide one-on-one options counseling to streamline the intake and eligibility determination process for consumers,” HHS said in announcing the grants. About eight states are expected to be selected for the single-entry accelerations, the department said. <br><br>Up to 40 states will receive help for their ADRC programs starting next year, HHS said. <br><br>“We want these programs to serve as high-performing ‘one-stop shop’ models across the country,” Centers for Medicare & Medicaid Services’ Acting Director Marilyn Tavenner said.<br><br>But Gary Kelso, a member of Utah’s ADRC steering committee, said he was worried that the Obama administration was overlooking the vital role played by skilled nursing care centers in the lives of people who are elderly or have disabilities. <br><br>“We all want our seniors and individuals with disabilities to live at home if they so choose, but the fact remains that many of these individuals require much more care and attention than a home setting can provide,” he said in an e-mail. <br><br>“That’s where skilled nursing care centers continue to play their pivotal role in providing quality, long term care to Americans, including our veterans. Educating and encouraging individuals to live at home or in their community is a noble effort of the administration, but we hope that the focus remains on placing people in the best care setting for them and their care needs.”The money will be funneled to the states’ Aging and Disability Resource Centers (ADRCs) over the next three years, Sebelius said. States will also compete to be selected for an “accelerated” move to single-entry-point models, “which provide one-on-one options counseling to streamline the intake and eligibility determination process for consumers,” HHS said in announcing the grants. About eight states are expected to be selected for the single-entry accelerations, the department said. 2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/Headshots/Obama.jpg" style="BORDER:0px solid;" />PolicyColumn7
Intergenerational Project Creates Friendshipshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Intergenerational-Project-Creates-Friendships.aspxIntergenerational Project Creates FriendshipsCrystal Waters Retirement Community in Strongsville, Ohio, already had intergenerational programs in place, but the community’s director, Stephanie Chambers, wanted a different kind of intergenerational program: “One that makes our residents feel that they matter and that they are important,” she says. <br><br>After conducting some research on the Ohio Department of Education academic standards for second grade social studies, Chambers had an idea. She contacted the school district’s Talent and Development Coordinator Libby Davis and invited her to tour the community. Davis accepted the invitation. <br><br>After lunch, Davis said, “I have a teacher and a second grade class for you.” The teacher was Mary Whitcar, who taught a class of gifted and talented students at Drake Elementary School located about 15 minutes away.<br><br>Whitecar and Chambers developed a curriculum that fit Chambers’ idea and met Ohio’s education standards. The result was four, four-hour weekly sessions at Crystal Waters. <br><br>Students would ask residents biographical questions such as: “What was your childhood like?” and “Did you have a pet?” Then the students would write the residents’ answers in a booklet and write out their own responses to the same questions. <br><br>Through discussions between resident and second grader, the students learned about history. <br><br>Now, the “The Story of Our Lives: A Biographical Journey” program was set to begin.<br><img class="ms-rteImage-2 ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0712/100_1791.JPG" alt="" style="margin:5px 15px;width:351px;height:264px;" /><br>Finally, the day arrived for the children to come to Crystal Waters, and when Chambers saw the school bus full of children, she thought, “My dream is coming true.” <br><br>Chambers, staff, and residents were prepared to introduce the children to the residents through a series of get-to-know you games. But the children didn’t need the games; they warmed up to the residents instantly. <br>Each child was paired with a resident who had similar interests. For example, a girl who was taking piano lessons was paired up with a resident who had been a well-known piano teacher in the area. <br><br>The students began collecting biographical information from the residents, and while the answers were generationally different, the students and seniors discovered some commonalities, such as a love for pets or enjoyment in playing games. <br><br>The bonds between the second graders and the residents grew stronger as time progressed. They greeted each other with hugs and kisses and often said “I love you,” says Chambers. <br><br>The friendships continued after the program finished. Some children continue to visit the residents. The girl who played piano arrived at Crystal Waters on Easter Sunday with an Easter lily to visit the piano-teacher resident. Chambers explains that the resident did not have children of her own, but when the child showed up with the Easter plant for her, there wasn’t a dry eye among the witnesses, says Chambers. After receiving the lily, the piano teacher told Chambers, “This makes me feel young again.” Crystal Waters Retirement Community in Strongsville, Ohio, already had intergenerational programs in place, but the community’s director, Stephanie Chambers, wanted a different kind of intergenerational program: “One that makes our residents feel that they matter and that they are important,” she says. 2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0712/quilt.jpg" style="BORDER:0px solid;" />Caregiving;QualityColumn7
Like A Garden, Eden Growshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Like-A-Garden,-Eden-Grows.aspxLike A Garden, Eden Grows<img class="ms-rtePosition-1" alt="Eden" src="/Monthly-Issue/2012/PublishingImages/0712/eden.jpg" style="margin:5px 10px;" />An amiable yet robust crowd of more than 350 gathered in Grand Rapids, Mich., in late May for the Eden Alternative’s 6th International Conference, where Eden Associates, Mentors, and others immersed themselves in sessions that covered a wide range of topics, from the Quality Indicator Survey to Culture Change with Younger Adults with Disabilities.<br><br>And like the group’s name indicates, the Eden atmosphere was ripe with congeniality and hospitality that made it seem more like a family reunion than an educational conference. <br><br>In addition to providing continuing education credit opportunities, the organization, whose name has become synonymous with culture change, person-centered care, and the deinstitutionalization of nursing homes, was celebrating its 20th anniversary. <br><br>Attendees traveled from around the world for the three-day meeting, which included a prominently displayed exhibit on the growth of Eden overseas. <br><br>Among the more notable “Edenized” countries were Australia and New Zealand (Oz & NZ), where there are 38 Eden Registry homes between the two countries, as well as 1,550 Eden Associates—individuals who have completed a three-day training in the principles and practices of the Eden Alternative. <br><br>Cathy Meyer, board chair of Eden in Oz & NZ, described some of the challenges to implementing Eden in “Australasia,” including a perception that the organization is seen as a “fur and feathers” group, a reference to Eden’s beginnings as a movement to bring dogs, birds, and cats into nursing homes. Despite the obstacles, the trajectory of growth in the number of Associates between the two countries is impressive, since the seed was planted there just six years ago. <br><br>In Europe, the Netherlands, Germany, United Kingdom, Ireland, and Denmark have a handful of Eden-registered homes among them, and dozens of Associates are making their “Eden journey.” In South Africa, 223 Eden Associates were trained recently in a span of just six months.<br><br>Worldwide, more than 25,000 people have been trained as Associates in the organization’s Ten Principles.<br>Since its founding in 1992, 180 long term care providers have become Eden-registered in the United States and Canada, according to Chris Perna, Eden’s chief executive officer. <br><br>“We expect this number to grow over the coming months as we add to the Registry home- and community-based service providers and providers that serve individuals with special needs,” he says, noting that Eden has traditionally served only nursing homes and assisted living communities.<br><br>Education was the main focus at Eden, where sessions were almost exclusively aimed at one thing: improving the lives of residents. One example was a session that examined the pros and cons of alarm use for residents. In addition to there being “no evidence to support the effective use of alarms,” they are harmful to the psyche of residents, presenters said. <br><br>Among other things, resident alarms are disruptive, annoying, harmful to residents’ dignity, and have been known to boost agitation in residents, session participants noted. <br><br>Suggested alternatives to alarm use included adding thick padding under carpeting, installing better lighting, removing sharp objects from the environment, and employing the use of exercises that improve residents’ balance. An amiable yet robust crowd of more than 350 gathered in Grand Rapids, Mich., in late May for the Eden Alternative’s 6th International Conference, where Eden Associates, Mentors, and others immersed themselves in sessions that covered a wide range of topics, from the Quality Indicator Survey to Culture Change with Younger Adults with Disabilities.2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0712/eden.jpg" style="BORDER:0px solid;" />QualityColumn7
VA ‘Pension Poachers,’ Bad Actors Must Be Stopped, Senator Sayshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Pension-Poachers.aspxVA ‘Pension Poachers,’ Bad Actors Must Be Stopped, Senator SaysThe financial services and long term care industries must be “mobilized” to protect a pension program for poor, wartime vets from shady middle-men, Sen. Ron Wyden told the public in a Special Committee on Aging hearing. <br><br>“It’s pretty clear that pension poachers and bad actors have to be eliminated,” Wyden (D-Ore.) said at a hearing into Department of Veterans Affairs pension arbitrage in Washington, D.C., on June 6. Wyden said his goal is “to drain the swamp.”<br><br>The Aging committee’s hearing was called in the wake of a Government Accountability Office (GAO) audit that found that financial service companies were charging high fees to help veterans or their survivors move assets in order to qualify for pensions designed for the poor. <br><br>“The VA pension program provides a critical benefit to veterans,” GAO said in its report. “Without stronger controls over asset transfers, similar to other means-tested programs like Medicaid’s look-back and penalty period, VA cannot ensure that only those with financial need receive pension benefits.”<br><br>VA handed out some $4.3 billion in pension benefits to 517,000 veterans or their dependents in fiscal year 2011, GAO said. <br><br>There’s nothing illegal in helping veterans transfer their assets in order to qualify for the pension benefit, but GAO raised doubts about whether veterans were getting good advice from highly paid middle-men. <br><br>The long term care industry was a peripheral player in the GAO report and June 6 hearing. GAO raised concerns, for instance, about VA’s decision to offer formal accreditation to some lawyers and claims agents to help veterans obtain their pensions, which may give some veterans the impression that the agents are acting “in claimant’s best interests,” the report said. <br><br>Additionally, executives from assisted living or retirement homes “may have an interest in inviting organization representatives to conduct presentations on VA pension benefits because these benefits allow them to obtain new residents by making the costs more affordable,” GAO said. <br><br>“For example, we obtained documentation indicating that one retirement community paid an organization representative a fee for a new resident he helped the facility obtain,” GAO said. “Another community in another state paid organization representatives fees to assist residents in completing the VA pension application.” The financial services and long term care industries must be “mobilized” to protect a pension program for poor, wartime vets from shady middle-men, Sen. Ron Wyden told the public in a Special Committee on Aging hearing. 2012-07-01T04:00:00ZPolicyColumn7
Solving The Mysteryhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/Solving-The-Mystery.aspxSolving The Mystery<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>Everyone is talking about antipsychotic use in nursing homes…again. Ever since the Office of Inspector General (OIG) released a report on this issue last year, it has been on the minds of everyone, from administrators and medical directors to nurses and family members.<br><br>While the focus on antipsychotics has caused headaches for nursing facilities, it also has resulted in a renewed commitment to ensuring appropriate and limited use of these medications. Additionally, it has encouraged facilities to promote a culture where staff are empowered get to know residents and use this knowledge to resolve behavioral issues. When staff put their detective skills to work, their genius often rivals that of Sherlock Holmes, and they can solve behavioral issues without pharmacologic intervention.</div> <h2 class="ms-rteElement-H2">Antipsychotics Take Center Stage</h2> <div>The OIG report, “Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents,” evolved from a request by Congress to evaluate the extent to which elderly nursing facililty <img width="150" height="150" class="ms-rtePosition-1" src="/Monthly-Issue/2012/PublishingImages/0712/coverstory_thumb.jpg" alt="" style="margin:15px;width:215px;height:215px;" />residents were prescribed antipsychotic medications and what it was costing Medicare. Specifically, there were concerns about the use of these drugs for off-label uses, especially for residents with dementia.</div> <div><br>These concerns were not unwarranted. In 2006, one study found that 21 percent of antipsychotic prescriptions involved off-label uses. A 2007 Agency for Healthcare Research and Quality report indicated several off-label uses for antipsychotics, including treatment of depression, agitation in dementia, obsessive-compulsive disorder, post-traumatic stress and/or personality disorders, Tourette’s syndrome, and autism.In 2009, another study of antipsychotic use in the Veterans Affairs system concluded that 60.2 percent of patients receiving these medications had no recorded diagnosis that justified the prescription.</div> <div><br>Elsewhere, the report found that 14 percent (more than 300,000) of elderly nursing home residents had at least one Medicare claim for atypical antipsychotics (from January through June of 2007). Additionally, it showed that these claims accounted for 20 percent of the total 8.5 million claims for atypical antipsychotics for all Medicare beneficiaries. More significant was the finding that 83 percent of these Medicare claims for atypical antipsychotics for nursing home residents were associated with off-label conditions; 88 percent were associated with dementia, which is specified in the Food and Drug Administration (FDA) boxed warning. </div> <div><br>The vast majority of these residents showed signs of inconsolable or persistent distress, significant functional decline, and danger to themselves or others.</div> <div><br>While these numbers may be alarming, it is important to note that physicians are not prohibited from prescribing medications for off-label conditions or when there is a condition specified in the boxed warning.</div> <h2 class="ms-rteElement-H2">Challenging Validity Of Claims</h2> <div>Another finding from the report that has garnered attention involves the number of antipsychotic claims that were determined to be erroneous. More than 726,000 of the 1.4 million antipsychotic claims for nursing home residents didn’t comply with Medicare reimbursement criteria. Over 20 percent of the atypical antipsychotic claims weren’t administered in accordance with Centers for Medicare & Medicaid (CMS) standards regarding unnecessary drug use in nursing homes. This is significant, as failure to comply with CMS standards may impact Medicare participation.</div> <div><br>The cost of these erroneous claims amounted to $116 million. The cost of all antipsychotic claims for elderly nursing home residents was $309 million. </div> <div><br>Concerns about these costs, as well as the potentially dangerous effect of antipsychotics on elders, led <br>OIG to make several recommendations:</div> <div>■ Assessing whether survey and certification processes offer adequate safeguards against unnecessary antipsychotic drug use in nursing homes;</div> <div>■ Exploring alternative methods (beyond surveys) to promote compliance with federal standards regarding unnecessary drug use in nursing homes; and</div> <div>■ Taking appropriate action regarding claims associated with erroneous payments identified in the report.</div> <div>The report was not without its limitations. For instance, it didn’t take into consideration the potential harm from using conventional antipsychotics or benzodiazepines. It also failed to account for the risk versus <br>benefit evaluations on prescribers’ parts. </div> <div><br>Jennifer Hardesty, PharmD, FASCP, clinical services manager of Baltimore-based Remedi SeniorCare, also observes, “There is an inherent conflict of interest when a government entity responsible for payment and interested in saving money issues a report critical of higher-cost atypical antipsychotics, but continues to pay for cheaper and more potentially dangerous drugs like traditional antipsychotics and benzodiazepines in the same population.”</div> <h2 class="ms-rteElement-H2">CMS, Trade Groups Have Plans</h2> <div>CMS responded promptly to the report and announced plans for an education and awareness program. On May 30 of this year CMS Acting Administrator Marilyn Tavenner announced the establishment of a Partnership to Improve Dementia Care, an initiative to ensure appropriate care and use of antipsychotic medications for nursing home patients. </div> <div><br>This partnership, which involves federal and state partners, nursing homes and other providers, advocacy groups, and caregivers, has set a national goal of reducing the use of antipsychotic drugs in nursing home residents by 15 percent by year end.</div> <div><br>CMS has developed several steps to achieve this lofty goal. These include:</div> <div>■ Enhanced training. CMS has developed Hand in Hand, a training series for nursing homes that emphasizes person-centered care, prevention of abuse, and high-quality care for residents. CMS is also providing training focused on behavioral health to state and federal surveyors.</div> <div>■ Increased transparency. CMS is making data on each nursing home’s antipsychotic drug use available on Nursing Home Compare starting in July of this year and will update these data.</div> <div>■ <a href="/Monthly-Issue/2012/Pages/0712/Animals-Open-The-Conversation.aspx" target="_blank">Alternatives to antipsychotic medication</a>. CMS is emphasizing non-pharmacological alternatives for nursing home residents, including potential approaches such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities.</div> <div><br>CMS also is conducting research to better understand the decision to use or not to use antipsychotic drugs in residents with dementia. A study to evaluate this decision-making process is under way in several nursing homes. Findings will be used to target and implement approaches to improve the overall management of residents with dementia, including reducing the use of antipsychotics in this population.</div> <div><br>Earlier this year, the American Health Care Association and the National Center for Assisted Living had set a 15 percent reduction in off-label antipsychotic use by the end of 2012 as part of its new program, The Quality Initiative. The effort builds on existing work in long term care by setting specific, measurable targets to further improve quality care throughout the long term care continuum. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">The Facts About Atypical Antipsychotics</h2> <div>It is important to understand a little about the drugs that are causing so much controversy.<br><br>There are several atypical antipsychotics: aripiprazole, clozapine, olanzapine, olanzapine/fluoxetine, paliperidone, quetiapine, risperidone, and ziprasidone. While these medications were developed and approved to treat psychiatric illnesses such as schizophrenia, using atypicals off-label may help patients with mental health conditions for which there aren’t any FDA-approved options.</div> <div><br>However, these drugs hold a great risk for elderly patients, especially those with dementia. All atypicals increase the risk of death in these patients and may put elders with dementia at greater risk for stroke. <br>They also have many side effects, such as weight gain, agitation, sleepiness, gastrointestinal problems, dry mouth, cognitive problems, and fatigue.</div> <div><br>There are times when these medications are appropriate and necessary. According to regulations, antipsychotic medication should be used only for specific diagnoses identified in the “Diagnostic and Statistical Manual-IV.” </div> <div><br>These include schizophrenia, schizo-affective disorder, delusional disorder, mood disorders such as mania or bipolar disorders, schizophreniform disorder, psychosis, brief psychotic disorder, medical illness or delirium with manic or psychotic behavior, and—most significant in long term care—dementing illnesses that are with associated behavioral symptoms.</div> <div><br>However, antipsychotics can’t be used casually for any of these conditions. According to the regs, the symptoms must be identified as being due to mania or psychosis, the behaviors pose a danger to the resident or others, or the symptoms are severe enough that the resident exhibits inconsolable or persistent distress or significant function decline. These drugs must help stabilize or improve the person’s clinical outcomes, quality of life, and functional capacity.</div> <div><br>There are numerous issues—many of which are common in people with dementia—for which antipsychotic use is inappropriate and unacceptable. </div> <div><br>The regulations indicate that these drugs cannot be used simply for the behaviors of wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, unsociability, fidgeting, nervousness, uncooperative behavior, verbal outbursts, and behaviors that don’t endanger the resident or others.</div> <div><br><span><span><img class="ms-rteImage-1 ms-rtePosition-1" alt="Matthew Wayne, CMD" src="/Monthly-Issue/2012/PublishingImages/0712/MatthewWayne.jpg" style="margin:5px 10px;width:163px;height:183px;" /></span></span>Even when the use of antipsychotics is necessary and appropriate, they should be used only at the lowest effective dose and for the shortest possible time. </div> <div><br><span></span>They should be used to treat an enduring condition only when target behaviors are clearly and specifically identified and monitored, and usage must be documented carefully over time. The behavioral issues must be re-evaluated periodically to determine if medication dose reduction or discontinuation are viable options. </div> <div><br>As Matthew Wayne, MD, CMD, chief medical officer, CommuniCare Family of Companies in Ohio, says, “Sometimes, it is cruel not to do something with medications. In the right circumstances, they can provide a significant benefit.”</div> <h2 class="ms-rteElement-H2">Clinical Leaders Chime In</h2> <div>For many medical directors, directors of nursing, and consultant pharmacists, ensuring appropriate antipsychotic prescribing has been a priority for some time. In many ways, they actually have welcomed the focus on this issue as an opportunity to share their experiences and best practices.</div> <div><br>David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, Texas, says, “This has been my topic for a long time. As medical director, I look at every patient on an <a href="/Monthly-Issue/2012/Pages/0712/Antipsychotics-Resources-Abound.aspx" target="_blank">antipsychotic</a>.” He gets regular lists of patients on antipsychotics and watches to see who is prescribing these drugs, how they are documenting the diagnosis/treatment goals, what non-pharmacologic interventions were attempted, and what follow-up was done or scheduled.</div> <div><br>Smith won’t hesitate to have a talk with physicians who are on the outliers of prescribing, or who aren’t documenting what they have done, or why they aren’t following up or making efforts to reduce dosages or eliminate antipsychotics.</div> <div><br><img class="ms-rtePosition-2" alt="Karyn Leible, RN" src="/Monthly-Issue/2012/PublishingImages/0712/KarynLeible.jpg" style="margin:5px 10px;width:155px;height:193px;" />Such physician-to-physician communication is key, agrees Karyn Leible, RN, MD, CMD, senior vice president of medical services at Jewish Senior Life of Rochester, N.Y. She notes that at one of her facilities, “we made sure that there was a physician-to-physician communication whenever there were any medication changes or recommendations. This made it feel more like a peer review aimed at benefiting resident care.” </div> <div><br>Creating a culture where physicians and nurses don’t immediately make a connection between behaviors and medications can be challenging. However, as Smith says, “We have set an expectation for our nurses to compile all of the information before they call about a behavioral problem. ‘Agitation’ by itself is never an acceptable description of the problem. I want a full description of what is happening and what led up to it. <br><br>Are they hitting people? Who are they seeking out to hit—someone weaker? If they are yelling or shouting, what are they saying? If they are wandering, is it aimless or shadowing wandering? The answers to these questions help us understand what is going on in the resident’s head and what we need to do for him or her. I wholeheartedly endorse the ABC process [What are the antecedents to the behavior? What is the behavior? What are the consequences of the behavior?] for evaluation of behavioral and psychiatric symptoms of dementia [as outlined in the AMDA clinical practice guideline on delirium and acute problematic behaviors].”</div> <div><br>Robin Arnicar, RN, CDONA,FACDONA, director of nursing at Erickson Living’s Renaissance Gardens at Riderwood Village, a continuing care retirement community in Silver Spring, Md., encourages staff to start at the beginning and understand that many behaviors in residents with dementia are the result of unmet basic needs. By going through a list of possibilities—hunger, pain, cold, hot, wet, lonely, and so on—staff can resolve the behavior or rule out the possible reason for it. </div> <div><br>Nurses need to be trained to do this, she says, because many of them have been taught that they should call the physician right away when there is any change in condition or a problem.</div> <div><br>“We need to take the fear out of nurses’ actions. We need to teach them that it’s okay to say, ‘I’ve identified a problem, and I’m going to apply this intervention.’ Not all behaviors require a physician’s intervention. There is a lot nurses can do before they pick up the phone,” she says.</div> <h2 class="ms-rteElement-H2">Look For Behavioral Clues</h2> <div>Creating such a culture isn’t easy, Leible admits. In many ways, it is human nature to seek an immediate solution or response, she observes. “I challenge nurses to show me what they’ve done to understand and address the problem,” she says. She works with her team to help them find clues in the patient’s chart. </div> <div> </div> <div>For example, she says, “We recently had a resident who was highly agitated. Looking at her chart, we saw that she was sick with a respiratory illness. That is why she was anxious—she was having trouble breathing.” </div> <div><br>One way to motivate staff is to “harp on their successes,” she says. “They need to hear what they do well. We need to help them see more options.”</div> <div><br>Wayne notes the value of getting staff used to thinking in terms of taking the steps necessary to understand the behavior, its triggers and circumstances, and what might be done to address it before resorting to medications. “When staff feel overwhelmed and call requesting a prescription, this is an opportunity to walk them through these steps,” he says. </div> <div><br>Monthly team meetings with a focus on dementia and behavioral issues are good opportunities to help staff hone their problem-solving skills, work together to utilize everyone’s strengths and knowledge, and increase their confidence in their abilities to address behavioral issues, he says.</div> <div><br>Hardesty suggests psychiatric rounds, where team members, including the physician, pharmacist, and others, get together and review all psychiatric medications monthly. </div> <div><br>“This is a great forum that enables you to track changes and what has worked or not worked,” she says. When such rounds aren’t possible, she suggests doing a quick antipsychotic review during Quality Assurance Committee meetings. “This is a good opportunity to bring this issue to the surface and develop an action plan,” she says.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Involve Nurse Assistants </h2> <div>J. Kenneth Brubaker, MD, CMD, staff/faculty member of the Lancaster General Geriatric Specialists and chief medical director for the Pennsylvania Department of Aging, emphasizes the importance of involving certified nurse assistants (CNAs) in addressing behavioral issues. He says, “When I make rounds, I go to CNAs first. I will go over issues about particular patients with them and ask about any problems or concerns they have or have observed.” Because they know residents well and understand their personalities and behaviors, they often know what to do before anyone else does, he says.</div> <div><br>Brubaker gives an example: “A resident became agitated and picked up a chair. A CNA just took the chair from him and then diverted his attention to something else. She knew that this was a better approach than trying to talk him into putting down the chair.”</div> <div><br>Arnicar agrees that CNAs can be a wealth of information. The problem is, she says, that they don’t always realize the value of the information they have. “We need to educate them about how to use the information they have and tell them how important their observations are to the team,” she says.</div> <div><br>It is important for staff to understand the relationship between physical illness or discomfort and behaviors. </div> <div>Wayne says, “When a patient exhibits a behavioral issue, he or she should be evaluated medically. This needs to be done before we jump to treatment. If we rule out a medical change of condition, then we can move toward determining it’s a dementia-related condition. If we determine that it is, we then need to look at nonpharmacologic interventions before we jump to medications.”</div> <div><br>Pain actually is a common cause of a behavioral issue and often can be resolved easily. As Arnicar says, “On one dementia unit, we applied Tylenol BID, and we experienced a 60 percent reduction in [agitated] behaviors.”</div> <h2 class="ms-rteElement-H2">Painting A Personal Portrait</h2> <div>Knowing residents as individuals is essential to understanding their behavior. It can provide clues that lead to an effective—and often easy—non-pharmacologic solution. For example, Smith says, “We need to understand the person’s personality quirks and propensities. That can explain their behavior because dementia tends to disinhibit things like obsessive-compulsive traits.”</div> <div><br>He adds that the same is true of a culture of violence. People with a violent background might have been able to keep a reasonable check on it before, but once they become more demented, they lose control. “You can’t fix socialization with drugs,” Smith says.</div> <div><br>Leible agrees that knowing residents can make all the difference. “We actually had a family request that we put their loved one on medication. The woman kept asking to go home, and the family thought she was fearful about being in the facility. However, as we talked more, we found out that she had lived alone and was used to having peace and quiet, Leible says. From then on, when the resident would get agitated and ask to go home, the caregiver would take her someplace quiet, and she would calm down.</div> <div><br>Understanding a person’s coping mechanisms also can be an important clue. As Smith notes, “Most of us use intellectualization as a coping mechanism. So when we get dementia, we lose the tools to solve problems. The frustration that results from this loss often is missed in our evaluation of dementia patients.”</div> <div>Smith knows this from experience. When he was young—before he was a physician—his grandmother developed dementia. She began losing things around the house. Her explanation was that the neighbors were sneaking into her home and moving or stealing things.</div> <div><br>“On the surface, that sounds like an appropriate indication for an antipsychotic. However, looking back, I realize that she was a fiercely independent woman who couldn’t deal with the fact that she was losing control of her faculties. So she manufactured a rationale that supported her denial,” Smith explains. Instead of medications, he suggests, patients like this can benefit from efforts to support their self-reliance and confidence and enable them to get help without losing their pride.</div> <div><br>It can be challenging to get residents and families to talk about personal issues and histories that may be painful or embarrassing, Smith admits. “The tactics I have for this are imperfect, and they sometimes leave me short. However, I make sure [family members] understand that anything they tell me is private,” he says. </div> <div><br>“You don’t have to write all the nuances in your notes—just enough to help craft an answer, and you don’t need them to tell you all the details, just the circumstances.” He adds, “You need to explain that this is not the time to keep things under wraps and that what they share can help you craft a solution for their loved one.” Building trust isn’t easy or quick. “It doesn’t happen on the first day. You need to wait for your moment,” Smith says. </div> <div><br>Making the family part of the care team can strengthen relationships. Brubaker says, “I spend time talking to family and tell them how important their input is.” </div> <div><br>Sometimes, as a result, miracles happen. He tells the story of one very sweet resident with dementia who suddenly stopped eating. “She was just dying in front of us,” he says. The team couldn’t find anything wrong with her. However, they thought she might be depressed, so they put her on an antidepressant. But they also got her daughter involved, and she began spending more time at the facility. Before long, the resident was eating and back to her old sweet self.</div> <div><br>“I suspect the daughter and the antidepressant were equally responsible. You can’t have too much family involvement,” says Brubaker.</div> <div><br>Arnicar agrees. “We had a resident who would get agitated every afternoon at about 2 or 3 p.m.,” she says. </div> <div><br>“We talked to her family and found out she used to have a cocktail every day at that time.” The facility got an order for her to get a cocktail, and her agitation disappeared. </div> <h2 class="ms-rteElement-H2">Establish Resident Profiles Early</h2> <div>While establishing these relationships can be time-consuming, it is well worth the effort. As Brubaker says, “We had a patient who couldn’t communicate because of a stroke. She became territorial, and staff couldn’t figure out what to do. So we contacted her family and found out that she had run a business before she got ill. She had been in control and used to giving orders.” Everyone agreed that she was acting out because she was frustrated that she had lost control. So her son told staff to call him anytime she acted up, and he would pretend to be taking orders from her. This resolved her behavior and created a bond between staff and family.</div> <div><br>Obtaining and documenting information about the resident’s personality, history, interests, and pet peeves is important, and Smith is working on developing a form that family members or other responsible parties can complete.</div> <div><br>“Written in fifth-grade language, it should include questions that help us get an idea of who this person was before he or she got dementia,” he says. If staff have this information early on, it can make all the difference in the world in terms of preventing triggers or responding effectively and quickly when there is a sentinel event. As Smith explains, “Knowing someone is intensely bigoted because he was a POW of the Japanese can help you understand why he goes on a tirade when a person of any ethnicity goes into his room.”</div> <div><br>If it ultimately is determined that a resident needs antipsychotic medications, Wayne stresses the importance of communicating with the family members about why the drugs are being prescribed, what the advantages and risks are, and what specific behaviors are being targeted. Even though this is not required by law, he says, “When we prescribe these medications, there should be a consistent form to enable us to gain the understanding and buy-in of family members.”</div> <div><br>During these or any conversations with family regarding behavioral or other dementia-related issues, Wayne says, “We always need to look for common ground. We need to communicate what we are trying to do and how it is in the best interest of the resident. If you couch these discussions in these terms, it gets everyone on the same page.”</div> <div><br>Brubaker agrees that these conversations are valuable. “We call the family and explain to them why we want to use the medication,” he says. “Sometimes, they will say ‘no.’ But more often, they agree that it is important to do what is best for their loved one.”</div> <h2 class="ms-rteElement-H2">Slow But Steady Journey</h2> <div>Hardesty hopes that the focus on antipsychotics will help create a more consistent approach to prescribing and using these drugs. “In the past, different facilities had different philosophies and approaches. There wasn’t always strong documentation around toxicity, diagnosis, goals, or outcomes,” she says.</div> <div><br>Facilities now see that they need to have a template for an ongoing plan to make sure the diagnosis is correct, documentation is consistent and includes descriptions of behaviors and their circumstances, what non-pharmacologic interventions were attempted, target behaviors and treatment goals, results of monitoring (including side effects), and what dosage reduction efforts were pursued, Hardesty says.</div> <div><br>“Facilities should keep a flow chart of when they last attempted a dose reduction. This should be clearly outlined so that surveyors have no questions,” she says, stressing that clear, concise, detailed, and consistent documentation will save the facility a lot of headaches.</div> <div><br>Changing the way antipsychotics are viewed and used in long term care isn’t an easy puzzle to solve. Not every team player is Sherlock Holmes or even Dr. Watson.</div> <div><br>It’s a process of change, and it won’t happen overnight. We have to redo our thinking,” says Leible. </div> <span class="ms-rteStyle-Normal"></span><div>Wayne suggests, “This really isn’t about antipsychotics. It’s about good quality, person-centered dementia care. For people to look at this as an antipsychotic issue is missing the point.”<br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div> <img width="150" height="150" src="/Monthly-Issue/2012/PublishingImages/0712/coverstory_thumb.jpg" alt="" style="margin:5px;" /><br><br>Everyone is talking about antipsychotic use in nursing homes…again. Ever since the Office of Inspector General (OIG) released a report on this issue last year, it has been on the minds of everyone, from administrators and medical directors to nurses and family members.2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0712/coverstory_thumb.jpg" style="BORDER:0px solid;" />Clinical;ManagementCover Story7
‘Observation’ Incidents, Lengths Increasing, Researchers Findhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0712/‘Observation’-Incidents,-Lengths-Increasing,-Researchers-Find.aspx‘Observation’ Incidents, Lengths Increasing, Researchers Find<img src="/Monthly-Issue/2012/PublishingImages/0712/hospital.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:5px 10px;" />The percentage of patients being taken into hospitals for “observation” is increasing and so is the length of their time under such observation, a new study from Brown University found. <br><br>The ratio of observation stays to inpatient admissions grew 34 percent between 2007 and 2009, from an average of 86.9 such stays per 1,000 inpatient admissions per month in 2007 to 116.6 in 2009, study authors Zhanlian Feng, Brad Wright, and Vincent Mor said. <br><br>Two to three out of every 1,000 Medicare patients were put under observation in any given month from 2007 to 2009, rising from an average of 2.3 per 1,000 patients per month in 2007 to 2.9 per 1,000 in 2009, the study found.<br><br>But Medicare patients were increasingly put under “observation” and then discharged for outpatient treatment, “which can expose them to greater out-of-pocket expenses if they are eventually admitted to skilled nursing facilities,” the authors found in the report, released June 5. <br><br>Overall, there were 814,692 hospital observation stays involving 742,888 unique fee-for-service patients in 2007. By 2009, those figures had grown to 1.02 million observation stays for 918,180 patients, increases of 25 and 24 percent, respectively, the study found. <br><br>Even as the numbers and percentages of observation stays were rising, so, too, were the length of observation stays, the study found. In 2007, patients were kept under observation for 26.2 hours on average. By 2009, the length of observation stays had grown to an average of 28.2 hours, an increase of 7 percent, the study found. <br><br>Only a handful of Medicare beneficiaries—less than 3 percent per month—were held for more than 72 hours over the years in the study. But “their absolute number more than doubled, from an average of 1,025 each month in 2007 to 2,258 each month in 2009,” Feng, Wright, and Mor said. <br><br>The study’s authors relied exclusively on Medicare claims data, they said. “Our counts of observation stays should be taken as conservative estimates because we followed official instructions regarding the coding and reporting of hospital observation services,” the authors wrote. “To our knowledge, the accuracy of Medicare claims data … is less than perfect.” <br><br>The spike in observation may be “an unintended consequence” of several Medicare policy changes, including the Centers for Medicare & Medicaid Services’ 2004 decision to authorize the so-called Condition Code 44, the authors said.<br><br>Under that code, “hospitals may retroactively change a patient’s status from inpatient to outpatient with observation services if the utilization review committee determines, and the attending physician concurs, that an inpatient admission was not medically necessary,” the authors wrote. <br><br>Another change stemmed from the Medicare Recovery Audit Contractor program, which began as a pilot program under the 2003 Medicare Modernization Act and was formally nationalized in 2006. <br><br>“Presumably, both policy changes—especially the latter—may have motivated hospitals and physicians to reduce inpatient admissions, especially of patients whose prognosis might be thought to require only short-term treatment,” Feng, Wright, and Mor said. “Facing more stringent criteria for inpatient admissions and uncertainties over the prospects of retroactive payment denial, physicians may choose to place their patients under observation more often than they would otherwise.”Two to three out of every 1,000 Medicare patients were put under observation in any given month from 2007 to 2009, rising from an average of 2.3 per 1,000 patients per month in 2007 to 2.9 per 1,000 in 2009, the study found.2012-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0712/hospital.jpg" style="BORDER:0px solid;" />CaregivingColumn7

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Superior Documentation Means Superior Wound Carehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0812/Superior-Documentation-Means-Superior-Wound-Care.aspxSuperior Documentation Means Superior Wound Care<div><img class="ms-rtePosition-1" alt="documentation" src="/Monthly-Issue/2012/PublishingImages/0812/caregiving/caregiving2.jpg" width="221" height="147" style="margin:5px 15px;" />Wounds and pressure ulcers afflicting long term care residents incite visceral reactions in lay persons due to the fragile population served and the misconception that poor care is always the causative factor. In addition, such misconceptions have been known to lead to criminal charges, malpractice suits, and federal regulations to protect this vulnerable population. </div> <div> </div> <div>As a result, there are significant regulatory guidelines for caregivers, surveyors, and suppliers as to minimal documentation requirements for all wound types. The most basic premise behind these guidelines is to document what is seen, clearly enough for another caregiver to understand the wound presentation and treatment interventions, and for a supplier to provide—and be reimbursed for—the appropriate materials needed for treatment interventions. </div> <div> </div> <div>Documentation is also critical in the unfortunate cases where a lawyer is needed to defend charges. In such cases, trouble could arise when the minimum documentation standards are not met or when contradictory information is present in the medical record.</div> <h2 class="ms-rteElement-H2">F-tags, MDS 3.0 Provide Guidance</h2> <div>Those working in long term care are familiar with the angst prior to the survey process and the fear of being cited for insufficient care via an F-tag. The tags most commonly associated with wounds and pressure ulcers are F309 and F314. The “State Operations Manual Guidance to Surveyors for Long-Term Care Facilities” clearly states the requirements for minimal wound documentation standards and pressure ulcer risk assessment. <br></div> <div>F-tag 314 says that with each dressing change, or at least weekly, an evaluation of the pressure ulcer should be documented, including the following criteria at a minimum: location; stage; size (length, width, depth, undermining, or tunneling); exudate (amount, type, color, odor); the presence, nature of, and frequency of pain; the tissue types and color, and amounts present in the wound bed; wound edges; and the presence of infection or possible complications. </div> <div><br>Photographs may be used if the facility has a protocol consistent with accepted standards. F-tag 314 also requires daily monitoring and documentation of the ulcer if a dressing is not present, the status of the dressing and the area surrounding the ulcer, and possible complications and pain.<br></div> <div>The minimum data set 3.0 “Resident Assessment Instrument Manual” collects the following data points in Skin Conditions—Section M: pressure ulcer risk; etiology; highest-stage pressure ulcer; number of unhealed pressure ulcers of all stages, including non-stageable ones; pressure ulcer assessments, including dimensions in length, width, and depth; tissue type, including most severe; the number of worsening and healed pressure ulcers; the number of venous, arterial, and other ulcers or wounds, such as diabetic foot, surgical sites, burns, and skin tears; and skin and ulcer treatments. <br></div> <div>These data are derived from the medical record, skin care flow sheets, tracking forms, and information gathered upon admission or within the seven-day look-back period. Thus, weekly assessments capturing at the data points are pivotal.</div><div><br></div> <div><div>Click here for a sample wound care evaluation form: <a title="Wound care evaluation " href="/Monthly-Issue/2012/Pages/0812/Sample-Wound-Documentation-Form.aspx"><font color="#b10069">Sample-Wound-Documentation-Form.aspx</font></a></div></div> <h2 class="ms-rteElement-H2">Checklists, Forms Make It Easier</h2> <div>The Surgical Dressings Coverage and Documentation Checklist, available via National Government Services, a Centers for Medicare & Medicaid Services (CMS) contractor (www.ngsmedicare.com), also clarifies that the following criteria for documentation are expected in the physician’s record: baseline wound measurements, such as length, width, depth, and exudate; routine wound evaluations at least monthly, and more frequently for patients in nursing facilities or with heavily draining or infected wounds; and patient history relevant to the wound, including cause, location, prior care, debridement, type of surgical dressing, and its intended use, such as for primary or secondary. </div><div><br></div> <div>Continued coverage requires monthly assessments, including length, width, depth, and exudate, in addition to types and locations of the wounds, again more frequently if in a nursing facility or if infected or heavily draining.<br></div> <div>Furthermore, the Agency for Healthcare Research and Quality funds the On-Time Quality Improvement for Long-Term Care Program, which provides background, materials, and tools for the Pressure Ulcer Healing Project, including detailed Wound Assessment Forms, which can be found at: <a href="http://www.ahrq.gov/research/pressureulcerhealing">www.ahrq.gov/researc/pressureulcerhealing</a>. </div><div><br></div> <div>It is important to note that Medicare requires that wound evaluations be performed by a nurse, physician, or other health care professional, as the forms available for this project lack signature lines for identifying the assessing health care professional—a significant deficiency for meeting a key Medicare requirement that may be overlooked by someone using the forms. </div> <h2 class="ms-rteElement-H2">Documentation Continuity, Consistency Vital</h2> <div>Given the dearth of wound documentation required by CMS (<em>see table, below</em>) and the state of medical records in nursing homes where that information may be found in the physician’s notes, nurse’s notes, or various flow sheets such as Treatment Administration Records, one may have to search to gather all the critical documentation elements. And that search may lead to conflicting or contradictory information.</div> <div><img class="ms-rtePosition-2 ms-rteImage-1" alt="wound care requirements" src="/Monthly-Issue/2012/PublishingImages/0812/caregiving/Caregiving.gif" style="margin:15px 10px;" /><br>For example, in one instance a nursing home resident received a feeding tube placement in November 2011 with the physician’s note briefly confirming the presence of such a tube, and the nurses’ notes mentioned flushing of the feeding tube, yet the MDS 3.0 record lacked the information in the appropriate section (K). </div><div><br></div> <div>This resident also had suffered complications related to the feeding tube that led to significant peritubular skin damage that was not recognized in the chart. This scenario does not allow for adequate care planning or for quality of care as the documentation did not clearly represent the resident’s state of health or needs. It also prevented the implementation/provision of necessary services to allow the resident to heal and achieve or maintain the highest quality of life possible.</div> <h2 class="ms-rteElement-H2">Measurements Must Match</h2> <div>Another common occurrence is that of conflicting wound measurements and exudate levels across the sections of the medical record and interdisciplinary team notes. </div><div><br></div> <div>One note may have disclosed all necessary measurements, such as length, width, and depth, while another has only the length and depth, and the numbers in the notes may be transposed or not matching at all. Another scenario may have the wound site labeled differently in the various sections. Additionally, incomplete physician notes or orders stating to cover the wound with a protective dressing or a clean dry dressing are not sufficient enough to relay the care being provided to another health care provider, a surveyor, or a judge.</div><div><br></div> <div>This inconsistent and fragmented method of documentation has the potential to undermine continuity of care, particularly for the medically complex resident with wounds, who is most at risk. These medical complexities require an even more robust understanding of wound management. </div> <h2 class="ms-rteElement-H2">Consider A Holistic View </h2> <div>Treatment decisions, evaluations on wound status, and dressing efficacy are made weekly, if not at each dressing change. But current documentation standards provide little framework to prompt the health care practitioner to identify, and thus incorporate, “other relevant criteria” into wound assessment and care planning approaches when working with a more medically diverse population. <br></div><div><br></div> <div>More often than not, the available assessments and supplemental documentation lack sufficient clinical context to offer patients a more holistic solution to elderly wound care patients.</div><div><br></div> <div>Integration of a clinically complicating data set into wound assessments for residents already identified as at-risk enables caregivers to have relevant information for developing treatment protocols tailored to the unique needs of each resident.</div><div><br></div> <div>Given the varying skill level of facility wound care practitioners, efforts to create more user friendly “prompts” could result in resident-centered treatment decisions that reflect the complexity of a resident’s condition(s), a better undertanding of the consequential impact on wound healing, and the therapeutic intent of interventions.</div><div><br></div> <div>Widespread incorporation and utilization of such documentation, supplemented with photo documentation according to accepted standards, will go a long way to impact and improve wound healing outcomes within this vulnerable population. Go to www.providermagazine.com for a sample evaluation form that incorporates such prompts.</div> <div> </div> <div>Go here for a sample wound care evaluation form: <a title="Wound care evaluation " href="/Monthly-Issue/2012/Pages/0812/Sample-Wound-Documentation-Form.aspx">Sample-Wound-Documentation-Form.aspx</a></div> <div><em> </em></div> <em></em><div><em>Holly Korzendorfer, PT, PhD, CWS, FACCWS, is vice president of clinical development at DermaRite, Paterson, N.J. Adrianna Cantu, PT, CWS, FACCWS, is vice president of clinical operations for American Medical Technologies, western division. Cantu provides strategic leadership and direction to the company’s clinicians.</em></div>Wounds and pressure ulcers afflicting long term care residents incite visceral reactions in lay persons due to the fragile population served and the misconception that poor care is always the causative factor. In addition, such misconceptions have been known to lead to criminal charges, malpractice suits, and federal regulations to protect this vulnerable population. 2012-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0812/caregiving/caregiving_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;ManagementFocus on Caregiving8
Focus On Integrated Care Fosters Transformation In Assisted Livinghttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0812/Focus-On-Integrated-Care-Fosters-Transformation-In-Assisted-Living.aspxFocus On Integrated Care Fosters Transformation In Assisted Living<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>Chelsea Senior Living is renovating one of its 15 assisted living communities to create a 20-bed short-stay unit equipped with hospital beds and 24-hour nursing care. </div> <div> </div> <div> </div> <div> </div> <div>The unit, occupying one floor of an existing community in Bridgewater, N.J, will include an expanded therapy room, a nurses’ station, and private dining area. The completed project will be at the center of a pilot program to provide subacute-type care to patients from one or more of the area’s accountable care organizations (ACOs). “We have met with ACOs in New Jersey with the idea of providing short-term rehab stays, similar to a skilled nursing or subacute care facility,” says Roger Bernier, president and chief operations officer for Fanwood, N.J.-based Chelsea. “We believe we can do a good job and save the ACO money compared with a normal subacute setting.”</div> <div> </div> <h2 class="ms-rteElement-H2">Starting The New Enterprise</h2> <div> </div> <div>In addition to hiring subacute care nurses, and possibly a medical director, Chelsea will rely on partnerships with therapy and home health care providers to bring a higher level of medical services into the short-stay unit. <br><br></div> <div> </div> <div>Interviews are under way, too, with electronic health records companies for the development and implementation of a system that will track outcomes and rehospitalizations, as well as manage Chelsea’s financial and marketing functions. One thing that’s not yet settled is how payment for short-stay residents will be calculated, Bernier says. </div> <div> </div> <div><br>The impetus for the short-stay pilot is a Medicare policy that takes effect Oct. 1—the same month that Chelsea’s new unit is slated to open—penalizing hospitals for certain readmissions. Under the Hospital Readmission Reduction Program, Medicare will withhold 1 percent of a hospital’s reimbursement rate for readmissions that take place within 30 days of a discharge and are deemed to be excessive. </div> <div> </div> <div><br>The initiative, which will focus initially on three conditions—congestive heart failure, heart attack, and pneumonia—is spurring a shift toward more intensive management of patients who can be safely cared for in long term and post-acute care settings, rather than being transferred to a hospital. </div> <div> </div> <div><br>Assisted living providers are meeting the challenge with a wide range of strategies and preparations, from the use of tools and protocols to help them better manage conditions associated with readmissions, to enhanced staffing, the adoption of electronic medical records systems, and, in some cases, renovations to accommodate new services and levels of care. </div> <div> </div> <div><br>Some of the most dramatic efforts are emerging in states with regulations that allow high levels of medical care to be delivered in assisted living settings, enabling providers like Chelsea to ramp up their clinical capabilities for higher-acuity residents. </div> <div> </div> <div><br>New Jersey, for example, where 11 of Chelsea’s 15 communities are located, allows assisted living providers to meet most post-acute care needs, short of ventilator care and conditions that require “true 24-hour” nursing, says Bernier. He describes Medicare’s initiative to reduce unnecessary hospital readmissions, coupled with the formation of ACOs that share the rehospitalization goal, as a “potential game-changer” for assisted living.</div> <div> </div> <h2 class="ms-rteElement-H2">The ACO Connection</h2> <div> </div> <div>ACOs are groups of physicians, hospitals, insurers, and community-based organizations that come together to coordinate care for a defined population of patients. </div> <div> </div> <div><br>The Accountable Care Act established a Medicare ACO program, launched by the Centers for Medicare & Medicaid Services (CMS) in January 2012, which is intended to hold down costs and meet an array of quality goals, including the reduction of preventable hospital readmissions. ACOs are rewarded for meeting cost and quality objectives by sharing in the Medicare savings they achieve. Those organizations that agree to take on risk share a larger portion of savings.</div> <div> </div> <div><br>Medicare ACOs care for a minimum of 5,000 beneficiaries. Patients do not enroll as they would in a managed care organization. Instead, an ACO’s population is defined by CMS. Patients are not obligated to participate in an ACO and are free to choose non-ACO providers for any or all of their health care needs.</div> <div> </div> <div>In July, 89 new ACOs began serving 1.2 million Medicare beneficiaries, Health and Human Services Secretary Kathleen Sebelius announced. With this latest growth spurt, there are now 154 ACOs participating in the Medicare Shared Savings Program (MSSP), providing care for more than 2.4 million beneficiaries. Sebelius said the MSSP could save as much as $940 million over four years.</div> <div> </div> <div><br>A report on ACO growth and activity, released in June by the Salt Lake City, Utah-based Leavitt Partners, identified 221 ACOs in 45 states as of May 2012. </div> <div> </div> <div><br>“By taking on risk for a defined population and being reimbursed, in part, for reaching quality benchmarks, ACOs seek to both improve health outcomes and decrease the growth of health care expenditures,” the report said.</div> <div> </div> <h2 class="ms-rteElement-H2">Looking For Dependable Partners</h2> <div> </div> <div>Leavitt Partners, a consulting firm that looks at the future of health care, found that 118 of the ACOs it identified were sponsored by a hospital system, while 70 were sponsored by a physician group, 29 by insurers, and four were sponsored by community-based organizations. </div> <div> </div> <div><br>ACO growth is concentrated in large metropolitan areas, and the organizations are testing “multiple, varied models for sharing risk,” the report said. By the end of May, 59 of the organizations had become Medicare ACOs.</div> <div> </div> <div><br>Accountable care organizations are expected to seek out long term and post-acute care providers that can demonstrate the ability to safely prevent readmissions. Those that do so will become favored partners for Medicare discharges and gain a competitive edge in the markets where ACOs are active, providers say. </div> <div> </div> <div>As subcontractors to ACOs, assisted living providers may, for the first time, become part of the Medicare revenue stream. </div> <div> </div> <div><br>“It’s a huge opportunity for assisted living,” Bernier says. “Medicare dollars that were never available to us are going to be available to us. If we do it right, if we do it safely, it may be the advent of a new assisted living.”</div> <div> </div> <h2 class="ms-rteElement-H2">Acuity Rising</h2> <div> </div> <div>Whether an assisted living provider engages in the effort to reduce avoidable hospitalizations as part of an ACO agreement, or through closer alliance with local hospitals, the emphasis on preventable readmissions is expected to launch an evolution along the long term care continuum and drive up acuity in assisted living settings.<br><img class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0812/cover%20story/cs1.gif" alt="" style="margin:5px 15px;" /><br></div> <div> </div> <div>“There’s no question assisted living is moving toward higher acuity,” a trend that has been ongoing for some time, says David Kyllo, executive director of the National Center for Assisted Living (NCAL). Last year, 16 states modified their assisted living regulations, often making changes “designed to recognize that residents are staying longer” and need more medical care, he says.</div> <div> </div> <div><br>Assisted living communities care for about 750,000 Medicare beneficiaries nationwide, according to NCAL. Though assisted living providers cannot participate directly in the program, they must be able to “demonstrate to Medicare providers that they can deliver good care and be actively involved in trying to reduce unnecessary hospital readmissions,” Kyllo says.<br><br></div> <div> </div> <div>One organization moving rapidly in that direction is Avamere Health Services in Wilsonville, Ore., which operates a total of 12 assisted living and independent living communities in Oregon and Washington state. <br><br></div> <div> </div> <div>Avamere started adding certified nurse assistants (CNAs) last year at its Oregon communities, in anticipation of the need for higher-qualified staff to meet the clinical expectations of ACOs and to help contain hospital readmissions, says Nicolette Merino, regional director of operations and a former NCAL chair. Rather than hire new staff, Avamere is putting existing staff through CNA training. </div> <div> </div> <div><br>Oregon allows assisted living communities to care for a “medically advanced population,” she says. Residents with bowel and bladder incontinence, those who need a two-person transfer or require sliding scale insulin, can have their needs met in assisted living under Oregon rules, Merino says. </div> <div> </div> <div><br>As Avamere aligns with ACOs and engages in the readmission effort, Merino expects to see heightened acuity, with residents requiring such services as wound management and rehabilitation.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2">Meeting ACO Expectations</h2> <div> </div> <div>To accommodate rising medical needs, Avamere plans to hire on-site home health care providers and has converted one apartment in each of its assisted living communities to a “mini rehab room,” which will be staffed by local rehabilitation providers, she says.</div> <div> </div> <div><br>The company has also started measuring its hospital readmission and unplanned hospitalization rate and is tracking associated diagnoses, such as urinary tract infections, falls, and COPD, Merino says.</div> <div> </div> <div><br>“We know we will have to have that data to give to hospitals and ACOs to stand out as quality providers.” Avamere is also in the process of converting its properties to a standardized electronic medical record system. As residents move from “home care to hospice and all options in between, we will have the continuity of the same medical record up and down the continuum,” Merino says.</div> <div> </div> <div><br>The company is reaching out to hospitals and to ACOs that are forming in the marketplace, designating the marketing director as its chief liaison. </div> <div> </div> <div><br>“We want to make sure they’re seeing the steps we’re taking to be prepared,” Merino says. Though it may take time for ACOs to roll out completely, Avamere wants to establish relationships early on and develop the data capabilities it will need to demonstrate performance. </div> <div> </div> <div><br>“The more work we can do for ACOs, the more likely they are to refer to us,” Merino says.</div> <div> </div> <h2 class="ms-rteElement-H2">Assisted Living Interacts With Readmissions</h2> <div> </div> <div>To help providers manage unnecessary hospital transfers, including emergency room visits, observation stays, inpatient admissions, and readmissions safely, NCAL is working with the American Assisted Living Nurses Association (AALNA) on adapting a set of tools for use in assisted living settings. </div> <div> </div> <div><br>The average assisted living resident is 87 years old and vulnerable to the risks of an unnecessary hospital stay, such as trauma from the disruption caused by the event, or complications like a urinary tract infection, Kyllo says. Reducing unnecessary hospitalizations lowers these risks and “contributes to quality of life,” he says.</div> <div> </div> <div><br>The <a href="/Monthly-Issue/2012/Pages/0812/Brookdale-Gets-Innovation-Grant-To-Test-Readmissions-Tools.aspx" title="readmission tools" target="_blank">tools</a>, created for skilled nursing facilities (SNFs), are a component of Interventions to Reduce Acute Care Transfers (INTERACT), a quality improvement program created to help nursing staff manage conditions before they become serious enough to require a hospital transfer. </div> <div> </div> <div><br>The program’s clinical practice tools are “not unique to the nursing home setting,” says Joseph Ouslander, MD, project director for INTERACT and senior associate dean of geriatric programs at Florida Atlantic University’s Charles E. Schmidt College of Medicine in Boca Raton, Fla.</div> <div> </div> <div><br>“If a frail older person has symptoms of a lower respiratory infection, it doesn’t matter whether she is in a nursing home or assisted living facility,” he says. “While the capacity of an assisted living facility to manage acute illness may be more limited than in a SNF, the clinical evaluation, management principles, communication protocols, and quality improvement tools are the same.”</div> <div> </div> <div><br>NCAL and AALNA have started the effort with a tool designed to help reduce the off-label use of antipsychotic medications. Ultimately, the changes to INTERACT tools will be “really minor,” in some cases changing “nursing home” to “assisted living,” Kyllo says. The final products will be reviewed by the INTERACT team before being released.</div> <div> </div> <h2 class="ms-rteElement-H2">Not Lost In Translation</h2> <div> </div> <div>Ouslander developed the first INTERACT tools in 2007 for the Georgia Medical Care Foundation, a Medicare quality improvement organization that contracted with CMS to look at the issue of avoidable hospitalizations and strategies to reduce them, he says.</div> <div> </div> <div><br>The program was piloted in three Georgia facilities and subsequently tested in a larger project supported by The Commonwealth Fund, in which hospital admissions fell 17 percent over a six-month period among 25 nursing facilities in Florida, Massachusetts, and New York.</div> <div> </div> <div><br>The tools are “translatable” across care settings, Ouslander says. “They are just good clinical practice put into formats people can use.”</div> <div> </div> <div><br>An array of INTERACT tools (<em>see box, below</em>) have been created for early identification and timely assessment, documentation, and communication of changes in the status of residents. Central to the effort to reduce preventable hospitalizations is the SBAR, which stands for Situation, Background, Assessment, and Request, a two-page form used by nurses to gather resident information before calling a physician.</div> <div> </div> <div><img src="/Monthly-Issue/2012/PublishingImages/0812/cover%20story/cs2.gif" class="ms-rtePosition-2" alt="INTERACT tools" style="margin:15px 5px;" /><br>The SBAR documents changes in condition, vital signs, and symptoms to help determine whether a person needs to be transferred to the hospital or can be treated in place. There is also a separate SBAR for reducing antipsychotic medications under development.</div> <div> </div> <div><br>“The goal is to have communication tools so that when nurses make the call to physicians, they have all the information needed for doctors to make a decision and take appropriate action,” Kyllo says. </div> <div> </div> <div><br>An assisted living resident who is dehydrated, for example, may be treated by a home health nurse who can start intravenous fluids, rather than transferring the resident to a hospital, he says. </div> <div> </div> <div><br>Among the newest tools being created is a template that addresses family expectations for hospitalization, Ouslander says. Ruth Tappen, MD, a scholar in the Florida Atlantic University Christine E. Lynn College of Nursing and partner in the INTERACT projects, has received a grant from the Patient-Centered Outcomes Institute to develop “ethnically sensitive decision support for patients and families around the issue of hospitalization,” Ouslander says. “This is a very difficult issue,” one that is different for each group, he says.</div> <div> </div> <div><br>In conjunction with the tools, it’s important that providers have “a really good relationship with patients and families so they trust you,” Ouslander says. “If they know you and think you know what you are doing, they will trust you and listen to you,” he adds. “We can provide tools, but unless you have a good relationship and communicate well, a piece of paper won’t help.” </div> <h2 class="ms-rteElement-H2"> Readmissions: The Competitive Edge</h2> <div> </div> <div>At Tealwood Care Centers in Bloomington, Minn., where INTERACT tools have been implemented in skilled nursing facilities with funding from a state grant for that purpose, President Howard Groff plans to use the same tools in the company’s 32 assisted living communities. Though the organization is still in the process of reviewing its SNF experience with INTERACT and rolling out the tools to assisted living, the initiative appears to already be giving Tealwood a competitive edge when it comes to developing relationships with hospitals and ACOs. </div> <div> </div> <div><br>One of Tealwood’s assisted living properties is across from a hospital, in a community of about 15,000, says Groff, a former NCAL chair. “When I told them about using the INTERACT tools in our nursing facilities and applying them to assisted living, they really listened,” he says. </div> <div> </div> <div><br>“We’re going to meetings with hospitals and saying, ‘Here’s where our readmission rates are, and here’s what we’re doing about it,’” Groff adds. He believes that providers at the forefront of these efforts will make early inroads in reducing avoidable readmissions, strengthening their appeal as subcontractors to ACOs. </div> <div> </div> <div><br>Three ACOs are forming in the Minneapolis area, and Tealwood is reaching out to all of them, Groff says. </div> <div> </div> <div>“ACOs really want to have a connection to assisted living” as a less costly option for chronic illness, he says. </div> <div> </div> <div><br>Tealwood is in preliminary discussions with one of the area’s ACOs about a potential payment model and may even dedicate sections of its assisted living communities to residents that come from ACOs, creating smaller units with separate dining areas designed to meet the needs of shorter-stay residents with more intensive medical needs, Groff says.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Concentrating On Services</h2> <div> </div> <div>Like other assisted living providers that anticipate higher acuity, Tealwood is broadening its clinical capabilities, implementing 24-hour nurse staffing and CNA hiring at six communities.</div> <div> </div> <div><br>Tealwood has an established relationship with a certified home health agency and is developing an association with a physician group that specializes in assisted living, which, like Tealwood, is reaching out to the area’s emerging ACOs, Groff says. </div> <div> </div> <div><br>Physicians and nurse practitioners from the group make visits to assisted living communities, giving frail residents the option of onsite primary care, Groff says.</div> <div> </div> <div><br>Among the many benefits of the arrangement, physicians and nurse practitioners review the panoply of medications that residents are taking, discontinuing those that are no longer needed or pose a risk of unwanted interactions or side effects, he adds.</div> <div> </div> <div><br>Over time, Groff envisions a long term care continuum in which the site of care is not as important as the services provided. “We are going to see services become more critical than the actual location” where services are delivered, Groff says. “It may be that the lines will become blurred between what takes place in a SNF and assisted living community.”</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Managed Care Compounds Marketplace Challenge</h2> <div> </div> <div>Assisted living providers in New Jersey are readying for a transformation of the state’s Medicaid program, in which all long term and post-acute care benefits will be administered through a managed care organization (MCO). Effective Jan. 1, 2013, the massive overhaul compounds the changes assisted living providers face in the marketplace, observers say.</div> <div> </div> <div><br>Paul Langevin, president of the Health Care Association of New Jersey, expects managed care organizations to overshadow the impact of ACOs.</div> <div> </div> <div><br>“On Jan. 1, 28,000 nursing home and 3,500 assisted living residents will move into Medicaid managed care,” Langevin says.</div> <div> </div> <div><br>State regulations allow assisted living communities that have been operating for at least three years to have 20 percent of their census comprised of residents who are eligible for nursing facility care. </div> <div> </div> <div><br>While other states might require residents needing that level of care to leave assisted living, New Jersey allows those services to be brought into the residences, Langevin says. With assisted living providers capable of managing higher-acuity residents, Langevin speculates that the four Medicaid MCOs that will serve the state may try to reduce long term care costs by “loading up on assisted living providers.”</div> <div> </div> <div><br>The state’s Medicaid managed care revolution is expected to usher in many of the same performance expectations that ACOs bring to the marketplace, including pressure to reduce unnecessary hospitalizations as well as ever-increasing acuity along the long term care continuum.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Data Delivery Critical</h2> <div> </div> <div>Christian Health Care Center (CHCC) in Wyckoff, N.J., is prepared to meet the new competitive challenges with a diverse array of services and data—loads of data.</div> <div> </div> <div><br>“We were one of the first in New Jersey to implement a complete electronic medical records (EMR) system in 2008,” says Kevin Stagg, chief financial officer. <br><br></div> <div> </div> <div><img src="/Monthly-Issue/2012/PublishingImages/0812/cover%20story/cs3.gif" class="ms-rtePosition-4" alt="" style="margin:5px;" /><br><br>Located on a campus with skilled nursing, assisted living, and rehabilitation care, CHCC has developed a sophisticated information system, capable of generating detailed performance data on rehospitalization, Stagg says.</div> <div> </div> <div><br>“We have the ability to identify the specific codes and diseases to track individuals who are readmitted to the hospital” from assisted living as well as the nursing facility,” he says. By reviewing quality indicators, implementing clinical protocols, and monitoring diseases associated with readmissions, CHCC has driven down its rate of avoidable hospitalizations, Stagg says. </div> <div> </div> <div><br>Data are entered into the system from medication and treatment carts, hand-held devices, and laptops. The pocket-sized devices used by staff in assisted living “get smaller and smaller,” so the system doesn’t intrude on the residential environment, Stagg says.</div> <div> </div> <div><br>CHCC also uses its EMR system to track the various levels of care in assisted living, which include basic care, wound care, and assistance with several functions. The EMR measures and tracks care and outcomes for each of those levels. Ultimately, Stagg says, he expects MCOs to drive the development of a case-mix index for assisted living, which would allow measurements among and within states. “I see that coming about as managed care organizations want to get a handle on how sick a patient in assisted living is,” he says.</div> <div> </div> <div><br>Stagg predicts that as managed care organizations come to understand what assisted living providers can do, there will be a push to care for more Medicaid beneficiaries in those settings, accelerating a shift that has been occurring all along the long term care continuum.</div> <div> </div> <div><br>“What we’ve seen in the past five years is residents who previously would have been in a nursing home are still in assisted living,” Stagg says. Care that was once provided in the hospital is moving to nursing facilities, “and from nursing homes to assisted living.”</div> <div> </div> <div> </div> <div> </div> <div><em>Lynn Wagner is a freelance writer based in Shepherdstown, W.V.</em></div> Assisted living providers are meeting the challenge with a wide range of strategies and preparations, from the use of tools and protocols to help them better manage conditions associated with readmissions, to enhanced staffing, the adoption of electronic medical records systems, and, in some cases, renovations to accommodate new services and levels of care. 2012-08-01T04:00:00Z<img alt="rehospitalizations, ACOs" src="/Monthly-Issue/2012/PublishingImages/0812/cover%20story/cs_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Management;ClinicalCover Story8
Investments In Direct-Care Staff A Big Win For Everyonehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0812/Investments-In-Direct-Care-Staff-A-Big-Win-For-Everyone.aspxInvestments In Direct-Care Staff A Big Win For Everyone<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Direct care workers and the strength of their relationships with the individuals they support are the key to both the quality of caregiving services and the quality of life for millions of Americans. Yet, employers sometimes perceive these staff members—who provide the majority of hands-on care—as unskilled laborers who can be easily replaced. </div> <h2 class="ms-rteElement-H2">Better Jobs, Better Care</h2> <div>Some long term care providers are taking a different approach to employing and supporting their direct care staff. PHI, with funding from the <a href="http://www.hitachifoundation.org/">Hitachi Foundation</a>, issued a series of case studies profiling eight providers that are investing time, money, and other resources to improve the quality of direct-care jobs. <br><br></div> <div>Each of these employers believed they could get better value from their frontline staff by improving the quality of their jobs, and each has experienced significant and measurable benefits because of their investments in these workers. <br><br></div> <div>The PHI case studies found that employers are creating quality jobs by investing in three crucial areas: compensation, opportunity, and support. That is, they are making an effort to provide their direct-care staff with competitive wages and benefits, opportunities for training and career advancement, and better-quality supervision.</div> <h2 class="ms-rteElement-H2">Cash Awards Pay Back</h2> <div>All the organizations profiled in PHI’s series of case studies exhibited a clear dedication to their direct-care staff, finding innovative ways to build staff loyalty and improve quality of care. One of those organizations, Benchmark Senior Living, a for-profit company that develops and manages dozens of assisted living facilities throughout New England, has developed a unique way to provide extra compensation to exemplary employees. <br><br></div> <div>Through Benchmark’s Culture Compensation program, all of the company’s frontline staff can earn cash awards for performing acts that embody the company’s values and culture. Caregivers are rewarded with bonuses of $10 to $100 if a manager or department head spots them performing an action deemed to be above and beyond their job description.<br><br></div> <div>The company also distributes monthly and yearly prizes of $100 and $500, respectively, to truly exceptional caregivers.<br><br></div> <div>Benchmark has also supported its frontline caregivers through the One Company Fund, a separate nonprofit organization it spun off to celebrate the company’s 10th anniversary. The fund provides employees with need-based grants of up to $5,000 to cover the costs of unforeseen circumstances, such as a health emergency, a fire, or a death in the family. In 2009 and 2010 alone, the One Company Fund distributed more than $175,000 in grants to Benchmark caregivers—many to staff of Haitian descent who were directly affected by the devastating 2010 earthquake there. The fund “has been an enormously positive thing for the people affected, and also for the morale of everybody, because they know they work for a company that really cares,” said Benchmark founder and Chief Executive Officer Tom Grape.</div> <h2 class="ms-rteElement-H2">Green House Gets It Right</h2> <div>Meanwhile, the Green House Project has restructured staffing in ways that empower direct-care workers, giving them much greater responsibility than in a typical nursing home. All Green House homes are managed by self-directed teams of direct care staff (called Shahbazim). </div> <div><br>Nurses and other professional staff come to the home to provide services to residents, but day-to-day decisions regarding daily routines, meals, activities, and so on are made by residents and the Shahbazim who support them. </div> <div><br>As a result, direct-care staff feel that they are truly valued, and teamwork is improved, resulting in greater satisfaction on the part of both workers and residents. </div> <div><br>Other long term care facilities profiled by PHI provide their frontline caregivers organizational advancement opportunities via career ladders. Ararat Nursing Facility in Los Angeles, for example, maintains a five-tier ladder that allows certified nurse assistants (CNAs) to ascend to management positions. Employees secure a 50-cent wage increase for each rung on the career ladder they achieve.</div> <div><br>Overall, the ladder has motivated Ararat’s employees to strive for better things, says Margo Babikian, Ararat’s executive director. </div> <div><br>The career ladder tells CNAs that “if you have the ambition, if you want to grow, yes, there is an opportunity for you,” Babikian says.</div> <div><br>One company profiled by PHI, a Philadelphia-area nonprofit that provides nursing home care, community services, and affordable housing to seniors, launched its Ladder of Opportunity in 1999 as a way of attracting and retaining quality employees. By completing a free seven-week training, CNAs can become CNA Specialists, assuming additional care and administrative responsibilities. CNA Specialists also receive a $1 increase to their hourly wage. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Supervisory Skills Play Important Role</h2> <div>While training opportunities for frontline caregivers constitute an essential and obvious component of quality direct-care jobs, training programs that provide supervisors with the skills they need to support direct-care staff are equally important.</div> <div><br>Several of the case studies showcase the PHI Coaching Approach to Supervision, skills-based training that focuses on strengthening supervisory relationships and diminishing the need to constantly “put out fires.” </div> <div><br>In 2008, administrators at Orchard Cove, a continuing care retirement community in Canton, Mass., trained approximately 50 of its supervisors in the Coaching Approach to Supervision. </div> <div>The supervisors were taught such skills as active listening, self-management, clear communication, and collaborative problem solving. </div> <div><br>The results of the training were extremely positive, with CNAs throughout the facility reporting that they felt closer to—and better supported by—their supervisors. After the coaching training, Stare Guerrier, a CNA, said she began to see a shift in supervisors’ behavior. “They see what’s going on, and they try to help us do our jobs better,” says Guerrier.</div> <div><br>Other organizations profiled by PHI have used peer-mentoring programs to support direct-care staff. These programs provide both better support for new employees and a professional growth opportunity for senior assistants. </div> <div><br>At Edgewood Centre in Portsmouth, N.H., just-hired workers are shadowed and guided by a mentor for the first five to 10 days of their employment. These peer mentors are nurse assistants who have been trained in communication and problem-solving skills and receive a wage increase for their upgraded title. </div> <h2 class="ms-rteElement-H2">The Stats Say It All</h2> <div>Of course, a commitment to support, compensation, and opportunity means most to employers when it produces measureable improvements. PHI’s case-study series demonstrates that all of the organizations profiled have, in fact, experienced tangible, positive outcomes. </div> <div><br>For example, Benchmark’s turnover rate is far lower than most comparable long term care organizations, averaging between 37 to 39 percent per year in a field in which an annual 100 percent turnover rate is not uncommon. </div> <div><br>In addition to higher retention and lower turnover rates, employers who invested in their workforce also demonstrated significant improvements to their quality of care. Orchard Cove residents displayed marked improvements in several quality-of-care indicators, including decreases in falls, pressure ulcers, urinary tract infections, anxiety, depression, and reliance on nine or more medications. </div> <div><br>Many organizations also demonstrated higher satisfaction rates for both staff and residents. At Ararat, resident and family satisfaction hovers between 98 and 100 percent year to year, while staff satisfaction consistently ranks high—around 95 percent in annual surveys.</div> <div><br>Ultimately, organizations that make the most creative and unwavering investments in their direct-care staff are likely to see the best results in terms of the quality of care provided and the staff loyalty engendered. </div> <div>“They’ve invested money in us to see us become better,” says Guerrier. “We don’t feel like we are only here to do a job. We are important, too.” </div> <div> </div> <div><em>Marcia Mayfield, MPH, is the former director of evaluation for PHI, a national nonprofit committed to fostering dignity, respect, and independence for those who receive—and those who provide—long-term services and supports. Matt Ozga is a PHI staff writer. </em></div>Direct care workers and the strength of their relationships with the individuals they support are the key to both the quality of caregiving services and the quality of life for millions of Americans. Yet, employers sometimes perceive these staff members—who provide the majority of hands-on care—as unskilled laborers who can be easily replaced. 2012-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0812/hr/hr_thumb.jpg" style="BORDER:0px solid;" />Management;FinanceColumn8
The CCRC Conundrumhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0812/The-CCRC-Conundrum.aspxThe CCRC Conundrum<div>The approximately 1,900 continuing care retirement communities (CCRCs) in the United States are currently grappling with issues relating to fair housing and reasonable accommodation due to the unique nature of the CCRC model.</div> <div> </div> <div>A CCRC offers a continuum of care model that encompasses independent living, assisted living, and skilled nursing care. As such, CCRCs have a wide age range of seniors residing on their campuses in varying stages of mental acuity and physical health. </div> <div> </div> <div>Recently, questions have arisen as to whether a CCRC can restrict access to certain part of a campus by very ill residents or exercise its contractual authority to move a resident from his or her independent living unit (ILU) to full-time care. </div> <div> </div> <div>Every CCRC should be aware of the potential litigation hazards it faces when dealing with these questions and of the two federal statutes upon which a plaintiff will most likely base his or her potential discrimination case.</div> <div> </div> <div>A CCRC is contractually obligated to provide a continuum of care to its residents and is authorized to assess its residents’ health along the continuum and transfer them accordingly. What happens, however, if a resident does not wish to move from his or her ILU to full-time care? </div> <h2 class="ms-rteElement-H2">Removal From Independent To Assisted Living</h2> <div>In Herriot v. Channing House, a case in the U.S. District Court for the Northern District of California, a resident sued her CCRC, claiming that its failure to accommodate her request to stay in her ILU with private caregivers violated both the failure to accommodate under the Fair Housing Amendments Act (FHAA) and the Americans With Disabilities Act (ADA). She claimed that the policy of transferring residents on the basis of their disabilities constituted discrimination. <br><img class="ms-rtePosition-2" src="/Monthly-Issue/2012/PublishingImages/0812/legal/legal.gif" alt="" style="margin:15px 10px;" /><br></div> <div>Upon her admission to the CCRC, the resident had signed a contract that granted the CCRC the authority to transfer the resident “to the appropriate medical unit” when she became permanently ill or enfeebled; the CCRC staff physician had determined that it was in her best interest to transfer her.<br><br></div> <div>The CCRC, in brief, claimed that it should not be required to seek an exception to its policy or to the California Department of Social Service’s regulations because it could not legally delegate its duty of care to private aides, and, even if an exception could be granted, it would fundamentally alter its continuing care program.</div> <h2 class="ms-rteElement-H2">The Court’s Ruling</h2> <div>The court ultimately granted the CCRC’s motion for summary judgment and held the following:<br><br></div> <div>■ The proposed accommodation was not “reasonable,” as: 1.) the requested accommodation would be unlawful as California law not only prohibited the CCRC from delegating its care duties to private aides but also expressly authorized its proposed transfer of the resident to its staffed nursing floor; and 2.) it would fundamentally alter the nature of the CCRC’s business to have control of level-of-care decisions and to have the ability to authorize involuntary transfers along the continuum of care. Neither the FHAA nor the ADA require that the provider offer an accommodation that would alter the nature of its business.<br><br></div> <div>■ FHAA discrimination claim. The CCRC’s transfer policy did not result in differential treatment toward or exclude a specific class of persons; the resident was being treated no differently than other residents, all of whom agreed contractually to move through the continuum of care. Essentially, the CCRC had legitimate nondiscriminatory reasons for its policy and for its transfer of the resident.<br><br></div> <div>■ ADA discrimination claim. In order to prevail on this claim, the resident would have had to show that her disability was one factor in the alleged discriminatory treatment. The court found that the transfer policy and decisions to transfer residents were based specifically on compliance with state regulations and upholding its continuum of care plan; the motivation behind the transfer was compliance with policy and not, as the resident had argued, the disabilities themselves. <br><br></div> <div>The Herriot case ultimately settled, and the resident agreed to move out of the CCRC.</div> <h2 class="ms-rteElement-H2">Treatment Of Residents In Communal Areas</h2> <div>Another tricky issue arising in the context of CCRC management is the separation of residents with disabilities from healthier ones in communal areas such as dining rooms. <br><br></div> <div>In Hyatt v. Northern California Presbyterian Homes, a case in the U.S. District Court of the Northern District of California, a resident claimed that the policy of banning the use of walkers in the communal dining room constituted discrimination under the FHAA, the ADA, and the relevant California statutes. <br><br></div> <div>Specifically, the dining room had two sides: one with wait staff and a dress code and one with a buffet side. Residents using walkers were to give them to staff who would store the walkers during the meal, thus preventing residents from using their walkers to access the buffet.<br><br></div> <div>The resident alleged that she discussed possible accommodations with the CCRC, which in turn granted her access to the buffet tables, but only after 5:45 p.m., an offer she did not accept.<br><br></div> <div>In its answer, the CCRC admitted that it was its “general practice” to “store walkers once the resident had been seated in order to eliminate the tripping hazard they represent.” It also asserted that the resident’s requested modifications were not feasible, would fundamentally alter the nature of its services, and would impose an undue financial hardship upon the CCRC. This case eventually settled.</div> <h2 class="ms-rteElement-H2">Wheelchairs And Walkers</h2> <div>In a similar case, the Colorado Court of Appeals held in Weinstein v. Cherry Oaks Retirement Community that a policy requiring residents who used wheelchairs or walkers to transfer to ordinary chairs when taking meals in the communal dining room violated the Colorado Fair Housing Act (which is almost identical to the FHAA). <br><br></div> <div>The facility, at the trial court level, argued that wheelchairs in the dining room would violate the city fire code, that state and local regulations required such a transfer, and that the policy would help to determine eligibility to remain at the facility.<br><br></div> <div>The court held that the facility did not present a legitimate reason for its transfer policy and had not shown that a reasonable accommodation could not have been made.<br><br></div> <div>Interestingly, the trial court found that the “real reason” for the policy was to maintain a “disability-free” atmosphere; facility personnel had said the wheelchairs in the dining room did not “look good.”<br><br></div> <div>Recently, the New York Times wrote about a CCRC in Norfolk, Va., that had enacted a policy making three dining facilities off limits to all but independent living residents. The CCRC’s executive director told the New York Times that the policy was enacted to prevent overcrowding and that the policy of letting residents of varied disabilities dine together violated Virginia regulations and left it vulnerable to lawsuits or to revoked licenses.<br><br></div> <div>The resident’s attorney believed that the policy violated the FHAA, the ADA, and Virginia law. </div> <div>In light of the uproar that ensued, the CCRC ultimately retracted the policy; the new policy provides that any resident willing to sign a liability waiver, produce a doctor’s consent form, and pass a simple health screening can eat anywhere in the building. </div> <h2 class="ms-rteElement-H2">Ensure Compliance With FHAA, ADA </h2> <div>A CCRC should ensure that its policies comply with (along with the relevant state statutes and regulations) the dictates of the FHAA and the ADA. </div> <div><br>Any policy treating sicker residents differently from healthier residents in connection with access and/or rights to communal areas should be carefully scrutinized.</div> <div><br>CCRCs should attempt to find reasonable accommodations to meet residents’ needs in a way that does not fundamentally alter the CCRC’s services or impose an undue administrative or financial hardship. </div> <div>Most importantly, there are no hard and fast rules in this developing arena, and a CCRC should stay apprised of the latest legal developments. </div> <div> </div> <div><em>Andrew I. Bart is an attorney with Tenzer and Lunin, a New York City law firm. He may be reached at (212) 262-6699 or at <a href="mailto:andrewibart@gmail.com">andrewibart@gmail.com</a>.</em></div>The approximately 1,900 continuing care retirement communities (CCRCs) in the United States are currently grappling with issues relating to fair housing and reasonable accommodation due to the unique nature of the CCRC model.2012-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0812/legal/legal_thumb.jpg" style="BORDER:0px solid;" />LegalColumn8
The QIS Experthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0812/The-QIS-Expert.aspxThe QIS Expert<h2 class="ms-rteElement-H2">Q. What should providers do during the “hiatus” in the QIS rollout?</h2> <br> <div>A. Recognizing that quality, as defined in QIS, has become an expectation of all nursing homes over the past five years, providers can and should incorporate the standards and tools of the QIS into care. <br><br>With 25 states and the District of Columbia having completed or begun implementing the QIS, a critical mass exists for change to a more resident-centered survey process that is influencing providers and agencies in all states.</div> <div><br>More importantly, residents and families are seeking long term and post-acute care environments where quality of life is more of a focus. </div> <div><br>Evidence of the latter is the growth of the culture change movement and the expansion of alternatives to nursing homes. That said, nursing homes are expected to keep an increasingly frail group of residents safe, healthy, and satisfied, which is no small challenge. <br><br></div> <div>Providers need not wait until the QIS comes to their state agency to meet this new standard for care. The quality metrics contained in the QIS comprehensively define measurements for today’s expectations of nursing homes. </div> <div><br>QIS metrics cover quality-of-life issues such as dignity and choices; quality-of-care issues, such as adequate staffing to meet resident needs and off-label use of antipsychotics; and post-acute care quality, such as readmission to hospital and rehabilitation outcomes, to name just a few. </div> <div><br>Nursing homes can use these tools to assess all of these areas. </div> <div><br>Starting today, providers should measure themselves based on the full set of QIS assessments. This is the first step. There are numerous situations where even high-performing organizations find areas where they can improve. </div> <div><br>The second step is to conduct a root-cause analysis of chosen areas of concern using the many tools that exist to help providers do this—to identify units and systems where problems occur. </div> <div><br>The third step is corrective actions utilizing resources for all disciplines to assist providers.</div> <div><br>The fourth step is for providers to measure themselves again to see if they have achieved the desired improvement.</div> <div><br>Sound familiar? </div> <div><br>Yes, in simple terms this is quality assurance and performance improvement. The challenge is that this is not simple to do, and it takes time to complete the improvement cycle of assessment, improvement, and re-assessment. </div> <div><br>So take advantage of the hiatus in the QIS rollout to build Quality Assurance and Performance Improvement systems around the QIS assessments and tools. </div>Providers need not wait until the QIS comes to their state agency to meet this new standard for care. The quality metrics contained in the QIS comprehensively define measurements for today’s expectations of nursing homes. 2012-08-01T04:00:00Z<img alt="Andy Kramer, MD" src="/Monthly-Issue/2012/PublishingImages/Headshots/AKramer_rollup.jpg" style="BORDER:0px solid;" />QualityThe Quality Forum8
Unleash The Power Of Supply Chain Controlhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0812/Unleash-The-Power-Of-Supply-Chain-Control.aspxUnleash The Power Of Supply Chain Control<div>With the number people aged 65 and older set to double in the next 20 years, the growth in assisted living will likely continue. </div> <div> </div> <div>Still, market uncertainties have always been challenging. With fluctuating costs and the future of government spending in question, running a successful food service program is always a challenge. </div> <div>In addition, long term care communities must also balance freshness, quality, and nutritional concerns, both to maintain the health of residents and to attract new ones. </div> <div> </div> <div>So how can food service programs manage two of their largest expenses—salaries and supplies—without compromising quality and thus patient care? Re-evaluating the supply chain is the most practical approach to cutting costs while directly benefitting the bottom line. </div> <h2 class="ms-rteElement-H2">Reduce Supply Expenses</h2> <div>Supply chain management in most assisted living food service programs encompasses planning, acquisition, quality control, storage, and disposal. In addition to food supplies, purchasing includes capital equipment acquisition; technology-related items, which can improve operational efficiency; staffing services; and other purchased services. <br><br></div> <div>The potential benefit of improved supply chain management is significant because every dollar cut from supply expenditures drops straight to the bottom line. To achieve the same bottom line impact, food service managers will have to increase top-line revenue many times over, so why spend money to make money if it isn’t necessary?</div> <h2 class="ms-rteElement-H2">Manage Inventory To Manage Costs</h2> <div>In food service especially, no other component of the supply chain is as closely related to customer service, customer satisfaction, and cost reduction as is managing inventory. <br><br></div> <div>Fresh, high-quality ingredients, including a variety of seasonal fruits and vegetables, keeps residents in good health and can serve as a differentiator to attract new customers. </div> <div><br>A smoothly running supply chain recognizes that inventory is costly to maintain, and having the right amount of inventory to meet customer needs is essential.</div> <div><br>With changing tastes and more dining options available to individuals, nursing home and assisted living managers need to strike a balance between making sure that the food service program is well stocked, but not overstocked with excess inventory.</div> <div><br>Following are four tips to help managers get a handle on inventory and the creation of an inventory management system:</div> <div><div> </div> <ul><li>Know the ABCs of inventory. Evaluating usage trends to get a sense of the most ordered items will often reveal that a large percentage of food that residents order, which is often as much as 80 percent, represents only 20 percent of total inventory. Creating an A-B-C ranking system of inventory usage helps managers predict replenishment rates. An ABC stock system classifies stock items according to criteria that determine their importance. For example, class A items would be the top 10 percent of items that have highest priority while class B items are the next set of items, perhaps, the top 20 percent, and so on.</li></ul> <ul><li>Get rid of dead stock. Determine when the last time inventory was truly assessed. In particular, take a look at the “received” date. Containers of foods that are used infrequently not only take up storage room but can also spoil, creating a hazard if inadvertently used. Implement a process for regularly checking and clearing old and out-of-date products from the inventory.</li></ul> <ul> <li>Consider “just-in-time” purchasing. Some organizations have found that doing business without an inventory store room works well for their food service program. For a smaller facility, a system that brings in needed items a day or two before they are to be used may offer flexibility and cost savings. But it’s important to monitor product flow and have triggers in place to alert staff when a critical product is running low. Also, tracking variances over time and standardizing product selection are key to making a just-in-time ordering system work successfully.</li></ul> <ul><li>Consolidate and standardize. A good rule of thumb is that the greater variety of items offered to residents, the higher the overall inventory costs will be and the harder it will be to monitor usage. For larger facilities, it may make sense to reduce the variety of a certain type of food so that managers can negotiate better prices, service levels, and payment terms by increasing the volume purchased.</li></ul> <h2 class="ms-rteElement-H2"> Consider Partnering With A GPO</h2></div> <div>A group purchasing organization (GPO) may be the solution for some food service managers. GPOs are organizations that leverage the purchasing power of a group of businesses to obtain discounts from vendors based on the collective buying power of members. While GPOs are commonly used to purchase clinical products within the health care industry, some may not realize that they offer products to all areas of operation, including food service. If considering a GPO, here are some tips to get started. <br><br></div> <div><ul><li>Talk to the purchasing department. Some communities are already GPO members. Then, begin discussions about accessing the purchasing contracts that are in place for supplies and equipment.</li></ul></div> <div><ul><li>Assign a person to manage the food service supply chain. This should be someone who knows the program and knows what products are used most, how the program runs, and what has worked with vendors. </li></ul></div> <div><ul><li>Invest in information systems. This effort will support the operational decision making the building requires. Alternatively, the GPO may have products or services that support data need.</li></ul></div> <div><ul><li>Continually look for standardization. To identify if there’s an opportunity to reduce the number of brands being used, managers should adopt policies and procedures to streamline and improve the menu and nutrition systems.</li></ul></div> <div><ul><li>Track appropriate metrics. The facility’s purchasing department may have appropriate metrics to monitor for cost and service. Establish a tracker that visually shows the progress of the metrics, and update it monthly.</li></ul></div> <div><ul><li>Partner with a distributor. With the support of a GPO, partnering with a distributor could help food service managers ensure that the facility is taking advantage of all the contract discounts available. </li></ul></div> <div>With demographic trends supporting growth, working with a GPO can provide facilities with quick solutions that yield lasting results. </div> <div> </div> <div><em>Kelly Rodriguez is a strategic account executive at Provista, a leading supply chain improvement company that helps facilities in the health care, education, hospitality, and corporate markets improve their financial performance.</em></div> With the number people aged 65 and older set to double in the next 20 years, the growth in assisted living will likely continue. Still, market uncertainties have always been challenging. With fluctuating costs and the future of government spending in question, running a successful food service program is always a challenge. In addition, long term care communities must also balance freshness, quality, and nutritional concerns, both to maintain the health of residents and to attract new ones. 2012-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0812/mgmt/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn8

September


 

 

Culture And Familiarity Matter To Eldershttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Culture-And-Familiarity-Matter-To-Elders.aspxCulture And Familiarity Matter To Elders<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div><img width="190" height="203" src="/Monthly-Issue/2012/PublishingImages/0912/caregiving/Caregiving1.jpg" alt="Native Alaskan resident" class="ms-rteImage-2 ms-rtePosition-1" style="margin:10px;" /><br>As the country faces a rapidly growing population of older adults, with a majority of them being ethnic minorities, the numbers requiring long term and post-acute care will also increase.</div> <div> </div> <div>Recognizing this growing need among its own residents, the Denali Center in Fairbanks, Alaska, incorporates unique architectural style, plants, animals, and multigenerational interaction to bring a true sense of community to those who call it home.</div> <div> </div> <div>Denali is an Eden Alternative site that operates from an elder-centered approach by identifying what is important to its residents, a majority of whom are Alaska Natives.</div> <h2 class="ms-rteElement-H2">Honoring Culture</h2> <div>Alaska Natives have a strong connection to their cultural practices and traditions, and just because they are in a facility does not mean they should leave this part of themselves behind. <br><br></div> <div>Denali management understands the importance of culture to its residents and has incorporated cultural activities into facility care as a way to honor the Alaska Native residents and make them feel more at home. The foundation of these activities came from knowing that honoring the culture of the Alaska Native residents is important to their health and well-being and realizing the importance of establishing and building rapport before providing care. </div> <div><span><img width="308" height="205" class="ms-rteImage-2 ms-rtePosition-2" alt="Native Alaskan culture" src="/Monthly-Issue/2012/PublishingImages/0912/caregiving/Caregiving3.jpg" style="margin:5px 10px;" /></span><br>The communication patterns of Alaska Natives are different; it takes time and patience to gain their trust to provide quality care, and the cultural activities have assisted in this process for both residents and staff. </div> <div><br>Many of the activities at the center focus on Alaska Native culture, and the sharing of culture includes the following: traditional native music and dances; videos, such as village documentaries, celebrations, the World Eskimo-Indian Olympics (WEIO), and the Athabascan fiddle festivals; native news from villages, regional corporations, and Denakkanaaga (an Alaska native elders organization); traditional native foods, such as moose, caribou, salmon, dried meats, and berries; and participation in cultural activities in the community, such as WEIO, the Festival of Native Arts, potlatches (a gift-giving festival and primary economic system practiced by Alaska Natives), and the North American race.</div> <div><br>The purpose of these cultural activities is to support residents in their transition to placement, nourish their bodies and souls, and to celebrate cultural wealth. </div> <div><br>Listening to the residents, it became apparent that many of them miss home, family, native foods, and their familiar environment. One can imagine the challenges associated with moving from a home where they have lived all their lives to an unfamiliar facility. The inclusion of these activities is one way to ease the transition and help the residents feel connected culturally, as well as provide them native foods and activities that previously brought them joy and pleasure. </div> <div><br>The center incorporated these cultural activities with the aim of improving the health and well-being of the residents, but also to celebrate the cultural diversity that exists among the residents and across the state of Alaska.</div> <div><br>The activities implemented at Denali incorporate various aspects of Alaska Native cultures familiar to the residents; they bring back memories of their families and communities and help them maintain their cultural identity. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Residents Respond Positively</h2> <div>As testimony to the importance and benefit of these activities for the center, residents have expressed their appreciation with the following quotes: “I really enjoy the food they serve. It is just like I had growing up.” “I like dried meat mixed with fat and moose or caribou on the bone so I can have the marrow.” “I feel like I was at a real native meeting. It always feels like we are family.” <br></div> <div><br>One resident summarized the feelings of the native residents: “I really like the activities; it reminds me of back home.” </div> <div><img width="288" height="192" src="/Monthly-Issue/2012/PublishingImages/0912/caregiving/Caregiving4.jpg" alt="Native Alaskan culture" class="ms-rteImage-2 ms-rtePosition-1" style="margin:20px;" /><br>The center began incorporating these activities because it recognized that the loss of culture and community ties increases isolation, boredom, and grief. </div> <div><img src="/Monthly-Issue/2012/Pages/0912/Culture-And-Familiarity-Matter-To-Elders.aspx?ControlMode=Edit&DisplayMode=Design" alt="" style="margin:5px;" /><br>Based on testimony from the Alaska Native residents, the response to these well-attended activities has been positive. Providing these cultural activities has increased satisfaction with placement; increased involvement in the activities, including participation in local events and sharing stories and recipes; and strengthened relationships between residents, family, and staff. </div> <div><br>The family members of these residents are also happy with their loved ones’ involvement in the activities; they no longer view their family members as sick and dependent, but as active and healthy. </div> <div><img src="/Monthly-Issue/2012/Pages/0912/Culture-And-Familiarity-Matter-To-Elders.aspx?ControlMode=Edit&DisplayMode=Design" alt="" style="margin:5px;" /><br>In addition to improving their health, the support for these activities is positive because they are low cost and provided by the residents, family members, and community, which highlights the generosity of the community. </div> <div><br>Denali is supported in the provision of these services as a majority of them are donated, in both money and time, and the activities department and residents council also fund some activities. </div> <div><br>Throughout the year, family and community donate food, such as moose, caribou, duck, salmon, whitefish, muskrat, beaver, and berries. </div> <div><br>The residents receive newsletters from regional native corporations, and the native videos are either purchased or donated to keep the residents abreast of tribal news, politics, and celebrations in their respective regions. <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Visits Home Boost Satisfaction</h2> <div>As a skilled nursing facility, Denali is home to elders who cannot live at home by themselves and require some type of nursing care. The Leave of Absence program enables residents to return to their home communities for memorial potlatches, holiday events, family celebrations, tribal meetings, subsistence activities, or an extended weekend visit.<br><br>A volunteer or trained staff member who is able to attend to physical needs accompanies elders on their trips home. Being able to return to the village and participate in cultural events removes the stigma of being a “sick person” or patient, which is the dominant thought often associated with nursing homes or long term care facilities in urban Alaska. Airfare or gas money for some of these trips is usually provided by the elders themselves, and additional support has come from families, guardians, or a regional native corporation. </div> <div><br>The story of “Jake” illustrates the importance of these trips and the reasoning behind Denali’s support of these events. </div> <div><br>Jake was given the opportunity to go home to visit his family in a rural village in Interior Alaska. During the visit, his family was reminded of his physical limitations that his family could not provide for in the village, but they also saw that he appeared to be healthy and doing well. </div> <div><img width="391" height="293" src="/Monthly-Issue/2012/PublishingImages/0912/caregiving/Caregiving2.jpg" alt="aerial view of Alaska" class="ms-rteImage-2 ms-rtePosition-2" style="margin:10px 15px;" /><br>Jake enjoyed his visit home, as did his family, but they realized he needed more care than they could provide and understood he had to return to the center. </div> <div><br>According to the social worker who coordinated the visit, Denali staff saw the joy this visit brought to Jake and realized the value in this particular activity, which continues to this day. </div> <div><br>Today, the traditional foods have now become full meals on a weekly basis for the residents and are fully embraced and accepted by Denali staff. These activities started with a vision and have become a fully supported and respected program that has benefited numerous residents, families, and staff.</div> <div><br>Denali is one example of a nursing home that sees firsthand the benefits and importance of integrating cultural activities and traditional foods. </div> <div><br>It is the hope of the center that it can serve as an example of how long term care and skilled nursing facilities can incorporate cultural activities for the residents that will improve their quality of life and honor their cultural identity, language, values, and customs.</div> <div> </div> <div><em>Jordan Lewis, PhD, MSW, is Aleut and a postdoctoral fellow at the University of Washington School of Medicine. He can be reached at: (907) 328-8984 or <a href="mailto:dr.jordan.lewis@gmail.com">dr.jordan.lewis@gmail.com</a>. Don Thibedeau is the Denali Center social worker. He can be reached at: (907) 458-5166 or <a href="mailto:Don.Thibedeau@bannerhealth.com">Don.Thibedeau@bannerhealth.com</a>. </em></div> Denali management understands the importance of culture to its residents and has incorporated cultural activities into facility care as a way to honor the Alaska Native residents and make them feel more at home. The foundation of these activities came from knowing that honoring the culture of the Alaska Native residents is important to their health and well-being and realizing the importance of establishing and building rapport before providing care. 2012-09-01T04:00:00Z<img alt="Alaskan Natives" src="/Monthly-Issue/2012/PublishingImages/0912/caregiving/Caregiving1_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Culture ChangeColumn9
Minding MDS Accuracyhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Minding-MDS-Accuracy.aspxMinding MDS Accuracy<div>Near the top of the list of an administrator’s worst conversation starters with a minimum data set (MDS) coordinator is: “I’m sorry, I missed a <a title="Building A Strong Team" target="_blank" href="/Monthly-Issue/2012/Pages/0912/Building-A-Strong-Team.aspx">Medicare assessment</a>, and we won’t get paid.” Unfortunately, refrains like this one are occurring on a regular basis in nursing homes across the country. </div> <div> </div> <div>The difficulty of accurately scheduling End of Therapy (EOT), EOT with Resumption, and Change of Therapy (COT) assessments can make the MDS team crazy, not to mention the time intensiveness of getting it right. </div> <div> </div> <div>Every day on the 12,000-member American Association of Nurse Assessment Coordination (AANAC) community discussion groups, MDS coordinators submit questions and challenges concerning the scheduling of their MDS assessments. On far too many occasions, their situations result in loss of payment.</div> <h2 class="ms-rteElement-H2">Default Payments Can Be Avoided</h2> <div>Among the most common reasons that a facility receives default payments is for late or missed EOT or COT assessments. This occurs when communication breaks down between therapy and the MDS scheduling coordinator. <br></div> <div><br>Many times, each one is relying on the other to track the MDS schedule, and assessments fall through the cracks. An example that illustrates this is a therapist not notifying the MDS nurse that a resident has missed therapy or has ended therapy coverage, resulting in the assessment not being started in a timely manner. </div> <div><br>Sometimes, the cause of a scheduling error is simply miscounting the days of missed therapy for the EOT or being off-count for the seven-day rolling COT. For example, one MDS nurse continued to count the rolling seven-day COT from the most recent 14-day assessment when there was an intervening Significant Change of Status Assessment completed, which reset the COT count. </div> <div><br>Other errors occur when the MDS that is scheduled has the wrong reason code for the assessment type, such as when a coordinator codes a 30-day assessment when it should have been coded as a COT. <br>These errors result in default payments if they are noticed and corrected while the resident is still on Medicare. <br></div> <h2 class="ms-rteElement-H2">Provider Liability Risks</h2> <div>Once the resident is discharged from Medicare, however, it’s a whole different story. When a prospective payment system assessment is missed and the resident has already been discharged from Medicare, the facility cannot receive payment for the days that the assessment covers (there are few exceptions). </div> <div><br>If a resident has been discharged from Medicare when it is discovered that a submitted MDS contains an error that cannot be corrected using the modification process, the facility cannot collect payment for those days.</div> <div><br>There are five reasons that an MDS has to be inactivated instead of modified: incorrect information for the type of assessment, wrong assessment reference date (ARD), the wrong type of provider, an incorrect entry date on an entry tracking record, or an erroneous discharge date on a discharge record. </div> <h2 class="ms-rteElement-H2">The Result Is Nonpayment</h2> <div>In these situations, the Resident Assessment Instrument (RAI) User’s Manual states, “The new MDS 3.0 record being submitted to replace the inactivated record must include new signatures and dates for all items based on the look-back period established by the new ARD and according to established MDS assessment completion requirements” (RAI Manual [v1.08] Errata [v4], April 2012, page 8). <br><br></div> <div>The result of this inactivation process is nonpayment. Facility staff are then required to submit a claim to the fiscal intermediary, indicating that the resident used the Medicare days. However, the days are recorded as provider liability, and the facility receives no payment for the care provided.<br><br></div> <div>Even the most knowledgeable, savvy, and detail-oriented clinicians can make mistakes and miss information when scheduling MDS. Administrators can support their teams by helping them create facility MDS systems that share the burden and improve accuracy. </div> <div> </div> <div><em>Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em></div> Every day on the 12,000-member American Association of Nurse Assessment Coordination (AANAC) community discussion groups, MDS coordinators submit questions and challenges concerning the scheduling of their MDS assessments. On far too many occasions, their situations result in loss of payment.2012-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0912/MDS1_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ManagementColumn9
Medicaid HCBS Definition Concerns Assisted Living Grouphttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Medicaid-HCBS-Definition-Concerns-Assisted-Living-Group.aspxMedicaid HCBS Definition Concerns Assisted Living GroupIn the agency’s second attempt to define Medicaid home- and community-based services (HCBS), the Centers for Medicare & Medicaid Services (CMS) proposed recently that assisted living units providing Alzheimer’s care could be considered institutional, thereby eliminating them from serving Medicaid beneficiaries.<br><br>The language was not what the National Center for Assisted Living (NCAL) wanted to hear.<br><br>“In essence, it says that certain settings are guilty of being institutions before being proven innocent,” Karl Polzer, senior director of policy for NCAL, said in response to the proposed rule. “It prejudges settings, including assisted living units in continuing care retirement communities, Alzheimer’s care communities, and multi-level campuses.”<br><br>CMS expects to issue further guidance on such settings. <br><br>In the meantime, the proposed rule states, “Settings that are located in a building that is also a public or privately operated facility that provides inpatient institutional treatment, or in a building on the grounds of, or immediately adjacent to, a public institution, or disability-specific housing complex” will be considered institutional, unless a state can prove otherwise.<br><br>Also eliciting concerns from NCAL was another CMS proposal to use landlord/tenant laws to apply to “provider-owned or -controlled residential” units or apartments. Most states have statutes and regulations for assisted living providers that specify move-in and move-out procedures as well as defining the level of care and conditions, NCAL said. <br><br>“General landlord tenant law and the use of leases are incompatible with assisted living regulatory standards in most states,” NCAL said.In the agency’s second attempt to define Medicaid HCBS, CMS proposed recently that assisted living units providing Alzheimer’s care could be considered institutional, thereby eliminating them from serving Medicaid beneficiaries.2012-09-01T04:00:00ZColumn9
New Alzheimer’s Model Promising For Treatmenthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/New-Alzheimer’s-Model-Promising-For-Treatment.aspxNew Alzheimer’s Model Promising For TreatmentScientists have created a new model of Alzheimer’s that takes skin cells from people afflicted with the disease and reprograms them by adding genetic factors, according to research released at the Alzheimer’s Association (ALZ) 2012 International Conference. <br><br>Skin cells extracted from Alzheimer’s patients were reprogrammed into brain cells using genetics research focused specifically on induced pluripotent stem cells (iPSCs). iPSCs are genetically reprogrammed adult cells that resemble an embryonic stem cell. Consequential iPSCs in the study conducted by The New York Stem Cell Foundation (NYSCF) were the result of combined skin cell samples from unaffected family members of Alzheimer’s patients and the patients themselves. Once the skin cells of the affected and unaffected participants were combined, scientists added genetic factors to reprogram the cells, resulting in iPSCs that accurately resembled Alzheimer’s patients’ brain cells in a petri dish. <br><br>Prior to these findings, scientists habitually studied mouse subjects of the disease in hopes of breaking new ground. <br><br>“Current animal models of Alzheimer’s are highly engineered to express elements of the disease,” said William Thies, PhD, ALZ chief medical and scientific officer, “and, while valuable for research, [the mouse subjects] incompletely represent how the disease forms and progresses in people.”<br><br>“One advantage of this technology is that we get a near infinite supply of disease- and control-patient stem cells,” said Andrew Sproul, PhD, researcher for NYSCF. “Another is that we can then turn the iPSCs into any tissue in the body. This allows us to investigate the role of various cells in Alzheimer’s disease progression by manipulating the iPSCs to form different types of brain cells that we and others believe are involved in Alzheimer’s.” <br><br>iPSCs have already mobilized scientists, offering them the ability to access formerly unattainable aspects of the disease. NYSCF scientists and Mount Sinai School of Medicine researchers found that neurons in Alzheimer’s patients produce a higher level of the toxic form of beta amyloid, a protein fragment that makes up amyloid plaques. These plaques are a standard indicator of Alzheimer’s in the human brain. <br><br>The research reported at the ALZ conference focuses on the relatively rare young-onset Alzheimer’s disease (comprising less than 2 percent of all cases). <br><br>NYSCF has expressed plans to join forces and resources with other educational institutions to expand their research to cover the more prevalent late-onset Alzheimer’s.<br>Scientists have created a new model of Alzheimer’s that takes skin cells from people afflicted with the disease and reprograms them by adding genetic factors, according to research released at the Alzheimer’s Association (ALZ) 2012 International Conference. 2012-09-01T04:00:00ZCaregiving;ClinicalFocus on Caregiving9
Plugged In With HIThttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Plugged-In.aspxPlugged In With HIT<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Over the course of the past five years or so, health information technology (HIT) has been developed and fine-tuned to match the ever-changing needs of long term and post-acute care—delivering what caregivers and residents want and need. </div> <div> </div> <div>From electronic health records and e-prescriptions to automated medication dispensing and in-room monitors, the right technology allows better care management and more time with residents to provide care. </div> <h2 class="ms-rteElement-H2">Achieve Across-The-Board Efficiencies</h2> <div>Several key factors weigh in on this wave of technology developments: increased documentation requirements and the impact on an already overburdened staff, cost cuts by public and private payers requiring more efficient resource utilization, regulations spurred by provisions of the health care reform law that require short-cycle dispensing of medication, and constant efforts toward improving accuracy and quality of patient care. </div> <div><br>Now added to the list are accountable care organizations requiring health care providers to adeptly collect, manage, and analyze critical patient data for gauging their own performance. </div> <div><br>As demands grow and change, effective budget management becomes more challenging for providers every day. By identifying efficiencies achieved through new HIT systems and capturing new savings through labor efficiencies, waste reduction, and more effective patient care, the HIT systems can more than offset the costs associated with their deployment. </div> <div><br>But reasons to <a target="_blank" href="/Monthly-Issue/2012/Pages/0912/Tips-For-Implementing-Technology.aspx" title="implementation tips">implement</a> them go much further than the savings achieved. Better accuracy and increased efficiencies that result in better resident-centered care actually create a method of attracting and retaining quality caregivers. And electronic health records, for example, provide a tremendous opportunity to reduce the massive fragmentation within long term care systems. Providers are better positioned to reduce errors, improve resident safety and quality, increase nurse satisfaction, and decrease costs.</div> <div><br>Plus, improving the marketability of a facility to new clients and referral sources can result in higher occupancy rates and recognition as an innovative provider. What’s more, it demonstrates to the community a commitment to quality care.</div> <div><br>Recent major technological advancements in health care, such as e-prescribing and electronic order entry, allow nurses, physicians, nurse practitioners, and physician assistants to electronically transmit new prescriptions or renewals to the pharmacy.</div> <h2 class="ms-rteElement-H2">Electronic Ordering,Dispensing </h2> <div>Electronic ordering can eliminate three or more points of transcription—and the associated risk of error—from the medication ordering process. The order to delivery process is much faster and safer as a result. </div> <div> </div> <div>Electronic ordering is also a critical piece in the accelerating move to electronic health records. By sharing medical prescription information, electronic ordering leads to a complete medical profile for each resident, and the delivery of real-time data—without transcription—eliminates the medication record turnover process.</div> <div><br>At the same time, when done correctly, automated medication dispensing can eliminate waste, increase efficiency, and make medication administration safer and easier. </div> <div><br>It is not only a life-saver for residents, but also a boon for nurses who, for years, fumbled with bingo cards and boxes; crammed, unorganized carts; missing pills; dropped pills; or co-mingled unidentified pills—especially those little white generics. </div> <div><br>Automated medication dispensing creates better efficiency, improves unit dose safety, and helps comply with new regulations. New automated medication dispensers offer two-day dispensing for prescriptions, which ultimately reduces financial waste and physician frustration with typical 30-day fills when a med needs to be changed mid-month. <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Consider Open Architecture</h2> <div>As technology decisions are being made, it is critically important to ensure that integration is possible now and in the future. Open-system architecture, which allows multiple vendors to create add-on products that increase a system’s flexibility and functionality, and the use of industry standards by technology providers allow facilities to keep ownership of and access to their data. </div> <div><br>They also enable future flexibility in choosing additional technology providers and partners and more nimble integration with newer technologies when available. </div> <div><br>Today, there is an accelerated move to implement many of these solutions and systems. For many long term and post-acute care operators, the choices of what to implement can be daunting. Not only is there fear of change, but there are also major investments to consider. </div> <div><br>To get the best return on investment, each decision should be carefully thought out. A complete, integrated and efficient approach must be taken to get the true value of technology. Administrators must consider all of the critical clinical components involved, including labs; dietary; treatments; and, of course, medications.</div> <div><br>Vendors are making a significant investment in new technologies to benefit providers in lieu of federal funding. Long term care facilities are becoming much more sophisticated in keeping up with the demand of consumers, regulators, and others and are at the beginning of the advancing curve of adoption.</div> <div><br>Facilities have to make the investment in technology to reap the myriad benefits. <br></div> <h2 class="ms-rteElement-H2">IT Investment Options</h2> <div>Making initial investments now, like creating wireless campuses, adding nurse computer stations to enable electronic ordering and communication, switching to electronic health records, and converting from manual to automated medication dispensing will, at a minimum, level the playing field but could provide a competitive advantage. <br></div> <div><br>When researching new technologies, systems, and solutions, there are several things to consider. Adoption of an industry-standard information exchange and communication protocols is the first step toward ensuring that the interdisciplinary environment of long term and post-acute care is effectively maintained through the ability to share and exchange information. </div> <div><br>Executing due diligence ahead of time can help ensure the right product and right vendor have been chosen. Make sure the lab partner knows lab; the pharmacy knows medication order entry; and the electronic health record vendor knows administration tracking, documentation, and management. <br></div> <h2 class="ms-rteElement-H2">Make It Easy</h2> <div>Also of great importance is the system’s ease of use. Changing the culture of long term care from a largely paper-based world to one that embraces technology does not come without its challenges. </div> <div><br>Success of the HIT systems is driven by the competency of the users, which is dependent upon their ability to use the systems accurately and effectively. Therefore, even when a system is relatively easy to use, training is critical to successful implementation.</div> <div><br>In addition, engaging partners with systems that can communicate effectively with one another is essential to achieving the systems’ full clinical, operational, and financial benefits. </div> <div><br>Balancing complexity of features with ease of operation is a delicate task and one that should be thoroughly evaluated to ensure a successful outcome. </div> <div><br>Everyone benefits by implementing these advancements. Using HIT will benefit operators financially and with greater efficiencies. </div> <div><br>Clinical staff will be relieved of much administrative work in many cases, resulting in more time spent caring for residents. Residents benefit because not only do they get more quality care time, but technology can improve safety.</div> <div> </div> <div><em>Robert Kerr is senior vice president of information systems for Remedi SeniorCare, Baltimore, an institutional pharmacy business serving a growing number of facilities extending from the Mid-Atlantic to the Midwest. Go to <a target="_blank" href="http://www.remedirx.com/" title="www.remedirx.com">www.remedirx.com</a> for more information.</em></div>Several key factors weigh in on this wave of technology developments: increased documentation requirements and the impact on an already overburdened staff, cost cuts by public and private payers requiring more efficient resource utilization, regulations spurred by provisions of the health care reform law that require short-cycle dispensing of medication, and constant efforts toward improving accuracy and quality of patient care. 2012-09-01T04:00:00Z<img alt="health care technology" src="/Monthly-Issue/2012/PublishingImages/0912/tech/tech1_thumb.jpg" style="BORDER:0px solid;" />TechnologyColumn9
SNF PPS Rule Boosts Medicare Payments For Skilled Nursinghttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/SNF-PPS-Rule-Boosts-Medicare-Payments-For-Skilled-Nursing.aspxSNF PPS Rule Boosts Medicare Payments For Skilled NursingSkilled nursing facilities (SNFs) will see a slight increase of 1.8 percent to their Medicare payments under new guidelines published recently by the Centers for Medicare & Medicaid Services (CMS). <br><br>The agency estimates that net Medicare Part A payments to SNFs will increase by about $670 million over the year.<br><br>The notice, issued on July 27, updates the SNF Prospective Payment System (PPS) for fiscal year (FY) 2013. The complicated math boils down to a 2.5 percent increase for the market basket and a 0.7 percent decrease for a productivity adjustment.<br><br>The update, which takes effect Oct. 1, was expected, but was “still welcome news,” American Health Care Association President and Chief Executive Officer Gov. Mark Parkinson said in a statement. <br><br>“Skilled nursing facilities have already been hit too many times over recent years through government reductions, including last year’s devastating SNF PPS rule,” Parkinson said. “Any additional cuts could be devastating to many facilities all over the country and threaten our ability to provide quality care to our residents.”<br><br>Additional highlights of the rule include: <br>■ The per diem rate for SNF patients with AIDS had been increased by 128 percent as of Oct.1, 2004, and under the CMS notice, this add-on will remain in effect for FY 2013.<br>■ All rates and wage indexes outlined in the notice for FY 2013 apply to all swing-bed rural hospitals, but not to critical access hospitals that would continue to be paid on a reasonable cost basis for SNF services furnished under a swing-bed agreement.<br>■ The labor-related weight for FY 2013 is 68.383 percent, down from 68.693 percent for FY 2012. <br>Also in the notice, CMS expressed concerns about SNFs that are requiring patients to sign binding arbitration agreements at admission. CMS plans “to monitor this closely and take action consistent with current rules and guidelines,” the rule says, “and consider rulemaking or any additional steps that may be appropriate.”<br><br>For all of the good news, the future of the long term and post-acute care profession “remains at risk,” Parkinson said. <br><br>“While CMS appears to have understood the current state of the profession, Congress will continue to indiscriminately hunt for pay-fors, and we, like all other providers, are in its sights,” Parkinson said. “We must remain vigilant that any additional reductions to skilled nursing facilities are not the answer.”<br><br>Earlier this year, House Republicans briefly flirted with the idea of slashing provider assessments to help pay for student loans. They backed off after an uproar from the long term care industry. <br><br>In 2010, some 1.7 million Medicare patients were treated in the nation’s 15,000 SNFs. Medicare spent almost $32 billion on SNF care in 2011 alone. 2012-09-01T04:00:00ZCaregivingColumn9
Study Finds Provo, Sioux Falls Best Cities For Aginghttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Study-Finds-Provo,-Sioux-Falls-Best-Cities-For-Aging.aspxStudy Finds Provo, Sioux Falls Best Cities For AgingProvo, Utah, and Sioux Falls, S.D., topped the Milken Institute’s recent list of the “Best Cities for Successful Aging.” <br><br>The study, which analyzed 359 metropolitan areas in the United States, identified 78 factors that influenced seniors’ quality of life. In addition to scrutinizing the cities’ health care initiatives and weather patterns, researchers dug deeper to inspect job conditions, accessible transportation, and affordable housing. <br><br>Touted for its physically active community, Provo is home to multiple medical centers, three of which are magnet hospitals, and a philanthropic populace that values volunteerism. <br><br>Ranked as the best large city among the 100 studied, Provo also holds the No. 1 growth ranking for small businesses. <br><br>Similarly, Sioux Falls features several hospitals that specialize in geriatric services, in addition to “the highest employment rate among seniors among the 259 small cities” studied.<br><br>The Milken Institute’s study is significant in that it acknowledges the economic crisis’ influence and seniors’ willingness and, oftentimes, necessity to continue working past their expected retirement ages.<br><br>“We hope the findings spark national discussion and, at the local level, generate virtuous competition among cities to galvanize improvement in the social structures that serve seniors,” said Paul Irving, senior managing director and chief operating officer.<br><br>Interestingly, location rankings tend to fluctuate between the 65 to 79 and 80 and older age groups. One city touted as ideal for the 65 to 79 age range may be ranked considerably lower with regard to the 80 and older age group. <br><br>For example, Anchorage, Alaska, ranked as the 8th best location for the 65 to 79 age group due to high job growth, but dropped to the 87th spot for the 80 and older age set because of its gloomy weather patterns and high housing costs. 2012-09-01T04:00:00ZColumn9
ZPIC Program Rife With Potential Conflicts, Audit Findshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/ZPIC-Program-Rife-With-Potential-Conflicts,-Audit-Finds.aspxZPIC Program Rife With Potential Conflicts, Audit FindsZone Program Integrity Contractors (ZPICs) had more than 1,900 pre-existing business relationships or other potential conflicts with the Centers for Medicare & Medicaid Services (CMS), a recent government audit found. <br><br>The Department of Health and Human Services’ inspector general reviewed thousands of disclosure forms offered up by 18 contractors and 85 subcontractors in the ZPIC program. <br><br>Investigators found that the so-called “offerors”—would-be contractors—had potential conflicts of interest in at least 1,919 instances. At least 16 offerors had actual conflicts of interest, investigators wrote in the July report. <br><br>Among the report’s findings: <br>■ Companies “often” had prior business relationships with CMS or other ZPIC contractors “but rarely considered them to be actual conflicts;”<br>■ “Seven offerors were subsidiaries of health insurance companies that offered Medicare plans;”<br>■ Some two-thirds of would-be contractors “either were Medicare claims processors or had financial ties to claims processors;”<br>■ Half of the offerors “had existing” ZPIC contracts with CMS;<br>■ Companies often “subcontracted with each other as well as with entities that had a contractual relationship with CMS;” and<br>■ In 173 cases, ZPIC contractors reported conflicts “without specifying whether they were actual or possible conflicts.”<br><br>Investigators are worried that “conflicts of interest that affect the impartiality of ZPICs could weaken CMS’ efforts to protect Medicare from fraud, waste, and abuse,” the Office of Inspector General report said.<br><br>“Because ZPICs perform program integrity functions for CMS, it is crucial that they be free from conflicts of interest that could affect their work.”<br><br>That’s not to say that “improper activity is taking place among CMS contractors,” investigators wrote. <br><br>“However, the public trust in CMS and its contractors could come into question if conflicts are not explicitly and openly disclosed as well as properly mitigated.”<br><br>CMS officials told the inspector general’s office that it had “mitigated” the impact of potential and actual conflicts, mostly by putting “restrictions on information and resource sharing within the offeror’s or subcontractor’s company.” <br><br>“CMS has had considerable experience addressing Organization Conflict of Interest [OCI] matters,” Acting Administrator Marilyn Tavenner wrote. <br><br>“The contracting officer is responsible for exercising common sense, good judgment, and sound discretion when making OCI determinations. CMS addressed the ZPIC conflicts of interest through exchanges with the apparent awardees.”<br><br>But CMS invited trouble by not having a written policy on conflicts, investigators wrote. <br><br>Long term care providers have complained roundly about the ZPIC program. The inspector general’s findings did little to calm nerves. Scot Hasselman is the general counsel to the American Health Care Association, which has been among the most vocal of ZPICs’ critics. He says the ZPIC program is so frustrating that he’s considering proposing a seminar entitled, “Yes, the government IS out to get you.”<br><br>“The bottom line,” he says, “is that the government is outsourcing provider claims review, fraud detection, and judicial review to private contractors, many of whom are related parties.”2012-09-01T04:00:00ZPolicyColumn9
Bridging The Gap In Dementia Carehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Bridging-The-Gap-In-Dementia-Care.aspxBridging The Gap In Dementia Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><p>​<img width="327" height="327" class="ms-rteImage-3 ms-rtePosition-2" alt="bridging dementia gap" src="/Monthly-Issue/2012/PublishingImages/0912/CS/cs1.jpg" style="margin:20px 15px;" />Before “Maggie” developed severe dementia, her gregarious personality had led her to find much joy in her many social activities. </p> <p>But after the diagnosis, and after her condition worsened to the point that she could no longer live in her own home, her family moved her into an assisted living facility. </p> <p>The facility was large and unfamiliar to her. Staff tried to pull her into social activities, but she resisted, and as time went along she became increasingly <a href="/Monthly-Issue/2012/Pages/0912/Interpreting-And-Responding-To-‘Difficult-Behaviors’.aspx" target="_blank">withdrawn and isolated</a>. </p> <p>What had given her so much joy throughout her life was now inaccessible to her. </p> <p>Maggie’s family tried to compensate by increasing the time they spent with her, but it seemed to do little if any good. They were losing their mother, even more than they already had.</p> <h2 class="ms-rteElement-H2">Consider The Person With  Dementia, Not The Disease</h2> <div>G. Allen Power, MD, author of “<a href="/Monthly-Issue/2012/Pages/0912/Dementia-Beyond-Drugs.aspx" title="Dementia Beyond Drugs" target="_blank">Dementia Beyond Drugs: Changing the Culture of Care</a>,” proposes a simple yet, for many providers, radical idea: Stop thinking of dementia patients as people with diseases to be treated, and start thinking of them as people with a terrifying, shifted reality who still have lots left to give if their trust can just be earned.</div> <div> </div> <div>Negative attitudes toward people with dementia are a big factor in the combative atmosphere that can arise at times between those with the disease and their caregivers, writes Power in his recent award-winning book.</div> <div><br>“We look at the person with dementia from a single viewpoint—that of a broken person in need of medication to mitigate the decline,” he writes. “Our standardized tests reduce” the elder to a list of “disordered thinking processes, while we ignore the complex cognitive and emotional qualities that can be retained even in advanced stages” of the disease.</div> <div><br>In other words, just because someone has a brain disorder doesn’t mean the person isn’t still experiencing life, a growing number of health professionals say. Their life histories, values and spirituality, and coping styles, for example, remain. </div> <div><br>In fact, anecdotal evidence points to people with dementia being more exquisitely attuned to their environment, relationships, and spirituality than those without the disease. </div> <div><br>But the challenges of experiencing dementia are overwhelming for the sufferer, and that must be recognized, Power says.</div> <div><br>A board-certified internist and geriatrician, Power has been a full-time long term care physician for nearly 20 years and an Eden Mentor at St. John’s Home in Rochester, N.Y., for more than a decade. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Culture Change Critical To Dementia Care Model</h2> <div>During his time at St. John’s, Power has helped shepherd the skilled nursing facility’s journey toward accomplishing the goals set forth by the Eden Alternative. He admits they still have a long way to go—the not-for-profit residence is home to almost 500 patients, two-thirds of whom are on Medicaid, and the facility still has long hallways and central nurses’ stations—but the transformation is taking place. In fact, St. John’s just opened its first two Green Houses to be in the mainstream community. </div> <div><br>The years of caring for people with dementia have taught Power many lessons, some painful, some inspiring. Today, changing the way people with dementia are cared for has become something of a mission for him. </div> <div><br>“The most important [message] is that we need to change the way we look at people with dementia,” Power tells Provider. “We need to see the whole person, what their strengths are, and not just their disability.” </div> <div><br>Critical to making this happen is culture change, because without it, “no matter what philosophy you adopt, the philosophy will die,” he warns. “The system will kill it.” </div> <div><br>In his book, Power details a new method of approaching dementia care, which posits that individuals with the disease, rather than merely being victims of a decline into oblivion, are full human beings who have experienced a radical, frightening shift in perception, and their “difficult behaviors” are their attempts to gain their footing, achieve control, cope with stressors, problem-solve, and communicate unmet needs. </div> <div><br>Verbal or not, people’s personalities are still in there, and they’re communicating, Power says. Providers are just not understanding them. And because they don’t understand, and because they’re steeped in a medical point of view, they ascribe residents’ “difficult” behaviors to their disease and try to solve it with a pill, he says.</div> <div><br>When a resident with dementia begins to express him- or herself in ways that are difficult for staff and other residents to handle, Power says, using antipsychotics should be a last resort, rather than the first thing doctors turn to, as is too often the case. Rather than rely on antipsychotics that mostly just sedate patients with dementia and sink them into a state in which they’re even less able to communicate and are more confused, Power has come up what he calls the experiential model of care.</div> <h2 class="ms-rteElement-H2">Nonpharmacological Interventions Key To Model</h2> <div>The essential element in making the experiential model work is transforming the mindset of the residence’s staff from a medical/institutional viewpoint to one that prioritizes building meaningful relationships with each resident and partnering with the resident in each caregiving event and activity of the day.</div> <div><br>This requires consistent staffing, the elimination of agency staffing, and incorporating meaningful communication between two people—resident and care partner (a term that implies a two-way street in which residents participate in their own care, rather than the term “caregiver,” which implies all the giving occurs on the provider’s side)—who are getting to know and trust each other. </div> <div><br>It’s only when the care partner really understands the resident—including history, current views and preferences, spirituality and values, and what tends to trigger anger or unhappiness—and gains the person’s trust that effective,<a href="/Monthly-Issue/2012/Pages/0912/Essential-Oils-A-Nonpharmacological-Intervention.aspx" target="_blank"> nonpharmacological interventions</a> can take place. All people are more likely to open up about what they’re really feeling to a friend than to a stranger.</div> <div><br>The model also requires that caregivers learn how to see through the eyes of an individual battling dementia, which takes a great deal of thoughtfulness and learning about both the disease and the individual, because just as no two people are the same, no two experiences of dementia are alike, Power says.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Resident's Life History Provides Major Clues </h2> <div>American Medical Directors Association President-Elect Jonathan Evans, MD, agrees with Power’s approach.</div> <div><br>Understanding the reasons why someone is behaving in what seems like an unusual or disruptive way makes acceptance easier for staff, Evans says.</div> <div><br>“This isn’t premeditated, conscious mischief, this is someone responding to their environment in a way other people don’t want. We need to substitute something meaningful for behavior that might be undesirable.”</div> <div><br>Evans recounts the story of a man living in a nursing home who would roll his wheelchair over to other people’s wheelchairs and polish the chair’s chrome, which would distress the person sitting in it. Or he would go around polishing door-knobs in the building. </div> <div><br>But because the clinical team knew his life history, they could understand what he was doing and that it wasn’t a threat to anyone. “In his life, he’d had two jobs simultaneously. He worked as a car salesman and in the evening as a volunteer fire fighter,” and both of those jobs involve polishing up the chrome on the cars or the fire engine. “He’d shined chrome objects for so long that it was overlearned behavior. He was just working,” Evans says.</div> <div><br>Another example: A nurse who developed Alzheimer’s disease and lived in a nursing facility would push other residents in their wheelchairs, sometimes right onto the elevator, push buttons, and send them down. That sometimes led to fighting. </div> <div><br>“So, why would she do that? The environment she was in looked just like her place of work for decades,” Evans says. “The environment was telling her she’s at work. The behavior was really entirely predictable. The challenge for us is how to allow her to be fulfilled, to continue to make a contribution. If the environment is telling her to do something, how can we possibly expect to convince her to do otherwise?”</div> <div>The facility’s nurses’ hearts went out to their colleague struggling with dementia, and they put a lot of thought into how to involve her in meaningful but safe ways. </div> <div><br>“At times if they saw she was causing distress to others, they would call her name and say it was time to make rounds, and they would hand her a clipboard and distract her with some tasks,” says Evans. “Her attention span wasn’t too great, and she would lose interest, but they could do it over and over again by acknowledging her as a nurse rather than trying to convince her that her professional life was over.” Well, Evans notes, telling someone they’re wrong doesn’t even work well with spouses or teenagers, so why would it work better with someone with dementia? </div> <h2 class="ms-rteElement-H2">Interpersonal Relationships Work</h2> <div>Most people in long term care like these ideas, Power says, but are worried that having caregivers engage in meaningful conversations with residents as they provide care—or merely as they see them in the common areas—would take up so much time that they wouldn’t be able to fulfill all the regulatory requirements. </div> <div><br>“Those are always the concerns,” he tells <em>Provider</em>, but these well-meaning people are viewing the issue from within the constraints of the current, institutional system. “The way you do things now, you don’t have time for this. You need to change how you do things. Most people are very caring; they just need to know how to get there.”</div> <div><br>Although Power writes about changing the environment to suit the needs of the person with dementia, he doesn’t primarily mean the physical environment of the facility—in fact, physical renovation is the last step he recommends—but primarily the interpersonal environment. <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Consistent Staffing A First Step</h2> <div>The first step toward transformation is consistent staffing. Residents won’t be able to develop meaningful relationships with constantly changing caregivers, Power says. And he recommends entirely eliminating agency staffing, for the same reason. </div> <div><br>Secondly, thoroughly educate everyone who interacts with residents—from administrators to housekeeping and maintenance staff—about the basic concepts of learning to see through the eyes of a person with dementia, how to interpret facial expressions and body language, and the kinds of nonpharmacological interventions that might be useful, always tailoring those to each individual resident.</div> <div><br>Next, find ways to restore choice and control to both the resident with dementia and those closest to him or her. This helps restore self-determination to individuals with dementia, but it also causes residents, families, and staff to collaborate, which counteracts the us-vs.-them mentality that can develop. </div> <div><br>Ways to ensure residents have choice in their lives involve such things as including them in meetings to plan their care (and speaking directly to them, not only to other interdisciplinary care team members), or just something as simple as asking them if they’d like to wear this blouse or that one, or what food on their plate they’d like to eat first. </div> <div><br>Rebuilding residents’ sense of usefulness is also critical, because life without any meaning is terrible, Power says. Involve these residents in group decisions that affect others’ lives as well as their own, such as discussions about fun things to do or what they’d like to see on the menu.</div> <div><br>Further, Power has seen in his own long years of practice that people with dementia can be exceptionally caring and giving, and allowing them to continue to express these basic needs—to care for and give to someone other than themselves—will go far in helping them to feel useful and give their lives meaning. </div> <div><br>“People with dementia can almost always give care on some level,” writes Power, “whether by reading to a child, watering a plant, stroking a cat—even ‘nurturing’ a doll, as people with advanced dementia may do.”</div> <h2 class="ms-rteElement-H2">Experts Join Forces To Improve Care</h2> <div>Evans and Power joined many other dementia care experts recently at the National Dementia Initiative (NDI) meeting June 29 in Washington, D.C. </div> <div><br>The NDI is a collaborative effort of 70 diverse dementia care experts across the country—experts from the practice, policy, and research sectors who’ve shown longstanding commitment to enhancing knowledge, understanding, and practices to advance quality outcomes, according to Karen Love, founder of CCAL—Advancing Person-Centered Living, who organized the event.</div> <div><br>These experts gathered June 29 to form consensus recommendations on dementia care. Their first recommendation was that care be person-centered. </div> <div><br>“Within all of us resides the need to be whole,” said Oliver Sachs, MD, summing up the basic humanistic need.</div> <div><br>Person-centered care, wrote Love in an e-mail to Provider, reframes the entire conversation. </div> <div><br>“Understanding and addressing the wholeness of the person living with dementia changes the need to even have ‘interventions.’ The approach to care becomes inclusive and addresses proactively rather than reactively,” she says.</div> <div><br>The NDI is preparing a white paper expected to be finished by mid-October. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">A Nurturing Environment </h2> <div>Interestingly, a fairly recent study by the Macklin Intergenerational Institute based in Findlay, Ohio, found that preschoolers who interacted regularly with people with dementia were nearly six months ahead of their peers once they started school in such areas as cooperation, expressing emotions, and social abilities. </div> <div><br>A follow-up study found that those children were 11 months ahead of their peers. The study’s authors theorized that this advancement was because the loneliness, boredom, and helplessness suffered by residents were counteracted by preschoolers’ need for interaction, guidance, and exploration—needs people with dementia were able to meet.</div> <div><br>A care partner who knows a resident well can inject more meaning into his or her life merely by knowing what topics of conversation he or she will care most deeply about, what gestures of friendship will be touching, or what activities will tap into that resident’s greatest interests.</div> <div><br>And, speaking of activities, those that occur spontaneously are more meaningful to a resident than those for which they must wait for the scheduled time to come around.</div> <div><br>“These are the attributes of home,” writes Power, “nurturing relationships with people you know well, choice and control over daily life, opportunities to give care, variety, spontaneity, and meaning in everyday life. This is the foundation of the transformed environment, and its impact on the care of people with dementia is enormous.”</div> <h2 class="ms-rteElement-H2">Doesn’t That Take Time?</h2> <div>In reality, done right, time is actually saved by developing in-depth, consistent relationships with people with dementia and treating them in ways that feel comfortable to them, says Evans. And not only does it serve the resident, it heightens the job satisfaction of staff, resulting in less turnover.</div> <div><br>“I’ve yet to meet a nurse who went into nursing school hoping that if things went well they would spend the majority of their time pushing a med cart,” Evans says. “Or a doctor who wanted to do a lot of paperwork. That’s especially true for people in primary care and people who gravitate toward long term care. </div> <div><br>“First of all, we’re all trying to find meaning and fulfillment through our jobs,” he says. “We’re trying to do our life’s work. Particularly CNAs [certified nurse assistants] and nurses and therapists and food service people in long term care—everybody’s there for a reason. There’s something each of us needs from the people who live there,” says Evans.</div> <div><br>“We give comfort and receive comfort at the same time.”</div> <div><br>It’s a calling for most people, and people are most fulfilled when they are given the tools and time to fulfill their calling, Evans says. “Fundamentally, most people work in long term care because that’s what they feel that they’re called to do; they want to make a difference in the lives of others, and it’s often easy to see that impact in long term care” where the residents have already experienced so much loss, he says.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Rethinking The Job</h2> <div>However, Evans acknowledges that “sometimes the job gets in the way of the work” of spending time caring for people they care about. “The leadership in facilities has an obligation to help all of their staff do things that are maximally important to others.”</div> <div><br>But it’s a fallacy, he says, that talking in-depth with residents—not just when they’re admitted but as caregivers wake them up in the morning, sit with them at meal time, or just meet them in the hall—is time that can’t be reimbursed and so is time wasted in terms of the facility’s financial bottom line.</div> <div><br>“It’s actually time well spent,” Evans says. “When someone is in distress, that requires attention and it cannot be ignored, but it’s seemingly unpredictable and hard to plan for.” And calming a resident who’s upset certainly takes longer than doing simple things that prevent the disturbance from ever happening. </div> <div><br>In addition, when front-line staff deeply understand the people they care for, that empowers them to help this individual whom they’ve grown to care about, which is much more satisfying to the CNA (as well as to the resident) than having a doctor jump in with his magic pill, Evans says. “Being able to identify a situation and solve problems is very satisfying. That’s why a lot of people go into health care in the first place. </div> <div><br>“I’m excited about the future because we’re just beginning to understand this condition, and the sky is literally the limit in helping others in need.”</div> <h2 class="ms-rteElement-H2">Postscript: <a target="_blank" href="/Monthly-Issue/2012/Pages/0912/Maggie-A-Case-Study-In-Dementia-Care.aspx">Maggie’s Case</a></h2> <div>The story of Maggie, the resident with dementia whose case was alluded to at the beginning of this article, has a happy ending.</div> <div><br>When Maggie’s family realized she just wasn’t going to get any better on the path the facility was taking, they researched local options for dementia care and settled on <a href="/Monthly-Issue/2012/Pages/0912/Open-Minds,-Open-Hearts-English-Rose-Suites’-Dementia-Care-Philosophy.aspx" target="_blank">English Rose Suites</a>, an assisted living chain that features family homes in Minneapolis neighborhoods. English Rose, which has spent decades developing its own program of person-centered solutions for people with dementia, worked with both Maggie and her family to write up Maggie’s life story so they would know what things had been pleasurable or comforting to her in the past, and so they could identify things that might trigger feelings of fear, uneasiness, or anger. </div> <div><br>Getting to know Maggie intimately resulted in gaining her trust and allaying her fears.</div> <div><br>It took a lot of work, and it never stops being hard work; Maggie doesn’t have a perfect day every day. She just has hard days much less frequently, and she has moments of joy now where before everything was psychic pain and confusion. </div> <div><br>English Rose caregivers have learned that striving for excellence must become a way of life, not a plateau to achieve and then rest. </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em></div> <p> </p>G. Allen Power, MD, author of “Dementia Beyond Drugs: Changing the Culture of Care,” proposes a simple yet, for many providers, radical idea: Stop thinking of dementia patients as people with diseases to be treated, and start thinking of them as people with a terrifying, shifted reality who still have lots left to give if their trust can just be earned. Negative attitudes toward people with dementia are a big factor in the combative atmosphere that can arise at times between those with the disease and their caregivers, writes Power in his recent award-winning book.2012-09-01T04:00:00Z<img alt="dementia care" src="/Monthly-Issue/2012/PublishingImages/0912/CS/cs1_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;ManagementCover Story9
Duals Deserve Better, Senate Panel Sayshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Duals-Deserve-Better,-Senate-Panel-Says.aspxDuals Deserve Better, Senate Panel Says“Dual eligibles are the most vulnerable of the vulnerable,” said Sen. Herb Kohl (D-Wis.) at a briefing of the Senate Special Committee on Aging, referring to the 9 million seniors who suffer from significant medical and financial struggles and in turn are eligible for both Medicare and Medicaid. <br><br>The briefing was spurred by a public letter sent from Sen. Jay Rockefeller (D-W.Va.) to Centers for Medicare & Medicaid Services (CMS) Secretary Kathleen Sebelius, citing his concerns over the Coordinated Care Office’s new Financial Alignment Initiative. <br><br>Past efforts to modify the budget and restructure the systems have proven unsuccessful. Improved quality, coordination of care, payment reform, and reduction of duplicity within the Medicare and Medicaid systems were among the key stumbling blocks highlighted by the briefing panels, which consisted of representatives from across the country. <br><br>Multiple states have garnered success from their reorganization efforts, according to the hearing’s witnesses. The Medicaid Redesign Team (MRT), based in New York, was one such successful program that, under New York Gov. Andrew Cuomo’s direction, worked in two phases to better address the needs of dual eligibles. <br><br>The first phase immediately identified and eliminated $4 billion in unnecessary spending. In order to do so, the MRT opened a line of communication with the public, and “in less than two months, these efforts generated more than 4,000 ideas,” said Jason Helgerson, Medicaid director for the New York State Department of Health, in his testimony. <br><br>The MRT devised a comprehensive five-year plan to alter its Medicaid program. Helgerson said that dual eligibles will especially benefit from the MRT’s promotion of Health Homes, which “provide care management for duals [who] don’t require long term care services.”<br><br>The program, which begins in January 2013, is projected to benefit some 126,000 dual-eligible enrollees.<br>Dual eligibles are “real people stuck in broken systems,” said Melanie Bella, director of the CMS Medicare-Medicaid Coordination Office. <br><br>CMS recently introduced controversial potential care models targeted at helping 2 million dual eligibles. One area of focus is State Design Contracts, first presented in April 2011 when “CMS awarded 15 states up to $1 million each to design person-centered approaches to coordinate care across primary, acute, behavioral health, prescription drugs, and long-term supports and services for Medicare-Medicaid enrollees,” Bella said. <br><br>In addition to cutting costs, all 15 states surveyed concluded that service delivery and payment reforms were necessary. <br><br>Bella noted the financial misalignment between Medicare and Medicaid and said that CMS aims to encourage beneficiaries to become engaged in their care and more aware of their options. 2012-09-01T04:00:00ZPolicyColumn9
Honest Apologies Inspire Trusthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/0912/Honest-Apologies-Inspire-Trust.aspxHonest Apologies Inspire Trust<div>One of the best risk management tools a provider can use is an expression of compassion and a genuine commitment to remedying problems. Saying “I’m sorry,” in fact, is statutorily protected and not an admission of liability, thanks to “I’m Sorry” laws adopted in 36 states.</div> <div> </div> <div>“I’m Sorry” laws began as a movement in the medical industry after providers realized that being honest with patients and apologizing for mistakes when warranted is not only the right thing to do, but also financially sound. </div> <div> </div> <div>One provider of continuing care retirement communities, American Baptist Homes of the West (ABHOW), embraces such compassion through its corporate compliance program. The organization has established a cultural platform of compassion and care across all of its departments, with qualities formulated into its training programs, manuals, and guides. </div> <h2 class="ms-rteElement-H2">The Most Valued Assets</h2> <div>The entire organization, including all executives and staff members, is clear about the risk management mission: to provide the safest environments and practices for its residents and employees and maintain the highest quality of care and services.</div> <div><br>A prudent business model analyzes claims in search of root causes and future prevention. Taking it a step further, the organization looks closely at the behavior surrounding each claim and its relationship with the patient and employee.</div> <div><br>“I look at a resident who is 85 years old, and I try to picture them 40 years ago, raising a family and working at their career, rather than as an old and frail person,” says David Grant, ABHOW senior vice president and general counsel.</div> <div><br>“When you see people’s true nature, it is easy to show compassion and go out of your way to give comfort, sympathy, concern, and care.”</div> <div><br>Using analytics, such as claims reports that are shared with the communities, helps management understand the impact a claim may have on the organization’s bottom line. </div> <div><br>Analytics identify how management can intercede early on with an injured employee, helping him or her  return to work promptly and mitigating the need for an attorney’s involvement. </div> <div><br>Ergonomic training for employees is also vital, “so they know how to handle slips, trips, and falls,” says Grant. “Training is conducted on a regular basis as well as pilot programs like safety shoes for the health centers.” </div> <h2 class="ms-rteElement-H2">Apologies Go To Staff As Well</h2> <div>After years of sending “get well” cards to employees who are on leaves of absence, the organization reasoned that it should do the same for employees on workers’ compensation leaves. It introduced a program where every injured employee receives an “I am sorry you were injured” card. </div> <div><br>This simple yet effective gesture of care resulted in a significant reduction of workers’ compensation program costs, which was close to 8 percent of payroll costs at one point.</div> <div><br>Additionally, management regularly tracks all complaints, incidents, and occurrences to note patterns or trends that need a particular risk management focus.</div> <div><br>When an unfortunate event occurs with a resident, meetings are conducted throughout the organization in order to address the resident’s injury and provide the best resolution to the family member’s predicament. The resident and family must feel compassion from the organization and all of its members.</div> <div><br>“Expressing compassion and acknowledging and investigating any ‘adverse events’ increase resident satisfaction and trust, which helps us maintain a positive resident relationship,” says Grant. “If a mistake is found, we are honest with the patient and openly acknowledge mistakes so safer procedures and systems can be created.” <br></div> <h2 class="ms-rteElement-H2">Take Proactive Responsibility</h2> <div>The value of such sincerity is illustrated by an incident that occurred at one of the organization’s retirement communities, which is situated on a large campus where staff members use golf carts to move residents around. </div> <div><br>The incident involved a resident who was injured when a golf cart became stuck in the mud. The resident received an official apology for the accident, and his medical expenses and physical therapy were covered at the request of the family. </div> <div><br>“It was the right thing to do,” says Grant. “If we lacked genuine care for our resident, we could have run the risk of a case filed against us, which might have cost upwards of $200,000 before even going to trial. </div> <div><br>“This particular incident cost approximately $12,000. We can’t solve all the problems; however, our caring approach has warded off unnecessary litigation and has proven to benefit everyone involved.” <br></div> <h2 class="ms-rteElement-H2">An Environment Of Caring</h2> <div>Regular visits by management to the company’s various retirement communities are not limited to surveying employee safety, but resident care as well. The executive team frequently participates in resident reviews, holds town hall meetings, and dines in the cafeteria with residents. </div> <div><br>This level of attention allows executives to draw a holistic picture of the resident—physically, emotionally, and socially. It also enhances trust between residents and management, which, as a byproduct, shelters the organization from litigation and other negative external forces.</div> <div><br>Genuine compassion extends beyond the organization’s internal and external customers. Charitable activities, which topped $17 million last year, are rampant, as posted in the organization’s “Social Accountability Program Report.” </div> <div><br>Many studies have shown that employees feel good working for a company that gives back to the community in pure charity and good works. And happy employees create happy residents. Moreover, engaged employees create a better environment for residents. For this reason, the importance of communicating its charitable activities cannot be underscored enough. </div> <div><br>Whether it is treating an injured employee fairly or empowering employees with information and access to tools to better manage the care of their customers, taking a caring approach can have a dramatic effect on an organization’s bottom line.</div> <div><br>Click here for more information about <a href="/columns/Pages/Apology-Laws-Foster-Compassion.aspx" title="apology laws" target="_blank">Apology Laws</a> and their application to long term care providers. </div> <div> </div> <div><em>David A. Jones is senior vice president at Lockton Companies, the world’s largest, privately owned independent insurance broker. Jones served as a risk and finance manager for various Fortune 500 companies before joining Lockton and holds an MBA and the designations of Associate in Risk Management and Chartered Property Casualty Underwriter.</em></div>One of the best risk management tools a provider can use is an expression of compassion and a genuine commitment to remedying problems. Saying “I’m sorry,” in fact, is statutorily protected and not an admission of liability, thanks to “I’m Sorry” laws adopted in 36 states.2012-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/0912/mgmt/mgmt1_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ManagementColumn9

October


 

 

A Better Medicare Programhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1012/A-Better-Medicare-Program.aspxA Better Medicare Program<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Historically, Medicare populations have been managed the same way as long-term  populations. In staff members’ eyes, there may be no significant distinction between the services they deliver (other than the charting requirements), even though the Medicare population is post-acute, requiring more knowledge and skills to manage their conditions.</div> <div> </div> <div>In addition, post-acute residents are not usually seen by nursing staff any more frequently than other residents. What’s more, there is sometimes internal conflict surrounding the incentive to transfer out, reaping the rewards of the three-night qualifying stay for reimbursement purposes, as opposed to treating within the facility and preventing a hospital readmission.</div> <h2 class="ms-rteElement-H2">Incentives On The Horizon</h2> <div>Avoidable readmissions cost Medicare an estimated $12 billion each year. One thing is clear—there will soon be incentive to improve the management of post-acute conditions of skilled nursing facility (SNF) Medicare beneficiaries through the Centers for Medicare & Medicaid Services (CMS) Nursing Home Pay for Performance initiative. The initiative includes staffing, quality measures, survey inspections, and potential avoidable hospitalizations.<br><br> </div> <div>Even the Quality Improvement Organizations (QIOs) are on board. The CMS Care Transitions program, implemented through the QIOs, focuses on improving the process of care at the system level for specific conditions that lead to rehospitalizations. <br><br></div> <div>It’s never too early to begin improving systems to deliver better post-acute care. Following are some steps to polish up a facility’s Medicare system,yielding improved care management and decreased rehospitalizations.<h2 class="ms-rteElement-H2">Tighten up the Medicare admissions process.</h2></div> <div><ul><li>Include the hospital care plan in the inquiry information; the care plan should follow the patient.</li> <li>Review the paperwork, and interview the patient and family to identify all conditions that may impact recovery. For example, if the primary reason for admission is therapy, there are surely other conditions and comorbidities that can impact the outcome of the therapy goals, such as congestive heart failure, chronic obstructive pulmonary disease, and diabetes. These conditions must be managed by nursing at the same time therapy is treating for the post-acute condition.</li> <li>Prior to actual admission, or on admission, explain the Medicare coverage criteria to the patient and/or significant other. Don’t assume that the hospital discharge planner has already done this.</li> <li>Have one designee make a visit to the resident and/or a phone call to the significant other no longer than 48 hours post admission to communicate the care plan, explain the skilled service, and any other information. This is a collaborative approach to the patient’s care experience. Let this designee be the “go-to” person for the family. <br></li></ul></div> <h2 class="ms-rteElement-H2">Hold weekly Medicare meetings.</h2> <div><ul><li>Document progress made.</li> <li>Use this meeting as an opportunity to ensure that certifications are signed, orders for services are written, and progress toward goals is checked.</li> <li>Identify training needs.</li> <li>For nursing skills, review documentation for the last six hospital readmissions to determine if issues were addressed during the early symptoms. People don’t just wake up with a urinary tract infection or pneumonia needing hospitalization. There are signs and symptoms that would have been communicated along the way and interventions implemented, which would be reflected in the nursing documentation.</li> <li>Ask nurses what they feel their weaknesses are (skills and conditions), anonymously.</li> <li>Stress early recognition of complications and appropriate interventions to both nurses and nurse assistants. Implement documentation and communication training that supports critical thinking skills. Often, skilled documentation will say, “Call light within reach. No complaints of pain. Seeing therapy for skilled services.” This type of documentation does not support a skilled need.</li> <li>Conduct an experiment: Ask the nurses which patients are on Medicare Part A. The nurses will certainly know which residents are Medicare Part A because they chart on them every day. However, many do not know what specific skilled services are required by the patient. Use this exercise as an opportunity to educate nurses about Medicare Part A residents.</li> <li>Teach nurses the three categories of skilled coverage: skilled nursing or rehab (management and evaluation of the care plan, observation and assessment of a changing condition, teaching and training); skilled nursing (IVs, dressing changes, enteral feedings); and skilled rehab (physical therapy, occupational therapy, speech-language pathology).</li> <li>Focus on the quality of the documentation, not the quantity. Designate one person to check the quality of documentation as it relates to the skilled service and other pertinent conditions. This is best done during a daily nursing start-up routine.</li> <li>Include categories of skilled service, the specific service for the category, and reason for skilled service in the documentation guidelines.</li> <li>Use a simple documentation format to promote critical thinking skills (for example, PIE—problem, intervention, evaluation). Even if the resident is only receiving therapy services, interventions for conditions that may impact the therapy outcome must be documented. </li></ul> If there is a review of a therapy claim that results in a denial of payment, at least there is a chance that payment will be reduced to a lower nursing resource utilization group if nursing documentation supports it. Without the additional nursing documentation, the claim will most likely be denied in its entirety.<br></div> <div><ul><li>Let the minimum data set (MDS) coordinator facilitate the training of the MDS team. By now, it is obvious that the MDS 3.0 system cannot be conducted as it was with MDS 2.0. There must be a collaborative team in place that is trained to understand the coding guidelines and its implications on care and revenue. The team must be unique, the best athletes for the job, different from the standard “cookie cutter” team of pre-October 2010 that included department heads from each department. </li></ul></div> <div>There are now several assessments performed in the MDS process (Start of Therapy, End of Therapy, End of Therapy Resumption, Change of Therapy). <br></div> <div><br>Setting the Assessment Reference Date is now a collaborative effort, just as it is when determining the need to conduct a Significant Change in Condition assessment. The MDS coordinator must communicate daily with therapy to stay on top of the Change of Therapy observation window.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Utilize INTERACT II tools.</h2> <div><ul><li>“Stop and Watch” for nurse assistants is an easy tool to communicate subtle changes in condition so that early interventions may be implemented.</li> <li>“Care Paths” help guide the nurse in assessing and managing several conditions, promoting critical thinking skills.</li> <li>The “SBAR” communication tool helps nurses organize their information prior to contacting the physician. It includes the situation, background information, assessment/appearance, and the request.</li></ul></div> <h2 class="ms-rteElement-H2">Conduct daily rounds.</h2> <div><ul><li>Include frontline charge nurses and nurse assistants and take the medical records along to review the documentation and care plans. In addition, it’s a good opportunity to interact with residents and families along the way.</li></ul></div> <h2 class="ms-rteElement-H2">Triple-check claims before sending.</h2> <div><ul><li>This includes therapy, billing, and nursing. At a mini-mum, nursing should check the accuracy of the certifica-tions, documentation, diagnoses, and MDS coding; billing will ensure the claim reflects the appropriate diagnoses, billing dates, and additional codes; therapy will review its documentation to ensure it supports medical necessity and that the appropriate medical and treatment diagnoses are utilized.</li> <li>Implement a discharge planning program.</li> <li>Use teach-back approaches, and document the successful return demonstrations.</li> <li>Train residents in management of their conditions and when to contact the physician or seek help. Community resources and contact numbers are essential.</li></ul></div> <h2 class="ms-rteElement-H2">Keep Up With Regs And Practices </h2> <div>Designate one person to inform the rest of the team and update policies and procedures as necessary. This individual should be well trained in Medicare regulations and know who the sources of authority are for regulatory changes. <br></div> <div><br>Finally, consider purchasing software that is user friendly, customizable, and able to address multiple care settings. Point-of-care data capture, claims editing, and MDS scheduling are recommended features to look for. </div> <div> </div> <div><em>Frosini Rubertino, RN, is the founder of TrainingInMotion.org, a regulatory specialist in long term care, and author of a new book, “Carmelina: Essential Nursing Systems for Long Term Care.” For more information on Medicare workshops or other services, go to <a target="_blank" href="http://www.traininginmotion.org/">www.TrainingInMotion.org</a> or e-mail Frosini at <a target="_blank" href="mailto:frosini@TrainingInMotion.org">frosini@TrainingInMotion.org</a>.</em></div>Avoidable readmissions cost Medicare an estimated $12 billion each year. One thing is clear—there will soon be incentive to improve the management of post-acute conditions of skilled nursing facility (SNF) Medicare beneficiaries through the Centers for Medicare & Medicaid Services (CMS) Nursing Home Pay for Performance initiative. The initiative includes staffing, quality measures, survey inspections, and potential avoidable hospitalizations.2012-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/1012/Caregiving1_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn10
A Harvest Of Purposehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1012/A-Harvest-Of-Purpose-.aspxA Harvest Of Purpose<div>Just as it only takes a single seed to grow a tree, it takes a single idea to spark revolution. Last year, Velma Stricker, a 94-year-old resident at Arroyo Grande Care Center in Arroyo Grande, Calif., asked Matthew Lysobey, the administrator at the facility, to build her a greenhouse. A former avid gardener, Stricker felt depressed and yearned for a creative outlet.</div> <div> </div> <div>“She said, ‘If you do build it, I will take charge of it, I will be out there every day,’” says Lysobey. “I said, ‘Okay, we’re going to do it,’ and now she is out there doing her work every day. She now has a reason to get out of bed.”</div> <h2 class="ms-rteElement-H2">A Farm Is Born</h2> <div>Last November, Arroyo Grande Care Center, which was ranked one of the top nursing homes by <em>U.S. News & World Report</em> in 2012, permitted volunteers and maintenance workers to break ground on “The Farm,” a one-acre produce and poultry farm. <br></div> <div><br>The Farm, which is located on the facility’s grounds, is completely wheelchair-accessible and was purposely designed to offer residents, many of whom are former farmers, the opportunity to weed, water, and prune crops in addition to tending to chicken coops. </div> <div><br>Residents are responsible for their own crops, and all food produced is harvested by the residents themselves. </div> <div><img width="241" height="323" class="ms-rteImage-2 ms-rtePosition-1" alt="Arroyo Grande Care Center" src="/Monthly-Issue/2012/PublishingImages/1012/Farm-Feature-3.jpg" style="margin:10px 15px;" /><br>After the food is collected, residents are transported across the street to a free farmers market that serves underprivileged elderly community members. </div> <div><br>“We mobile all the residents over in their wheelchairs, and they have this huge bounty of chard, carrots, peas, string beans, lettuce, and pumpkin cookies that they made, along with flowers they’re growing so these people have nice flowers, and there are 40 to 50 people lined up every time with their bags,” says Lysobey. <br></div> <h2 class="ms-rteElement-H2">Residents Feel Needed</h2> <div>The need to be needed is essential to the human condition and does not fade in the elderly, health care experts say. Lysobey believes that programs like The Farm are fairly simple to incorporate and can be hugely effective in lowering levels of depression in long term care facilities. <br></div> <div><br>The widely held notion that residents should simply rest and relax through their “golden years” is erroneous, experts say. “There are nonprofits in every community and nursing homes asking to help,” Lysobey says. “Residents just want to be needed and to help.”</div> <h2 class="ms-rteElement-H2">Giving Purpose To Residents’ Lives</h2> <div>Arroyo Grande also recently teamed with a local nonprofit, Children’s Resource Network, to open a free clothing and school supply store located on its grounds to benefit disadvantaged youths. <br></div> <div><br>“Advocates in the community, high school and junior high counselors, and homeless shelters can call and place a request. We then print that out, give it to a resident here, and she calls from her room and makes appointments for these disadvantaged teens to shop in the store. Three to four residents work with teens, helping them pick out clothes,” Lysobey says. </div> <div><br>Creating opportunities for residents in long term care facilities to team with nonprofits is a no-brainer, according to Lysobey. Health care providers have “been so focused on improving the quality of care, which we have,” he says. </div> <div><br>“Quality care has made tremendous strides in the past 20 years—but no matter how nice the infrastructure is, that doesn’t mean people will have need and purpose in their lives.” </div> <div><br>Providing purpose to residents is, therefore, as critical—if not more critical—as providing basic health care amenities, he says. </div> <div> </div> <div>To see a video about the farm, click <a href="http://youtu.be/4zuH-7BUGdA">HERE.</a>   </div> The need to be needed is essential to the human condition and does not fade in the elderly, health care experts say. Lysobey believes that programs like The Farm are fairly simple to incorporate and can be hugely effective in lowering levels of depression in long term care facilities. The widely held notion that residents should simply rest and relax through their “golden years” is erroneous, experts say. “There are nonprofits in every community and nursing homes asking to help,” Lysobey says. “Residents just want to be needed and to help.”2012-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/1012/farm_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn10
Bed Bug Basicshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1012/Bed-Bug-Basics.aspxBed Bug Basics<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>In 2011, the National Pest Management Association and the University of Kentucky conducted a survey of U.S. pest professionals and found that bed bug encounters in settings outside single-family homes and apartments had increased significantly from the previous year. </div> <div> </div> <div> </div> <div> </div> <div>Specifically, 46 percent of pest professionals treated bed bugs in nursing homes and assisted living communities in 2011, compared with 25 percent in 2010. In both settings, the issue of bed bug infestations can generate anxiety among residents, their families, and staff. </div> <div> </div> <div> </div> <div> </div> <div>The foot traffic of daily visitors or employees and the moving in of personal belongings of tenants can all provide easy access for bed bugs to enter a facility. Because of their small size and need to be near humans, bed bugs can hitchhike in bags, shoes, luggage, and on clothing. </div> <div> </div> <div> </div> <div> </div> <div>Unlike other facilities of similar sizes, such as college dorms or schools, these environments pose a greater challenge in terms of treatment of bed bugs because of the physical state of the residents and the importance of not disrupting the care that is provided. </div> <div> </div> <h2 class="ms-rteElement-H2">Bed Bug Biology</h2> <div> </div> <div>Adult bed bugs resemble a flat apple seed, while hatchlings are so small they can pass through a stitch-hole in a mattress. These pests feed on human blood and are found wherever people are, often hiding in spots humans can’t see and only coming out to feed when an opportunity presents itself. </div> <div> </div> <div><span><img src="/Monthly-Issue/2012/PublishingImages/1012/mgmt_thumb.jpg" class="ms-rteImage-2 ms-rtePosition-2" alt="" style="margin:5px 10px;" /></span><br>Bed bugs are especially problematic and challenging to treat because they are quite elusive and breed quickly. A female bed bug can lay one to five eggs in a day and more than 500 in a lifetime.<br><br></div> <div> </div> <div>Their name is a bit of a misnomer, as bed bugs tend to hide not only in beds, but also in other areas such as behind headboards and baseboards and in upholstered furniture, suitcases, shoes, boxes, wallpaper, picture frames, electrical switch plates, and other small cracks and crevices close to humans. </div> <div> </div> <h2 class="ms-rteElement-H2">Developing An Action Plan</h2> <div> </div> <div>In 2011, two nursing home employees in Ohio placed an anonymous call to a local television news station, informing a reporter that the nursing home had discovered a bed bug infestation. The nursing home, the callers reported, was not telling the families of residents about the infestation, and employees were being threatened with termination if they spoke up about the problem. <br></div> <div> </div> <div><br>Once the news van showed up at the nursing home and the reporter began asking questions, family members learned about the bed bug problem, and the facility’s parent company issued a statement. </div> <div> </div> <div>When the story appeared on the news, the facility was portrayed negatively. Despite taking all the right steps to deal with the infestation once it became public, it appeared as if the management had tried to keep the problem under wraps. </div> <div> </div> <div><br>This is why a written “<a href="/Monthly-Issue/2012/Pages/1012/Guidelines-For-Managing-A-Bed-Bug-Problem.aspx" target="_blank">bed bug action plan</a>” is so important. It prepares management and staff to respond to a problem as it arises and to deal with it in a swift and effective manner. </div> <div> </div> <div><br>Everyone from management, to nurses, to the custodial staff should be educated in basic bed bug biology and habits, especially their hitchhiking nature, which allows them to easily go from place to place.</div> <div> </div> <div><br>Staff must know how to recognize bed bugs and their bites; the responsibility and roles regarding bed bugs, including the facility’s response and notification policy; and actions needed to reduce the risk of future infestations or incidents.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"> </h2> <h2 class="ms-rteElement-H2">Preventing Future Infestations</h2> <div> </div> <div>Because of their size and elusive nature, as well as the conducive environment an assisted living community or nursing home provides, it can be difficult to prevent bed bug infestations from ever occurring again. However, education and vigilance on the part of management, staff, and family members can go a long way in minimizing or detecting the problems in time.<br><br></div> <div> </div> <div><div style="text-align:center;"><img class="ms-rteImage-2" src="/Monthly-Issue/2012/PublishingImages/1012/mgmt1.jpg" alt="" style="margin:5px;" /></div> <div> </div> <div> </div> <div>Following are some prevention tips:</div></div> <div> </div> <div><ul><li>Develop a bed bug information sheet, including information on how to avoid bringing bed bugs into the facility.</li> <li>Consider encasing mattresses and box springs with bed bug-proof encasements.</li> <li>Establish a prohibition on used or secondhand furniture.</li> <li>Require that furniture, luggage, and other personal items be inspected by a professional (or a certified canine bed bug detection team), especially if there are recurring problems.</li> <li>Regularly vacuum or steam clean areas prone to bed bugs (under and around beds, upholstered furniture, luggage racks, and wall/floor junctions).</li> <li>Reduce clutter; seal cracks, crevices, and holes near beds; and repair or replace peeling wallpaper or paint.</li> <li>Follow good laundry-handling practices to prevent the dispersal of bed bugs, including keeping carts in the hallway during room service; separating the clean and dirty laundry on carts and in processing rooms; and keeping dirty laundry away from linen storerooms, linen closets, or any room that contains clean linens.</li> <li>If dirty laundry is transported to an outside cleaning facility, do not use the same vehicle for clean linens unless clean and dirty laundry can be completely isolated from each other. </li></ul></div> <div> </div> <h2 class="ms-rteElement-H2">Act Fast, Be Honest</h2> <div> </div> <div>Many assisted living communities and nursing homes may worry about their reputation and that residents may leave should they experience a bed bug infestation. However, the problem of bed bugs has become so pervasive that Americans have almost come to terms with the pest, just as they do with others that may invade their living spaces. <br></div> <div> </div> <div><br>Nonetheless, it is imperative that long term care facilities deal with bed bugs quickly. Residents and their families will appreciate swift action and future precautions but may be less understanding of management if they’re not forthright, because that can often create even bigger problems. <br><br><em>Missy Henriksen is vice president of public affairs for the National Pest Management Association, a nonprofit organization committed to the protection of public health, food, and property. For more information about pests and prevention tips, visit <a target="_blank" href="http://www.pestworld.org/">www.PestWorld.org</a>.</em></div> <div> </div> Everyone from management, to nurses, to the custodial staff should be educated in basic bed bug biology and habits, especially their hitchhiking nature, which allows them to easily go from place to place. Staff must know how to recognize bed bugs and their bites; the responsibility and roles regarding bed bugs, including the facility’s response and notification policy; and actions needed to reduce the risk of future infestations or incidents.2012-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/1012/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn10
Health Care Takes Center Stage In Electionhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1012/Health-Care-Takes-Center-Stage-In-Election.aspxHealth Care Takes Center Stage In Election<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div>Health care cuts are coming. <div> </div> <div>For long term care providers, the cuts may be the least of it. </div> <div> </div> <div>No one in national politics says that health care’s status quo is okay. President Obama, already having successfully defended the Affordable Care Act at the Supreme Court, is defending it in his campaign. Mitt Romney has promised to repeal the reforms, but his running mate, Rep. Paul Ryan (R-Wis.), is the author of a plan that would fundamentally change Medicare. </div> <div> </div> <div>It has been years since health care has taken on such weight in a national election. For providers, the November elections are an opportunity to make their case that they can deliver quality health care efficiently. </div> <h2 class="ms-rteElement-H2">What’s At Stake</h2> <div>But the election also presents great risks. Few industries are as vulnerable to unintended consequences. And few issues are as complex as health care delivery and distribution. <br><br></div> <div>“Regardless of who wins, reality has got to be faced,” says Steve Monroe, a partner and analyst who covers long term care issues at Irving Levin Associates. “Nobody is going to be opening up the purse strings, because that’s just suicide on top of suicide.”</div> <div><br>That’s not to say that the elections don’t matter. Experts <em>Provider</em> talked to said that if Romney wins the presidency, it’s likely the Republicans will have the Senate, because the swing states are also electing senators. </div> <div><br>That means that, under a Romney presidency, Obamacare is a dead letter, observers say. Even if Romney doesn’t have a friendly Senate, he won’t have to have an outright repeal to kill Obama- care. He can undermine it through executive orders, observers say. </div> <div><br>If Obama wins (which again, means that the Democrats will likely control the Senate), he’ll have more leverage to expand his reforms. That doesn’t mean that Obamacare will be implemented, as-is. Even now, experts say, the administration is considering ways to define “full-time” employees for the purposes of the health care reforms. The administration could still set a high threshold of worker hours before requiring employers to provide health insurance. That would bring enormous relief to a lot of businesses—but especially long term care providers, who typically see high employee turnover.</div> <h2 class="ms-rteElement-H2">Change Inevitable </h2> <div>Still, changes are underway no matter who wins. “The population is changing,” says J. Emmett Reed, CAE, executive director of the Florida Health Care Association. “There are going to be significant changes in the business model no matter what. Either we’re going to have to bring more money into the system or manage the money that’s already in the system better.”<img width="137" height="206" class="ms-rteImage-2 ms-rtePosition-2" alt="J. Emmett Reed" src="/Monthly-Issue/2012/PublishingImages/1012/JEmmettReed.jpg" style="margin:10px 15px;" /><br><br>Legislators and policy makers are already rethinking payment models for skilled nursing facilities, says Gov. Mark Parkinson, president and chief executive officer (CEO) of the American Health Care Association.</div> <div><br>“Congress has not enacted major reform, but state-directed managed care and [the Centers for Medicare & Medicaid Services] demonstration projects are changing the way we are paid,” he says in an e-mail. “The common themes through the changes are an emphasis on outcomes, care coordination throughout the continuum, and increasing pressures to take money out of the system. We will continue to see these changes regardless of who wins the presidential election or who controls Congress.”</div> <div><br>“Either way you look at it, there are cuts to Medicare funding,” Reed says. “So our folks are fearful of the future.”</div> <h2 class="ms-rteElement-H2">Strife Within Parties</h2> <div>It’s not just that there are uncertainties as regards the two parties. There are intra-party upheavals, especially in the Republican Party, that make it difficult for providers to gauge what’s coming.<br><br></div> <div>In Kansas, considered a safe Republican vote in the national elections, Tea Party enthusiasts have purged the state GOP of anyone even suspected of liberal tendencies, including state Senate President Steve Morris. Morris claimed he was an indirect victim of Obamacare, blaming his defeat on a series of ads sponsored by the right-wing Koch brothers, David and Charles. </div> <div><br>“They tried to tie our folks to President Obama even though we had nothing to do with him,” Morris told HuffPost after his loss. “They said we all supported Obamacare, and that’s not true.”</div> <div><br><img width="184" height="184" class="ms-rteImage-2 ms-rtePosition-1" alt="Mark Parkinson" src="/Monthly-Issue/2012/PublishingImages/Headshots/Parkinson.jpg" style="margin:5px 10px;" />True or not, Morris and several moderate Republicans are looking for work, and the state legislature is now in the hands of people who are unlikely to smile on efforts to expand social spending. “It’s effective,” Morris said of the advertising that brought him down. </div> <div><br>A similar Tea Party uprising also claimed longtime Republican, Florida Rep. Cliff Stearns.</div> <div><br>“He was a champion, and he understood,” Reed says of Stearns. “Now the whole re-education process begins again. There’s no doubt it’s an uphill battle.”</div> <div><br>Two other congressmen long regarded as friends of long term care are also in trouble, although not for the idealogical reasons that torpedoed Stearns.</div> <div><br>In Iowa, veteran Republican Rep. Tom Latham is in a tough race against Democratic Rep. Leonard Boswell. In Ohio, Rep. Jim Renacci, a Republican, is trying to beat Rep. Betty Sutton, a Democrat. Both races have become acute because redistricting has pitted two sets of incumbents against one another (<a target="_blank" href="/Monthly-Issue/2012/Pages/1012/Close-Election-Races.aspx">see sidebar</a>).</div> <div><br>That’s not to say that either Boswell or Sutton is an enemy of long term care. But the uncertainty over the seats makes it difficult for long term care providers to decide how to approach their lobbying, says Iowa Health Care Association (IHCA) Executive Director Steve Ackerson. </div> <div><br>“Everybody right now is in a wait-and-see attitude,” he says. “Nobody wants to go ahead with anything until they know who the next president is.” Complicating matters in Iowa, the state is in the midst of rebasing its Medicaid spending, Ackerson says. IHCA has already held 90 events with the state’s incumbents and their challengers, hoping to get their message across. </div> <div><br>“It’s a continuing education with legislators,” Ackerson says. “They just sit there and look at you and say, ‘I had no idea this was how things are.’”</div> <div><br>Deborah Petrine is founder, president, and CEO of Commonwealth Care, which runs 12 skilled nursing facilities in Virginia, another swing state. </div> <div><br>“For us in the long term care industry, there is so much change right now,” she says. </div> <div><br>“I see it as a real opportunity. But it’s also a big challenge. And part of the challenge is getting your arms around it.” <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Medicare, Medicaid, And More</h2> <div>Medicare cuts—even prospective ones—are a frontal challenge to providers, says University of Illinois Law Professor Richard Kaplan. <br><br></div> <div>“Medicaid has been squeezing them for 20 years,” he says of providers. “Now, you have another one of those big players saying we’re going to cut our fees, too. That’s just going to put more pressure on health care providers to have more paying patients.”</div> <div><br>“They’re getting zapped at both ends,” Kaplan says. “Their reimbursement rates are getting lower, and their costs are getting higher.”</div> <div><br>The problem for providers, Kaplan says, is that while health care is a prominent issue in this year’s elections, it’s not the only one. “It probably doesn’t have the salience to determine votes of people under <br>age 65, and that’s the vast majority of the electorate,” he says. </div> <div><br>This could have been different. </div> <div><br>When the Supreme Court surprised the political world by upholding Obama-care, it seemed that the November elections would become a referendum on health care policy. Romney claimed that he raised more than $100 million in the aftermath of the Supreme Court’s decision. </div> <div><br>Then Romney picked Rep. Paul Ryan (R-Wis.) as his running mate. As the author of his own Medicare reform package, Ryan instantly became a target of Democratic ads, especially in states such as Florida. <br></div> <h2 class="ms-rteElement-H2">Other Issues Bear Weight</h2> <div>But <a href="/Monthly-Issue/2012/Pages/1012/Other-Political-Questions-Forcing-Existential-Crisis-.aspx" title="Other Political Questions" target="_blank">other matters</a> have pressed in on the election. When Republican Rep. Todd Akin (R-Mo.) told a Missouri news program that he didn’t think women could get pregnant from “legitimate rape,” it dominated the news cycle for three days, just ahead of the Republican convention. <br></div> <div><br>Then there are local problems that feel every bit as pressing. “Lawmakers—yes, they’re thinking about Medicaid and Medicare,” Florida’s Reed says, “but they’re also thinking about farms and roads and jobs for their areas.”</div> <div><br>More than two-thirds of Iowa is suffering from drought, for instance, Ackerson says. “Iowans are going to look at who’s going to look at my needs, who has the most leverage?”</div> <div><br><img width="160" height="240" class="ms-rteImage-2 ms-rtePosition-2" alt="Debbie Petrine" src="/Monthly-Issue/2012/PublishingImages/1012/Debbie.jpg" style="margin:5px 10px;" />Things are a little different in Ohio, says Peter Van Runkle, executive director of the Ohio Health Care Association. “I think the issues are more global. Democrats in Ohio are going to identify with Obama’s positions, Republicans with Romney’s and Boehner’s,” Van Runkle says, referring to House Speaker John Boehner (R-Ohio). </div> <div><br>That still may make it difficult to get the kind of attention providers want and need, Van Runkle adds. “Legislators will listen to what we have to say, but clearly our issues aren’t going to drive the outcomes of the elections,” he says. </div> <div><br>Kaplan says that older voters have more clout in the primaries, “because they turn out to vote.” But “in so many of these elections, the November elections are almost beside the point,” he says. </div> <div><br>Parkinson says that most of Washington’s leaders are focused on the national debt. “That means that even our allies are challenging us to find ways to save money,” he says. <br></div> <h2 class="ms-rteElement-H2">The Provider Argument</h2> <div>But that doesn’t mean that hope is lost, because providers have a good argument to make, Parkinson says. “The very good news is that we are a huge part of the answer to cutting state and federal spending, because we are the most efficient, high-quality provider to take care of the elderly and those who need rehabilitation,” he says. “We are not the problem. We are the solution.” <br></div> <div><br>So how do long term care providers get their message across amidst the cacophony of a national election? Reed says that the answer lies within.</div> <div><br>“I think that no matter who is leading the charge … it’s got to come from the nursing home owners,” he <br>says. “They have to become political advocates and politically involved as never before.”</div> <div><br>The message will take care of itself, Reed says.</div> <div><br>“If you provide excellent care,” he says, “then you’ve got a great story to tell.” </div>If Obama wins (which again, means that the Democrats will likely control the Senate), he’ll have more leverage to expand his reforms. That doesn’t mean that Obamacare will be implemented, as-is. Even now, experts say, the administration is considering ways to define “full-time” employees for the purposes of the health care reforms. The administration could still set a high threshold of worker hours before requiring employers to provide health insurance. That would bring enormous relief to a lot of businesses—but especially long term care providers, who typically see high employee turnover.2012-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/1012/coverstory_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Management;QualityCover Story10
The QIS Experthttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1012/Safely-Reducing-Readmissions.aspxThe QIS Expert<h2 class="ms-rteElement-H2"><strong>Q.</strong> Based on QIS data, can you provide any current information on readmissions to hospitals from skilled nursing facilities (SNFs)?</h2> <div> </div> <div><strong style="font-size:13.3pt;">A.</strong> In my <a href="/archives/archives-2011/Pages/0611/The-QIS-Expert.aspx">June 2011 column</a>, I described how QIS measures readmissions to hospitals from SNFs in 30 days and discussed why this has become so important for SNFs to measure. Since that time, interest in this topic has grown among hospitals because payment penalties from the Hospital Readmission Reduction Program (HRRP, as established by the Affordable Care Act) will begin in October 2012 for hospitals with higher-than-expected readmission rates for pneumonia, heart failure, and acute myocardial infarction. </div> <div> </div> <div>This has resulted in pressure on SNFs to partner with hospitals to reduce readmission rates. </div> <div> </div> <div>Other policy and private-sector initiatives are aimed at reducing hospital readmissions from SNFs. In its March 2012 report, the Medicare Payment Advisory Commission recommended that Congress direct the Department of Health and Human Services to reduce payments to SNFs with relatively high risk-adjusted rates of rehospitalization during Medicare-covered stays and be expanded to include a time period after discharge from the facility. </div> <div> </div> <div>Importantly, the American Health Care Association (AHCA) has made reduction of readmissions to hospitals in 30 days one of four goals in its 2012 Quality Initiative.</div> <div> </div> <div>Despite all of this activity, current and rigorous data are not widely available on SNF readmission rates to hospitals. A recent study based on 2011 Centers for Medicare & Medicaid Services (CMS) Hospital Compare data suggested that there has been no significant reduction in readmissions to hospitals for all hospital discharges with the three conditions included in the HRRP.</div> <div> </div> <div>But reported data on the subset of patients discharged from hospitals to SNFs is no more recent than 2010, before there was much emphasis on readmissions from SNFs and before the fiscal year 2012 rule on it was adopted. </div> <div> </div> <div>Data systems based on QIS do not depend on claims data and are much more current. At the 2012 AHCA Quality Symposium and during a March 2012 national webcast, for example, I presented an average readmission rate from SNFs in 2011 of 17.4 percent for a sample of close to 700 SNFs with 25 or more admissions, based on privately collected QIS data. </div> <div> </div> <div>Similar analyses of 2012 QIS data suggest two findings: 1. Patient acuity is increasing over time in SNFs, resulting in higher risk of readmissions and the need for rigorous risk adjustment if rates are going to be compared over time; and 2. Risk-adjusted rates of readmission are decreasing in SNFs that are using QIS tools to measure and address root causes of readmission. </div> <div> </div> <div>The take-home messages from this work are threefold. First, we must obtain real-time data on readmissions, such as QIS data, if we are going to measure and improve performance in this rapidly changing area. Data from 2010 and before, which is the case for most claims data, are of little relevance to current SNF care. </div> <div> </div> <div>Second, we must risk adjust for the increasing acuity of SNF discharges from hospitals in order to determine if we are impacting readmission rates. </div> <div> </div> <div>Third, using QIS methods can assist providers with managing readmissions to hospitals from SNFs, helping them to meet requirements of evolving public policy for SNFs and to partner with hospitals. </div> <div> </div> <div><em>Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).</em></div>The American Health Care Association (AHCA) has made reduction of readmissions to hospitals in 30 days one of four goals in its 2012 Quality Initiative.2012-10-01T04:00:00Z<img alt="Andy Kramer, MD" src="/Monthly-Issue/2012/PublishingImages/Headshots/AKramer_rollup.jpg" style="BORDER:0px solid;" />QualityColumn10
2012 AHCA/NCAL Annual Awardshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1012/2012-AHCANCAL-Annual-Awards.aspx2012 AHCA/NCAL Annual Awards<div>The American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) are pleased to announce the individual and group winners of their annual awards. They want to commend all of the award recipients for their selfless service and care. <br></div> <div> </div> <div> </div> <div> </div> <div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">REBECCA RIGGINS</h2></div> <div> </div> <div> </div> <div> </div> <div>Adult Volunteer of the Year</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Prepare to be humbled. Volunteer Rebecca Riggins is truly one-of-a-kind and has put more heart into her volunteering than one would think possible. As if her interaction with residents of McDowell Nursing and <span><img src="/Monthly-Issue/2012/PublishingImages/1012/BeckyRiggins.jpg" alt="Rebecca Riggins" class="ms-rteImage-2 ms-rtePosition-2" width="168" height="247" style="margin:5px;" /></span>Rehabilitation Center in Gary, W.Va., is not enough, Riggins coordinates with community organizations and churches to provide activities that include birthday parties, Christmas shopping and in-facility holiday </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>events, adopt-a-resident (or group of residents), pet therapy (well, it is her dog!), and intergenerational programs (well, they are her grandchildren!), and she often purchases items requested by residents. Yet her weekly time at the facility is not all about being busy.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“Becky is without a doubt my best friend and confidant,” says resident Charlotte Mitchem. “She has given me the motivation to keep going even when life gets difficult.” </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Comments like this offer a window into the thinking of Administrator Patty Lucas when she says, “Without Rebecca our facility may not have reached the quality standards that we have.” Wilma Johnston, activity director, sums up this volunteer’s qualities: “Rebecca’s attitude and motivation are an inspiration to everyone she encounters.”</div> <div> </div> <div> </div> <div> </div> <div><span>—Tom Burke<span style="display:inline-block;"></span></span></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">WEST JORDAN CARE CENTER</h2> <div> </div> <div> </div> <div> </div> <div>Not-for-Profit Services of the Year<br></div> <div> </div> <div> </div> <div> </div> <div><br>The residents of West Jordan Care Center (WJCC), West Jordan, Utah, have developmental and intellectual disabilities. Most residents are medically fragile and have seizure disorders and physical disabilities. The facility, Utah’s only Eden Alternative-registered home, developed a mission statement based on its Eden commitment: “We are on a mission to create a community that provides human growth, spontaneity, and compassion by enhancing meaningful relationships, activities, and independence. Our promise is to give our residents a life worth living!” Basically that means, “While caring for the body, we feed the spirit.”<br></div> <div> </div> <div> </div> <div> </div> <div><br>Staff live their mission, too. Take the center's community outreach program, Caring for Kids—Paying Back in Community Service. The community benefit program works with troubled youth who have been court-ordered to provide community service as restitution for minor or petty offenses. WJCC provides a venue in a structured environment that allows children to assist in the kitchen, gardens, greenhouse, and planned events and activities. </div> <div> </div> <div> </div> <div> </div> <div><br>These “volunteers” are taught about people with disabilities, people-first language, the benefit of having an inclusive society, and the challenges that face people with disabilities in being accepted as valued members of the community.</div> <div> </div> <div> </div> <div> </div> <div><br>In the past three years, WJCC has hosted nearly 1,400 community service hours. Many of the volunteers return to volunteer on their own; some even apply for WJCC jobs when they are old enough. After 17 years, Caring for Kids is seeing increasing referrals from courts and families because they know that WJCC staff mentor children and provide substantial learning experiences and meaningful relationships.</div> <div> </div> <div> </div> <div> </div> <div>—Tom Burke</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">ALEXIS NAST</h2> <div> </div> <div> </div> <div> </div> <div>Young Adult Volunteer of the Year<br><br></div> <div> </div> <div> </div> <div> </div> <div>Fifteen-year-old volunteer Alexis Nast could be thought of as the “Director of Encouragement” at the 200-bed Pines at Poughkeepsie, just north of New York City. Facility Administrator Dana Diorio-Casey shares why Nast is such a valued volunteer: “She has discovered the secret of happiness—caring for others brings joy tenfold back to the person. Alexis is a mix of the joy of youth and the maturity of an old soul.”<br><img class="ms-rteImage-1 ms-rtePosition-2" alt="Alexis with residents" src="/Monthly-Issue/2012/PublishingImages/1012/Alexis-with-Residents.jpg" width="385" height="257" style="margin:10px;" /><br></div> <div> </div> <div> </div> <div> </div> <div>Resident Geraldine Johnson says that “Alexis has a passion for working with the elderly and a good work ethic.” After two years of steady service, with increased hours during summer vacation, it is apparent that Nast enhances residents’ quality of life by bringing the outside community to them, along with other student volunteers and a new Adopt-a-Grandparent program.<br><br></div> <div> </div> <div> </div> <div> </div> <div>“Alexis is a great resource to us,” says Karen Barone, Pines’ director of recreation. “She is comfortable with all residents regardless of cognitive level or physical limitations. Alexis is respected by residents, their families, and the staff.” Her time at the facility is spent in one-on-one visits, nail polishing, transporting residents, delivering items to rooms, and encouraging residents to participate in group activities.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Nast is especially adept with people with Alzheimer’s disease. “Rebecca has excellent communication skills,” notes Director of Nursing Colleen Gibb, “is self motivated, independent, and a pleasure to have as a volunteer.”</div> <div> </div> <div> </div> <div> </div> <div>—Tom Burke</div> <div> </div> <div> </div> <div> </div> <div> <br></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">CAROLYN O<span></span>LSON</h2> <div> </div> <div> </div> <div> </div> <div>DD Hero of the Year<br><br></div> <div> </div> <div> </div> <div> </div> <div>Carolyn Olson has found her passion in life through volunteering, and it is reflected in the faces of residents at CARC, a multi-faceted ICF/MR for persons with developmental disabilities (DD) in Carlsbad, N.M.<br><br></div> <div> </div> <div> </div> <div> </div> <div>“She encourages the community to recognize that individuals with DD share the same needs as all other members of the community and encourages the community to support these individuals,” says Mark Schinnerer, CARC chief executive officer.<br><br><img class="ms-rteImage-2 ms-rtePosition-1" alt="Carolyn Olson" src="/Monthly-Issue/2012/PublishingImages/1012/Carolyn-Olson.jpg" width="205" height="205" style="margin:10px;" />Olson is an active member of the CARC community and volunteers for a number of programs, including the CARC Farmhouse Bargain Store and the CARC Human Rights Committee, and is president of the CARC Board of Directors.<br><br></div> <div> </div> <div> </div> <div> </div> <div>However, Olson is best known and recognized for the time and energy she dedicates to the Area IV Special Olympics programs.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Olson, the overall coordinator of the program, recruits community members, including the local fire and police departments, church groups, and others to participate in unified sports leagues alongside individuals with DD. She also is the coach for several Special Olympics teams, including bocce, aquatics, and bowling. Olson has been an active participant in the Special Olympics program since the early 1970s and exemplifies the Special Olympics motto, “Let me win, but if I cannot win, let me be brave in the attempt.”</div> <div> </div> <div> </div> <div> </div> <div>—Tom Burke</div> <div> </div> <div> </div> <div> </div> <div> <br></div> <div> </div> <div> </div> <div> <span class="ms-rteThemeForeColor-5-3"> </span></div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">SENIORS AID NEW HAMPSHIRE</h2> <div> Group Volunteer of the Year</div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Seniors Aid New Hampshire is a one-of-a-kind group. It consists of residents from more than 37 facilities in the state.</div> <div> </div> <div> </div> <div> </div> <div><br>In 2006 as part of a campaign to promote culture change and person-centered care, the New Hampshire Health Care Association (NHHCA) sponsored several resident forums. From these, attendees found they shared a vision to ensure that older adults who wished to remain active contributors to society were given the chance to do so. These founding members agreed on a mission to help charitable causes that benefit the long term care community and the greater state community. The mission also includes advocacy if called for.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><img src="/Monthly-Issue/2012/PublishingImages/1012/SANH.jpg" class="ms-rteImage-2 ms-rtePosition-2" width="336" height="253" alt="" style="margin:10px;" /><br>An example of Seniors Aid fundraising prowess is the $120,000 given to the New Hampshire Food Bank over a five-year period. Funds were raised by the members working within their communities.<br><br></div> <div> </div> <div> </div> <div> </div> <div>Yet beyond the dollars lies a deeper meaning, identified by Mel Gosselin, executive director of the Food Bank. “Participating seniors inspire their friends, family, and neighbors by showing that philanthropy has no age limit.” The bottom line is that Seniors Aid is a “thriving organization that changes the lives of many people living in long term care,” says John Poirier, president and chief executive officer of NHHCA. Life continues, especially when mission meets motivation. </div> <div> </div> <div> </div> <div> </div> <div>—Tom Burke<br></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-5-3">ERNEST</span> <span class="ms-rteThemeForeColor-5-3">KASTNER</span></h2> <div> </div> <div> </div> <div> </div> <div>Noble Caregiver in Assisted Living<br><br></div> <div> </div> <div> </div> <div> </div> <div>Ernest Kastner is more than the director of environmental services for Van Dyk Park Place in Hawthorne, N.J.</div> <div> </div> <div> </div> <div> </div> <div><br>“He is not that ‘maintenance guy’ who replaces a light bulb and moves on to the next task, he is the guy that dances up the ladder, changes the light bulb, and dances back down the ladder, making his audience cheer!” says Jaime Cerritelli, Van Dyk Park Place’s director of activities and volunteers. “His passion for life and desire to make people happy shine through each and every task he completes.”</div> <div> </div> <div> </div> <div> </div> <div><img class="ms-rteImage-2 ms-rtePosition-1" alt="Ernie Kastner" src="/Monthly-Issue/2012/PublishingImages/1012/ErnieKastner.jpg" width="207" height="279" style="margin:10px;" /><br>It’s those characteristics that made him the 2012 Noble Caregiver in Assisted Living. This award is given to a frontline staff person from any department who contributes to the positive well-being of the residents and the morale in the assisted living community. He also demonstrates initiative and performs above and beyond the call of duty. </div> <div> </div> <div> </div> <div> </div> <div><br>Cerritelli says that Kastner spends his personal time reading and learning so he can give presentations to </div> <div> </div> <div> </div> <div> </div> <div>the residents. He also delivers the homily at memorial services. </div> <div> </div> <div> </div> <div> </div> <div><br>Kastner can be found in a hula skirt having a good time with the residents. He’s equally as good at spending quality one-on-one time with them.</div> <div> </div> <div> </div> <div> </div> <div><br>“He has no problem taking a break in his day to sit and talk with residents who may be down. When he sees a staff member who needs help with a task, he makes sure that he gets involved and empowers them to be the best that they can be,” Cerritelli says. </div> <div> </div> <div> </div> <div> </div> <div><br>Kastner understands how to be a leader. He joined Van Dyke Place in 2008. </div> <div> </div> <div> </div> <div> </div> <div><br>“He listens to resident suggestions, takes them seriously, and truly understands how to be a leader,” says Cerritelli. “The beauty in his character is not what he does to make our community a better place, but how he does it with heart.”</div> <div> </div> <div> </div> <div> </div> <div>—Lisa Gluckstern</div> <div> </div> <div> </div> <div> </div> <div> <br></div> <span class="ms-rteThemeForeColor-5-3"> </span><h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3"> </h2> <span class="ms-rteThemeForeColor-5-3"> </span><h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3"> </h2> <span class="ms-rteThemeForeColor-5-3"> </span><h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3"> </h2> <span class="ms-rteThemeForeColor-5-3"> </span><h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">BEVERLY JOHNSTON</h2> <div> </div> <div> </div> <div> </div> <div>NCAL Assisted Living Nurse of the Year<br></div> <div> </div> <div> </div> <div> </div> <div><br>Staff and residents at The Chelsea at Tinton Falls, in New Jersey, benefit from the dedication and passion of Beverly Johnston, RN, C-AL, director of health services. </div> <div> </div> <div> </div> <div> </div> <div><br>“She works tirelessly to give dignity to all by addressing the needs of mind, body, and soul, not only involving her caregivers but the entire staff,” says Kathie Deak, executive director of the Tinton Falls residences. Deak nominated this year’s recipient of the 2012 NCAL Assisted Living Nurse of the Year. </div> <div> </div> <div> </div> <div> </div> <div>Johnston has been the residences’ health services director since 2005. She supervises 25 health care workers and coordinates the health care and personal care needs of 70 residents. </div> <div> </div> <div> </div> <div> </div> <div><br>Johnston exhibits the critical leadership, supervisory, and teamwork skills that are inherent in providing high-quality care in the assisted living setting. </div> <div> </div> <div> </div> <div> </div> <div><img src="/Monthly-Issue/2012/PublishingImages/1012/BeverlyJohnston.jpg" alt="Beverly Johnston" class="ms-rteImage-2 ms-rtePosition-2" width="193" height="244" style="margin:5px;" /><br>“When encountering difficulties, she enlists the cooperation of outside providers, such as social workers, physical therapists, occupational therapists, and speech therapists, as well as frontline staff,” says Deak. <br><br>“She listens to each one’s point of view and leads them to establish a plan to address those needs together. Because all of the disciplines are involved, everyone shares in the outcomes and strives to have positive results. She sees to it that everyone also shares in the success.”</div> <div> </div> <div> </div> <div> </div> <div><br>Johnston effectively communicates with family members, physicians, staff, and other stakeholders about the needs of the resident, Deak says.</div> <div> </div> <div> </div> <div> </div> <div><br>“Understanding the emotional turmoil that family members face, she meets with them on their own time, often nights or weekends, to fully communicate the complexities of their loved one’s diagnosis, care, and treatment,” Deak says. </div> <div> </div> <div> </div> <div> </div> <div><br>Johnston’s reputation in the surrounding medical community is well known. Recently, she helped develop a protocol for a local hospital’s geriatric emergency medicine program that improved the communication between caregivers at the hospital and the assisted living centers. A local physician told a prospect for head of a department of The Chelsea at Tinton Falls that Johnston “ran a tight ship,” and there could be no better place to work. </div> <div> </div> <div> </div> <div> </div> <div><br>“Her favorite mantra is, ‘Know your resident,’ a philosophy incorporated in everything she does,” says Deak, adding, “She adjusts to changing situations quickly and is never flustered. She is ever patient, kind, considerate, and is that ‘once-in-a-lifetime’ person we all hope to have in our lives.”</div> <div> </div> <div> </div> <div> </div> <div>—Lisa Gluckstern</div> <div> </div> <div> </div> <div> </div> <div> <br></div> <div> </div> <div> </div> <div> </div> <div>HELEN CRUNK </div> <div> </div> <div> </div> <div> </div> <div>NCAL Administrator of the Year<br><br></div> <div> </div> <div> </div> <div> </div> <div>When a staff member told her about a resident’s desire to see Mt. Rushmore, Helen Crunk, RN, administrator of Mable Rose Estates in Papillion, Neb., immediately said, “Let’s do it.” </div> <div> </div> <div> </div> <div> </div> <div><br>Crunk wore many hats during the weeklong trip. She drove the van 1,100 miles round trip, carrying a total of 10 adults—seven residents and four children—to fulfill one resident’s dream. She also acted as attendant nurse to the residents on the trip. </div> <div> </div> <div> </div> <div> </div> <div><br>While the trip may have been a once-in-a-lifetime event, Crunk exhibits leadership daily, holding to a high standard of person-centered care for the residents and advocating for her staff and residents.</div> <div> </div> <div> </div> <div> </div> <div><br>Crunk is the 2012 NCAL Administrator of the Year. The award is the highest national honor an assisted living administrator can receive. </div> <div> </div> <div> </div> <div> </div> <div><br>An independent panel of judges from across the nation reviews nominations each year, but the names of nominees and community locations are not provided to the panel. This is the second time Crunk has received the award—she had won it earlier in 2007.</div> <div> </div> <div> </div> <div> </div> <div><img src="/Monthly-Issue/2012/PublishingImages/1012/HelenCrunk.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:15px;" /><br>Lisa Summers, memory support director for Mable Rose, an affiliate of Hillcrest Health Systems, believes the Mt. Rushmore trip reflects Crunk’s commitment to her staff and residents. Summers was the staff member who told Crunk that she wanted to make a 90-year-old resident’s dream of seeing Mt. Rushmore come true.</div> <div> </div> <div> </div> <div> </div> <div><br> “She is continually an active advocate for seniors and accepts nothing less than the absolute highest quality of care and standards for her residents,” says Summers. “She plays an active role in advocating for those in her community, state, and nation.”<br><br></div> <div> </div> <div> </div> <div> </div> <div>The Bellevue Chamber of Commerce named Crunk Nebraska Business Woman of the Year. She participates in the state’s public television series on dementia and was recently named chair of NCAL’s Quality Committee. </div> <div> </div> <div> </div> <div> </div> <div><br>“She took this weeklong journey of a lifetime to help fulfill a dream for our resident. Really, who does that? My administrator does that,” Summers says, adding, “She is well respected and admired by her peers and the team she leads. She creates leaders, promotes talents, and empowers others to reach their full potential. She exhibits every trait found in a great leader and serves as a role model for all those expressing the desire to serve our senior population.” </div> <div> </div> <div> </div> <div> </div> <div>—Lisa Gluckstern<br></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2 ms-rteThemeForeColor-5-3">RIVERSIDE LODGE RETIREMENT COMMUNITY</h2> <div> </div> <div> </div> <div> </div> <div>NALW Programming Award<br><br></div> <div> </div> <div> </div> <div> </div> <div>The 2011 National Assisted Living Week (NALW) celebration began on the 10th anniversary of the Sept. 11, 2001, tragedy. On that Sunday, the Riverside Lodge Retirement Community, Grand Island, Neb., held a parade that included the state’s lieutenant governor, Grand Island’s mayor, and a float made by Riverside Lodge residents, with all the names of those who perished on 9/11 on its sides. </div> <div> </div> <div> </div> <div> </div> <div><br>The Statute of Liberty was painted on the back of the float by a Riverside Lodge resident who is a 98-year-old retired art teacher. Riverside Lodge veterans marched in the parade, along with local Boy and Girl Scout troops and the local high school’s cheerleaders and drum and flag corps. </div> <div> </div> <div> </div> <div> </div> <div><br>Riverside Lodge’s long-time staff members Grace Nordlund, assisted living activity coordinator, and Cathy Roark, resident services coordinator, designed, planned, and implemented a week full of programming that successfully integrated the 2011 NALW theme, “Forever Proud,” into all of its activities. Their work so impressed the NCAL Awards judges that they made Riverside Lodge the 2012 National Assisted Living Week Programming Award recipient.</div> <div> </div> <div> </div> <div> </div> <div><br>“We are ‘Forever Proud’ of our God, country, community, culture, accomplishments, and military, which is why these were chosen as the areas to program activities around,” wrote Nordlund and Roark on their award application. <br></div> <div> </div> <div> </div> <div> </div> <div><br>To celebrate the military, three Riverside Lodge residents spoke about their war experiences. The residents baked cookies and had them delivered to the Riverside Lodge veterans group. </div> <div> </div> <div> </div> <div> </div> <div><br>Local businesses that had been visited by residents were invited during the week to share their histories and memories. An owner from Lee’s Family Restaurant, a family-owned business for three generations and a local favorite, gave a presentation and served up its famous mile-high Sour Cream Raisin Pie. The marketing director from the Union Pacific Railroad gave a presentation on the company’s history and afterward asked residents who had worked for the railroad to share their memories. Celebrating the local community featured a resident who was instrumental in moving Henry Fonda’s birth house to Grand Island. </div> <div> </div> <div> </div> <div> </div> <div><br>Two staff members, dressed as movie stars Ginger Rogers and Fred Astaire, danced to the waltz part of the USO show. Residents dressed up as the Andrews Sisters, Liberace, Judy Garland, and Marilyn Monroe. Everyone sang to songs from the Big Band era or Shirley Temple movies. Residents enjoyed a tailgate party before the Nebraska University Huskers played Washington State’s Huskies. </div> <div> </div> <div> </div> <div> </div> <div><br>“The activities of [NALW] week are an extension of the type of activities that we offer on an ongoing basis,” Nordlund and Roark wrote. “Our program focuses on the body, mind, and spirit of each resident. We provide daily offerings that reflect individual interests and needs.”</div> <div> </div> <div> </div> <div> </div> <div>—Lisa Gluckstern</div> AHCA/NCAL are pleased to announce the individual and group winners of their annual awards. They want to commend all of the award recipients for their selfless service and care.2012-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/1012/specialawards_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality AwardsAHCA/NCAL Annual Awards10

November


 

 

Providers Find Ways To Enable Choicehttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1112/Providers-Find-Ways-To-Enable-Choice.aspxProviders Find Ways To Enable Choice<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>Daily life is fraught with subtle dangers. There are risks associated with a trip to the grocery store, a walk in the park, or even a relaxing bath. Despite these risks, most people continue to buy groceries, bathe, and walk outdoors. They accept the idea that accidents happen, but they think it is more important to live fulfilling, happy lives.</div> <div> </div> <div> </div> <div> </div> <div>This attitude generally doesn’t change just because someone enters a long term care facility; yet ensuring safety sometimes overshadows quality of life. However, with the evolution of person-centered care, more facilities—as well as family members and policymakers—are beginning to see risk as part of life and giving more weight to resident choices and autonomy. <br></div> <div> </div> <div><br>The risk-versus-choice seesaw is tipping toward giving residents more say in what they want. As Judah Ronch, PhD, professor of practice, professor, and dean at the Erickson School at the University of Maryland Baltimore County, says residents have the “right to folly”—to make the same bad or unpopular decisions that any adult has the right to make.</div> <div> </div> <h2 class="ms-rteElement-H2">Transition A Work In Progress</h2> <div> </div> <div>There are many factors driving the move toward making choice a higher priority. The Centers for Medicare & Medicaid Services (CMS) has led the way on many facets of this movement.<br></div> <div> </div> <div><br>For example, Colorado-based author, consultant, and former surveyor Carmen Bowman says CMS “came out with additional interpretive guidance on f-tags regarding choice and other issues. At the same time, the MDS [minimum data set] 3.0 is making us ask questions about choice.”</div> <div> </div> <div><br>CMS also has implemented the Quality Indicator Survey (QIS), a computer-assisted long term care survey process that is being phased in by region and state. The QIS was designed to improve consistency and accuracy in identifying quality-of-care and quality-of-life issues. It is a more interactive survey that enables feedback for surveyors and managers alike. It also provides facilities with tools for continuous improvement and focuses survey resources on those facilities that have the most quality concerns. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Surveyor Interpretation Varies</h2> <div> </div> <div>Despite the growing emphasis on prioritizing choice, there is still some resistance. As Eden Mentor and physician Al Power, MD, FACP, says, “One underlying issue is ageism in society—the idea that older people need to be looked after. Even in nursing homes, we have a tendency to tell people what they should and shouldn’t do. It’s a very difficult environment in which to be empowered.” If there is any question that residents have the right to choice, Power says, they need only look in the regulations, or so it would seem. <br></div> <div> </div> <div><br>F-tag 151 “Exercise of Rights” states that the “resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.” Power says, “This is very basic and simple.” At the same time, he notes, it is not always interpreted the same way by surveyors. He says, “Surveyors take different approaches to the application of standards, and that is where we get into conflict.” <br></div> <div> </div> <h2 class="ms-rteElement-H2"><span><img width="461" height="306" class="ms-rtePosition-1 ms-rteImage-2" src="/Monthly-Issue/2012/PublishingImages/1112/Alice-Riggs_Jamie-Babcock_HW_gardening.jpg" alt="resident choosing activity" style="margin:10px;" /></span>Negotiating Risk </h2> <div>The key to juggling risk management in choice is risk negotiation, says Power. “We tend to take an all-or-nothing approach,” he says. “We all face risk every day. It is a part of life. You can’t completely eliminate risk, but you can minimize it and create a balance.” The best way to find the balance is to communicate and listen, he says.</div> <div> </div> <div><br>“We have to fight the tendency to insert our own values for someone else and instead listen to and understand their judgment. When we count on substituted judgment, we often miss the boat.” </div> <div> </div> <div><br>To understand what residents want, Power says, “We really have to put the focus on the individuals, their life experiences, and what they want out of life. We need to ask them about what they want to do, how it supports their health and well-being, and what the ability to do these things means to them.” </div> <div> </div> <div><br>“We need to explain the risks and ask if the activity is worth the risk to them,” he says. “Then we need to honor the person’s wishes. Even it it’s not what we would do, we have to honor their choice and mobilize our resources to support it in a way that maximizes the benefits and minimizes the risks.”</div> <div> </div> <div><br>Kallander shares a story of successful <a href="/Monthly-Issue/2012/Pages/1112/When-Residents-Risk-Choking.aspx" target="_blank" title="When Residents Risk Choking">negotiated risk.</a> A resident loved Pringles potato chips and would eat them at every meal. “The dietitian was beside herself and insisted that he shouldn’t have them. We met with the resident’s daughter and told her about the dietitian’s recommendations and concerns. His daughter says that this was his favorite food, and she was adamant that he should be able have these chips.”</div> <div> </div> <div><br>After some discussion, the facility and the daughter agreed that the resident would continue to get the chips, but the physician would monitor him and let them know if there was a problem. <br><span id="__publishingReusableFragment"></span><br></div> <div> </div> <h2 class="ms-rteElement-H2">Put It In Writing</h2> <div> </div> <div>It’s been said many times, but it needs to be said again: document, document, document. However, while most agree that detailed documentation is good protection, it may not be infallible. As Troxel says, “My attorney friends tell me there is almost no document that really lessens the risk.” While he encourages documentation, he suggests keeping it clear and simple.</div> <div> </div> <div><br>“Overdocumentation could be as troublesome as lack of documentation. Note what you’re doing, why you’re doing what you’re doing, and a summary of the family and resident communication,” he says. He also suggests composing a letter that lists the pros and cons of, for example, daily walks, and that says the family authorizes this behavior. “Keep it to one page, and have the family sign it,” he says.</div> <div> </div> <div><br>“Even if it doesn’t protect you legally, it puts you in a better position with the family,” he says. “Everything I understand about risk reduction is that good relationships and communication are the best defense.”</div> <div> </div> <div>When Kallander negotiates risk with a resident or family, she has them complete and sign a form that details their discussion and what they agreed to do. “It’s not perfect, but it generates conversations and makes staff feel safer,” she says. </div> <div> </div> <div><br>Power is working on what he calls a “radical” idea—eliminating traditional policies and procedures. He explains, “The problem is that most P&Ps have several qualities that make them restrictive. They tend to be black and white, with no room for nuances. They often are based on worst-case scenarios. Because they try so hard to be fair and equal, they often are unfair and unequal. </div> <div> </div> <div><br>“We have moved to principles and guidelines instead of P&Ps, where you have things based on values rather than rules,” he says. </div> <div> </div> <h2 class="ms-rteElement-H2">Looking At The Legalities</h2> <div> </div> <div>For legal purposes, says Howard Sollins, a Baltimore-based health lawyer, “the strength is on who is making the decision and if he or she is authorized to make that decision, how you documented the information provided, and how you determined and gained informed consent.”</div> <div> </div> <div><br>Perhaps most challenging are the situations where a resident’s choice may be so problematic that it could jeopardize the person’s ability to receive care.</div> <div> </div> <div><br>“We’ve worked with facilities to put in place a process for progressively setting some parameters for these kinds of behaviors,” Sollins says. Typically, these are coupled with documented efforts to educate the residents and identify risks and agreements about expected behaviors. <br><br></div> <div> </div> <div>Sollins stresses the value of facility ethics committees and resident advisory committees to address difficult situations. “People can come in and discuss a particular situation. These are extremely valuable in helping everyone get comfortable with difficult choices,” he says.</div> <div> </div> <h2 class="ms-rteElement-H2">Choice And Dementia</h2> <div> </div> <div>One of the most challenging risk-versus-choice situations involves residents with Alzheimer’s disease or other dementias. However, Troxel believes that there’s been progress. He says, “The contemporary view is that people with dementia are like the rest of us. There are more outings—unconventional things such as going to baseball games, museums, and restaurants—and these involve greater risk.” Not only are families increasingly supporting these types of events, they are encouraging them, Troxel says. “Families almost universally want mom and dad to enjoy life and have fun.”</div> <div> </div> <div><br>At the same time, providers are effectively communicating the benefits of choice for residents with dementia. </div> <div> </div> <div><br>“Families are starting to understand that falls can happen anywhere and that elopements can happen in even the best places. We’re communicating that when mom and dad have exercise and activities, their wellness, happiness, and mood go up, and that lowers the risk of falls and their desire to leave,” says Troxel. He adds, “Having good communication and a strong activities program is the best defense.”</div> <div> </div> <div>Sometimes facilities have to use their own judgment. For example, Kallander spoke of her community’s decision to include a rose garden on its grounds.</div> <div> </div> <div><br>“We had people say we were foolish, that residents would fall or climb in the roses and get scratched or cut. However, my research told me that residents have certain skills and abilities that don’t leave them just because they have cognitive impairment. They know not to jump in the bushes,” she says.</div> <div> </div> <div><br>So facility leaders agreed to take a “reasonable risk.” Kallander says, “We decided to monitor the situation carefully, to file any incident reports, and trend accidents related to the rose bushes.” The result? Never once in three years was there a problem. Kallander concludes, “Sometimes you have to be a little brave about trying things. Hovering over and coddling people isn’t the way our residents want to live their lives.” <br></div> <div> </div> <h2 class="ms-rteElement-H2">The Choice To Wander</h2> <div> </div> <div>“My experience has been that most of the time people wander because the opportunity presented itself. They walk out with a family member. The UPS man holds the door open for a resident. They’re walking and see an open door,” says Cynthia Lilly, MSW, National Memory Care and Dementia Program director, Atria Senior Living, Louisville, Ky. Only a few residents actually plan their escape.</div> <div> </div> <div><br>She says, “One resident with Lewy Body dementia knew when the therapy dog went out, and he would sneak out with it.” While the facility is responsible for preventing these elopements—whether they are impromptu or planned, they can do it without restricting residents’ movements.</div> <div> </div> <div><br>As Lilly says, “Locks need to work, windows need to close, and doors need to have alarms. Staff need to make sure that these things are working. However, the best way to prevent elopements is to keep people engaged and give them a reason not to be hanging out by the door.” <br><span id="__publishingReusableFragment"></span><br></div> <div> </div> <h2 class="ms-rteElement-H2">Ways To Mitigate Elopement</h2> <div> </div> <div>Staff also can use common sense to prevent wandering while enabling residents the freedom to move around at will. Lilly says, “A lot of times, these elopements happen in the later afternoon when the sun is going down and there are shift changes. Residents can read the body language of staff and know that something is going on. They get restless, and they can wander. So it is important to keep them occupied during these times.” </div> <div> </div> <div><br>Many<a href="/Monthly-Issue/2012/Pages/1112/Care-Dogs-A-New-Option.aspx" target="_blank" title="Care Dogs A New Option"> attempts at wandering</a> happen during the first 48 hours after someone enters the facility, Lilly says, so staff need to take this time to get to know new residents and make them feel safe and comfortable. </div> <div> </div> <div>“During the first few days, you have to do regular checks on the new resident. Make sure they are okay. Are they comfortable? Are there familiar things in their room? Do they know where the bathroom is?” Lilly trains staff to call new residents by name every time they see them. “It makes them feel safe and more at home,” she says.</div> <div> </div> <div><br>Family members can help by sharing information about the resident’s patterns, habits, and routines. For example, she says, “One resident was very restless and wasn’t adjusting well to her new surroundings. She wanted to leave. We discovered from her family that she loved tea, so we gave her the job as hostess for an afternoon tea party. She went from exhibiting difficult behaviors to being someone with a sense of purpose.</div> <div> </div> <div><br>“Let family members and other visitors know that when they leave the facility, they need to make sure no one follows them. They may need to take the resident by the hand and turn him or her over to a staff member,” she says. <br></div> <div> </div> <h2 class="ms-rteElement-H2">To Fall Or Not To Fall</h2> <div> </div> <div><a href="/Monthly-Issue/2012/Pages/1112/An-Alarming-Controversy.aspx" title="An Alarming Controversy" target="_blank">Fall prevention</a> is one area where risk management often takes precedent over choice. “There is this false idea that if people go into a nursing home, they won’t ever fall. While we can reduce the chance that someone will fall, falls still happen. We have to create an environment that keeps people safe and honors choice,” says Power.</div> <div> </div> <div><br>Part of the problem is confusion about how to interpret the regs. As Bowman says, “Tag 323 has one sentence that says in the end the facility is responsible for preventing falls. In some states, surveyors hang onto that sentence. However, there are other parts of the tag that say things such as, ‘not all falls can be prevented.’ Many surveyors don’t pay enough attention to this concept. Instead, they focus on the idea that the facility clearly didn’t do something that could have prevented the fall.”</div> <div> </div> <div><br>Unfortunately, Bowman notes, this can causes staff to focus more on fall prevention and risk management than what the resident wants. It also can penalize good facilities. She says, “If a facility has a good system and someone still falls, they may still get cited even it had a good practice in place.</div> <div> </div> <div><br>“State by state it varies when surveyors are in your building,” Bowman says. “I’ve had surveyors say that they go after safety issues harder because they are black-and-white issues, whereas quality-of-life issues are much harder because they are not so clear cut.” She adds, “It’s easier to focus on what could have been done to prevent accidents rather than on what residents really want. The resident’s voice is still missing.” <br></div> <div> </div> <h2 class="ms-rteElement-H2">Success Stories</h2> <div> </div> <div>When the resident has a voice, the results can be surprising. Power relates a story about a nursing facility resident in Ohio. “He was weak and unsteady on his feet. He would fall often, and they wanted to restrain him. He had meetings with staff and said that he would rather die. So they put it in his care plan, and he continued to move about on his own. He fell dozens of times in a few months, but eventually he was able to ambulate independently without falls.”<br></div> <div> </div> <div><br>Troxel suggests documenting why someone is allowed to participate in a potentially risky ambulation. For example, Mr. Jones worked in a grocery store all of his life, and he really enjoys trips to the local supermarket. Troxel says, “That way, if dad falls, the family is reminded of why he was there, what he got out of the walks, and how they benefited him.”</div> <div> </div> <div><br>Most facilities stress their successful falls prevention programs and fall and injury rates to families on admission. While this makes sense, it also can encourage unrealistic expectations about the facility’s ability to prevent falls. As Lilly says, “Residents fall more as they get older. But we also have to keep them up and moving as much as possible.”</div> <div> </div> <div><br>This often calls for compromise. For example, she relates an incident where a family member wanted to purchase a “Lap Buddy” to confine a resident. “We proposed that we instead get him into physical therapy and help him build his strength. We also gave them information about the pros and cons of the Lap Buddy so that they could make an informed decision,” she says. However, she admits that it may be futile to talk to the family when emotions are high.</div> <div> </div> <div><br>“The intellect will accept only what the emotions allow. Sometimes when the family is upset, we really can’t educate them at that time. We have to wait for the right moment and plant little seeds,” she says.</div> <div> </div> <h2 class="ms-rteElement-H2">The Younger Resident</h2> <div> </div> <div>Younger residents, a growing segment of the long term care population, are less likely than their older counterparts to wait to make their own choices. “Younger people may have a different idea of what they want to do,” says Power. These individuals often want to leave the facility and spend time with their friends and families. This often involves leaving the facility or pursuing unhealthy activities such as drinking alcohol, smoking or using drugs, or eating junk food.</div> <div> </div> <div><br>While facilities don’t have to like these choices, they have to respect them. As Robert Gibson, PhD, JD, senior clinical psychologist, Edgemoor DPSNF, Santee, Calif., says, “Some of these people made bad choices before they entered the facility, and that behavior is likely to continue. However, we are in a position to protect them and mitigate risks to some degree.” </div> <div> </div> <div><br>Gibson’s facility focuses on ongoing assessments of residents’ decision-making capacity to make sure they are capable of making choices—good or bad. He says, “If they can articulate the reasons they want to do what they want to do, and they aren’t impaired by depression, suicidal thoughts, etc., they generally are able make the decision they choose to make.” He stresses the need to revisit these assessments over time.</div> <div> </div> <div><br>“If a situation involves a more complex decision, the resident will have to demonstrate greater capacity to make that decision. If they have that capacity, document it. Then work with the resident to mitigate the risk.”<br><br> </div> <div> </div> <div>Facilities that are still uncomfortable or unsure about how to balance risk management and choice should make this issue a priority. The growing baby boomer population in long term care likely will create a new generation of residents who expect choice. “Baby boomers won’t tolerate being told what to do. They will demand the ability to take risks,” says Power. Ronch adds, “Boomers grew up with a sense of entitlement. Any facilities that don’t prepare for these individuals are in for a rude awakening. They need to get ready for boomers and understand what is in the regs regarding choice and risk.”</div> <div> </div> <div> </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div>Daily life is fraught with subtle dangers. There are risks associated with a trip to the grocery store, a walk in the park, or even a relaxing bath. Despite these risks, most people continue to buy groceries, bathe, and walk outdoors. They accept the idea that accidents happen, but they think it is more important to live fulfilling, happy lives.2012-11-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/1112/coverstory_thumb.jpg" style="BORDER:0px solid;" />Management;CaregivingCover Story11
A Dementia Care Revolutionhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1112/A-Dementia-Care-Revolution.aspxA Dementia Care Revolution<div>One size doesn’t always fit all. One care plan doesn’t work for everybody, and this is especially true for dementia care. People living with dementia are just that—people. Each and every one of them has a unique personality, life experiences, interests, and preferences. </div> <div> </div> <div>Similar to the hospice movement that changed the culture of care for individuals with terminal conditions, dementia care is going through its own revolution. </div> <div> </div> <div>The industry is moving away from the task-driven dementia care model, which focused on disease and behavior management, and turning to a new person-centered care method. </div> <h2 class="ms-rteElement-H2">A Look At The Whole Person</h2> <div>Person-centered dementia care is both a philosophy and a practical approach to patient care. Also known as holistic, individualized, or patient-oriented care, it is concentrated on the whole person—not on the biomedical manifestation of a particular person’s brain functions. </div> <div> </div> <div>The technique focuses on a patient’s emotions, strengths, and remaining abilities—not on their disabilities. This approach takes into account everyone’s needs within the context of their network of relationships, their identity, history, health, religion, and culture.</div> <div> </div> <div>As dementia progresses, individuals can lose the ability to articulate their needs or express their feelings. However, numerous studies have revealed that people living with dementia still maintain qualities such as self-awareness, autonomy, individuality, and sense of identity. </div> <div> </div> <div>Person-centered dementia care preserves the value of the person and enhances an individual’s personhood by promoting positive feelings, nurturing abilities, and maximizing independence. </div> <h2 class="ms-rteElement-H2">Putting It Into Practice</h2> <div>Individualized dementia care starts with asking the right questions. A holistic assessment includes an analysis of a person’s medical and social history, as well as an understanding of their preferences and interests. </div> <div> </div> <div>Often this information can be gleaned from the patient directly, but this is also where family and friends can be helpful. Understanding the person and his or her needs and wants is the first step to creating an accurate person-centered care plan.</div> <div> </div> <div>A person with dementia often feels lost, not being able to make sense of the immediate surroundings. </div> <div>Studies indicate that a person’s dementia-related behavior change and emotional stress are often caused by not knowing how to recover a sense of self and not being able to be the person they were before the illness. </div> <div> </div> <div>Care providers, using a person-centered approach, can reintroduce a patient to his or her own identity and improve a feeling of control.</div> <div> </div> <div>In addition to addressing basic needs like hygiene and nutrition, person-centered dementia care also addresses the core psychosocial needs of an individual living with dementia. </div> <div> </div> <div>For example, a caregiver can foster a sense of belonging and inclusion for clients by organizing family events, helping people with dementia attend community events, and including them in discussions.</div> <h2 class="ms-rteElement-H2">Meaningful Activities, Interactions </h2> <div>The person-centered dementia care approach is based on the belief that people with the disease can live fulfilling lives. With this type of positive focus, a patient can enjoy meaningful activities instead of predetermined programs. </div> <div> </div> <div>For example, if a person used to take pleasure in gardening, providing some plastic plant pots, soil, and seedlings can offer a person a renewed sense of purpose and accomplishment. </div> <div> </div> <div>The ability to maintain social activities and past pleasures—a key principle of patient-centered care—directly contributes to an improved quality of life for people with dementia.</div> <div> </div> <div>What’s more, the person-centered method encourages patients to take part in activities they enjoy. For instance, if a person wants to walk barefoot in the back yard on a sunny day, it should be granted. </div> <div> </div> <div>Little things really matter to people with dementia—it allows them to regain a lost sense of control.</div> <div> </div> <div>A client-oriented care plan for people with dementia emphasizes their freedom of choice and improves their self-esteem. The approach promotes positive, failure-free, and social environments. As a result, care recipients feel far less anxious about their situations and more enthusiastic about their routines. </div> <div> </div> <div>An important part of the person-centered dementia care approach is interaction, which fosters empathy and validation of a person’s emotions and individual identity. Professionals who specialize in this type of care acknowledge and respond to an individual’s feelings and provide close personal comfort. <br></div> <h2 class="ms-rteElement-H2">Support The Whole Family</h2> <div>As it is often said, dementia doesn’t affect only those diagnosed—it affects their whole family. With this in mind, involving relatives and friends is especially important when developing a care plan. </div> <div> </div> <div>The person-centered technique acknowledges this reality by fostering a range of relationships and encouraging connections between those involved in the process of caring. </div> <div> </div> <div>This is also where a skilled care provider can really prove her worth by becoming a partner who offers support and education to family members, while bringing families together toward a common goal of improving the quality of life for their loved ones with dementia.</div> <h2 class="ms-rteElement-H2">Make A Connection </h2> <div>In the confusing and disconnected world of dementia, professional caregivers trained in person-centered dementia care can intervene and find ways to connect an individual to their surroundings. These care providers understand what reality is like for people with dementia, enabling them to help patients make choices and even encouraging expressions of spontaneity. Providing this type of care also requires a special kind of caregiver—highly trained in dementia care, open to positive changes, and eager to make an effort to understand their patients’ needs. </div> <div> </div> <div>This approach doesn’t just happen, however. Viewing dementia care in a new light requires individual and organizational changes, shifting power from the routinized world of most care programs and into the hands of those receiving the attention. </div> <div> </div> <div>Despite the decreased mental and physical functions associated with dementia, it is possible to create an environment in which both a person’s physical and psychosocial needs are met, where they feel valued and respected and where they are treated the way they want to be treated. </div> <div> </div> <div>This is exactly what person-centered dementia care accomplishes. </div> <div> </div> <div>Increasingly, researchers, health care providers, and advocates are working on finding treatment options or even a cure for dementia. </div> <div> </div> <div>Although it is still not possible to influence the <a target="_blank" href="/Monthly-Issue/2012/Pages/1112/Communication-Changes-As-Dementia-Progresses.aspx">progression of the disease</a>, it is feasible to influence the quality of life for people living with the ailment. </div> <div> </div> <div>Inspiring a dementia care culture change is a long process, but as care providers and advocates for people living with dementia, it’s time to embrace change and focus on delivering person-centered dementia care.</div> <div> </div> <div><em>Jennifer Tucker, vice president of Homewatch CareGivers, a national home care company that utilizes the Pathways to Memory™ program, has worked in case management, corporate wellness, women’s health, and health education. She can be reached at <a target="_blank" href="mailto:%20jtucker@homewatch-intl.com">jtucker@homewatch-intl.com</a>.</em></div>One size doesn’t always fit all. One care plan doesn’t work for everybody, and this is especially true for dementia care. People living with dementia are just that—people. 2012-11-01T04:00:00Z<img alt="" src="/Monthly-Issue/2012/PublishingImages/1112/caregiving.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalFocus on Caregiving11
A Never-Ending Journeyhttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1112/A-Never-Ending-Journey.aspxA Never-Ending Journey<div><img class="ms-rteImage-2 ms-rtePosition-1" alt="Grand Islander" src="/Monthly-Issue/2012/PublishingImages/1112/Gold_012grandislander.jpg" width="288" height="233" style="margin:5px 10px;" /><br>Of the 39 total applicants vying for Gold awards from the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) National Quality Awards program this year, only two received the highest honor. </div> <div> </div> <div>Grand Islander Center, a Genesis HealthCare skilled nursing facility in Middletown, R.I., and Golden LivingCenter—Continental Manor, in Abbotsford, Wis., were the two long term care facilities met the stringent requirements to clench Gold awards.</div> <h2 class="ms-rteElement-H2">Staff Valued </h2> <div>Sculpted after the prestigious Baldrige Performance Excellence Program, the Quality Awards are organized into three categories—Bronze, Silver, and Gold. In order to become eligible to apply for a Silver award, a facility is required to have already received a Bronze award; similarly, facilities must have attained both Bronze and Silver awards in order to qualify for a Gold award. <br></div> <div><br>The system emphasizes the importance of quality sustainability in long term care facilities, while also encouraging continual efforts to enrich residents’ lives. </div> <div><br>Grand Islander Center (GIC) pinpoints its employees as its most valuable resource and treasured asset. GIC takes pride in employing educated, competent staff members. Staff satisfaction remains high, and employees report feeling appreciated and respected. </div> <div><br>“I spend a lot of time with the new hires, telling them that they are our most valuable resource,” says Joan Woods, administrator at GIC. “We’re only as good as the level of service that we provide our residents.” </div> <div>GIC retained 88 percent of its registered nurses last year.</div> <div><br>High employee contentment levels are due at least in part to GIC having formulated models to help empower employees to participate in decision-making processes. Listening circles invite uninhibited communication between staff members. </div> <div><br>“We listen to our employees through the satisfaction survey,” Woods says. “[In listening circles] one at a time, staff members talk—they’re not allowed to interrupt each other—and we listen to them.” <br></div> <h2 class="ms-rteElement-H2">Teams Make A Difference</h2> <div>Similarly, six designated performance improvement teams comprised of staff members allow the opportunity for each individual to truly make a difference in the facility. <br></div> <div><br>“The thing that is most fundamental to Grand Islander is how we have structured our performance improvement teams,” Woods says. </div> <div><img class="ms-rteImage-2 ms-rtePosition-2" alt="Grand Islander" src="/Monthly-Issue/2012/PublishingImages/1112/gold_048grandislander.jpg" width="281" height="187" style="margin:10px;" /><br>“The teams do two things: They work to establish the improvement objectives and complete audits every month.”</div> <div><br>The performance improvement teams, first established 11 years ago, are concentrated in the areas of Business, Clinical, Staff, Customer, Culture Change, and Safety. </div> <div><br>Woods believes that GIC has greatly benefited from the Quality Awards program. </div> <div><br>“If you focus and use this process, you’re going to have a better bottom line,” she says of the program. “It nets great results.” <br><br></div> <h2 class="ms-rteElement-H2">Meeting Community Needs</h2> <div>The second 2012 Gold recipient, Golden LivingCenter—Continental Manor (GLCM), cites collaboration with staff, residents, and community members as the best strategy to improve quality care; it partners with its stakeholders in myriad ways.</div> <div><br>“Market research was wonderful in leading us to meet our community’s needs,” says Trudy Erickson, GLCM executive director. </div> <div><img class="ms-rteImage-2 ms-rtePosition-1" alt="Grand Islander" src="/Monthly-Issue/2012/PublishingImages/1112/gold_109grandislander.jpg" width="428" height="285" style="margin:5px 10px;" /><br>“There were no facilities that had a specific Alzheimer’s unit. When we identified that need in the community, the unit filled rapidly because of our specific programming.”</div> <div><br>Ed McMahon, PhD, considered by many to be a “founding father” in the design and development of specialized Alzheimer’s units in long term care facilities, is also national director of Alzheimer’s Care/Quality of Life at GLCM.</div> <div><br>“The Continental Manor staff know how to turn data into knowledge and manage that knowledge to improve the lives of their patients and residents,” says McMahon.</div> <div><br>“You know the people there care, they have the passion for taking care of others. It is palpable when you walk through the door—it’s a different feel, a different look. We also have very sophisticated IT programs.” <br></div> <h2 class="ms-rteElement-H2">The Journey Continues</h2> <div>Erickson and McMahon confirm that the Quality Awards program had a major positive influence in the Continental Manor facility.</div> <div><br>The three levels in the Quality Awards “keep the quality focus right in front of us,” says Erickson. “We received the Bronze award in 2000 and Silver in 2005. It has been an ongoing journey, and we’re always looking to improve.”</div> <div><br>McMahon agrees. “They never took their eyes off the prize, and they never got discouraged. It takes that long-term commitment to succeed.”</div> <div><br>Though they have already achieved the ultimate award, GLCM continues to look to the future.</div> <div><br>“We continue to learn every day, it’s a journey that’s never ending,” says Erickson. </div> <div><br>“We’ll continue to use our tools and gather data, identify resident changes, and continue to use those tools so that we don’t have a decline,” Erickson says. </div>Of the 39 total applicants vying for Gold awards from the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) National Quality Awards program this year, only two received the highest honor. 2012-11-01T04:00:00Z<img alt="Gold Awards Grand Islander" src="/Monthly-Issue/2012/PublishingImages/1112/goldaward_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality AwardsNational AHCA/NCAL Quality Awards11
In Touch With iPadshttps://www.providermagazine.com/Monthly-Issue/2012/Pages/1112/In-Touch-With-iPads.aspxIn Touch With iPads<div><img width="200" height="268" src="/Monthly-Issue/2012/PublishingImages/1112/Tech1112.jpg" alt="resident with iPad" class="ms-rteImage-1 ms-rtePosition-1" style="margin:5px 10px;" />The typical nursing home patient is no longer somebody’s grandmother; many people in their 40s and 50s live in nursing homes alongside those in their later years. Because of the paradigm shift in health care, programming has taken a dramatic turn. Staff members are learning to adjust and create new ways to deliver care and activities to this new diverse population.</div> <div> </div> <div>The therapeutic recreation department at TownHouse Center for Rehabilitation and Nursing in Uniondale, N.Y., has channeled many community resources, along with technology, to make its programs continue to grow and improve.  </div> <div> </div> <div>The staff ensure that they keep up with the latest and greatest information, arming themselves with all the education that they can to deliver the best programming to residents. </div> <h2 class="ms-rteElement-H2">Computer Club Opens Door</h2> <div>One of the center’s latest recreational programs is the Computer Club, which started as a computer-based instructional group. TownHouse provided computers with Internet access in resident areas for independent leisure. <br></div> <div><br>After the growing success of the club, the recreation director brought in an iPad for residents to experiment with. The residents responded enthusiastically, and the <a target="_blank" href="/Monthly-Issue/2012/Pages/1112/Apps-Offer-Therapeutic-Entertainment-.aspx">iPad</a> seemed to open up a whole new world for them. The iPad was easily navigable and offered seemingly endless possibilities. Residents retrieved information, viewed photos from all over the world, listened to music, and watched videos.</div> <div><br>Amidst all the excitement, many residents had their families purchase iPads for them. The iPads have given these patients an incredible amount of freedom and pleasure as they can pursue leisure at their own pace on a daily basis. </div> <div><br>They surf the Web, e-mail, play games, and talk to family members through the video telephone technology called FaceTime. In addition, several of the residents’ personal lives were significantly enriched as a result of using the iPad. </div> <h2 class="ms-rteElement-H2">Making Connections</h2> <div>Tony, a veteran of World War II, was able to reconnect with an old army buddy. They hadn’t been in touch since the war. </div> <div><br>Through the use and guidance of the Computer Club, Tony was able to do a search and locate his friend, who now lives in London. After connecting, they have e-mailed back and forth a number of times and exchanged pictures as well. </div> <div><br>This reconnection was a great source of excitement and allowed Tony to have a social experience outside the normal day-to-day life most residents have while living in a home. </div> <div><br>Without the Computer Club and the technology of today, this relationship would never have been reconnected. Tony felt that the reconnection to his past helped him to remember details of his time during the war that he had forgotten. </div> <div><br>Tony was able to share with his family