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Aquatic Therapy Brings Reliefhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0113/Aquatic-Therapy-Brings-Relief.aspxAquatic Therapy Brings Relief<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Arthritis in all its forms—rheumatoid arthritis (RA), osteoarthritis (OA), gout, and fibromyalgia—has likely been a bane for humankind since the beginning of time. So, too, have tonics for this condition that can lead to a lesser quality of life for the approximately 50 million adults in the United States who are afflicted.</div> <div> </div> <h2 class="ms-rteElement-H2">The Toll Of Arthritis</h2> <div> </div> <div>Perhaps one of the most poignant aspects of this drop in perceived life quality is that as seniors succumb to age-related decline, they lose their general sense of freedom, including freedom to do what they want, when they want, and with whom they want. </div> <div> </div> <div><br>They may be unable to access community events and resources; they may be reluctant to walk or even get out of a chair frequently due to the pain and effort involved; and by struggling to maintain their previously enjoyed standard of living, they can exacerbate problems even further.  Without freedom, they begin to feel trapped and isolated from interacting with friends, family, and loved ones.</div> <div> </div> <div><br>The joy that comes with being able to perform some of life’s simple pleasures is effectively anesthetized. </div> <div> </div> <h2 class="ms-rteElement-H2">Remedies Abound</h2> <div> </div> <div>Plenty of arthritis remedies have been marketed to those with the condition that affects all ethnicities, including one solution that has been gaining widespread popularity and applicability in an era where arthritis is taking a toll on social, financial, and occupational freedoms: aquatic therapy. The Greeks, Romans, Chinese, and other cultures touted hot spas as a soothing way to provide relief from the stiffness, soreness, and swelling of arthritis. Currently, warm pools and tubs are still being prescribed.  <br><img width="324" height="258" src="/Monthly-Issue/2013/PublishingImages/0113/caregiving1_0113.jpg" alt="aqua arthritis therapy" class="ms-rteImage-2 ms-rtePosition-1" style="margin:10px;" /><br></div> <div>However, physical and occupational therapists can now offer a technologically advanced twist on a historical arthritis treatment, with pools equipped with variable-depth treadmill floors, resistance/massage jets, and video cameras.  </div> <div> </div> <div><br>This “back to the future” opportunity for unique rehabilitation options has proven advantageous, especially to those over 50 years of age who deal with arthritis-related symptoms. </div> <div> </div> <h2 class="ms-rteElement-H2">Physical, Psychological, Social Benefits</h2> <div> </div> <div>Seniors, some of whom who cannot securely walk across the room to retrieve a soda from the refrigerator, are able to walk, jog, or even run—a definite boon to their sense of freedom—using this high-tech twist on an old remedy.<br></div> <div> </div> <div><br>The overall benefits can be divided into three distinct silos:  physical, psychological, and social.</div> <div> </div> <div>It is not unusual for arthritic seniors to initially come to physical and occupational therapists in response to a medical need such as rehabilitation post-surgery, pain, obesity due to lack of ability to exercise, or perceived reduction in quality of life. </div> <div> </div> <div><br>Unfortunately for these populations, traditional land-based therapy may exacerbate the problem more than relieve it. Many of these patients would not tolerate the intensity and duration of exercise on land that is possible in these high-tech pools.</div> <div> </div> <h2 class="ms-rteElement-H2">Much Less Stress On Body</h2> <div> </div> <div>For example, a 200-pound man who has undergone joint replacement surgery may be unable to withstand the pain associated with land-based therapies, especially if he suffers from arthritis in other areas of his body. His discomfort (both physical and emotional) can lead to subpar performance during therapy, cancelled appointments, and, ultimately, decreasing or delaying positive outcomes and discharge.</div> <div> </div> <div><br>With aquatic therapy in a pool with an underwater treadmill, this same man can enjoy a warm, inviting environment that provides the same results as land-based therapies without the inherent problems noted above. Essentially, his 200-pound frame could be made to feel as little as 40 pounds depending upon water depth.<br><br></div> <div> </div> <div>Positive outcomes, such as patients able to walk comfortably on the underwater treadmill for specified periods of time, can lead to physical strength gains. These gains then make land-based therapies easier, should patients and their physical or occupational therapists decide to divide their prescribed rehab allotment between traditional and aquatic therapies.</div> <div> </div> <div><br>As time goes on the program can be advanced objectively; the underwater treadmill speed and resistance jets can be increased incrementally, which has been shown to provide the same physical responses for participants as walking or jogging uphill, but without joint stress.</div> <div> </div> <div><br>Being able to sustain exercise for a significant length of time also benefits cardiovascular health and weight management better than traditional “reps and sets” programs, a critical component that is missing in this population, especially given that about 52 percent of persons with doctor-diagnosed arthritis are either overweight or obese.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><div>Emotional Assurance Fuels Consistency</div></h2> <div> </div> <div>Another element of aquatic therapy for arthritis sufferers that takes place in a pool with an integrated underwater treadmill is the psychological response that occurs on the part of the patient.<br></div> <div> </div> <div><br>Arthritis sufferers often struggle with emotional issues due to their inability to comfortably complete what they once deemed “simple” tasks like walking to get the mail, walking their dog, or even simple home tasks like cooking or doing the laundry.  These feelings of inadequacy can become persistent and lead to conditions such as depression, including major depressive episodes (as reported by almost one in five patients with arthritis).</div> <div> </div> <div><img width="283" height="293" src="/Monthly-Issue/2013/PublishingImages/0113/caregiving2_0113.jpg" alt="aqua arthritis therapy" class="ms-rteImage-2 ms-rtePosition-2" style="margin:5px;" /><br>The pool with treadmill releases patients from those limitations. They can challenge their balance, in addition to working their heart and muscles intensely enough to cause change without worsening problems. </div> <div> </div> <div><br>Beyond the physical benefits of exercise, such as the release of endorphins, for instance, the ability to participate in a rigorous activity without the negative responses is both encouraging and motivating. </div> <div> </div> <h2 class="ms-rteElement-H2"> Advanced Treatment, Old-Fashioned Principles </h2> <div>There is a saying that “everything old becomes new again.” </div> <div> </div> <div><br>This may be true of utilizing water’s influence—and then improving upon it with technologies like underwater treadmills and resistance jets—to alleviate the symptoms of arthritis for individual patients. </div> <div> </div> <div><br>The end result? A reduction of the onerous impact arthritis has on families, communities, and workplaces, as well as more options for physical and occupational therapists seeking to help their clientele safely and effectively reach their goals.<br></div> <div> </div> <div><br>In other words, it’s the freedom seniors seek when looking forward to their golden years. </div> <div> </div> <div> </div> <div> </div> <div><em>Jeffrey Kallberg has been a physical therapist since 1994 and is co-founder of ACCUA (www.accua.net). He and his brother started ACCUA with the goal of making aquatic therapy more accessible to “ordinary” people.</em></div> <div> </div> <div> </div> <div> </div> <div>Research Resources</div> <div> </div> <div>■ “The Heavy Burden of Arthritis in the U.S.,” Arthritis Foundation, Aug. 10, 2011</div> <div> </div> <div>■ “Arthritis-Related Statistics,” Centers for Disease Control and Prevention, Aug. 1, 2011</div> <div> </div> <div>■ “Comparative Efficacy of Water and Land Treadmill Training for Overweight or Obese Adults,”  Greene, et al., Medicine and Science in Sports and Exercise, 2009</div> <div> </div> <div> </div>Arthritis in all its forms—rheumatoid arthritis (RA), osteoarthritis (OA), gout, and fibromyalgia—has likely been a bane for humankind since the beginning of time. So, too, have tonics for this condition that can lead to a lesser quality of life for the approximately 50 million adults in the United States who are afflicted.2013-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0113/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn1
Stars In Their Own Righthttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0113/Stars-In-Their-Own-Right.aspxStars In Their Own Right<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><a href="/ReusableContent/4_.000">a</a></div><div style="text-align:right;"><div style="text-align:right;"><strong>Sponsored by <a href="http://www.silverchairlearning.com/" target="_blank">Silverchair Learning Systems</a></strong></div></div> <div> </div> <div>They listen, they lead, they love their work, and they want to make a difference in the lives of elders in nursing homes, assisted living communities, and elsewhere across the country. They are <em>Provider’s</em> <span class="ms-rteForeColor-2">20 To Watch in 2013</span>. In this inaugural feature are profiled some of the most compassionate and committed folks in long term and post-acute care. </div> <div style="text-align:right;"> </div> <div><span></span>From an impressive group of nearly 50 nominations, <em>Provider</em> editors, along with a <a title="Panel of judges" href="/Monthly-Issue/2013/Pages/0113/Stars-In-Their-Own-Right.aspx" target="_blank"></a><span><a href="/Monthly-Issue/2013/Pages/0113/Meet-Our-20-To-Watch-Selection-Committee.aspx" target="_blank">panel of judges</a></span>, have chosen the individuals who deserve recognition—to be watched, if you will—due to their leadership capabilities and their commitment to improving the quality of care in the field.</div> <div> </div> <div>To paraphrase one honoree, improving quality of care in this field will come about through the telling of stories about the incredible caregivers, amazing residents, and astounding things that happen when resident-centered care becomes the norm. </div> <div> </div> <div>The <span class="ms-rteForeColor-2">20 To Watch in 2013</span> is a collection of such stories—of incredible humans doing incredible things to advance the cause of serving elders and making a positive impact on long term and post-acute care in this country (see the entire list <a href="/Monthly-Issue/2013/Pages/0113/Top-20-To-Watch-2013.aspx" target="_blank">here</a>). </div> <div> </div> <div>From nurses, physical therapists, and administrators, to social media gurus and music therapists, the debut of <span class="ms-rteForeColor-2">20 To Watch</span> pays tribute to some devoted and inspiring professionals who will surely leave their mark on the profession. <br></div> <div> </div> <div>On the following pages is the inaugural <span class="ms-rteForeColor-2">20 To Watch</span> list, along with profiles of six of the honorees. The remaining folks will be profiled in the upcoming February and March issues, and our website, providermagazine.com, will highlight additional information about some of the honorees’ accomplishments.</div> <div>  <br></div> <div><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <div> </div> <div><img class="ms-rteImage-1 ms-rtePosition-1" alt="Christine Reynolds" src="/Monthly-Issue/2013/PublishingImages/0113/ChrisineReynolds.jpg" style="margin:5px 10px;" /><strong>Christine Reynolds, PT</strong></div> <div>Facility Rehab Coordinator </div> <div>Tendercare</div> <div>Tawas City, Mich.</div> <div> </div> <div>“Christine has never been one to just do the job, she has to always bring something to it,” says Christine Reynolds’ colleague Jane Barbour, Tendercare’s clinical reimbursement coordinator.</div> <div> </div> <div>“Each day, Christine exemplifies compassion, intelligence, dedication, and leadership, promoting the growth of her team and the success and motivation of the residents receiving her services.” </div> <div> </div> <div>Reynolds’ laser-like focus on her patients has won praise from co-workers and residents alike (she knows every resident’s name, Barbour says). <br></div> <div> </div> <div>“I think that I always try to keep a vision of focusing on patients and doing what’s best for them and hoping to make their lives better,” says Reynolds. <br></div> <div> </div> <div>“She spends countless hours teaching direct care staff, families, and residents to produce the most effective outcome,” says Barbour. “She takes ownership of the residents and their needs and collaborates with all the disciplines to help ensure quality care.”</div> <div> </div> <h2 class="ms-rteElement-H2">Going Home Well is The Goal</h2> <div>Recently, Reynolds was awarded the ProStep 2012 Facility Rehab Coordinator of the Year designation from Extendicare, Tendercare’s parent company, and she was instrumental in creating and piloting the center’s Transition Week program, says Barbour. <br></div> <div><br>“The program, which is designed to facilitate the best possible transitions, from facility to home, for our rehab residents began in Tawas with Christine and has now been embraced nationally by Extendicare and is highly regarded by the residents who have completed the program.” <br></div> <div><br>Watching people progress and helping them return home is what motivates Reynolds, who has been with Tendercare for five years—this time. Her first stint at the center was 16 years ago as a staff physical therapist. She left the facility to work in the school system for nine years so that she could be closer to her children. Once they were grown, she returned to the work she loves. <br></div> <div><br>Reynolds, who says she is “terribly humbled” by her selection, is quick to point out that what she does is a calling for her. <br></div> <div><br>“I have always loved spending time with my grandparents and my great aunts and uncles,” she says. “I loved to spend time in the geriatric population, so when I went to school I kept that as my focus.” <br></div> <div><br>“I’m really honored [to be selected], but I believe that the people who have touched my life, along with the way they have allowed me to do what I have done, that’s how I got here,” she says. <br></div> <div><br>Reynolds notes that without such excellent support from her rehab and administrative team, as well as the “entire staff and my husband,” she could not have been selected. “It’s everyone who has contributed that’s allowed me to be successful and to be who I am.” <br></div> <div><br>Barbour, who has known Reynolds since she first worked at the facility more than two decades ago, notes that Reynolds is always striving to be the best. “She is not just going to rehab someone, she’s going to rehab them the best,” she says. “And she’s never going to settle for anything. She always takes something to the next step.” <br></div> <div><br>Among Reynolds’ standout leadership qualities, says Barbour, are that “she is patient, she listens, and she doesn’t just come to us with a problem—she comes with a way to fix it.”</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <div> </div> <div><img class="ms-rtePosition-1 ms-rteImage-1" alt="Angela Ross" src="/Monthly-Issue/2013/PublishingImages/0113/AngelaRoss.jpg" style="margin:5px 10px;" /><strong>Angela Ross, RN</strong> </div> <div>Vice President, Clinical Services Integration</div> <div>Prestige Care </div> <div>Vancouver, Wash.</div> <div>  <br></div> Like many nursing school graduates, Angela Ross began her career not thinking that she would one day work in long term care. Today, however, she cannot imagine being anywhere else. Ross says that working in a nursing home was the furthest thing from her mind when she worked as a labor and delivery nurse at a hospital more than two decades ago. <div><br>“I would have told you I would not be in long term care as I was going into nursing school,” she says. <br></div> <div><br>Now, however, she believes long term care is the place for her. It started some 21 years ago, when the hospital where she was working closed. She applied for a job at a local skilled nursing facility in Oregon, and the rest, as the saying goes, is history. <br></div> <div><br>Her new job suited her well—within nine months she was promoted to director of nursing, followed by a senior clinician role, and then a regional role. <br></div> <div><br>Eventually, she was recruited by Prestige, where she proceeded to take her facility through five consecutive deficiency-free surveys and had extremely low turnover in the nursing department, says Marcia LaMure, director of post-acute care management for Prestige. <br></div> <div><br>“As the director of rehab at the time, I watched as an occasional nurse who was commuting to work in our small town would resign in order to avoid the commute, only to return and ask for the job back because ‘Angela was so much better than any other nursing director,’” LaMure says. <br></div> <div><br>“Those returning nurses commented on Angela’s good organization and time management, how all systems were in place and working well and the relief of always having the correct supplies, feeling proud about the excellent quality of care, and especially about Angela’s teaching and training skills,” says LaMure.</div> <div> </div> <h2 class="ms-rteElement-H2">Improving Care Techniques </h2> <div>Ross brought a level of knowledge and enthusiasm to Prestige that has helped the company grow and excel in clinical and operations initiatives, LaMure adds. “From introducing basic Medicare levers years ago when she was first employed, to creating a sophisticated post-acute care department most recently, Angela has continually brought new ideas and systems to Prestige.” <br></div> <div><br>LaMure notes that Ross has been ahead of the game when it comes to health care reform. <br></div> <div><br>“She has helped position our company in an enviable spot by bringing information, education, processes, systems, and unique programming to address the requirements of the Affordable Care Act. She has been extremely successful in creating partnerships with referring hospitals and was instrumental in achieving preferred partner status for Prestige with Oregon Health Sciences University Hospital,” LaMure says. </div> <div> </div> <div>“No matter what position she holds, however, Angela is never far from interacting directly with staff members in the facilities.” <br></div> <div><br>Ross continues to single-handedly do training out in the field for each and every Prestige center, and at least 50 percent of her time is spent with residents and staff in the facilities, LaMure says. <br></div> <div><br>“No matter what changes come to our industry, we know that Angela Ross will be ready and able to lead us through them.” <br></div> <div><br>Ross says she loves her work. “I love the challenge. I think it’s incredible. I’m always busy,” she says.</div> <div> </div> <div>“I like the evolving nature of it all. I like to come up with really great strategies. So I don’t think I’ll ever leave long term care.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div><img class="ms-rteImage-1 ms-rtePosition-1" alt="Whitney Ostercamp" src="/Monthly-Issue/2013/PublishingImages/0113/WhitneyOstercamp.jpg" style="margin:5px 10px;" /></div> <div><strong>Whitney Ostercamp</strong> <br></div> <div>Music Therapist <br></div> <div>Valley Nursing Center <br></div> <div>Taylorsville, N.C.  <br></div> <div> </div> <div>“Energetic” is one of the many adjectives Sandra Loftin, administrator at Valley Nursing Center, describes Whitney Ostercamp. Inspirational and resourceful are two more descriptive words Loftin uses as she lauds Osteramp’s work. <br></div> <div><br>“She has been inspirational in developing a wide range of music programs at Valley Nursing Center since she has been here,” Loftin says. <br></div> <div><br>In addition to an intensive program for Valley’s ventilator residents, Ostercamp has also reinvigorated the very popular Tone Chime Choir, which performs for other residents, families, and guests at least three times a year, Loftin says. <br></div> <div><br>The program expanded so quickly in the past 12 months under her direction that Valley is now seeking a second full-time music therapist. <br></div> <div><br>“Whitney has also become a resource for new music therapists trying to enter the field in long term care,” Loftin says. “Her love is the geriatric population.” <br></div> <h2 class="ms-rteElement-H2">Not Just A Pretty Melody <br></h2> <div>Ostercamp, who started at Valley in August 2011 fresh out of graduate school, has always felt that she could use her musical abilities to help others. “We all know that music has an effect on the human body, and I was interested in understanding the science behind how and why,” she says. <br></div> <div><br>Part of Ostercamp’s work has entailed educating the staff about the difference between music as entertainment and music therapy. “They get it,” she says. “And they’re music therapy advocates now!”</div> <div> </div> <div>Ostercamp explains that music therapy is an intervention that can be listed as part of a care plan. “For example, if short- or long-term memory deficits of Alzheimer’s disease is listed as a problem in a patient’s care plan, one of the interventions to help target that goal is music therapy,” she says. <br></div> <div><br>Ostercamp will also write a music therapy treatment plan with specific music therapy goals and objectives to reflect work toward a problem that is identified on the care plan. <br></div> <div><br>“Once these goals are established, I choose the best music therapy interventions and implement these nterventions within the sessions. The session notes are then documented in the medical record,” she says. <br></div> <div><br>One thing she appreciates about the job is the ability to easily collaborate with other medical professionals at the facility. “That’s something you can’t do as much in other settings, or if you’re practicing on your own,” says Ostercamp. <br></div> <div><br>What has she learned from her work thus far? <br></div> <div><br>“No day is a typical day,” she says. “I’ve learned to be flexible, and I’ve learned how much I enjoy seeing effects of music therapy on residents and how it’s positively affected the whole facility.”</div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div><img class="ms-rteImage-1 ms-rtePosition-1" alt="Joyce Simard" src="/Monthly-Issue/2013/PublishingImages/0113/JoyceSimard.jpg" style="margin:5px 10px;" /></div> <div><strong>Joyce Simard</strong> <br></div> <div>Namaste Care Founder <br></div> <div>Geriatric Consultant, Author <br></div> <div>Land O’Lakes, Fla. <br></div> <div> </div> <div>Joyce Simard doesn’t talk much about herself. In fact, she spent most of her interview with Provider talking about the Namaste Care program she developed about 10 years ago for people with advanced dementia. <br></div> <div><br>Not surprisingly, Simard is modest about what appears to be her steadfast pursuit of advocating for elders with dementia. She describes her work as “simply putting structure to something that caregivers already know is the right thing to do.” <br></div> <div><br>Namaste, which is Hindu for “honoring the spirit within,” is about creating a peaceful space for residents with advanced dementia to go to at any time. <br></div> <div><br>A Namaste Care program takes place in a designated space, within a nursing home or assisted living community, where the environment is safe and comforting for all who enter, including residents, their families, and staff. <br></div> <div><br>Ideally a seven-days-per-week program, Namaste can include hand and foot massages, brushing or combing a person’s hair with slow movements, and facials. In nursing homes and assisted living facilities, the program can be presented to residents either in its own dedicated space, or in a converted space (such as a dining room, for example), where scent of lavender is present, lights are low, and music is soft—much like a spa. <br></div> <div><br>“I truly believe that people with dementia can have quality in their lives until their last breath,” says Simard. “But quality of life is more than keeping somebody dressed and fed and changed”—which is why Simard created Namaste. <br></div> <div><br>Simard now spends time traveling, speaking, and training folks about Namaste throughout the United States and in the United Kingdom, Greece, and Australia. <br></div> <div><br>Among the benefits of the program are reduced agitation, decreased and sometimes complete elimination of the use of antipsychotic medications, and reduced falls. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Spreading The Word <br></h2> <div>The program has become popular not just in nursing homes but in assisted living and hospice. In addition to her travels, Simard is working on a second edition of her book, “The End-of-Life Namaste Care Program for People with Dementia,” which was first published four years ago. <br></div> <div><br>“Joyce is totally focused on Namaste, which is a great quality about her,” says Pauline Coram, director of executive learning in the assisted living division of HCR ManorCare. Coram has worked with Simard since last February on the rollout of Namaste in the company’s dementia care communities, Arden Courts. </div> <div> </div> <div>“What sets her apart—and in thinking about it, it has become a refrain in my head—is that she is single-minded in her pursuit,” says Coram. “It comes out of her pores. And she is really almost flawless in her approach to training and educating folks about the program. She beats the drum consistently and constantly. <br></div> <div><br>“She’s like an Energizer bunny; she gets energized by talking about it and being around people. And she doesn’t do it for herself—she does it because people need it, and it’s worth it,” Coram says.</div> <div> </div> <div>Coram’s company has been so impressed by Simard’s work that all 54 Arden Court communities are in the process of implementing Namaste Care programs. <br></div> <div><br>Indeed, it is obvious that Simard is energized by talking about the program. “It’s so incredible,” she says. “It’s definitely not about me; it’s about the people in our industry. They are caring people. Namaste gives structure to what people want to do all the time.” <br></div> <div><br>At the end of her interview, Simard asked, “The article is going to be about the wonderful people we work with, and it’s definitely going to be more about people knowing what to do with people with advanced dementia than about me, right? Because that’s what it’s all about.” <br></div> <div><br>Yes, that’s what it’s all about. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div><img class="ms-rteImage-1 ms-rtePosition-1" alt="Kavan Peterson" src="/Monthly-Issue/2013/PublishingImages/0113/KavanPeterson.jpg" style="margin:5px 10px;" /></div> <div><strong>Kavan Peterson</strong> <br></div> <div>Partner, ChangingMedia <br></div> <div>Editor, ChangingAging.org <br></div> <div>Baltimore <br></div> <div> </div> <div>It’s all about the stories for Kavan Peterson, and he is a storyteller. Technically, he is a journalist, but he prefers to use the term “storyteller,” especially since his mission is to help pro-aging organizations such as the Green House Project and Eden Alternative, as well as not-for-profit provider organizations, tell their “incredible stories of culture change.” </div> <div> </div> <div>Why? “Because I think these stories have the potential to change aging,” he says proudly. <br></div> <div><br>Peterson, who founded ChangingMedia, a communications consulting firm and is editor of ChangingAging.org, a blog stream founded by Bill Thomas, MD, also describes himself as a mixed media consultant who “was trained as a writer, photographer, and videographer.” <br></div> <div><br>These titles, however, seem to inadequately describe Peterson’s interesting career path and impressive accomplishments in the field of aging services. Peterson, who is all of 35 years old, began his career as a reporter on Capitol Hill, but five years later was searching for something else and found work as communications director for the University of Maryland, Baltimore County (UMBC) Erickson School, which is aimed at preparing a “community of leaders who will use their education to improve society by enhancing the lives of older adults.” Thus Peterson’s “pro-aging” career began. <br></div> <div><br>“I found a good fit at the Erickson School,” says Peterson. He was successful in launching the school’s new program, which garnered worldwide attention, and he was able to work with culture change organizations tied to Thomas, founder of the Eden Alternative. <br></div> <div><br>Coinciding with his work at UMBC, Peterson helped Thomas launch his first blog, ChangingAging.org, “the purpose of which was to harness the power of social media in blogging to bring in the pro-aging message of culture change to people,” he says. <br></div> <h2 class="ms-rteElement-H2">Casting A Broad Net <br></h2> <div>After two years, Peterson struck out on his own to do social media consulting so that he could help “spread the word about what culture change means.” <br></div> <div><br>Through ChangingMedia, Peterson aims to “make it easy” for nonprofit organizations dedicated to culture change and pro-aging to enter the world of social media and blogging. “I help them set up blogs and integrate them into their websites and into their marketing strategies and plans,” he says. <br></div> <div><br>Chris Perna, chief executive officer of the Eden Alternative, has worked closely with Peterson for the past several years. He praises Peterson’s establishment of the ChangingAging blog stream as “a sounding board for some of the real thought leaders in the aging world,” he says. “The blog has created a worldwide reach for the message we’re trying to get out there, and Kavan has really been the architect of that whole effort. He created a platform for folks interested in aging.” <br></div> <div><br>Perna notes that Peterson’s “significant expertise in the world of social media” has helped the Eden Alternative make much more effective use of social media. <br></div> <div><br>What’s more, Perna says, he brings a unique skill set to the picture. “He’s been so helpful in getting us over our trepidation about social media, and we’re trying to take his message out to the nursing homes we work with, because they have some incredible stories to share and they don’t have the platform to do that,” he says. <br></div> <div><br>“I think that sharing more positive stories about what goes on in nursing homes every day will help remake the image of the industry, and there are incredible stories to be told. Social media is an incredible platform for getting that message out there.” <br></div> <div><br>Peterson says that through his work he has realized that within nonprofits in long term care, in particular, there is a “great need” for updating their websites and embracing social media technologies. “We’re doing everything to meet those needs and finding low-cost solutions for them,” he says.<br></div> <div><br>Although ChangingMedia serves a broad range of nonprofit interests, Peterson says his focus is “completely on long term care and completely on aging-related issues, primarily because the need is so great for improving communication and technology and for spreading culture change.” <br></div> <div><br>If it’s not yet obvious, Peterson is passionate about long term care and culture change. “You are not going to find any more compelling stories in any other field of work than what’s going on in culture change in this country and around the world,” he says. </div> <div> </div> <div><span id="__publishingReusableFragment"></span> </div> <div> </div> <div><img class="ms-rteImage-1 ms-rtePosition-1" alt="Jana Mallory" src="/Monthly-Issue/2013/PublishingImages/0113/JanaMallory.jpg" style="margin:5px 10px;" /><strong>Jana Mallory</strong> <br></div> <div>Advanced Practiced Registered Nurse <br></div> <div>Certified Wound Specialist <br></div> <div>Lebanon Care Center <br></div> <div>Lebanon, N.H. <br></div> <div> </div> <div>There are many stories of caring, compassionate, committed folks who have fallen into the long term care field, only to fall in love with it, and Jana Mallory is no exception. But she is exceptionally grateful for the serendipitous event that took her to Lebanon Care Center. <br></div> <div><br>“My husband came to his area, and I needed to find a job,” says Mallory. “This opportunity came up, and I absolutely love it. I think it’s the best job in the world.” <br></div> <div><br>Mallory says there is “no question” that she will be in long term care for the remainder of her career. </div> <div> </div> <div>“It’s very satisfying work—sometimes it’s hard—you lose people, you lose residents, and that’s the nature of what we do—but you also have such an opportunity to impact their lives dramatically. <br></div> <div><br>“It’s not like anything else,” she says. <br></div> <div><br>But loving the job is not what got Mallory nominated for 20 To Watch—it’s her talent, hard work, and dedication that won the hearts of co-workers at Lebanon Care Center. <br></div> <div><br>For example, colleague Heather Impey, unit manager at Lebanon, cited Mallory’s “knowledge and compassion that goes above and beyond” in a letter supporting her nomination. <br></div> <div><br>“Jana provides exceptional education to all our patients and families throughout their stay at our facility and often takes time out of her day to provide one-on-one education to nursing staff or facilitates group in-services to further our nursing capabilities or knowledge,” Impey writes. “Jana has the ability, through her compassion and love of her career, to motivate others and continues to set high expectations for exceptional care across the board. She is a wonderful role model for all of our nursing staff here at Genesis and continues to provide exceptional care on a daily basis.” <br></div> <div><br>Likewise, Kelly Leavitt, a therapy nurse, says Mallory is “a true asset to our team and to our patients. … Her combination of clinical knowledge and true compassion for all of the patients is evident each day,” she writes. <br></div> <h2 class="ms-rteElement-H2">Medication Passes Simplified <br></h2> <div>In addition to assisting in the successful implementation of the Early Watch Tool, which has decreased Lebanon’s rehospitalization rate, Mallory was also instrumental in reducing medication passes to twice daily in the facility’s long term care wing, says Martha Chesley, administrator. “This has improved the quality of life for our residents and enabled our nurses to spend the extra quality time with our residents, which has improved resident-to-staff relationships,” says Chesley. <br></div> <div><br>Also among her accomplishments, says Chesley, is the elimination of fall alarms with all residents. “In the fall of 2010, we went totally alarm free,” Chesley says. “It has made such a difference in our environment for our dementia/memory-impaired residents and has improved their quality of life as well.” <br></div> <div><br>Mallory is a bit more modest about her feats. She credits her colleagues with creating an environment that lets her thrive. “Truly, I cannot imagine being more fortunate,” she says. “Truly, every single person here will help anybody even if it’s not their patient. That makes my job fabulous. That’s the best part of my job here.” <br></div> <div><br>Mallory believes that hers is the perfect job for nurse practitioners. “Because of the amount of problem solving you have to do, it is not like anything I’ve done before. In long term care, it’s complicated—there are family issues, social issues, dementia issues. It’s very different, it’s challenging, and it really helps you grow,” she says. <br></div> <div><br>Among her strongest leadership qualities is listening to what other people have to say. “Because everyone, literally, from housekeeping to the supply person here, has something to say that gives you insight into your patients and what they’re doing,” she says. “So by listening you’re really able to provide a holistic approach” to caring for residents. <br></div> <div> </div> <div><strong>Sponsored by Silverchair Learning Systems</strong> <br></div> <div><em>Silverchair Learning Systems works with senior care leaders who want to improve key business processes in their organizations. Silverchair Learning offers: Silverchair For Staff, a user-friendly online training solution that improves compliance and eliminates record-keeping headaches; the Employee Feedback System, which easily delivers satisfaction surveys, provides in-depth analysis of results, and offers action tools to help reduce employee turnover; and Silverchair For Families, a resident family education and communication system that helps set expectations and solicit continuous feedback to help providers build strong family relationships and increase satisfaction. All Silverchair Learning products have been developed to help educate, empower, and inspire the senior care industry and to facilitate a higher quality of care. Silverchair Learning Systems is a Relias Learning company. Visit <a href="http://www.silverchairlearning.com/" target="_blank">www.silverchairlearning.com </a>to learn more.</em><br><br></div>They listen, they lead, they love their work, and they want to make a difference in the lives of elders in nursing homes, assisted living communities, and elsewhere across the country. They are Provider’s 20 To Watch in 2013. In this inaugural feature are profiled some of the most compassionate and committed folks in long term and post-acute care. 2013-01-01T05:00:00Z<img alt="" height="150" src="/Monthly-Issue/2013/PublishingImages/0213/20towatch2.jpg" width="150" style="BORDER:0px solid;" />Quality;Workforce;20 to WatchColumn1
The Future Of HIT In LTChttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0113/The-Future-Of-HIT-In-LTC.aspxThe Future Of HIT In LTC<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><div style="text-align:center;"><img src="/Monthly-Issue/2013/PublishingImages/0113/tech-banner0113.jpg" alt="" style="margin:5px;" /></div> <div>  <br></div> <div>As the long term care environment is facing continual change, new communications, as well as health information technology (HIT), are emerging at an ever-quickening pace. Recently, eight leaders in long term care HIT came together at the Long Term Post-Acute Care (LTPAC) HIT Summit to read the tea leaves and offer insights on topics ranging from the future impact of new tools like iPads and Siri, to HIT interoperability, to how long term care can add more value to the health care continuum.</div></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Q: What do you see as emerging technologies that will impact long term care (LTC)?</h2> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2">Czarnik: </span>Technology has leapfrogged in the past couple of years. I think that Apple’s Siri has paved the way for greater utilization of voice recognition technology. Think of improvements to smart charting and patient care at the bedside with a tool like Siri.</div> <div> </div> <div><span class="ms-rteForeColor-2">Mintz: </span>We see the benefits of technology in every industry. I rented a car recently and found the rental experience has really changed in recent years. In long term care, we see technology as more than just a kiosk on the wall, but at the patient bedside, enabling better care.</div> <div> </div> <div><span class="ms-rteForeColor-2">Green: </span>Technology is becoming more important in users’ lives and will continue to transform the way we provide care to our patients. A few years ago we would not have envisioned tablets and other mobile device use at the bedside; now mobility is essential for information access and for documentation of care. Also, technology enables remote patient monitoring, which will allow people to stay in the home longer and receive more care in home settings. </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Q: Any advice for LTC executives on financing new technology?</h2> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2">Green:</span> In LTC, budgets are very tight. Investments needed to support the electronic record don’t come with the benefit of incentive dollars as they do for eligible providers and practitioners. </div> <div> </div> <div>Careful planning and wise buying are essential to ensure we are not investing in short-term technologies and solutions.</div> <div> </div> <div><span class="ms-rteForeColor-2">Czarnik:</span> I see difficulties when the facility has a typical LTC-sized technology budget, but has board members with acute care expectations. It’s important to align the budget to reality.</div> <div> </div> <div><span class="ms-rteForeColor-2">Diller:</span> It’s hard to budget for technology projects because we typically like a three-year planning horizon. But in LTC, budgets can change frequently, whenever Medicare reduces reimbursement.</div> <div> </div> <div><span class="ms-rteForeColor-2">Claypool:</span> Leveraging technology gives LTC the opportunity to make improvements internally. Get our own house in order. Then we face the challenge of connecting across the spectrum of care providers. That’s the next wave. </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Q: What does the future hold for interoperability?</h2> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2">Page:</span> A lot has been said and promised about interoperability, but the moment of truth occurs every Friday evening for LTC facilities admitting patients. </div> <div> </div> <div>Hospitals discharging to LTC and nursing homes want electronic orders to avoid rekeying patient admission data. It’s still not happening seamlessly.</div> <div> </div> <div><span class="ms-rteForeColor-2">Green:</span> For regional providers, it can be simpler than for national providers, where the challenge is linking multiple pharmacy, lab, radiology, and other ancillary providers into a company’s single electronic health record. With increased HIE (Health Information Exchange) activity and the standardization that is expected to come along with that activity, the challenges should diminish.</div> <div> </div> <div><span class="ms-rteForeColor-2">Claypool:</span> As LTC providers and members of the continuum of care, we can help by driving for a shared data standard.</div> <div> </div> <div><span class="ms-rteForeColor-2">Mutschler:</span> True interoperability is science fiction. There will always be something else internal to integrate before we can step into the external realm of true interoperability.</div> <div> </div> <div>Czarnik: Interoperability is important but it’s an ongoing challenge that’s never going to go away. We’ll always have new technologies to integrate across the continuum of care.</div> <div> </div> <h2 class="ms-rteElement-H2"> </h2> <h2 class="ms-rteElement-H2">Q: How do you see technology improving LTC?</h2> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2">Claypool:</span> Technology is automating the cycle of patient care which includes:</div> <div> </div> <div>1. Assessment</div> <div> </div> <div>2. Development of the care plan</div> <div> </div> <div>3. Executing care giving activities according to the plan</div> <div> </div> <div>4. Capturing data</div> <div> </div> <div>5. Repeating the cycle with the first step and reassessing</div> <div> </div> <div>We have the opportunity to continually improve patient outcomes, put into place a system of checks and balances for patient care, and show how we make the best decisions for each resident. </div> <div> </div> <div><span class="ms-rteForeColor-2">Page: </span>The industry is already seeing the impact of data transparency across the continuum. It’s not uncommon for hospitals to monitor readmission rates by the LTC facilities and provide report cards on facility performance. Technology is useful as a feedback mechanism and also raises the level of competition.</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2">Q: What advice can you offer to LTC facilities going forward in the changing health care environment?</h2> <div> </div> <div> </div> <div> </div> <div><span class="ms-rteForeColor-2">Claypool:</span> While technology improves health care, it’s important that LTC providers don’t view this as a field of dreams. If you build it, referrals will not necessarily come. In the new health care environment, you need to earn referrals. It’s not about expecting your fair share, it’s about competition. It’s now cut-throat, full-contact, bare knuckles health care where you compete for patients, employees, referrals, and put others out of business.</div> <div> </div> <div><span class="ms-rteForeColor-2">Czarnik:</span> LTC can provide more value to the care spectrum. We can teach acute care about creating resident experience. That’s the seat we bring to the table and what we can lead with across the care spectrum. They have a 10-day relationship with the patients and we have sometimes at 10-year relationship with the resident. We know the patient better and that’s something we can all learn from. </div> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3">Spotlight on the Table Participants</h3> <div> </div> <div><ul><li><span class="ms-rteForeColor-2">Loren Claypool </span>is chief information officer (CIO) of Extendicare and vice president and managing director at VCPI, which provides solutions for business and IT.</li> <li><span class="ms-rteForeColor-2">Chuck Czarnik</span> is the senior director of Systems and Processes/HIT Strategy at Brookdale Senior Living, the nation’s largest owner and operator of senior living communities and senior-related services.</li> <li><span class="ms-rteForeColor-2">Marty Diller</span> is CIO at Complete Healthcare Resources, a consulting and management services firm that works with senior care providers.</li> <li><span class="ms-rteForeColor-2">Deborah Green</span> is vice president of health information management solutions at the American Health Information Management Association. Formerly, she was CIO for LaVie.</li> <li><span class="ms-rteForeColor-2">Scott Mintz</span> is vice president of business systems at Consulate Health Care, which provides outsourced IT and business solutions.</li> <li><span class="ms-rteForeColor-2">Keith Mutschler</span> is vice president and treasurer at Nexion Health Management, provider of nursing and rehabilitation services.</li> <li><span class="ms-rteForeColor-2">Karen Page</span> is the information systems director for White Oak Management, providers of long term care in the Carolinas.</li></ul></div> <div></div> <div> </div> WoundRounds® was the sponsor of the stakeholder discussion. WoundRounds provides the point-of-care wound management & prevention solution that empowers nurses to deliver better wound care in less time. For more information, go to <a href="http://www.woundrounds.com./" target="_blank">www.woundrounds.com.</a> <div> </div> <div> </div> <div> </div> <h3 class="ms-rteElement-H3">Suggested Reading:</h3> <div> </div> <ul><li>“Escaping the EHR Trap—The Future of Health IT,” New England Journal of Medicine. Online at <a target="_blank" href="http://www.nejm.org/doi/pdf/10.1056/NEJMp1203102">www.nejm.org/doi/pdf/10.1056/NEJMp1203102</a></li> <li>“LTPAC_HealthIT_Roadmap_2012-2014,” <a href="http://www.ahima.org/">www.ahima.org</a></li></ul> <div> </div> <div> </div> <div>Linda Kloss is president at Kloss Strategic Advisors, a consultancy offering thought leadership, policy, and strategy guidance and consulting in health care and information management. Formerly Kloss was chief executive officer of the American Health Information Management Association (AHIMA).</div>As the long term care environment is facing continual change, new communications, as well as health information technology (HIT), are emerging at an ever-quickening pace. Recently, eight leaders in long term care HIT came together at the Long Term Post-Acute Care (LTPAC) HIT Summit to read the tea leaves and offer insights on topics ranging from the future impact of new tools like iPads and Siri, to HIT interoperability, to how long term care can add more value to the health care continuum.2013-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0113/tech_thumb.jpg" style="BORDER:0px solid;" />TechnologyCover Story1
CMS Releases MDS 3.0 User’s Manual Updatehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0113/CMS-Releases-MDS-3-0-User’s--Manual-Update.aspxCMS Releases MDS 3.0 User’s Manual Update<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p></p> <div> </div> <div> </div> <div> </div> <div><img width="381" height="256" src="/Monthly-Issue/2013/PublishingImages/0113/mgmt0113.jpg" class="ms-rteImage-2 ms-rtePosition-2" alt="" style="margin:5px 10px;" />The Nov. 7, 2012, minimum data set (MDS) 3.0 Resident Assessment Instrument User’s Manual became effective immediately upon release. The changes impacted 133 pages of the manual and ranged from simple page number changes, corrected typos, and clarifications, to significant regulation updates. <br></div> <div> </div> <div> </div> <div> </div> <div><br>Knowing the highlights and significant changes that impact day-to-day work flow can assist providers in improving MDS coding accuracy and avoid default payments.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Chapter 1 Update:<br>Care Area Assessments Appendix C Tools Use Optional</h2> <div> </div> <div> </div> <div> </div> <div>The Care Area Assessment (CAA) process involves further investigation of triggered areas to determine whether interventions and care planning are required for a resident. The Centers for Medicare & Medicaid Services (CMS) has clarified that the CAA resources in Appendix C are provided as a courtesy to facilities. These resources include a compilation of checklists and Web links that may be helpful in performing the assessment of a triggered care area. “The use of these resources [is] not mandatory and represent[s] neither an all-inclusive list nor government endorsement” (p. 1-6).</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Though, as outlined in chapter 1, use of Appendix C’s CAA tools is not mandatory, in chapter 4 the facility’s interdisciplinary team (IDT) members are instructed to collaborate with the medical director to identify current evidence-based or expert-endorsed resources and standards of practice that they will use for the expanded assessments and analyses that may be needed to adequately address triggered areas. As part of the survey review process, facility staff should be able to provide surveyors with a list of the resources that they use (p. 4-8). The format for documenting the CAAs is not mandated, but the content is. The CAAs documentation should include an analysis of the cause and contributing factors; true nature of the issue or condition; complications affecting care; risk factors; and factors to individualize the care plan, the need for referral, and whether or not to proceed to care planning. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Resident Assessment Instrument Conceptualized</h2> <div> </div> <div> </div> <div> </div> <div>The Resident Assessment Instrument (RAI) involves assessment, decision making, and identification of outcomes, then the development, implementation, and evaluation of the care plan. The previous version of the manual had the “identification of outcomes” placed after the care plan development. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>In the RAI process, the language regarding “decision making” has changed from determining the resident’s “problems” to focusing on “clinical issues and needs.” The IDT is to work with the resident (and/or the resident’s family, guardian, or other legally authorized representative) and the resident’s physician to determine the severity, functional impact, and scope of a resident’s clinical issues and needs (instead of their “problems;” p. 1-9). <br></div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Resident’s Participation Guides Care Plan Development</h2> <div> </div> <div> </div> <div> </div> <div>Using the RAI process leads to improved outcomes for a resident’s quality of care and “enhanced quality of life.” A resident has experienced goal achievement when the resident actively participates in his or her care and when the care plan reflects appropriate resident-specific interventions that are based on careful consideration of individual problems and causes. Linking input from the resident, resident’s family (and/or guardian or other legally authorized representative), and the IDT leads to improved resident level of functioning or a slower rate of deterioration (p. 1-10).</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>It is noteworthy that the RAI process is the combination of resident-driven care that links Quality of Care and Quality of Life together. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"></h2> <div> </div> <h2 class="ms-rteElement-H2"><div>Chapter 2 Update:<br>Stand-Alone Unscheduled Assessment, Two-Day Flexibility Period</div></h2> <div> </div> <div> </div> <div> </div> <div>The two-day flexibility period for opening and setting the Assessment Reference Date (ARD) for stand-alone, unscheduled prospective payment system (PPS) assessments includes the Change of Therapy (COT) Other Medicare Required Assessments (OMRA), a stand-alone End of Therapy OMRA (EOT), and a stand-alone Start of Therapy OMRA (SOT).</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Facility staff must set the ARD for a day within the allowable ARD window for that assessment type (such as day seven of the COT rolling window), but may only do so by day two following the day after the window has passed (p. 2-40). </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><div>Optional Completion Of The EOT</div></h2> <div> </div> <div> </div> <div> </div> <div>The EOT is not required unless the resident remains skilled for at least three days after the last day of therapy. If the Resource Utilization Group (RUG) would be higher due to the EOT completion, facility staff may choose to complete it. If so, then the EOT may be combined with the Discharge assessment if those days coincide (p. 2-48). </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><div>EOT With Therapy Resumption</div></h2> <div> </div> <div> </div> <div> </div> <div>In cases where therapy resumes after the EOT OMRA is performed and the resumption-of-therapy date is no more than five consecutive calendar days after the last day of therapy is provided, an EOT with resumption (EOT-R) can be completed. The therapy services must be expected to resume at the same RUG-IV classification level and with the same therapy plan of care that had been in effect prior to the EOT OMRA (p. 2-49).</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><div>Combining COT With Scheduled Assessment Optional</div></h2> <div> </div> <div> </div> <div> </div> <div>If day seven of the COT observation period falls within the ARD window of a scheduled PPS assessment, the skilled nursing facility (SNF) staff may choose to complete the PPS assessment alone by setting the ARD of the scheduled PPS assessment for an allowable day that is on or prior to day seven of the COT observation period.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>If the scheduled assessment ARD falls on or before day seven of the rolling COT window, the window is reset (p. 2-51). Use this option when the RUG is estimated to drop. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>If it is not, facility staff may choose to combine the COT ARD with the scheduled assessment and receive a higher RUG back to the beginning of the COT window.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Clarification On Resident Interviews</h2> <div> </div> <div> </div> <div> </div> <div>The ability to carry resident interviews from a previous assessment to the current assessment is a continuation of previous updates and a welcome reduction in frequency (p. 2-52). CMS has indicated that when using a prior interview, the person who originally did the interview and attested to its accuracy must attest to its accuracy on the current assessment and enter the date the interview originally was completed as indicated on that prior assessment.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Early PPS Assessments</h2> <div> </div> <div> </div> <div> </div> <div>It is critical to note that when a COT is early, the rolling ARD window is reset with the ARD of the early COT. If facility staff don’t recalculate the rolling seven-day schedule with the early COT, the </div> <div> </div> <div> </div> <div> </div> <div>next COT ARD will be out of compliance (p. 2-73).</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Late PPS Assessments</h2> <div> </div> <div> </div> <div> </div> <div>One of the changes with the most impact is the new guidance on how to apply default days when an assessment is late.  For a scheduled assessment, default is applied for the number of days that an ARD is late rather than back to the beginning of the payment period. This is a very positive change for providers, as they will receive fewer default days under the new rules (pp. 2-73 and 6-53).<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Missed PPS Assessment</h2> <div> </div> <div> </div> <div> </div> <div>One of the most painful results of the complicated PPS scheduling is “provider liability” (when the facility cannot be paid for Medicare-provided days). This occurs when facility staff fail to set the ARD timely for either a scheduled or unscheduled PPS assessment and the resident has been discharged or is no longer on Medicare. <br><br></div> <div> </div> <div> </div> <div> </div> <div>If the SNF fails to set the ARD of a scheduled PPS assessment prior to the end of the last day of the ARD window, including grace days, and the resident was already discharged from Medicare Part A when this error is discovered, the provider cannot complete an assessment for SNF PPS purposes and the days cannot be billed to Part A. An existing Omnibus Budget Reconciliation Act of 1987 assessment (except a stand-alone discharge assessment) in the Quality Improvement and Evaluation System Assessment Submission and Processing (QIES ASAP) system may be used to bill for some Part A days when specific circumstances are met. See chapter 6, Section 6.8 for greater detail. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>In the case of an unscheduled PPS assessment, if the nursing facility fails to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident has been discharged from Part A, the assessment is missed and cannot be completed. All days that would have been paid by the missed assessment (had it been completed in timely fashion) are considered provider-liable. However, as with the late unscheduled assessment policy, the provider-liable period only lasts until the point when an intervening assessment controls the payment (p. 2-74).</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Chapter 3 Update: Unhealed Pressure Ulcers</h2> <div> </div> <div> </div> <div> </div> <div>Item M0210, Unhealed Pressure Ulcer(s), has a clarifying definition added: </div> <div> </div> <div> </div> <div> </div> <div>“Scabs and eschar are different both physically and chemically. Eschar is a collection of dead tissue within the wound that is flush with the surface of the wound. A scab is made up of dried blood cells and serum, sits on the top of the skin, and forms over exposed wounds such as wounds with granulating surfaces (like pressure ulcers, lacerations, and evulsions). A scab is evidence of wound healing.” (More on p. M-5.)</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Reduce Unnecessary Medications</h2> <div> </div> <div> </div> <div> </div> <div>While assuring that only those medications required to treat the resident’s assessed condition are being used, it is important to assess the need to reduce these medications wherever possible and ensure that the medication is the most effective for the resident’s assessed condition (p. N-4).</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Isolation Definition Changed</h2> <div> </div> <div> </div> <div> </div> <div>The concept of “strict isolation” now reads “single-room isolation” in multiple areas in section O. Instructions in item O0100M clarify that staff are to code this only when it includes isolation for active infectious disease and the resident requires transmission-based precautions and single-room isolation (alone in a separate room) because of active infection (for example, symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission (p. 0-4). </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Definition Of Continence Revised</h2> <div> </div> <div> </div> <div> </div> <div>Continence is “any void into a commode, urinal, or bedpan that occurs voluntarily, or as the result of prompted toileting, assisted toileting, or scheduled toileting.” With the updated definition, coders will focus on the voluntary and intended nature of the void in approved receptacles (Appendix A, p. A-5). </div> <div> </div> <div> </div> <div> </div> <div><em> </em></div> <em> </em><div><em> </em></div> <em> </em><div><em> </em></div> <em> </em><div><em> </em></div> <em> </em><div><em>Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of content management for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em></div> <div> </div> <div> </div> <div> </div> <p></p>The Care Area Assessment (CAA) process involves further investigation of triggered areas to determine whether interventions and care planning are required for a resident. The Centers for Medicare & Medicaid Services (CMS) has clarified that the CAA resources in Appendix C are provided as a courtesy to facilities. These resources include a compilation of checklists and Web links that may be helpful in performing the assessment of a triggered care area. “The use of these resources [is] not mandatory and represent[s] neither an all-inclusive list nor government endorsement” (p. 1-6).2013-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0113/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn1
Harassment By Residenthttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0113/Harassment-By-Resident.aspxHarassment By Resident<p>​A recent lawsuit filed by the United States Equal Employment Opportunity Commission (EEOC) against a private health care facility in Virginia serves as a reminder to nursing homes and other long term care providers of the potential liability they face when they have a resident who displays harassing conduct toward others. </p> <p><img width="283" height="221" class="ms-rteImage-2 ms-rtePosition-2" alt="harassment" src="/Monthly-Issue/2013/PublishingImages/0113/legal0113.jpg" style="margin:5px 10px;" />On Sept. 6, 2012, EEOC filed suit against the Virginia facility under Title VII of the Civil Rights Act, alleging that the employer failed to protect a female receptionist from sexual harassment by a resident, which created a “sexually hostile work environment” for her.<br></p> <p></p> <div>As with most harassment lawsuits, the employee alleged that she made numerous complaints to her supervisor about the harassment, yet the employer failed to take proper corrective action. <br></div> <h2 class="ms-rteElement-H2">Harassment Problems Specific To Residents</h2> <div>Sexual harassment is a difficult issue in any employment setting, but perhaps nowhere is it more problematic than in the resident care arena. Nursing home employees, including nurses and therapists, are in regular, physical contact with non-employees—primarily the residents for whom they care (and the family members of those residents). </div> <div><br>Under Title VII, nursing home employees are protected from harassment by residents just as they are from co-workers and supervisors. Hospitals, nursing homes, assisted living facilities, and other patient-care entities are responsible for providing a workplace free of sexual harassment, regardless of whether the harassment is perpetrated by a co-worker or by a paying resident. </div> <div><br>Most nursing home employers have experienced episodes in which a resident acts out in an inappropriate manner. Often, the inappropriate behavior is due to the resident having a deteriorated mental condition such as dementia or Alzheimer’s disease. As a result of this condition, residents may not understand that their actions are inappropriate. </div> <div><br>However, this mental condition does not act to shield nursing home employers from liability.</div> <h2 class="ms-rteElement-H2">Employers Must Act </h2> <div>Where sexual harassment has been alleged in a nursing home, a court will likely first look to whether the employer knew or should have known about the harassment and whether the employer did anything to correct the offending conduct. Of course, a nursing home is somewhat constrained in how it can respond to complaints of sexual harassment by residents. </div> <div><br>For example, a nursing home cannot transfer a resident unless the transfer complies with the Bill of Rights for Residents of Long Term Care Facilities. However, this constraint does not entitle an employer to sit back and do nothing.</div> <div><br>A case from Massachusetts in the late 1990s illustrates this point. A respiratory therapist sued her employer and alleged that the employer failed to remediate repeated sexual harassment against her by an elderly resident in her care. </div> <div><br>The employee also alleged that her employer retaliated against her after she complained. In that case, the employer had advance knowledge that the patient had been accused of making inappropriate sexual comments to female staff members at the hospital during his hospitalization. </div> <div><br>Upon his arrival to the employer’s facility, the employer developed a care plan designed to address his “misbehavior.” Despite these measures, the employee claimed that the patient harassed her and that her complaints went unanswered. </div> <div><br>The employer essentially argued that it was limited by the federal regulations governing long term care facilities from taking any action and that those regulations shielded it from liability. The court rejected that argument, finding that the employer could not disclaim all responsibility toward its employees in the name of patient care.</div> <div><br>A similar argument has been rejected more recently by courts in other jurisdictions. </div> <div><br>For example, a federal court in Illinois in 2008 rejected an argument from a defendant nursing home that it could not be held liable for the harassing conduct by a nursing home resident because it did not employ the resident. </div> <div><br>In that case, a dietary aide sued her employer after a resident in her care repeatedly harassed her. The court held that it did not matter whether the harasser was a co-worker or a resident; the employer could be held liable if it knew or should have known about the harassment and failed to prevent it. </div> <h2 class="ms-rteElement-H2">Steps A Nursing Home Should Take </h2> <div>These cases demonstrate that an employer will not be let off the hook simply because the harassing individual was not an employee. While it may not be possible to completely prevent harassment in the nursing home context due to the mental conditions of residents, employers can take steps to address and minimize the risk. </div> <div><br>First, the employer should maintain a policy and procedure that addresses sexual harassment by residents or other third parties. The policy should specifically address how employees can report the harassment when it occurs. </div> <div><br>Maintaining a “reporting” policy is critical for another reason: It provides the employer with important legal defenses in situations involving alleged harassment by a supervisor. </div> <div><br>Second, the employer should regularly train its employees on how to react when they are harassed by a resident. </div> <div><br>Because the duties of a nursing home employee often require him or her to work in close, physical contact with residents, there is an increased potential for misunderstandings or unwelcome incidents. </div> <div><br>If employees are trained to react properly and promptly, the unwelcome conduct may be stopped before it becomes “severe or pervasive”—the standard used by courts in analyzing sexual harassment claims.</div> <div><br>Third, the employer must investigate and respond to complaints appropriately. While the response will depend on the circumstances of the complaint, there are several “best practices” that an employer should consider. For example, the employer could assign the resident to another employee’s care or discuss with the employee whether he or she wants to transfer to another part of the facility. </div> <div><br>Other options include making staffing adjustments such that the employee never cares for the resident by himself or herself. The employer should also consider involving the resident’s family in an effort to stop the inappropriate behavior. </div> <div><em> </em></div> <em> </em><div><em>Ted Boehm is a labor and employment attorney with Fisher & Phillips in Atlanta. For questions about this or other labor and employment issues, please contact him at tboehm@laborlawyers.com or (404) 231-1400.</em></div> <p></p>Sexual harassment is a difficult issue in any employment setting, but perhaps nowhere is it more problematic than in the resident care arena. Nursing home employees, including nurses and therapists, are in regular, physical contact with non-employees—primarily the residents for whom they care (and the family members of those residents). 2013-01-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0113/legal_thumb.jpg" style="BORDER:0px solid;" />LegalColumn1
20 To Watch Selection Committeehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0113/Meet-Our-20-To-Watch-Selection-Committee.aspx20 To Watch Selection Committee <div> </div> <p class="ms-rteElement-P">When <em>Provider</em> editors Joanne Erickson and Meg LaPorte set out to create <span class="ms-rteForeColor-2">20 To Watch</span>, they enlisted the help of some long term and post-acute care veterans. Among them was a nonprofit leader, the head of an American Health Care Association (AHCA) state affiliate, a chief clinical officer of a health care analytics consulting firm, the president of an online education company, the head of public affiairs for AHCA, and the head of the National Center for Assisted Living (NCAL).</p> <p class="ms-rteElement-P"><br></p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P ms-rteForeColor-2"><strong>Sponsored by Silverchair Learning Systems</strong> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <img src="/Monthly-Issue/2013/Pages/0113/Meet-Our-20-To-Watch-Selection-Committee.aspx" alt="" style="margin:5px;" /><a href="http://www.silverchairlearning.com/"><img width="167" height="49" class="ms-rtePosition-1 ms-rteImage-0" src="/Monthly-Issue/2013/PublishingImages/Silverchair-Learning-Relias-Learning-logo.jpg" alt="Silverchair Learning" style="margin:0px 5px;" /></a><br><br><br><br> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <br><div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"><img width="343" height="741" class="ms-rtePosition-1" alt="Tamar Abell" src="/Monthly-Issue/2013/Documents/TamarHeadShot.JPG" style="width:114px;height:158px;margin:7px 10px;" /></p> <div> </div> <div class="ms-rteStyle-Normal ms-rteThemeFontFace-2 ms-rteFontSize-3" dir="ltr" style="text-align:left;"><div><div><div><p class="ms-rteElement-P">Tamar Abell<br>President<a title="Care2Learn" target="_blank" href="http://www.care2learn.com/"><br>Care2Learn</a><br>Skokie, Ill.</p> <p class="ms-rteElement-P"> </p> <p></p></div></div></div></div> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"><br></p> <p class="ms-rteElement-P"><br></p> <div> </div> <p class="ms-rteElement-P"><br></p> <p class="ms-rteElement-P ms-rteFontSize-3"></p> <div><hr class="ms-rteElement-Hr" />  </div> <p></p> <p class="ms-rteElement-P ms-rteFontSize-3"><img alt="Greg Crist, AHCA" src="/Monthly-Issue/2013/PublishingImages/headshots/GregCrist.jpg" class="ms-rtePosition-1" style="margin-left:10px;margin-right:10px;" />Greg Crist<span></span><br><span>Vice President</span>, Public Affairs<a href="http://www.ahcancal.org/"><br>AHCA</a><br>Washington, D.C.</p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"><br></p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p></p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><br></p> <p class="ms-rteElement-P ms-rteFontSize-3"></p> <div><hr class="ms-rteElement-Hr" />    </div> <p></p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><span class="ms-rteFontSize-3"></span></p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><span><span><img width="389" height="732" alt="Gary Kelso " src="/Monthly-Issue/2013/Documents/Gary%20Kelso%20Headshot.jpg" class="ms-rtePosition-1" style="width:119px;height:158px;margin:8px 10px;" /></span></span><span class="ms-rteFontSize-3">Gary Kelso</span><br><span></span>President, Chief Executive Officer, and Eden Mentor<br><span><a title="Mission Health Services" target="_blank" href="http://www.missionhealthservices.org/">Mission Health Services</a></span><br>Salt Lake City, Utah</p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><br></p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><br></p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><br></p> <p class="ms-rteElement-P ms-rteFontSize-3"></p> <div><hr class="ms-rteElement-Hr" />  </div> <p></p> <div> </div> <p class="ms-rteElement-P"><img class="ms-rtePosition-1" alt="David Kyllo, NCAL" src="/Monthly-Issue/2013/PublishingImages/headshots/DavidKyllo.jpg" style="margin:7px 10px;" /><span><span class="ms-rteFontSize-3">David Kyllo</span></span><span class="ms-rteFontSize-3"><br>Executive Director</span><span class="ms-rteFontSize-3"><br></span><a title="NCAL" target="_blank" href="http://www.ahcancal.org/ncal/Pages/default.aspx" class="ms-rteFontSize-3"><span>NCAL</span></a><span class="ms-rteFontSize-3"><br>Washington, D.C.</span></p> <div> </div> <p class="ms-rteElement-P"><br></p> <div> </div> <p class="ms-rteElement-P"><br></p> <div> </div> <p class="ms-rteElement-P"><br></p> <p class="ms-rteElement-P"><br></p> <p class="ms-rteElement-P"></p> <div><hr class="ms-rteElement-Hr" />  </div> <p></p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><img width="250" height="355" alt="Steven Littlehale" src="/Monthly-Issue/2013/Documents/Steven%20Littlehale%20(2).jpg" class="ms-rtePosition-1 ms-rteFontSize-3" style="width:114px;height:158px;margin:6px 10px;" /><span class="ms-rteFontSize-3">Steven Littlehale</span><br>Executive Vice President & Chief Clinical Officer<br><a title="PointRight" target="_blank" href="http://www.pointright.com/">PointRight</a><br>Lexington, Mass.</p> <div> </div> <div> </div> <div> </div> <div> </div> <div><div> </div> <div> </div> <div><hr class="ms-rteElement-Hr" />  </div></div> <div> </div> <p></p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p></p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><img class="ms-rtePosition-1" alt="Ned Morse" src="/Monthly-Issue/2013/PublishingImages/headshots/NedMorse.jpg" style="width:115px;height:159px;margin:0px 10px;" />Ned Morse<br>President<br><a href="http://www.maseniorcare.org/" target="_blank" title="Massachusetts Senior Care Association">Massachusetts Senior Care Association</a><br>Newton Lower Falls, Mass.</p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><br></p> <div> </div> <p class="ms-rteElement-P ms-rteFontSize-3"><br></p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <div> </div> <p class="ms-rteElement-P"> </p> <p class="ms-rteElement-P"><br></p> <p class="ms-rteElement-P"><br></p> <p class="ms-rteElement-P"><img src="/Monthly-Issue/2013/Pages/0113/Meet-Our-20-To-Watch-Selection-Committee.aspx" alt="" style="margin:5px;" /><br></p> <div> </div> <p class="ms-rteElement-P"> </p>Column1
Top 20 To Watch 2013https://www.providermagazine.com/Monthly-Issue/2013/Pages/0113/Top-20-To-Watch-2013.aspxTop 20 To Watch 2013<strong><br>Vivian Booker</strong><br>Director of Health Management <br>Mt. St. Francis Nursing Center<br>Colorado Springs, Colo.<br><br><strong>Dan Cohen</strong><br>Founder<br>Music and Memory<br>Mineola, N.Y.<br><br><strong>Elizabeth Davis</strong><br>Owner/Operator<br>Bright Side Manor Assisted Living<br>Teaneck, N.J.<br><br><strong>Tim Dressman</strong><br>Chief Executive Officer<br>St. Leonard Senior Living<br>Centerville, Ohio<br><br><strong>Grace Flight</strong><br>Administrator<br>Regency Heights of Stamford<br>Stamford, Conn.<br><br><strong>Sharonda Jenkins, RN</strong><br>Quality Assurance Nurse<br>Highland Pines Nursing and Rehabilitation Center<br>Longview, Texas<br><br><strong>Richard Kishaba</strong><br>President/Owner<br>Ohana Pacific Management Co.<br>Honolulu, Hawaii<br><br><strong>Heather Lemoine, RN</strong><br>Program Director<br>Bridges Memory Care<br>EPOCH Assisted Living at Melbourne<br>Pittsfield, Mass.<br><br><strong>Jana Mallory</strong><br>Advanced Practiced Registered <br>Nurse, Certified Wound Specialist<br>Lebanon Care Center<br>Lebanon, N.H.<br><br><strong>Whitney Ostercamp</strong><br>Music Therapist<br>Valley Nursing Center<br>Taylorsville, N.C. <br><br><strong>Kay Peruski</strong><br>Administrator<br>Courtney Manor<br>Bad Axe, Mich.<br><br><strong>Kavan Peterson</strong><br>Partner, ChangingMedia<br>Editor, ChangingAging.org <br>Baltimore <br><br><strong>J</strong><strong>effrey Philbrick</strong><br>Owner/Administrator<br>Colonial Poplin Nursing and Rehabilitation Facility - Poplin Way Assisted Living<br>Fremont, N.H.<br><br><strong>Christine Reynolds, PT</strong><br>Facility Rehab Coordinator<br>Tendercare<br>Tawas City, Mich.<br><br><strong>Angela Ross, RN</strong><br>Vice President, Clinical Services Integration<br>Prestige Care <br>Vancouver, Wash.<br><br><strong>Deb Ruebbelke, RD</strong><br>LTC Consultant—Reliable RD <br>Johnston, Iowa<br><br><strong>Joyce Simard</strong><br>Namaste Care Founder<br>Geriatric Consultant, Author<br>Land O’Lakes, Fla. <br><br><span><strong>Denise Tollefson</strong></span><strong></strong><br>Executive Director<br>Serenity Assisted Living<br>Dilworth, Minn.<br><br><strong>Timothy Wintz</strong><br>Director of Engineering<br>Island Nursing and Rehab<br>Holtsville, N.Y.<br><br><strong>Natalie Zeleznikar, LNHA</strong><br>Chief Executive Officer<br>Five Star Living<br>Duluth, Minn.<br>Column1

February



 

 

Stars In Their Own Right, Part 2https://www.providermagazine.com/Monthly-Issue/2013/Pages/0213/Stars-In-Their-Own-Right2.aspxStars In Their Own Right, Part 2<div><em><img class="ms-rteImage-1 ms-rtePosition-1" alt="20 To Watch" src="/Monthly-Issue/2013/PublishingImages/0213/20towatch2.jpg" width="224" height="159" style="margin:5px 10px;" /><br>Provider’s</em> inaugural 20 To Watch continues this month with profiles of seven honorees who—just as they did <a href="/Monthly-Issue/2013/Pages/0113/Stars-In-Their-Own-Right.aspx" target="_blank">last month</a>—shine bright as glittering examples of what’s best in long term and post-acute care today.</div> <div> </div> <div>An assistant administrator, a director of engineering, a dietitian, a nurse, an administrator, an owner, and a founder of a nonprofit organization all have the spotlight this month.</div> <div> </div> <div>Stay tuned, as next month will feature the final seven profiles of 2013’s 20 To Watch. For the complete list, click <a href="/Monthly-Issue/2013/Pages/0113/Top-20-To-Watch-2013.aspx" target="_blank">here</a>.</div> <div> </div> <div><strong>Sponsored by Silverchair Leaning Systems</strong></div> <div>Silverchair Learning Systems works with senior care leaders who want to improve key business processes in their organizations. Silverchair Learning offers: Silverchair For Staff, a user-friendly online training solution that improves compliance and eliminates record-keeping headaches; the Employee Feedback System, which easily delivers satisfaction surveys, provides in-depth analysis of results, and offers action tools to help reduce employee turnover; and Silverchair For Families, a resident family education and communication system that helps set expectations and solicit continuous feedback to help providers build strong family relationships and increase satisfaction. All Silverchair Learning products have been developed to help educate, empower, and inspire the senior care industry and to facilitate a higher quality of care. Silverchair Learning Systems is a Relias Learning company. Visit <a href="http://www.silverchairlearning.com/" target="_blank">www.silverchairlearning.com</a> to learn more.</div> <div></div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0213/SharondaJenkins.jpg" alt="Sharonda Jenkins" class="ms-rteImage-1 ms-rtePosition-1" width="188" height="212" style="margin:5px 10px;" /></div> <div><strong>Sharonda Jenkins, RN</strong></div> <div>Quality Assurance Nurse</div> <div>Highland Pines Nursing and Rehabilitation Center </div> <div>Longview, Texas </div> <div> </div> <div>Working with elders is a blessing for Sharonda Jenkins. In fact, Jenkins says, “it’s what God wanted me to do.” From her start as a certified nurse assistant (CNA), to becoming a licensed vocational nurse (LVN), to now being a registered nurse (RN), Jenkins says she wouldn’t change a thing. “I just love what I do; it’s where my heart is.” </div> <div> </div> <div>Prompting her entry into the world of long term and post-acute care was her daughter, who 18 years ago, at the age of just two, had a seizure. Jenkins’ mother administered CPR on the toddler, while Jenkins watched in horror, not knowing what to do. </div> <div> </div> <div>“After that, I said to my mother, ‘This is never happening again,’ so I became a CNA.” She went to work in a nursing home and now serves as quality assurance nurse at Highland Pines. </div> <div> </div> <div>“Sharonda is a caring, funny, and motivated nurse, striving to do her best each and every day. Her belief is that you should give your staff what they need to do the best job they can,” says Cindy Baldridge, director of staff development for Stebbins Five Companies, which manages the nursing home where Jenkins works. </div> <div> </div> <div>As a champion of staff training and education, Jenkins encourages staff to improve themselves both personally and professionally, says Baldridge. “She watches for those ready to receive more responsibility or duties and encourages those with LVNs to get their RN licenses.”</div> <div> </div> <div>Since joining Highland Pines, Jenkins has positively impacted the employees she supervises and the residents she is so compassionate about. “Not only does she provide daily training with the nursing staff, she monitors employee immunizations, provides annual check offs with the nurse assistants on their skills, and does extensive licensed nurse competency evaluations,” says Baldridge.</div> <div> </div> <div>Also among Jenkins’ accomplishments is a recent reduction of urinary tract infections (UTIs) in the facility. After noticing an uptick in facility-acquired UTIs, she initiated hands-on, side-by-side training with her CNAs, sure that better care, in addition to hand washing, would lead to a decrease in UTIs. </div> <div> </div> <div>She trained in groups of two aides, teaching them how to coach each other not to miss a step or break infection control procedures. “Whatever she thought would work, she did it,” says Baldridge. “Having such an open communication with the CNAs helped her to better help them. When they told her it was too hard to remember some steps, she gave them laminated pocket cards for the aides to carry and reference during care.”</div> <div> </div> <div>Jenkins’ efforts paid off—in July 2012, the facility logged two facility acquired UTIs; in August 2012, another two. In September, just one, and in October, there were zero facility-acquired UTIs. </div> <div> </div> <div>Always striving to be a team player, Jenkins says she takes the time to teach her co-workers from “A to Z,” which means she does what she can to make things easy to understand. “If someone has difficulty learning something, I will break it down to get through to them so they can learn it. I always start from A to Z and never leave out anything.” </div> <div> </div> <div>In response to her selection to 20 To Watch, Jenkins says, “I have lived for a moment like this; I’ll never forget it.”</div> <div></div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0213/GraceFlight.jpg" alt="Grace Flight" class="ms-rteImage-1 ms-rtePosition-1" width="201" height="205" style="margin:5px 10px;" /></div> <div><strong>Grace Flight, RN </strong></div> <div>Executive Director</div> <div>Regency Heights of Stamford</div> <div>Stamford, Conn. </div> <div> </div> <div>As if developing the patient care record system that has been adopted by 95 percent of the skilled nursing facilities in the state wasn’t enough, Grace Flight has also established a long term care educational consortium and was the first in the state to challenge the prohibition of allowing pets in nursing homes.</div> <div> </div> <div>Flight, who is executive director of Regency Heights of Stamford, Conn., has always been guided by the resident voice, says Steve Vera, regional director of operations for Ciena Healthcare, the company that owns Regency Heights. </div> <div> </div> <div>“Plus, her invaluable commitment to mentorship has left an indelible mark on countless long term care workers, administrators, and company officers.” </div> <div> </div> <div>Working with and learning from Flight has been a pleasure, Vera says. “She leads by example, and she does not expect more from her staff then she does of herself,” he says. </div> <div>“She combines clinical background being a nurse and years of administration experience.”</div> <div> </div> <div>As Kristine Halsey, chief operating officer of Ciena, notes, “Her legacy is not what she will leave us with but what she has left in us.” </div> <div> </div> <div>Not surprisingly, Flight has a long string of initials on her resume, including RN and MBA. Even more impressive is the fact that she received the Connecticut Nurses Association “Doris M. Armstrong” Nurse Administrator of the Year award in 2011, which was preceded by many other awards, including Administrator of the Year from the University of Connecticut in 2004. </div> <div> </div> <div>What’s more, Regency Heights received a Bronze award last year from the American Health Care Association/National Center for Assisted Living Quality Award program. </div> <div>“Grace is an icon in the industry in Connecticut,” says Vera. “She’s won multiple awards and had such a large impact and continues to. Her own knowledge base and ability to teach people is invaluable.”</div> <div> </div> <div>Flight has racked up numerous awards and distinguished appointments. They include: an advisor to the state Superior Court, several governor appointments, and the Nightingale Award for Excellence.</div> <div> </div> <div>Flight’s accomplishments also include the development of an Advanced Geriatric Nurse Aide Concourse Curriculum that is used by long term care facilities, founding a Committee on Geriatric Nursing Education, a non-profit organization of Long Term Care Para and Professionals dedicated to providing quality low-cost continuing education with a current membership of more than 800.</div> <div></div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0213/RichardKishaba.jpg" alt="Richard Kishaba" class="ms-rteImage-1 ms-rtePosition-1" width="219" height="182" style="margin:5px 10px;" /></div> <div><strong>Richard Kishaba</strong></div> <div>President/Owner </div> <div>Ohana Pacific Management Co.</div> <div>Honolulu, Hawaii</div> <div> </div> <div>Understanding Richard Kishaba’s commitment to caring for Hawaii’s elders first calls for a lesson in the Hawaiian language: “Ohana,” the namesake of his company, means family, and “kupuna” means elderly. </div> <div> </div> <div>Born and raised in Hawaii, Kishaba has been working in long term and post-acute care for 24 years, since he was 27 years old. But he has always held elders in high esteem. “Hawaiians have a lot of respect for elders, and we always treat them with dignity. That was always instilled in me,” says Kishaba.</div> <div> </div> <div>At a young age he realized that he needed to make a difference in the world and focused his energies in health care after a career in business, says Nadine Smith, his colleague at Ohana Pacific Management. “He became a nursing home administrator and accepted a position in his early twenties with virtually no experience. He took over the facility for the benefit of the staff, residents, and an intrinsic obligation to the owner.”</div> <div> </div> <div>Kishaba has since purchased four nursing facilities, two on Oahu and two on Kauai. He also acquired the Kauai Adult Day Health Center on Kauai to ensure the community continued to receive a needed service. </div> <div> </div> <div>“Richard views each and every resident as a family member, and when assessing the success of his business he uses resident outcomes, customer satisfaction, and employee engagement as his benchmarks,” says Smith.</div> <div> </div> <div>Perhaps most importantly, Kishaba invests highly in his staff and promotes and encourages them to achieve their highest goals, “even if that means leaving the organization,” says Smith. </div> <div> </div> <div>Many of the leaders within the state started at Ohana, including several who have gone on to influential positions, such as the director of operations for a state health plan and the Health Care Services Branch administrator for the state of Hawaii.</div> <div> </div> <div>“We put our residents first,” says Kishaba. “I think we go to great lengths to make sure we’re doing the proper things for elders, such as bringing in the right people and spending time building up staff, engaging staff, and treating them with dignity so they can treat our elders with quality care.”</div> <div> </div> <div>The company is also a strengths-based organization, thus allowing employees to do what they do best. “Richard seeks out opportunities for all employees to get the training support and mentoring necessary to promote their personal and professional growth,” says Smith. “Richard emulates all that is positive in health care in Hawaii. He demonstrates true leadership, collaboration, and commitment to providing high-quality care and customer service.”</div> <div> </div> <div>“I encourage people to take risks; we are an organization that allows people test things. I’m a real believer in empowering people to try new things,” says Kishaba.</div> <div> </div> <div>Amid the accolades from colleagues on his selection, Kishaba remains humble: “In all honesty, I do very little for our organization successes,” he says. “The true honor should go to all my staff, who are the true backbone of our organization.”</div> <div> </div> <div>Kishaba is an active and influential leader in the Hawaiian Long Term Care Association and is always willing to share his company’s expertise and advice with fellow members, says colleague Susan Mochizuki. “He firmly believes in resident-centered care and delivers the highest quality care by respecting, valuing, and supporting employees, especially those who are closest to residents.”</div> <div> </div> <div>Kishaba relays a story of a recent visit to one of his facilities: “The daughter of a resident just started crying as she expressed her appreciation for the loving staff that care for her mom. This happens on a routine basis because of the great team of people that we have in our ohana,” he says. </div> <div></div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0213/DebRuebbelke.jpg" alt="Deb Ruebbelke" class="ms-rteImage-1 ms-rtePosition-1" width="162" height="243" style="margin:5px 10px;" /></div> <div><strong>Deb Ruebbelke, RD</strong></div> <div>LTC Consultant—Reliable RD</div> <div>Appleton, Wis. </div> <div> </div> <div>Deb Ruebbelke is more than a dietitian: She is an educator, a leader, an author, and an “awesome” cook, according to longtime colleague, Barbara Thomsen. “Deb has a wonderful ability to work with all disciplines in our long term care facilities, engage our residents and their families, and promote good nutritional health. She is truly a blessing to our elder nutrition profession,” she says. “Her willingness to support dietary managers and the Association of Nutrition & Foodservice Professionals by helping to mentor, proctor, and teach is truly amazing.”</div> <div> </div> <div>Ruebbelke, who consults for nursing homes and assisted living communities, and recently formed Reliable RD (<a href="http://www.reliablerd.com/" target="_blank">www.reliablerd.com</a>) to help educate long term and post-acute care staff about nutrition, is also a ServSafe instructor, holds a position on the Iowa Dietetic Association Board and Council, and serves as an instructor the for Des Moines Area Community College Certified Dietary Manager course.</div> <div> </div> <div>“Deb is a unique dietitian that supports the role of the certified dietary manager and encourages and helps educate them to participate in clinical processes as well as kitchen management, focusing on sanitation and safe food handling,” says Thomsen. “Her willingness to promote teamwork amongst all long term care disciplines has been greatly appreciated by all the administrators that she has had the pleasure of working with.” </div> <div> </div> <div>Thomsen notes that Ruebbelke was recently instrumental in helping free-standing assisted living facilities in Iowa lay out and plan their dining services, thus enabling them to be in compliance with the regulatory guidelines for both the state- and federal-level food code. </div> <div> </div> <div>Also on her resume is adjunct educator for an Iowa community college for its Certified Dietary Manager program, and most recently, Ruebbelke co-wrote a training manual on the minimum data set (MDS) for dietitians, which “helps long term care nutrition professionals understand how to document resident-centered care and the MDS clinical process,” Thomsen says.</div> <div> </div> <div>“It’s very hard to talk about myself because, as a consultant dietitian in long term care, it’s a multidisciplinary team approach,” says Ruebbelke. <br></div> <div><h2 class="ms-rteElement-H2">Drawn From An Early Age</h2></div> <div>Her love of elders and long term care stems from her mother, who was a secretary to a nursing home administrator. Ruebbelke began volunteering at the nursing home at just 12 years of age. “At the facility, there was a dietitian, and I asked questions about what she did and why she liked her job. I’ve always been drawn to the elderly population,” she says. <br></div> <div><br>“When I did my internship in the late 1980s, I took it upon myself to shadow dietitians at nursing homes, and through that, I met a dietitian in Minnesota. When I graduated, she called me and asked if I would like to work for her.” </div> <div> </div> <div>Ruebbelke’s true calling is to “make a difference in an elder’s life,” she says. “I hope that I’m helping them to eat better, to help them have a better appreciation of nutrition, and that makes me feel good.” </div> <div> </div> <div>“Deb is a really great dietitian, she is very knowledgeable, and she has a knack for being able to educate and train as well,” says colleague Lisa Roeder. </div> <div> </div> <div>According to Roeder, her standout leadership qualities include having a “knack for being able to work with someone and bring the best part of them out and inspire them to want to do better. She makes people want to be better than they have been,” Roeder says. “Plus, she’s just awesome in general.”</div> <div> </div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0213/DanCohen.jpg" alt="Dan Cohen" class="ms-rteImage-1 ms-rtePosition-1" width="161" height="242" style="margin:5px 10px;" /><br><strong>Dan Cohen, MSW</strong></div> <div>Founder, Music & Memory</div> <div>Mineola, N.Y.</div> <div> </div> <div>With a viral YouTube video that was featured recently on “The Doctors” and National Public Radio, as well as a documentary about his organization, to his credit, Dan Cohen’s commitment to improving the lives of elders through music is indisputable. </div> <div> </div> <div>As the founding executive director of the nonprofit Music & Memory, Cohen’s mission is to give elders living in nursing homes, assisted living communities, and in hospice care individualized musical playlists using iPods and related digital audio systems. </div> <div> </div> <div>As a Mineola, N.Y.-based social worker, Cohen combined an extensive background in high tech training, corporate sales, and software applications with his social work experience to create the Music & Memory program, the goal of which is to enable those struggling with Alzheimer’s, dementia, and other cognitive and physical challenges to reconnect with the world through music-triggered memories.</div> <div> </div> <div>The viral YouTube clip is entitled “Henry,” and it demonstrates the power of Cohen’s program. Henry is a nursing home resident who comes alive as he listens to his beloved Cab Calloway on an iPod, donated to the home via Cohen’s organization. </div> <div> </div> <div>The goal of Music & Memory is to make personalized music accessible for every nursing home resident nationwide. “Cohen has taught hundreds of nursing home administrators and other staff in the U.S. and Canada how to create individualized music programs for patients,” says Michele Nolta, a certified recreation therapist who has worked with Cohen.  </div> <div> </div> <div>Through Music & Memory, Cohen has “inspired and captured the enthusiasm of nursing home administrators, executive directors, nursing home staff from every discipline, retired music teachers, elder-law attorneys, high school key club members, news writers, and more,” says Nolta. “He has already drastically improved the lives of the residents who have been provided with digital music.”</div> <div> </div> <div>In fact, Cohen and his project so impressed the American Health Care Association, the California Association of Health Facilities, and the Gerontological Society of America, all three premiered his documentary “Alive Inside” at their 2012 annual conferences.</div> <div> </div> <div>“Dan Cohen has found a way to initiate patient awakenings, improve difficult behaviors, provide helpful and joyful interventions for nursing home staff, and inspire community members of every age to involve themselves with nursing homes,” says Nolta. “That’s impressive!”</div> <div> </div> <div>Cohen himself explains that when his program is implemented in a nursing home, it raises the morale of the entire facility and adds a new layer of response to residents who are agitated, depressed, and lonely. “So rather than responding with ‘let’s get this person some medication to calm him down,’ it’s ‘let’s get him some music quickly.’”</div> <div> </div> <div>That kind of change is real, Cohen notes. “Personalized music does not work for everyone, but it works for most people, and there’s often a great deal to gain.”</div> <div> </div> <div>Although Cohen says he is honored to have been selected for 20 To Watch, he believes “it signifies the recognition that so many people have raised—that it is critically important to give people we are caring for the same kind of lifestyle that we would have for ourselves and our families,” he says. “I think we’ve gotten away from that, and lifestyle goes beyond ADLs [activities of daily living]; it takes a focus, and it won’t happen just because everyone is safe and secure and medically attended to—that’s not enough.”</div> <div> </div> <div>Indeed, Cohen’s mission is to ensure that all elders can benefit from music whenever and wherever they want it.</div> <div> </div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0213/TimWintz.jpg" alt="Timothy Wintz" class="ms-rteImage-1 ms-rtePosition-1" width="159" height="236" style="margin:5px 10px;" /><br><strong>Timothy Wintz</strong></div> <div>Director of Engineering & Security </div> <div>Island Nursing and Rehab Center</div> <div>Holtsville, N.Y.</div> <div> </div> <div>Tim Wintz’s colleagues were thrilled to learn that he was selected as one of <em>Provider’s</em> inaugural 20 To Watch. Making the news especially exciting was that it came just two days after Hurricane Sandy had hit the East Coast and slammed into the building where Wintz and his team’s engineering prowess kept the generator running, the lights on, and communication channels open throughout the night as wind and water whipped the building where he has worked for nearly a dozen years.</div> <div> </div> <div>Embarrassed by the attention, Wintz demurred when told of his honor. “I really didn’t expect it,” he says. “I turned three shades of red. I’m nothing; I’m nothing without my team.” </div> <div> </div> <div>Wintz, who grew up on Long Island not far from the nursing home, credits “his guys” for the recognition. “It’s my guys who work for me that really make me shine,” he says. “My crew means the world to me.”</div> <div> </div> <div>David Fridkin, chief executive officer of Island Nursing and Rehab Center, has nothing but praise for Wintz, especially as a leader and a role model for other employees. “Tim stayed over during the hurricane and made sure that everything was still running in the building,” says Fridkin “This place is like his home away from home.”</div> <div> </div> <div>Fridkin adds that the knowledge and experience Wintz has demonstrated in analyzing difficult engineering situations have proven to be a real asset in the projects that he has developed at Island.</div> <div> </div> <div>“Tim has conducted a broad range of analyses in his project investigations,” says Fridkin. “Tim always asks the right questions, ensuring that our projects meet strict code and regulatory compliance.” What’s more, he says, Tim is “exceptionally sensitive” to the individual needs and preferences of the residents, families, and staff.</div> <div> </div> <div>In nominating Wintz, Fridkin noted that nursing home engineers often go unrecognized, despite the fact that their role is “invaluable in ensuring the safe, secure, and efficient operation of the building.”</div> <div> </div> <div>Wintz’s philosophy is communicated through ongoing education of his team to employ the same care and consideration when interacting with the residents and staff during the course of the ongoing facility maintenance projects. Tim always is available to provide support and time whenever another employee or resident needs assistance. </div> <div> </div> <div>Moreover, Tim is always cooperative, energetic, and insightful in his approach to problem solving, Fridkin says. “He possesses a broad range of engineering and construction experience, which enables him to handle a wide range of projects. In situations where unusual obstacles are encountered, innovative cost-efficient solutions are offered to resolve complex problems. It is a comfort to know that no problem is considered too insignificant to deserve his attention.”</div> <div> </div> <div>As with many who have chosen the long term care profession, work becomes a family affair, with Wintz’s being no exception. His 12-year-old daughter volunteers at the home. “She’s here right now, mingling with the residents and painting some fingernails, I think,” he told <em>Provider</em>.</div> <div> </div> <div> </div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0213/DeniseTollefson.jpg" alt="Denise Tollefson" class="ms-rteImage-1 ms-rtePosition-1" width="172" height="241" style="margin:5px 10px;" /><br><strong>Denise Tollefson</strong></div> <div>Assistant Administrator</div> <div>Serenity Assisted Living</div> <div>Dilworth, Minn.</div> <div> </div> <div>Just as many in the field do, Denise Tollefson spends much of her life with residents and co-workers, and therefore she prefers to treat everyone she works with like family. </div> <div> </div> <div>In kind, her co-workers appreciate Tollefson as if she were a member of the family.  Her flexibility and compassion, as well as her ability to listen well while being very detail-orientated when administering residents medication and carrying out their daily needs, are what got her nominated for 20 To Watch, says Elaine Anderson, administrator at Serenity Assisted Living. </div> <div> </div> <div>“Denise has been very instrumental in developing a philosophy and culture here at Serenity that is built around having highly trained staff who are experts in pain management and in providing support and counseling for all residents and families,” says Anderson. “She has recognized that a person is more than a physical body, and we provide skilled professionals and volunteers to assist with not only the physical needs, but emotional and spiritual needs as well.”</div> <div> </div> <div>Among Tollefson’s outstanding qualities, explains Anderson, are that “she treats everyone as an individual, she believes that it is unfair to classify everyone as the same, and every person out there has their own personality.” </div> <div> </div> <div>In addition, Anderson explains that Tollefson has “an awesome ability to listen as if the listening portion of the assessment is the most crucial part of medicine. Taking the time to hear those words that differentiate us all will allow a medical provider to implement a better plan in treatment and surprisingly enough just the mere fact of having someone to talk to may be all the medicine that is warranted.”</div> <div> </div> <div>What’s more, Tollefson puts the residents first while knowing her own limits and professional boundaries. “She truly is a very unique breed. When one considers that care providers need to meet the many requirements while at the same time possess other innate qualities that enable them to compassionately perform job functions, as per resident wishes and the wishes of their families,” Anderson says. “These special qualities are what make all the difference between average home care providers and excellent senior care providers, and Denise has them and uses them.”</div> <div> </div> <div>Making even more of an impact on her colleagues and on the residents, Tollefson recently implemented a very unique spirituality and wellness program at Serenity. Central to the program, she created a position for a chaplain and found a means to pay for that position and its enriching activities, says Anderson. </div> <div> </div> <div>After surveying the residents, Tollefson realized that they had a need for a spiritual/wellness program. “So we hired a part-time chaplain, who started in October. She does devotions two or three times a week and makes a theme with it,” says Tollefson. “They focus on different topics each week, such as the Sandy Hook school shootings or soldiers in Afghanistan, and they have a spiritually based discussion about it.” </div> <div> </div> <div>Tollefson, who has been with Serenity for seven years in April, came out of college as a writing and communications major and interned at the facility during school. “I never thought I would do this, but the time I spend here is the best fit ever. I think I will always be in long term care.”  </div> <div> </div> <div>Her favorite part of the job: “I like everyday interactions with residents. It’s so homey that you sit down with them every day. They are really important people in my life. We have just 26 residents, and you get to know them really well.  They’re family members.”</div> Provider’s inaugural 20 To Watch continues this month with profiles of seven honorees who shine bright as glittering examples of what’s best in long term and post-acute care today.2013-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0213/top20_thumb.jpg" style="BORDER:0px solid;" />Quality;20 to Watch;Culture ChangeSpecial Feature2
Resident Choice Made Easierhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0213/Resident-Choice-Made-Easier.aspxResident Choice Made Easier<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Now that person-centered care is becoming the new standard in post-acute and long term care settings, providers are increasingly shifting away from the traditional medical model toward a new focus on improving consumers’ quality of life. However, making this cultural shift—to meet individualized psychosocial and physical needs—can be challenging. Providers need practical, efficient tools to translate the vision of person-centered care into on-the-ground reality. </div> <div> </div> <div>A team of researchers and clinicians at a senior care provider in Philadelphia developed a new assessment tool that captures the psychosocial preferences of older adults and speeds the adoption of more person-centered care practices. </div> <div> </div> <div>Known as the Preferences for Everyday Living Inventory (PELI), this useful rubric yields vital data about older adults’ individual preferences for social contact, personal development, leisure, living environment, and daily routine. </div> <div> </div> <div>It can also be used to assess health care access and family involvement in care and to help providers refine and customize care plans and service delivery. </div> <div> </div> <div>Nursing homes may find PELI helpful as they shift from an institutional model of clinical efficiency toward a culture of greater responsiveness to residents’ wishes, interests, and desire for a sense of purpose and control. </div> <div> </div> <div>It provides a useful level of specificity that can be deployed to guide staff training; measure quality improvement; and align services more closely with expectations of consumers, families, and regulatory agencies. </div> <h2 class="ms-rteElement-H2">How PELI Works</h2> <div>PELI consists of 55 questions in five domains of daily life: social relationships, growth and diversionary activities, self-dominion, and enlisting others in care. Fourteen of the questions are consistent with the minimum data set (MDS) 3.0 for nursing homes but delve more deeply into residents’ preferences for everyday living. </div> <div> </div> <div>Phrased in clear, conversational language, the questions elicit basic and in-depth insights about daily preferences, such as what time individuals like to wake up, take a shower, and get dressed, and what kinds of recreational activities they enjoy. </div> <div> </div> <div>Professional and paraprofessional staff can administer PELI in one sitting, or over a series of conversations. Optimally, the questions are asked annually or at more frequent intervals, as well as when a person begins receiving service and experiences a significant change in status.</div> <div> </div> <div>PELI is the first tool of its kind to pass rigorous scientific testing. In 2005, it was piloted with more than 500 home health clients enrolled in the Visiting Nurse Service of New York. The tool proved to be a reliable and valid measure of preferences and was well accepted by a wide range of older adults.</div> <div> </div> <div>An advisory panel of long term care experts concurred that it covered the key aspects of daily life. While PELI has been tested in home health and nursing home settings, it is also designed for use in subacute, rehabilitation, and assisted living facilities. <br></div> <h2 class="ms-rteElement-H2">Residents’ Perspective On Sharing Preferences</h2> <div>In the pilot study, as well as at a 324-bed nursing facility, staff found that residents enjoy reflecting on what is important in their lives and appreciate the opportunity to voice their preferences to an interested listener. These kinds of focused, thorough discussions aren’t the norm in service settings. Yet they are deeply meaningful to consumers and form the foundation for comfortable, trusting relationships with staff. </div> <div> </div> <div>Emerging research indicates that integrating preferences into care delivery for older adults is beneficial. When activities are appealing, or services are provided in a familiar way, seniors are more apt to be receptive, enjoy the experience, and feel validated. These positive feelings have a measurable effect on physical and mental well-being among people of all ages. </div> <div> </div> <div>Data and insights elicited by PELI ensure that the consumer’s voice is heard and help the whole team—client, family, and staff—work together toward the same goals. At the nursing home, matching preferences to activities tripled resident participation in recreational activities. </div> <div> </div> <div>PELI has also been used to assess broad-ranging outcomes. So far, its use has resulted in greater congruence between preferences and activities, leading to fewer behavior issues among residents, as well as reduced levels of depression and fewer falls. </div> <div> </div> <div>Data are being compiled for a more comprehensive study of this dynamic. <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Advantages For Providers</h2> <div>Direct care staff members use PELI to get to know consumers, build relationships, and devise more successful care plans. The questionnaire provides a consistent protocol to discover each client’s unique interests, passions, and priorities. </div> <div> </div> <div>“PELI is a great tool for becoming better acquainted with new residents,” says Sarah Humes, a recreation therapy supervisor. </div> <div> </div> <div>“It’s especially helpful for paraprofessional staff who may not have clinical training because it provides a way for them to learn more about the residents in their care and organize the information.”</div> <div> </div> <div>The nursing home team divides up responsibility for different sections of the PELI questionnaire. Recreation therapists talk to residents about their activity preferences, and certified nurse assistants handle questions about activities of daily living. Staff implement what they learn immediately and share findings at team meetings where they collaborate to customize care plans.</div> <h2 class="ms-rteElement-H2">A Positive Response</h2> <div>Humes says the process also improves job satisfaction. Findings inspire staff to stretch professionally to find ways to honor customer preferences. The tool asks seniors to talk about activities that they enjoy even if they feel that they can no longer do them. When the team understands what interests and motivates residents, they are eager to work collaboratively to prevent them from giving up treasured skills and activities prematurely. </div> <div> </div> <div>PELI findings have also been used to assess individual practice, such as “Am I meeting Mrs. Jones’ preferences this week?” at the unit level. Recreational therapists now aggregate residents’ preferences on each 27-person unit household to plan program offerings that meet the group’s top shared priorities. </div> <div>The resulting household activity board reflects residents’ authentic interests. </div> <div> </div> <div>The nationally recognized Green House Project now uses PELI in its train-the-trainers curriculum for Green House adopters nationwide. Those selected to be educators, including nurses, social workers, and activity directors, practice using PELI with an older adult and create an engagement activity based on interview findings. </div> <div> </div> <div>The exercise gives educators firsthand experience with deep listening and linking preference assessment to care. </div> <div> </div> <div>“PELI provides specificity for a paradigm shift that’s key to forming deep, knowing relationships with elders,” says Susan Frazier, Green House Project chief operating officer. “It helps sensitize direct care staff so they can offer life-enriching experiences that are significant to each elder. For example, residents love being asked not just if they like to read, but what they like to read and how important reading is to them.” </div> <div> </div> <div>A Philadelphia nursing home began using PELI this year to measure delivery of person-</div> <div>centered care. Without a structured system to gauge resident preferences, activity programming reflects the recreational therapist’s best guess as to what a resident wants. Recreational options may be biased or limited by the therapists’ own interests. </div> <div> </div> <div>PELI’s impact is being measured by examining progress on one or more areas of person-centered care in both PELI and the MDS 3.0. Although quantitative data aren’t yet available, anecdotal feedback indicates that preference-based care yields better satisfaction for families, staff members, and especially residents. </div> <div>When a trusted, understanding caregiver presents activities or services in a palatable way, a resident is less likely to become frustrated, confused, or agitated and more likely to become meaningfully engaged. </div> <div>Studies show that staying active and connected socially are closely linked with preventing or mitigating symptoms of depression in nursing home residents. </div> <h2 class="ms-rteElement-H2">Looking To The Future</h2> <div>The Abramson Center research team continues to refine the PELI tool by testing it with diverse populations of older adults. They are also conducting studies on the impact of preference-based care on nursing home residents’ quality of life, as indicated by the presence of depression or behavioral symptoms.</div> <div> </div> <div>The Advancing Excellence in America’s Nursing Homes campaign recently has announced new goals that focus in part on person-centered care. </div> <div> </div> <div>According to Mary Jane Koren, MD, immediate past chair of the campaign, the initiative will include PELI as one of the resources offered to nursing homes as part of its evidence-based toolkit of interventions and educational materials. “It’s an intuitively straightforward tool that’s useful not just for the long-stay population but for the short-stay population as well, because it allows you to frame rehabilitation programs around patient preferences,” says Koren. </div> <div> </div> <div><strong>For More Information </strong></div> <div>Where To Find PELI: Go to: <a href="http://www.abramsoncenter.org/pri/documents/PELIQuestionnaire.pdf" target="_blank">www.abramsoncenter.org/pri/documents/PELIQuestionnaire.pdf</a>.</div> <div> </div> <div><em>Kimberly Van Haitsma, PhD, is director of Polisher Research Institute, Madlyn and Leonard Abramson Center for Jewish Life, Horsham Township, Pa. She can be reached at (215) 371-1895 or at </em><a href="http://abramsoncenter.org./"></a><a href="mailto:vanhaitsma@abramsoncenter.org">vanhaitsma@abramsoncenter.org</a>.</div>Now that person-centered care is becoming the new standard in post-acute and long term care settings, providers are increasingly shifting away from the traditional medical model toward a new focus on improving consumers’ quality of life. However, making this cultural shift—to meet individualized psychosocial and physical needs—can be challenging. Providers need practical, efficient tools to translate the vision of person-centered care into on-the-ground reality. 2013-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0213/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn2
Relationships Matterhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0213/Relationships-Matter.aspxRelationships Matter<div>Despite all the advances in equipment and technology to improve care, leaders should remember that staff and their relationships have the greatest influence on performance. Researcher Jody Gittell, PhD, professor of management at Brandeis University’s Heller School for Social Policy and Management, documented that high-performing nursing homes have as their foundation high-quality working relationships among the staff. </div> <div> </div> <div><div>They found that residents’ experiences are powerfully shaped by relationships among staff and that the relationships among the staff that work closest to the residents matter most.</div> <div style="text-align:center;"><img src="/Monthly-Issue/2013/PublishingImages/0213/mgmt_relationships.jpg" class="ms-rteImage-1" alt="" style="margin:10px 5px;" /></div> <h2 class="ms-rteElement-H2">Communication Key In Relational Coordination </h2></div> <div>The interdependent nature of caregiving work requires what Gittell calls <a target="_blank" href="/Monthly-Issue/2013/Pages/0213/What-Is-Relational-Coordination.aspx">relational coordination</a> (RC). The theory of RC is that the effectiveness of care and service is determined by the quality of communication among staff. </div> <div> </div> <div>The quality of staff’s communication depends on their relationships with each other. This theory is highly applicable to the nursing home environment, where tasks employees perform are closely interrelated. </div> <div> </div> <div>Their interdependence forces staff to work with one another, but if their relationships and communication are weak, then residents’ needs will fall through the cracks and may cause staff conflicts.</div> <div> </div> <div>Leaders’ actions directly shape how well people work together. Effective leaders know the importance of communication and put in place the systems through which people communicate, such as through morning stand-up meetings and shift huddles. Leaders develop people’s communication and critical thinking skills so they know what to share and why it’s important. And effective leaders look for ways that make the work environment one that supports good communication.<br></div> <div><br>For example, eliminating overhead paging so there is less sensory overload enables staff to communicate directly with each other in a more thoughtful way. </div> <div> </div> <div>Systems that support RC among staff are the key to their success, whether it’s stabilizing operations, generating continuous quality improvement, or implementing culture change.</div> <h2 class="ms-rteElement-H2">Five Practices That Support RC</h2> <div>Following are five specific RC practices that provide the organizational foundation for success in any improvement effort:<br></div> <div><br>■ <strong>Relationship-Building Rounds.</strong> It starts with communication through rounds. Leadership makes rounds to check in on people, not to check up on people; foster relational coordination; and demonstrate active caring and listening. Maintaining a regular, timely, positive, problem-solving presence fosters quality communication and positive relationships. While it’s a good sentiment to say, “my door is always open,” requiring staff to come to you with a problem is not as effective as staff knowing they can count on you being present, asking how things are going and what they need.</div> <div> </div> <div>Rounding several times a day helps leaders mitigate staff concerns while they are still small matters, instead of having unchecked problems mount up into major conflicts and relationship breakers by day’s end. </div> <div> </div> <div>Whether working to stabilize a troubled building or launching a new area of improvement, rounding provides the regular positive presence that allows leaders to keep a finger on the pulse of the organization, catch problems early, and intervene effectively.</div> <div><br><img src="/Monthly-Issue/2013/PublishingImages/0213/mgmt_rate.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:5px 10px;" />■ <strong>Consistent Assignment.</strong> When staff work with the same residents and co-workers day to day, they are able to establish deep relationships. However, if assignments are perceived as “unfair,” problems can emerge. Current best practice involves engaging the staff in figuring out the best balance so that assignments are fair and work both for residents and for staff. Ask staff to rank residents by degree of difficulty, in physical and non-physical care. For residents that everyone finds very challenging, consider pairing up and engage all disciplines and departments in problem-solving individualized solutions. <br><br>Many organizations that intend to have consistent assignment struggle with what to do when they have an unscheduled absence. It’s better to localize the disruption through an all-hands-on-deck approach on the short-handed unit, because pulling a nurse assistant away to cover for the absence actually doubles the disruption by affecting two units. To solidify consistent assignment, monitor how many people now take care of a resident and how many times staff are pulled away from their assignment because of an absence elsewhere.</div> <div> </div> <div>Maintaining consistent assignment is easier with systems that make the daily staffing math work out. For example, in a “four on, two off” schedule, three staff can share two resident assignments, with one person serving as the consistent back-up for the other two.</div> <div><div style="text-align:center;"><img src="/Monthly-Issue/2013/PublishingImages/0213/mgmt_schedule.jpg" class="ms-rteImage-2 ms-rtePosition-4" alt="" style="margin:15px 5px;" /></div> <div> </div> <div> ■ <strong>Huddles.</strong> Have the huddles the same time every day so staff can count on them and be on time. Start and end on time, and be brief and on target. When starting with a huddle, consider using the elements of Stop and Watch, the early warning tool developed by INTERACT II as a guide for what to cover. </div></div> <div> </div> <div>One way to get started is to use a huddle to let staff know about any new residents expected or to check in on newly arrived residents. It may be best to huddle on an area that needs work, such as which residents are most at risk for re-hospitalization and what can be done to monitor and safely care for them. </div> <div> </div> <div>At Rosewalk Village of Indianapolis, staff huddle in a small back room and use a white board to note any significant information they need co-workers to know.</div> <div> </div> <div>Consider involving other members of the care team. In a 10- to 15-minute gathering at change of shift, the nurse assistants at an Augusta, Maine, nursing home discuss each resident’s risks, status, and pertinent events of this shift, including quality-of-life events. Nurses identify any acute medical changes and the follow-up plan and address any changes or additions to the plan of care. Several times a week, social work, activities, rehab, and dietary staff join the huddle to discuss needs, risks, and preferences. </div> <div> </div> <div>At a nursing home in South Bend, Ind., the management team takes its stand-up out to the units for a huddle to discuss the 24-hour report twice a week. Use the huddles for teachable moments. </div> <div> </div> <div>When staff share information, it’s crucial to let them know why what they said is important, what they should look for in their care, and to follow up with them as the situation develops. This creates a continuous learning process in which staff get better at catching situations early and knowing how to think them through together. </div> <div> </div> <div>When first starting a huddle, some staff may not know what to share about a resident. </div> <div><br>■<strong> Involving Dedicated Nurse Assistants in Care Planning.</strong> Once consistent assignment is in place, it will become evident that nurse assistants have a lot to offer. They really know their residents. This knowledge is valuable, but it has to be easy for them to share and comfortable to participate.</div> <div> </div> <div>Consider relocating the care planning meeting near where the residents and nurse assistants are located. Let them know when residents are in their assessment reference date period, and, during the shift huddle on the day of the meeting, let the nurse assistants know what time the care plan meeting will occur. </div> <div> </div> <div>Educate them about what information to share in the meeting. Families really appreciate being able to talk directly with their loved one’s primary caregiver.</div> <div><br>■ <strong>Unit-based Quality Improvement.</strong> With huddles in place, when faced with a problem, leaders should consider taking the issue to the unit and getting the staff involved in identifying the root causes that may be evident. </div> <div><br>Leaders can model effective, respectful group problem solving by setting guidelines such as “no finger pointing.” Then use this approach as a platform for enhancing everyone’s critical thinking and problem-solving competence. Stay with it because some staff members may not be comfortable at first. Recognize that “it takes a village,” and that many problems are not just the domain of the nursing staff. </div> <h2 class="ms-rteElement-H2">Systems Drive Outcomes    </h2> <div>Wherever improvement efforts are focused, systems shape the outcomes. The better staff work with each other, the better they can care for residents. It sounds so simple, but RC doesn’t happen by itself. It occurs when leaders put the systems in place to generate “timely, accurate, problem-solving” communication; help staff to develop the skills needed to make the most of these systems; and create an environment that supports staff to talk issues through and problem-solve together. </div> <div> </div> <div>Whether struggling to improve from a one-star rating, reducing antipsychotics, decreasing re-hospitalization rates,or working on culture change, success will come when systems that support and foster RC among staff are used and when those systems are backed up with a leadership approach that brings out and supports what staff have to offer. </div> <div> </div> <div>For more information: Go to <a href="http://www.bandfconsultinginc.com/WhatYouDoMatters" target="_blank">www.BandFConsultingInc.com/WhatYouDoMatters</a>. </div> <div> </div> <div><em>David Farrell, Barbara Frank, and Cathie Brady are co-authors of “Meeting the Leadership Challenge in Long-Term Care: What You Do Matters.”</em></div>Despite all the advances in equipment and technology to improve care, leaders should remember that staff and their relationships have the greatest influence on performance. Researcher Jody Gittell, PhD, professor of management at Brandeis University’s Heller School for Social Policy and Management, documented that high-performing nursing homes have as their foundation high-quality working relationships among the staff. 2013-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0213/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn2
The QIS Experthttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0213/The-QIS-Expert.aspxThe QIS Expert<h1 class="ms-rteElement-H1 ms-rteForeColor-8"><div>Can QIS Methods Help Providers Comply With The New QAPI Regs?</div></h1> <div> <br>While the new regulations on Quality Assurance and Performance Improvement (QAPI) involve processes that go beyond the QIS methods, use of the QIS process addresses many aspects of such a program. <br></div> <div>The next five columns will address how the QIS methods can be used in a QAPI system by showing the parallels between the five elements of QAPI included in the regulation and QIS methods. </div> <div><br>To better understand the QAPI regulation that will be enacted in this year, go to <a href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf" target="_blank">www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf</a>. </div> <div><br>Each column in this series will relate to one of the five QAPI elements, beginning with Element 1, the Design and Scope of a QAPI program:</div> <div><br>“A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. </div> <div><br>“When fully implemented, the program should address all systems of care and management practices and should always include clinical care, quality of life, and resident choice. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or residents’ agents). </div> <div><br>“It utilizes the best available evidence to define and measure goals. Nursing homes will have in place a written QAPI plan adhering to these principles.”</div> <div><br>If this description of the Design and Scope sounds overwhelming, it is! Breaking it down a bit, the first concept is that the QAPI program be “ongoing.” This column has previously described how the QIS process can be used continuously to assess quality in Stage 1 and improve performance in Stage 2. </div> <div><br>The second concept is that a QAPI program must be “comprehensive.” While QIS does not address every single aspect of nursing home care, it does cover the full range of regulations, and through the various assessments and facility tasks it addresses the major “services offered” and “departments.” </div> <div><br>The QAPI requirement to include “clinical care, quality of life, and resident choice” is certainly paramount in the QIS process with the range of assessments in Stage 1, including an emphasis on quality of life and choice. “Systems of care and management practices” are addressed in Stage 2 of QIS when one investigates what underlies problems identified in Stage 1. </div> <div><br>“Aiming for safety” certainly underlies the regulatory aspects of QIS. Aiming for “high quality” requires the use of QIS methods not just to meet the minimum requirements set by Centers for Medicare & Medicaid Services thresholds for the survey process, rather to meet the highest possible quality goals using the same methods. And the QIS offers a unique set of evidence-based measures to “define and measure quality goals.” </div> <div><br>Thus, while not providing a written QAPI plan, the QIS methods capture the spirit of this element of a QAPI <br>program and many of the tools that are needed to meet the intent of the regulation.</div> <div> </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> While the new regulations on Quality Assurance and Performance Improvement (QAPI) involve processes that go beyond the QIS methods, use of the QIS process addresses many aspects of such a program. 2013-02-01T05:00:00Z<img alt="Andy Kramer, MD" src="/Breaking-News/PublishingImages/headshots/AndyKramer.jpg" width="1248" style="BORDER:0px solid;" />Policy;ManagementColumn2
Under The Big Tophttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0213/Under-The-Big-Top.aspxUnder The Big Top<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div><br>Providers are increasingly recognizing the importance of providing a greater array of activities at long term care residences. Playing Lawrence Welk music and holding daily bingo games are becoming a thing of the past as today’s long term care residents become more connected to popular culture, some even bringing their own iPads when they move in.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>America is known for its emphasis on individuality, and that doesn’t change just because people grow older. An activity that enthralls one resident may bore another to tears. When a facility can offer a wider range of activities, residents’ quality of life improves, they become more social, loneliness and depression are lifted, physical health is improved, and the number of medications they require is reduced, studies show.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"> Array Of Activities Good For Business </h2> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>That’s compelling enough to consider broadening the variety of activities, but listen to this: Doing so can even improve the bottom line by appealing to more potential residents—even private-pay residents, according to John Overton, president and chief executive officer (CEO) of <a title="About Pines of Sarasota" target="_blank" href="/Monthly-Issue/2013/Pages/0213/About-Pines-Of-Sarasota.aspx">Pines of Sarasota</a>, Fla., who has had a lengthy career in long term care.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><img width="362" height="239" class="ms-rteImage-2 ms-rtePosition-1" alt="Pines of Sarasota" src="/Monthly-Issue/2013/PublishingImages/0213/Bobireland.jpg" style="margin:5px 10px;" />The active environment of Pines is one reason that the facilities are always at near-maximum capacity, “8 percentage points over the area-wide average,” says Overton. The Pines’ Alzheimer’s residence even has a waiting list, “primarily because of our exceptional programming,” he says. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Since he’s left the for-profit long term care world and taken on a not-for-profit, Overton doesn’t see a big difference between the two kinds of organizations. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“Even though we’re a not-for-profit organization, we still have to run this as a business,” he says, “because if we have a strong mission but no money—we have no mission. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><div>“Furthermore, the folks from our community who donate their hard-earned money want to make sure we’re responsible stewards and that we’ll be around well into the future. They want to know what we’re doing to make sure we’ll be here 30, 40 years from now.”</div> <h2 class="ms-rteElement-H2">Road To Success</h2></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>That philosophy may be why Overton has turned around an organization that was losing money when he was hired as CEO in 2001. Now, Pines of Sarasota is firmly in the black.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“I had two primary goals,” he says. “One: We wanted to become the center for excellence in care so that if you wanted to work in long term care we would conduct ourselves in such a way that you would want to work here.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“Two: If you need the kind of care we provide, we wanted to provide an environment that ensured you’d want to come here. Even though we’ve got a very large Medicaid population, we still have a large number of residents who can go any place in Sarasota that they choose, places with more bells and whistles than we have. Many come here because of the<a title="Quality of Staff" target="_blank" href="/Monthly-Issue/2013/Pages/0213/Quality-Staff-Equals-A-Quality-Experience.aspx"> longevity of staff</a> and the active environment. Those are the factors that we believe are very critical to making it a positive business result.” Doing creative activities that others aren’t doing is just good business, he says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Overton believes that an active, vibrant community full of meaningful activities builds business. Far from being a financial drain, “I see it as a way of being able to help people understand that what you’re doing is different from the norm,” he says. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Not only that, but the wide array of activities helps significantly to overcome the fact that Pines of Sarasota—established 65 years ago—is an older campus without the “glitz and glamour” of newly built facilities, he says. “As a result, even though it’s an older campus—a combination of old and newer buildings—the reality” is that the high demand for placement at the Pines “is because of our programming.” </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </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">Pines Of Sarasota’s Activities Program</h2> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>The number of activities available at Pines requires much more work than one activity director can perform. In fact, Pines puts such <a target="_blank" title="Activities" href="/Monthly-Issue/2013/Pages/0213/Activities-Improve-Physical,-Emotional-Health.aspx">emphasis on activities</a> that Kimberly O’Toole, Pines activities director, has 11 full- and part-time staff members dedicated solely to activities.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“I’m a working manager, constantly on the floor, running groups,” says O’Toole, who is a certified recreational therapist. Often three or more activities are going on at the same time, “but it’s necessary,” she says. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Getting the community involved in the lives of long term care facility residents can result in free or low-cost activities and may help encourage local businesses or individuals to sponsor a program or provide necessary equipment or materials to make those activities happen.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“Seeking out collaborations that can serve as a ‘win-win’ for both parties is the key to success,” Overton says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>For example, Van Wezel Performing Arts Hall, which puts on plays and features other performers such as musicians and magicians, provides free tickets for residents via a grant four times a year. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Players Theatre, a community theater, also gives residents free passes to performances. Pines has worked with a number of other venues to get residents free tickets, such as the local aquarium, Mote Marine Laboratory and Aquarium, which studies manatees and features not only manatees but also dolphins, turtles, and a host of sea creatures that residents can see up close. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>And volunteers and staff together donate tickets for residents to the Marie Selby Botanical Gardens, which features winding paths that lead visitors through rainforests, mangroves, and gardens of exotic plants from around the world, to name just a few of the specialized gardens, dotted throughout with benches and pagodas where residents can rest. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Several refurbished buildings, including a gorgeous mansion, provide opportunities to stop for a cup of tea and a snack.<br><span id="__publishingReusableFragment"></span><br></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </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">Inspiring Laughter, Positive Feelings </h2> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Programs designed to elicit laughter in health care settings have been studied and indicate that the physical and emotional outcomes are more positive when laughter is a part of daily life.<br></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><br>Pines has contracted with a local circus that achieved not-for-profit status by using laughter to help people of all ages, as well as long term care residents. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Circus Sarasota, however, is a real circus and performs several times a year. The money raised from the shows goes to help its not-for-profit mission. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Circus Sarasota’s program is called Laughter Unlimited. Part of the program involves clowns and musicians from the circus visiting residents as many as five times a week, cutting up and cracking jokes, as well as involving residents in conversations about their lives, both past and present.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“The old adage that laughter is the best medicine is clearly in evidence each time we are visited by the Circus Sarasota clowns,” says Overton. “Not only do they make a difference in the lives of other residents, but help to refresh and add laughter to our staff as well.”</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“Studies have shown an increase in cognitive abilities and a reduction, in some cases, in the need for medication” merely from increasing episodes of laughter, says Wendy Leslie, chief development officer for Circus Sarasota. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“Outcomes impact several groups of individuals, including patients, families, staff, and visitors, as well as enhancing the overall atmosphere,” she says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </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">Frequent Intergenerational Activities </h2> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>A major component of Pines’ ability to offer opportunities for residents to interact with children arose from an attempt to meet a completely different need. Pines’ children’s program involves not only a day care center for the children of both staff and the larger community, but a preschool as well. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“It was originally started to stabilize our staff turnover, and achievement of that goal has been dramatic,” says Overton. A published study by a gerontology professor at a local university found that the program had positive impacts on both staff and residents. The day care center, as a business, barely breaks even financially, “yet it is a critical business unit at Pines,” says Overton. A number of key staff would not have been able to stay with Pines without it, and the benefit to the seniors is “monumental,” he says.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>“Children interact with our seniors pretty regularly,” says O’Toole. “They call our residents ‘Grandma’ and ‘Grandpa.’” Pines has many special programs to bring the generations together. “We have a luncheon on Friday afternoons, the children come and sing songs for the residents. Most residents interact with children about twice a week, and some assisted living residents volunteer at the day care center.”</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> <img width="362" height="324" class="ms-rteImage-2 ms-rtePosition-2" alt="Pines of Sarasota" src="/Monthly-Issue/2013/PublishingImages/0213/007.jpg" style="margin:15px 5px;" /><br></div> <div>When O’Toole says “intergenerational,” she isn’t kidding. All age groups are integrated into activities at the campus. Pines’ 200 volunteers include retirees and students from local colleges—some of them there to learn as part of their curriculum and others just to help any way they can. High school students from the Sarasota Military Academy come by, too, some of them every day to play Wii and other games with the residents or to perform tasks that don’t require specialized training, such as passing out resident mail. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Students from an after-school program run by Circus Sarasota, who are learning skills such as juggling, also visit Pines, both to entertain the residents and to spend time just talking with them, says Leslie.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Pines uses music to engage residents in a number of ways.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>One is a drumming and rhythm group, or drum circle. Residents can select their own percussion instrument—anything from djembes (an African drum that rests on the ground and is held between the knees) to, for those who have limitations that restrict their drumming abilities, hand-held shakers filled with beads, other percussion instruments, or just pots and sticks to bang with. </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"> Music Activities Critical </h2> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Circus Sarasota also contributes to the music program, playing songs and encouraging residents to dance. “There are physical prompts and steps to each song,” says Leslie. “It also stimulates memory—I remember being surprised to hear the second verse of ‘Whoops, There Goes Another Rubber Tree Plant’ belted out by a lovely older woman who had lost her sight, but hadn’t lost her smile when she sang.”<br></div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><br>“It’s amazing how it’s all noisy and clattery in the beginning, but by the end of the second ‘song’ they’re all alert and making eye contact” and able to find a rhythm that fits with the dominant beat, she says. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><br>“It’s just magical; it makes me smile for days. And I love that this program can be adapted to everybody’s abilities and skills.”</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><span><img width="234" height="312" src="/Monthly-Issue/2013/PublishingImages/0213/085-1.jpg" alt="Pines of Sarasota" class="ms-rteImage-2 ms-rtePosition-1" style="margin:5px 10px;" /></span>Pines also has a program called Music and Memories every Friday. It’s part of the Laughter Unlimited program. Two clowns and a pianist from Circus Sarasota come to the facility—one of the clowns also plays a banjo—and they sing, make jokes, and do tricks. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Another component of the music therapy program is having the day care and preschool children come over, as they frequently do, and perform songs for the residents.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Fridays brings another musical event during which a music therapist brings a keyboard and residents play Name That Tune while O’Toole and her staff dance around holding residents’ hands and do line dancing and generally “make fools of ourselves,” she says, laughing.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> <br>Twice a week, a professional cellist comes to Pines and plays beautiful and moving classical music for interested residents.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>And music is also used to reduce the anxiety of residents with dementia when it’s time for a shower by piping their favorite music into the bathroom. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Activities that involve music may be the most important. “There is no question that music has the most powerful impact, as it takes you back to memories,” says JoAnn Westbrook, director of Pines’ Education Institute.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </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">Visual Arts </h2> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Pines has a certified art therapist as well as three volunteers who offer several art classes a month, during which residents paint or work with textile art, such as needlepoint. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Even residents with dementia can take part. Say the goal is to paint a sunset: The therapist will take the resident’s hand and help her daub paint on the left side of the canvas and then guideProviders are increasingly recognizing the importance of providing a greater array of activities at long term care residences. Playing Lawrence Welk music and holding daily bingo games are becoming a thing of the past as today’s long term care residents become more connected to popular culture, some even bringing their own iPads when they move in.2013-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0213/coverstory_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Management;QualityCover Story2
About Pines Of Sarasotahttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0213/About-Pines-Of-Sarasota.aspxAbout Pines Of Sarasota<div>Not-for-profit Pines of Sarasota has been in business for 65 years. Its campus is situated on 17 acres—soon to be 25 acres, once a recent acquisition is finalized, says John Overton. </div> <div> </div> <div>Pines—not far away from Sarasota Bay, which is on the Gulf Coast in southern Florida—consists of a number of smallish buildings, some quite old and others relatively new. </div> <div> </div> <div>They include Pine Harbor, an assisted living center with 57 residents; Keys, a 24-bed skilled nursing center; Garden Memory Care Unit, a 42-bed skilled nursing facility for residents with dementia; Veranda, a therapy and rehabilitation center with 38 short-term and long-term beds; and Veranda East, a skilled nursing residence with 22 beds. </div> <div> </div> <div>Other buildings include a child day care center and preschool, one of two thrift stores, a hair salon, the main kitchen, an employee lounge, and maintenance and laundry facilities, along with several administrative buildings. </div> <div> </div> <div>Elsewhere are the second “Fabulous Finds” thrift store and Pines’ Education Institute, which was created five years ago to “help educate caregivers who are struggling at home,” says JoAnn Westbrook, the institute’s director. They accomplish that with seminars, workshops, webinars, and DVDs. </div> <div> </div> <div>The institute works with an internationally known Alzheimer’s trainer, Teepa Snow, and soon will work with neuropsychologist Paul Nussbaum, who is also an adjunct professor in neurological surgery at the University of Pittsburgh’s School of Medicine. </div> <div> </div> <div>And, as do many not-for-profits, Pines of Sarasota is affiliated with a foundation, whose mission is to raise funds to ensure that all residents, regardless of economic status, are able to continue to receive care at the campus. <br></div> <h2 class="ms-rteElement-H2">Sarasota A Major Destination For Retirees</h2> <div>Sarasota has become one of the top destinations for retirees. As a result, the city’s population—about 52,000 and growing in a county of 382,000—has an average age approaching twice that of the nation as a whole. While the national percentage of people over age 65 is 17 percent and Florida’s is 19 percent, Sarasota’s is a surprising 31.6 percent. Competition among nursing homes and assisted living facilities is fierce. </div>Column2

March


 

 

Oral Health Basics, Part 1https://www.providermagazine.com/Monthly-Issue/2013/Pages/0313/Oral-Health-Basics.aspxOral Health Basics, Part 1<div><img alt="iStock_000014189379Medium.jpg" src="/Monthly-Issue/2013/PublishingImages/iStock_000014189379Medium.jpg" class="ms-rtePosition-2" width="1227" height="814" style="margin:5px;width:257px;height:173px;" /><br>It has been more than 150 years since the great pioneers journeyed to Kansas in search of unknown territory and new lives for their families. Kansans have always been strong and hard-working folks wanting to do the right thing for their neighbors, for the right reason. </div> <div> </div> <div> </div> <div> </div> <div>So it’s not surprising that the folks from Kansas have been some of the first pioneers to initiate oral health programs into their long term care facilities.</div> <div> </div> <div> </div> <div> </div> <div>Some Kansas nursing homes have had great success with the BLISS Oral Health Training Program (OHTP) that has been in use over the past 14 years (BLISS, 2007). The program has been copyrighted, and a patent is pending for the software version. </div> <div> </div> <h2 class="ms-rteElement-H2">Program Boosts Quality Care</h2> <div> </div> <div>The OHTP provides and monitors training for nursing home staff by a registered dental hygienist (RDH) who assists them in providing oral care for their residents. At each facility, an RDH trains a team of staff, known as the oral health team. The team is responsible for providing oral health assessments and referrals as needed. The OHTP includes: initial and quarterly oral health assessments; referrals to dentists as needed; identification of dentures; staff oral health in-service presentations; and, most important of all, maintenance of daily oral care for residents who find it difficult or impossible to provide it for themselves.</div> <div> </div> <div> </div> <div> </div> <div>Fourteen years ago, Teresa Achilles, administrator at the Cheney Golden Age Home, was one of the first pioneers to take the challenge of providing a comprehensive oral health program to residents. </div> <div> </div><br> <div> </div> <div><span><img src="/Monthly-Issue/2013/PublishingImages/0313/caregiving2.jpg" alt="OHTP training" class="ms-rteImage-1 ms-rtePosition-2" style="margin:5px;" /></span>The oral health team at Cheney assesses each new resident upon admission using the OHTP protocol. This determines the level of assistance a resident will need to maintain optimal daily oral care. The staff then provide the required support specific to each resident, dependent on the functional or cognitive restrictions of the individual. </div> <div> </div> <div> </div> <div> </div> <div>When there is a change in the functional or cognitive condition of the resident, the level of assistance will also change accordingly.</div> <div> </div> <h2 class="ms-rteElement-H2">Prevention Improves Outcomes</h2> <div> </div> <div>There are numerous benefits to daily oral health for residents, including freedom from discomfort and pain and the ability to enjoy eating and socializing without embarrassment, all of which serve to improve residents’ self-esteem.</div> <div> </div> <div> </div> <div> </div> <div>Maintenance of daily oral health involves removal of dental plaque, which is a natural bacterial biofilm composed of various micro-organisms tenaciously attached to teeth and other oral surfaces (Harris, Garcia-Godoy, & Nathe, 2009). Plaque-related oral diseases are dental caries (tooth decay) and periodontal disease (gum disease). These diseases are not caused by a single pathogenic microorganism. The accumulation of numerous bacterial species makes up dental plaque (Harris et al., 2009).</div> <div> </div> <div> </div> <div> </div> <div>Oral problems experienced by older adults are preventable and can often be detected early. They are not the direct result of aging. Dental caries and periodontal disease are plaque-related, preventable oral diseases. Although these diseases are generally not life-threatening or seriously impairing for most older adults, they can have an effect on the management of medical conditions, general health, nutrition, and quality of life (Blanco-Johnson, 2012). </div> <div> </div> <div> </div> <div> </div> <div>It is important to remember that infections in the gum tissue create an open route to the body’s bloodstream. Oral infection can also lead to aspirated bacteria into the respiratory system. These routes of infection can clearly compromise a resident’s overall health.</div> <div> </div> <div> </div> <div> </div> <div>There are other conditions and diseases that can affect residents’ ability to maintain their own oral health. These include: arthritis, dementia, diabetes, hypertension, stroke, visual changes, and xerostomia (dry mouth). For example, xerostomia is a common side effect of more than 400 medications—many of which are often prescribed for nursing home residents. With dry mouth, there is less saliva, which is necessary to lubricate the soft tissues and aid in chewing, swallowing, and speaking. </div> <div> </div> <div> </div> <div> </div> <div>Saliva also neutralizes the acids produced by bacterial plaque. Without adequate saliva buffering, decay can become rampant. Therefore, if there is inadequate saliva, plaque readily sticks to the teeth, dentures, and partials, making it easier for decay to occur and compromising normal oral function.</div> <h2 class="ms-rteElement-H2"> </h2> <h2 class="ms-rteElement-H2">Individual Needs Should Be Met</h2> <div> </div> <div>In addition to providing assessments and referrals, staff at Cheney Golden Age Home are taught to be aware of the individual needs of each resident, which helps in maintaining optimum oral health. For example, many residents will exhibit gum recession, which exposes the dentin, a portion of the tooth root. The dentin is much softer than the enamel, which is the hard, mineralized outer covering of the tooth. Due to the dentin’s porous nature, it decays much faster than the enamel. </div> <div> </div> <div> </div> <div> </div> <div>In the presence of xerostomia, root decay can rapidly spread, causing pain, abscess, and even tooth loss. Additionally, dentin is sensitive to hot and cold drinks. Many residents are likely to drink more water if it is served to them at room temperature instead of ice cold. In addition, it’s more comfortable to rinse the mouth, after brushing, with room temperature or warm water. </div> <div> </div> <div> </div> <div> </div> <div>Residents who are suffering from dehydration will respond to drinking more water if this simple formula is used: Provide room-temperature water for their use.</div> <div> </div> <div> </div> <div> </div> <div>Maintaining good oral health for residents has provided an amazing array of successes for nursing home residents. Some OHTP testimonies include the following: fewer hospital admittances due to respiratory problems, less-frequent behavioral problems, improvement in overall self-esteem, and enhanced quality of life, especially when oral cancer is detected early.</div> <div> </div> <div> </div> <div> </div> <div>Kansans will continue to be pioneers in the field of oral health. They are well aware that the baby boomers are a population who value maintaining optimum oral health. Once they enter a nursing home, they will expect, and appreciate, the dedicated staff who assist their neighbor with maintaining oral health. </div> <div> </div> <div> </div> <div> </div> <div>“As a result of the OHTP, Cheney has less expense with the purchase of supplements, and since the oral health problems are found in the early stages, less cost once a resident goes to the dentist,” says Achilles. “In addition, it is a great marketing tool for the facility because we are able to say that we offer an excellent oral health program for our residents.” </div> <div> </div> <div> </div> <div> </div> <div>And as many Kansans are fond of saying, “It’s the right thing to do!” <br><br>READ MORE: <a href="/Monthly-Issue/2013/Pages/0313/Paying-For-Dental-Work-In-Long-Term-Care.aspx">Paying For Dental Work</a></div> <div> </div> <div> </div> <div> </div> <div><em>Loretta J. Seidl, RDH, MHS, is president of BLISS & Associates and an oral health consultant for the Kansas Health Care Association and Oral Health Kansas.</em></div> <div> </div> <div> </div>Oral problems experienced by older adults are preventable and can often be detected early. 2013-03-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0313/caregiving_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;Oral CareFocus on Caregiving3
Providers Try To Keep Bearings In Tech Foghttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0313/Providers-Try-To-Keep-Bearings-In-Tech-Fog.aspxProviders Try To Keep Bearings In Tech Fog<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Yogi Berra once said, “The future ain’t what it used to be.” Many providers must know exactly what he’s talking about. Technology is changing so quickly that even the most gifted administrator has vertigo.</div> <div> </div> <div> </div> <div> </div> <div>It’s not just that technology is changing quickly. The demands of it, and from it, are spiraling. </div> <div> </div> <div> </div> <div> </div> <div>Regulators, consumers, and even business rivals are pushing—as well as pulling—new technologies, as well as a new attitude toward technology, and each new innovation introduces new paradoxes. And the thing is—again to quote Yogi—it’s getting late early. </div> <div> </div> <div> </div> <div> </div> <div>“In health care, automation in the billing and the medical records area—I’m not sure even the smallest providers can avoid those types of things,” says Mark Eich, a partner at the auditing firm of Clifton, Larson, Allen. </div> <div> </div> <div> </div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0313/coverstory_hippa.gif" alt="HIPAA" class="ms-rteImage-1 ms-rtePosition-1" style="margin:5px 10px;" />Long term/post-acute care has been slow on the uptake here, especially as regards health information technology (HIT) and privacy laws that were introduced in the Health Insurance Portability and Accountability Act (HIPAA), Eich says.</div> <div> </div> <div> </div> <div> </div> <div>“When HIPAA came around in the late ’90s and was a hot topic in 2000, that group probably yawned at the whole thing, in my view. And I’m worried about that industry segment.”</div> <div> </div> <h2 class="ms-rteElement-H2">Regulators Leading The Way</h2> <div> </div> <div>It’s clear that policymakers want long term care professionals to adopt new technologies and adopt open attitudes to technology. The Affordable Care Act, for instance, requires states to adopt stringent information technology (IT) requirements for Medicaid enrollment. Forty-seven states already have either submitted or been given approval for plans, according to a recent report from the Kaiser Family Foundation. The feds have promised to pay for 90 percent of upgrade costs for now, but the requirements “require substantial investments in IT infrastructure at a time when state fiscal situations remain constrained,” Kaiser said. </div> <div> </div> <div> </div> <div> </div> <div>Meanwhile, Medicare is moving quickly to an all-electronic claims system. The government, notoriously, is way behind business in thinking about, and incorporating, new technologies. So any provider that is behind the regulators here at adopting technology may well find itself in deep trouble. (Not that there aren’t opportunities there for the nimble: A New York Times piece found that the move to electronic billing increased Medicare reimbursement to hospitals by more than $1 billion in 2010.)<br><br>One of the problems when government leads the way is that small providers can find themselves locked out of new progress, experts say. When the government sets the bar for technology, it automatically gives an advantage to the biggest companies, which, because of their size, set the market and the parameters of new technology. For little operators on the outside looking in, even the best innovations can be swallowed by the procurement officers of big-time companies, experts say.</div> <div> </div> <h2 class="ms-rteElement-H2">Ripple Effects</h2> <div> </div> <div>And then there are questions about definitions. Some operators are concerned that, despite the government rhetoric about innovation, they may well find themselves on a tech island. </div> <div> </div> <div> </div> <div> </div> <div>For instance, many new tech developments allow for remote telemonitoring of patients. The question for some futurists is, at what point does a telemonitoring technology cross over from nursing home care to home care? Since the government reimburses at far different rates for the two categories, this question isn’t moot in any event, they say. </div> <div> </div> <div> </div> <div> </div> <div>Even those providers that are able to adapt to new government demands still have to think quickly—as well as differently—about the ripple effect of the new technology. For instance, small providers, especially, are increasingly vulnerable to hackers, says Juli Ochs, an engagement director at Clifton, Larson, Allen. “I think long term care is the next victim,” Ochs says of the sector.</div> <div> </div> <div> </div> <div> </div> <div>For a hacker, getting into a nursing home’s patient records is “a two-fer,” Ochs says. “They can not only get a fraudulent Medicare payment, they can get someone else’s ID.” And since this is a largely elderly and/or largely disabled and/or largely solitary population, the identity fraud can be that much harder to keep up with. The problem is, very few small providers are even aware of how vulnerable they are to hackers, Ochs says. </div> <div> </div> <h2 class="ms-rteElement-H2">Illusion Of Safety</h2> <div> </div> <div>“A lot of these rural homes and assisted living centers, they feel they’re immune to the problems in the cities,” Ochs says. “They’re in a small environment; they know everybody who comes through the door. They don’t understand that there can be somebody sitting in a car with a laptop.’”</div> <div> </div> <div> </div> <div> </div> <div>Just ask the Hospice of North Idaho, which early this year was slapped with a $50,000 fine for violations of patient privacy laws. </div> <div> </div> <div> </div> <div> </div> <div>In 2010, someone stole a laptop from a hospice employee. The laptop had the records of a mere 441 patients in it, but auditors at the Department of Health and Human Services’ (HHS’) Office of Civil Rights (OCR) weren’t amused. </div> <div> </div> <div> </div> <div> </div> <div>The fine is the first of its kind. But it won’t be the last, Ochs says. </div> <div> </div> <div> </div> <div> </div> <div>“When the laptop is stolen, it’s bad enough in itself,” she says. “What’s worse is that they self-report this, then the OCR comes in and looks at them and they get fined because they don’t have policies and procedures in place. If you look at fines from the last year, look at that second sentence in the news release and, over and over again, you’ll see, ‘policies and procedures.’”</div> <div> </div> <div> </div> <div> </div> <div>In Ochs’ experience, many of these providers’ wounds are self-inflicted. </div> <div> </div> <div> </div> <div> </div> <div>“When I go in and work on an audit and start talking about HIPAA, I think they can be very cavalier,” Ochs says. “I think they think, ‘No one’s coming to</div> <div> </div> <div>get us.’”</div> <div> </div> <div> </div> <div> </div> <div>Nothing could be further from the truth, Ochs says. Last summer, HHS published early results from an audit of health care companies’ privacy compliance. Twenty companies were singled out for inadequate privacy controls. Six of them were small businesses with under $50 million in revenue. They were blasted for having “little to no use of HIT—almost exclusively paper-based workflows.”<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2">Compliance Culture Change</h2> <div> </div> <div>That’s the Washington way of giving providers a whiff of grapeshot, Ochs says. What they want is to change the entire culture of long term care, she says. </div> <div> </div> <div> </div> <div> </div> <div>“If you Google ‘Office of Civil Rights’ and ‘culture of compliance,’” she says, “you’ll find out that this is what they’ve been barking about all year. Anytime they can put something in the media and slap [providers’] hand really hard, they will.”</div> <div> </div> <div> </div> <div> </div> <div>IT culture change is easily invoked, but hardly embraced, many experts say. The problem is, that it’s not just government that is pushing and pulling long term care into the 21st century. Consumers are doing it, too. </div> <div> </div> <div> </div> <div> </div> <div>Technology “really does make people feel less isolated,” says Elaine Eshbaugh, an associate professor of gerontology at the University of Northern Iowa. </div> <div> </div> <div> </div> <div> </div> <div>“If I go to a nursing home now, I go in and see people in wheelchairs talking on their cell phones,” she says. “I think we’ve been so slow to jump on that.”<br><br></div> <div> </div> <div>Eshbaugh says she’s astounded at how slowly it’s taking nursing homes to offer wireless Internet service. “I think it’s a no-brainer. I don’t think we ask people to leave their homes and move into a place that we are pushing as their new home and not have wireless Internet,” she says. </div> <div> </div> <div> </div> <div> </div> <div>Everyone in the profession is talking about the so-called “Silver Tsunami” as baby boomers age and move into long term care. Eshbaugh is one of many who say that the boomers, the generation that gave the world Apple and the Internet, simply won’t tolerate 20th century technology in their care environment. </div> <div> </div> <div> </div> <div> </div> <div>“It would make them much more independent,” she says. </div> <div> </div> <div> </div> <div> </div> <div>And it also reduces the burden on caretakers, Eshbaugh says. </div> <div> </div> <div> </div> <div> </div> <div>“My mom was an activity director, and we would always go shopping for things that the residents needed,” she says. “Now those are things that people can order online. A number of older adults use online banking. There are a lot of adults in nursing homes now who will never access the Internet, but I think it’s going to be one of those things that is just considered part of life in the home.”</div> <div> </div> <div> </div> <div> </div> <div>So why have providers been so reluctant to embrace technology? It’s a mystery to Nina Willingham, senior executive director of Life Care Center of Sarasota and a former president of the Florida Health Care Association. </div> <div> </div> <div> </div> <div> </div> <div>“I could not begin to answer,” she says. “During my time as president, I visited numerous facilities and districts across the state and talked about culture change initiatives and person-centered care. If we could give them a recipe of how to get there, it would be so nice.”</div> <div> </div> <h2 class="ms-rteElement-H2">Accommodating Tastes</h2> <div> </div> <div>Willingham, at least, is willing to try a few new spices. The company has applied to the Centers for Medicare & Medicaid Services for a $25,000 technology grant that would bring new (and more) iPads, iPods, Kindles, and other electronic devices for the residents, she says. </div> <div> </div> <div> </div> <div> </div> <div>The idea for the grant came out of resident demand, Willingham says. Her activity director came to her one fine morning and said that the residents wanted a bigger recreation room. </div> <div> </div> <div> </div> <div> </div> <div>The problem was, Life Care’s building dimensions wouldn’t allow for expansion. “When I explained to them we couldn’t do that because of the building, I said to them, ‘Tell me what you want to do?’ We had three focus groups. ‘If you were still at home, what would you do?’”</div> <div> </div> <div> </div> <div> </div> <div>What came back was a Santa’s list of goodies: shuffleboard, pinball, a bigger television, a poker table (the residents love poker, Willingham says).<br><br></div> <div> </div> <div>The problem wasn’t just the space constraints. Pinball machines, for instance, were difficult to get wheelchairs under. </div> <div> </div> <div> </div> <div> </div> <div>Technology, though, provides an answer. iPads and the like have apps that would allow residents to play pinball, poker, and even shuffleboard (though the center has “a nice shuffleboard table” anyway).</div> <div> </div> <div> </div> <div> </div> <div>Kindles and other tablets allow for a nearly limitless electronic library. Seventy-five percent of Willingham’s residents are there on short-term rehabilitation assignments. Most of them are insatiable readers. </div> <div> </div> <div> </div> <div> </div> <div>“We have a nice library … but with the Kindles, it gives us a whole new opportunity for patient satisfaction and happiness,” she says. “We have a couple of ladies who read all the time. But the books are getting heavy, and the print has to be large. It’s difficult.”</div> <div> </div> <div> </div> <div> </div> <div>Willingham had already seen the wonder-working power of the gizmos. The center has three Wii systems (they had to buy extras because there was such demand for the games). One of the elderly residents had a particular affinity for one of the games. </div> <div> </div> <div> </div> <div> </div> <div>“He sat in his wheelchair every day boxing,” Willingham says. “He had the best upper-body strength, and his ADLs [activities of daily living] were great.”<br><br></div> <div> </div> <div>Even if her center doesn’t get the grant, Willingham says she’ll pinch her pennies and buy the electronics piecemeal. “We definitely are moving in the right direction,” she says.</div> <h2 class="ms-rteElement-H2"> Pays For Itself </h2> <div>If government or consumer demands aren’t enough to push or pull long term care into the tech age, business rivalry certainly will. <br></div> <div> </div> <div><br>A few years ago, Tom Kelly, chief executive officer of <a href="/Monthly-Issue/2013/Pages/0313/One-Community’s-Successful-Journey.aspx" target="_blank">Village on the Isle</a> in Venice, Fla., took a look at emerging technology trends and read the writing on the wall. </div> <div> </div> <div> </div> <div> </div> <div>“I’m older than dirt, so I’ve been around a long time,” he says. But “we really determined that the complexities of the Medicare program alone require that we jump into this process. We as a group said, ‘We’ve got to do something.’”</div> <div> </div> <div> </div> <div> </div> <div>In 2008, the Village rebuilt its computer system from the ground up (see page 28).The computer remodel was expensive—about $150,000. But “it’s been [very] profitable.” Not only has employee satisfaction improved dramatically, “staff retention has been phenomenal,” Kelly says, but patient care has been so as well. </div> <div> </div> <div> </div> <div> </div> <div>That doesn’t mean that merely investing in new technology will answer every problem, experts say. In a Provider roundtable reported on in January, Extendicare Chief Information Officer Loren Claypool warned providers against seeing technology “as a field of dreams.”</div> <div> </div> <div> </div> <div> </div> <div>“If you build it, referrals will not necessarily come,” she said. “It’s not about expecting your fair share, it’s about competition. It’s now cut-throat, full-contact, bare knuckles health care where you compete for patients, employees, referrals, and put others out of business.”</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Work Smart And Hard</h2> <div> </div> <div>But just because there is a sense of urgency doesn’t mean that providers can’t be smart in their approach to new technology, Clifton, Larson, Allen’s Ochs says. “New technology” doesn’t have to mean the same thing as “bankruptcy.” </div> <div> </div> <div> </div> <div> </div> <div>There really are shortcuts to better technology (and a better culture of technology), Ochs says: “I don’t know that I personally would advocate for a whole new IT system,” for instance. “I would argue for a full-time, experienced IT person.”</div> <div> </div> <div> </div> <div> </div> <div>As another example, many homes could save themselves a lot of tech headaches by just hiring a privacy and compliance officer, Ochs says. “That’s easy to take care of. You create a job description and send it through your board.” </div> <div> </div> <div> </div> <div> </div> <div>And there are some answers that are even cheaper than that, Ochs says. </div> <div> </div> <div> </div> <div> </div> <div>“Some of the answers are simple, like just changing your passwords. You’d be surprised how many homes I go into and the staff are still using their starter passwords that they got on the first day.”</div> <div> </div> <div> </div> <div> </div> <div>Whatever path long term care professionals take toward more robust technology, sitting out simply isn’t an answer, Ochs’ colleague, Mark Eich, says. </div> <div> </div> <div> </div> <div> </div> <div>“I’m seeing two trends kind of converging on one another,” he says. “One is a tremendous spike on malicious hacking activity. And then on the other side, we’re seeing the increased regulatory scrutiny. You’ve got very troubling trends right there.”</div>It’s clear that policymakers want long term care professionals to adopt new technologies and adopt open attitudes to technology. The Affordable Care Act, for instance, requires states to adopt stringent information technology (IT) requirements for Medicaid enrollment. Forty-seven states already have either submitted or been given approval for plans, according to a recent report from the Kaiser Family Foundation. The feds have promised to pay for 90 percent of upgrade costs for now, but the requirements “require substantial investments in IT infrastructure at a time when state fiscal situations remain constrained,” Kaiser said. 2013-03-01T05:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0313/coverstory_thumb.jpg" style="BORDER:0px solid;" />TechnologyCover Story3
Stars In Their Own Right Part 3https://www.providermagazine.com/Monthly-Issue/2013/Pages/0313/Stars-In-Their-Own-Right-Part-3.aspxStars In Their Own Right Part 3<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><div><img class="ms-rtePosition-1 ms-rteImage-1" src="/Monthly-Issue/2013/PublishingImages/0113/coverstory_thumb.jpg" alt="" style="margin:15px;" /><br>The final seven of this year’s 20 To Watch illustrate the best of long term and post-acute care.<br><br>In the third and final round of <em>Provider’s</em> inaugural 20 To Watch feature are two administrators, a director of health management, two chief executive officers, a dementia care program director, and an owner/administrator. For more information about each of the 20 outstanding individuals featured during the past three months, click <a href="/Monthly-Issue/2013/Pages/0113/Top-20-To-Watch-2013.aspx" target="_blank">here</a>.</div> <div> </div> <div> </div> <div> </div> <div><strong>Sponsored by Silverchair Learning Systems</strong></div> <div> </div> <div><em>Silverchair Learning Systems works with senior care leaders who want to improve key business processes in their organizations. Silverchair Learning offers: Silverchair For Staff, a user-friendly online training solution that improves compliance and eliminates record-keeping headaches; the Employee Feedback System, which easily delivers satisfaction surveys, provides in-depth analysis of results, and offers action tools to help reduce employee turnover; and Silverchair For Families, a resident family education and communication system that helps set expectations and solicit continuous feedback to help providers build strong family relationships and increase satisfaction. </em></div> <div> </div> <div><em>All Silverchair Learning products have been developed to help educate, empower, and inspire the senior care industry and to facilitate a higher quality of care. Silverchair Learning Systems is a Relias Learning company. Visit </em><a href="http://www.silverchairlearning.com/" target="_blank"><em>www.silverchairlearning.com</em></a><em> to learn more.</em><span style="display:inline-block;"></span></div> <div> </div> <div> </div> <div><br><span style="display:inline-block;"><span id="__publishingReusableFragment"></span></span></div> <div><span></span> </div> <span></span><h2 class="ms-rteElement-H2"><span><img width="188" height="221" class="ms-rtePosition-1" alt="Kay Peruski" src="/Monthly-Issue/2013/PublishingImages/0313/KayPeruski.jpg" style="margin:5px 10px;" /></span>Kay Peruski </h2> <div>Administrator</div> <div>Courtney Manor</div> <div>Bad Axe, Mich.</div> <div> </div> <div>Kay Peruski feels very much at home in the long term care setting. “I treat Courtney Manor like it’s my home,” she says of the 112-bed skilled nursing center where she is administrator. “This is my hometown, with people I know; it’s very important to me.” </div> <div> </div> <div>Home, indeed. Peruski has been at Courtney Manor for some 26 years. “Dedication and commitment are two words to accurately describe Kay,” says Dan Echler, regional director of operations for Ciena, the company that owns Courtney Manor. “Under Kay’s leadership, Courtney Manor received the Calvin H. Monfils Facility Excellence Award from the Health Care Association of Michigan in 2010 and a Bronze [National Quality] award from the American Health Care Association in 2011.” </div> <div> </div> <div>Courtney Manor has also been recognized as one of the “Best in Bad Axe” by local business owners for the past five years in a row.<br> </div> <div>Peruski describes herself as “approachable” and customer-service oriented. “I let employees know my expectations. I want everyone to feel welcome and secure in leaving their loved one here. I’m always looking for a way to improve things and try something different.”</div> <div> </div> <div>This approach has paid off for Peruski. When Ciena developed eight best practices for all of its homes to incorporate, six of those eight were ideas spawned at Courtney Manor. </div> <div> </div> <div>Peruski is proud of her staff as well. “I get a lot of compliments on the staff on how friendly they are and how helpful they are. I always tell them, ‘You will not get into trouble for doing something for someone, but you will for not doing something [to help a resident or family member].’ They are very accommodating to families, especially at the end of life.”</div> <div> </div> <div> </div> <div><strong>What It Takes</strong></div> <div> </div> <div>Having worked with Peruski for 20 years, Echler says she turned around a facility through innovative ideas and outside-of-the-box thinking.<br></div> <div>Leading a nursing center like Courtney Manor requires people and problem-solving skills, says Peruski. “You have to be able to deal with a family that is frustrated and sit down with them. I think that makes them feel confident that they’ve made the right choice. And you really have to be able to read people. And if you treat people right and take good care of them, all the rest comes. The staff, longevity, we’ve got a lot of staff who’ve been here for years. If you get the people part right, the rest of it will come.”</div> <div> </div> <div>Peruski has passed on her passion about long term care to her two sons, both of whom work in nursing homes as well. “My younger son is an administrator at Ciena at Waterford, and my other son is an administrator in training.”</div> <div> </div> <div>When asked what she would do if she couldn’t do her job, Peruski is at a loss. </div> <div> </div> <div>“I couldn’t tell you what I would do. If I didn’t do this, I don’t know; it’s just my life now. This day-to-day contact, the things that I enjoy the most, spending time with families and residents, that part would be missing.”</div> <div> </div> <div> </div> <div> <span class="ms-rtestate-read ms-reusableTextView">:##:</span></div> <div> </div> <h2 class="ms-rteElement-H2"><img width="188" height="235" class="ms-rtePosition-1" alt="Jeffrey Philbrick" src="/Monthly-Issue/2013/PublishingImages/0313/JeffreyPhilbrick.jpg" style="margin:5px 10px;" />Jeffrey Philbrick</h2> <div>Co-owner/Administrator</div> <div>Colonial Poplin Nursing and Rehabilitation Facility and </div> <div>Poplin Way Assisted Living</div> <div>Fremont, N.H.</div> <div> </div> <div>Long term care is a family affair for Jeffrey Philbrick. His first job was as a cook at his parents’ rest home at the age of 15. “I held one title or another part-time since then, working during school breaks,” says Philbrick. “I started working full-time after college, in 1989, as the assistant administrator of Colonial Poplin, the family-owned and -operated skilled nursing facility. I took over as the administrator after my father’s death in 1996, and as co-owner with my brother after our mother passed away in 2002.”</div> <div> </div> <div> </div> <div>The family business, in fact, reaches back three generations: “My maternal grandfather opened one of the old-fashioned rest homes in the early ’70s where he and his wife lived and cared for about 10 elderly people. My parents bought that from them in 1979 and ran it for four years before they built and opened Colonial Poplin,” says Philbrick.</div> <div> </div> <div>Philbrick recalls he was always helping out around the grounds, mowing, shoveling, or plowing, as well as filling in shifts in dietary or activities. And although he flirted with the idea of moving to New York City, he realized that his calling was back in New Hampshire. </div> <div> </div> <div>Philbrick credits his mother with instilling in him the importance of treating residents with reverence.</div> <div> </div> <div>“Her strongest lessons to me revolved around how important it was to treat people as individuals and with respect. That people—residents, family, and staff—not money, were the foundation of a strong, rewarding business.” </div> <div> </div> <div>Natalie Gaudet, administrator at Poplin Way Assisted Living, lauds Philbrick for his foresight and ability to recognize the needs of the elders in the community. “In 2002, Jeff added an assisted living community, and since its inception, it has maintained an occupancy rate of over 98 percent, has met or exceeded its budgeted profit margin, and has achieved deficiency-free state surveys,” she says. </div> <div> </div> <div>“The underlying formula for success has been Jeff’s devotion both to the residents and his staff. He has implemented both employee wellness and incentive programs, making the employees vested in the company and in the seniors they serve.”</div> <div> </div> <div>As a leader, Philbrick respects his staff and encourages them to respect themselves and each other. “I believe firmly in leading by example and not asking others to do what I am unwilling to do myself,” he says. “I listen closely to what my staff have to say; offer advice, insight, and direction where needed; and then trust my staff to stay on task and succeed.”</div> <div> </div> <div>Both communities have come a long way in the past decade, says Philbrick. When his mother passed away 11 years ago, Colonial Poplin had a staff of 35. “Today, Colonial Poplin and Poplin Way have a combined staff of 135. Such growth required a lot of hiring, and not all of our hires were the best. Over time, by clarifying our expectations of the staff and working hand-in-hand with management and frontline-level employees, we have forged an excellent, caring, dedicated professional staff,” he says.</div> <div> </div> <div>“As the owner, my family name is inextricably linked with everything that goes on in my [centers],” Philbrick says. “I sleep soundly at night knowing that I can trust my staff to do what is best for the residents at all times. That affords a level of security that has value no dollar sign can define.”<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><img width="188" height="234" class="ms-rteImage-1 ms-rtePosition-1" alt="Natalie Zeleznikar" src="/Monthly-Issue/2013/PublishingImages/0313/NatalieZeleznikar.jpg" style="margin:5px 10px;" />Natalie Zeleznikar</h2> <div>Chief Operating Officer </div> <div>Five Star Living</div> <div>Duluth, Minn.</div> <div> </div> <div>Having been a nursing home administrator for a number of years, Natalize Zeleznikar knew her way around long term care. But when her grandmother needed 24-hour assistance, Zeleznikar realized that there was nothing in the area to accommodate her, and her parents had promised her she would never be in a nursing home. </div> <div> </div> <div>“I grew up on a farm where my great-grandparents, taking care of them and helping them, was very much part of our lives. From nine years old and up, I was exposed to that. My parents took care of their parents on the farm. But it wasn’t feasible for my parents to do this for my grandmother. She had become bedbound, and my only other option was to have her stay in her apartment and hire 24-hour care.”</div> <div> </div> <div>So Zeleznikar came up with a solution: She would build a new home. And build she did. Within six months, Zeleznikar had built a 10-bed assisted living community, much like a “miniature Keystone Bluff” (the nursing home where she worked at the time).</div> <div> </div> <div>"We took the best of Keystone but created a small home,” she says. “Grandma had all of her belongings with her, and we recreated her room the same way it was in her apartment. We integrated the best of smaller setting nursing homes so that it feels like home.”</div> <div> </div> <div>Zeleznikar borrowed from the Green House and Household models to create the home for her grandmother and nine other residents. She also picked sites that enable residents to see outdoors. The homes (there are now 10) are small in size with a great room and fireplace in the center. “We let seniors bring their pets with them. That’s been really important to families and residents,” says Zeleznikar. “We also have a high staffing ratio in each home.” </div> <div> </div> <div>“My goal is to give people a great ending. They’ve had their life, so I want give them a calm atmosphere that’s not overstimulating. Many homes are designed for memory care and dementia. But half have dementia and half have other needs and are eligible for nursing homes. I designed a building to handle them on their worst days, not just their best days. And having fewer people under one roof creates a more intimate setting.”</div> <div> </div> <div>The building was filled in one day, according to Zeleznikar. </div> <div> </div> <div>Zeleznikar’s dedication to creating a caring atmosphere for residents has won praise from staff. “She may be an owner of the company but you would never know it when she shows up on site at one of our facilities,” says co-worker Brenda Marshall. “She can be found doing residents’ hair, playing the piano, or holding a dying person’s hand so they don’t have to be alone in the last chapter of their life. She sets an amazing example for others to follow.”</div> <div> </div> <div>Marshall notes that when she thinks of all the Five Star employees who do a great job, “the most dedicated, and the person who continually goes above and beyond, is Natalie.”</div> <div> </div> <div>One example of this is an activity program Zeleznikar developed recently. “She wanted to honor our seniors and developed a traveling suitcase program with themes such as weddings, patriotism, and back to school. She filled those suitcases with items from the past to match the themes. The 25 suitcases are moved from facility to facility within the company.</div> <div> </div> <div>Marshall also gives kudos to Zeleznikar for making the corporate office a “support service” office to let all staff know they are available to them at any time. </div> <div> </div> <div>“Natalie has answered her phone at many hockey games, meeting breaks, family gatherings, and at all hours of the day,” Marshall says.</div> <div> </div> <div><span class="ms-rtestate-read ms-reusableTextView">:##:</span></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><img width="188" height="209" class="ms-rtePosition-1" alt="Elizabeth Davis" src="/Monthly-Issue/2013/PublishingImages/0313/ElizabethDavis.jpg" style="margin:5px 10px;" />Elizabeth Davis</h2> <div>Owner/Operator</div> <div>Bright Side Manor Assisted Living</div> <div>Teaneck, N.J.</div> <div> </div> <div>Affordable assisted living is Elizabeth Davis’ mantra. After working as a social worker in New York City in supportive housing for elders, Davis saw many seniors who didn’t need a nursing home but couldn’t afford to live independently. </div> <div> </div> <div>“We would have nowhere to send them,” Davis says. “We also made home visits, and some boarding homes were substandard. The physician I worked with at the time and I decided to buy a property that already met all of the life safety codes in place, and we found Bright Side Manor.” </div> <div> </div> <div>At the time, it was a “rundown” 50-bed residential health care facility that needed a lot of work, says Davis. “It was a nice community, and we felt it had great potential. The owners were very committed to selling to people who would not force the existing residents to leave—so we took over a management contract with the commitment to buy it when we had the funds.” </div> <div>  </div> <div>In 1990, Davis and her colleague took over the operations of Bright Side and applied for nonprofit status with the Internal Revenue Service. </div> <div> </div> <div>“We had very little capital and knew we would have to work hard and fast at cultivating community support,” Davis says. “We got grants and volunteers to help paint and decorate. We also began raising the bar in terms of staffing.”</div> <div>  </div> <div>Eventually, the state assisted living regulations were in place, and Bright Side was approved as an assisted living community, which meant that they could get reimbursed under Medicaid. However, raising money and getting approval for a major construction project was long and hard, Davis notes. In the end, they completed a $5 million construction project, all while the residents stayed there. </div> <div> </div> <div>“We now have a very committed board of directors. It’s been a labor of love. Half of the residents are here under Medicaid, and anyone can come in under Medicaid. Our private rate is consistent with Medicaid. It’s challenging, but somehow or other we do it.” </div> <div> </div> <div>Davis recognizes her “incredibly dedicated staff” for maintaining the mission and keeping things together. “We know each other, and we all have lot of fun together. We get support from churches, synagogues; it’s a very rich environment. Anyone can come here—money is never a factor,” she says.</div> <div> </div> <div>“In addition to her daily work of running a state-licensed health care facility, Davis continually seeks new and creative ways to ensure that seniors have options,” says co-worker Erika Kao. “She has developed a program that allows her to use a government grant to ‘subsidize’ residents whose incomes are too high to qualify for Medicaid but too low to pay Bright Side’s lowest rate, which is sometimes half of what one might pay in a traditional assisted living facility. She meets with elected officials to push for the Medically Needy Program to pay for not just nursing home and home care, but also assisted living, because there are many older adults who can’t stay at home but who don’t need to be in a nursing home.”</div> <div> </div> <div>If that weren’t impressive enough, Bright Side has become a placement field site for Columbia University School of Social Work. “During a time when the number of social workers committed to the aging population appears to be shrinking—despite that the population is growing—Davis has devoted her entire career to this underserved population,” says Kao. “I never dreamed this career would take me down the path it has taken me. I think that social workers—as we face ongoing economic challenges—will find ways to create the programs to address the needs and solve the problem,” Davis says.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><img width="188" height="234" class="ms-rtePosition-1" alt="Vivan Booker" src="/Monthly-Issue/2013/PublishingImages/0313/VivianBooker.jpg" style="margin:5px 10px;" />Vivian Booker</h2> <div>Director of Health Management </div> <div>Mt. St. Francis Nursing Center</div> <div>  </div> <div>As 10 wildfires raged across Colorado last summer, nursing homes and assisted living facilities were forced to escape the flames via evacuation. Leading residents and staff through the crisis at Mt. St. Francis Nursing Center was Vivian Booker, director of health management. </div> <div> </div> <div>“She made sure her staff had everyone prepared for evacuation as the residents were dispersed to 10 facilities,” says colleague David Skipper, Colorado Health Care Association. “She followed every resident to each facility, spending nights without sleep while making sure that they were being integrated into the receiving facilities as best as possible. She wanted to be certain that all were safe. </div> <div> </div> <div>“She followed up with families to reassure them their loved ones were well cared for and not in harm’s way.”</div> <div> </div> <div>But Booker is more modest about her role. “The real story should be about the long term care community instead of someone who just happens to have a higher title. This is really an inspiring story of communities that exist everywhere in this country. People who care about who they serve and what they do, people who don’t always get the recognition they deserve.”</div> <div> </div> <div>Instead of talking about herself, Booker insists that the focus should be on the administrator and employees who had “so much courage, determination, and heart when evacuating out residents under a very stressful situation.” </div> <div> </div> <div>“Many received the mandatory alert to evacuate their homes at the same time we learned of the immediate evacuation,” says Booker. </div> <div> </div> <div>“Those employees didn’t leave, and employee titles disappeared that night—business office, housekeeping, culinary, and others didn’t leave.” Instead, says Booker, they pushed wheelchairs, held hands, and maintained a sense of calm and support by just being there. </div> <div> </div> <div>Booker, who also serves as chair of the Colorado Health Care Association Quality Initiatives and Leadership Committee, “is the unassuming individual that provided quality leadership and determination at a moment’s notice and provided guidance and continuity throughout the crisis,” says Skipper. </div> <div> </div> <div>“Employees in receiving centers prepared beds and food to shelter our residents and welcomed us into their homes. Many of their employees also had mandatory evacuation notices, and in the days following, our residents and employees would be spread in a 100-mile radius not knowing if they still had a home, whether they would still have a job or be paid for any of their work,” says Booker. </div> <div> </div> <div>“Some employees traveled 60 miles round trip to assure their residents would have a known caregiver. They gave each other hope and strength to persevere, care for their residents, and show a familiar face. They built new friendships, adapted to new environments, and became part of a family in the other locations. All our employees in all departments went to these centers each and every day to not interrupt routines and to help the other centers’ employees meet our needs and those of their own residents.”</div> <div>  </div> <div>“Booker had enough foresight to call upon the resources of the entire long term care community and coordinated the disbursement of the residents with their needs in mind,” Skipper says. “Once the residents could return to their facility, she was faced with the daunting task of making the facility safe and ready for their return.”</div> <div> </div> <div>In her debriefing with residents, one resident said it all, Booker recalls: “She said, ‘We woke up in a different place but you were all still there! You were always with us.’ This is the long term care community in Colorado who really deserves this recognition.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><img width="188" height="248" class="ms-rteImage-1 ms-rtePosition-1" alt="Heather Lemoine" src="/Monthly-Issue/2013/PublishingImages/0313/HeatherLemoine.jpg" style="margin:5px 10px;width:185px;height:244px;" />Heather Lemoine, RN</h2> <div>RN Program Director</div> <div>Bridges Memory Care</div> <div>EPOCH Assisted Living at Melbourne</div> <div>Pittsfield, Mass.</div> <div> </div> <div>After 10 years as the registered nurse (RN) program director for a dementia care program, Heather Lemoine is still excited about her job. “I like it very much,” she says. “I enjoy helping people. I think in some ways I was destined to go into this field of practice in nursing because my own mother was diagnosed with the disease, and I’m a family caregiver now as well.”</div> <div>  </div> <div>Lemoine’s co-workers are more than happy to have her with them. “Heather’s compassion for EPOCH residents is endless. Despite her role as a busy RN, she will always take the time to help or explain something to residents when the need arises,” says Elane McNabb, director of community relations. </div> <div> </div> <div>“Sometimes when she is answering questions for a tour, residents come up to her and say they need something. Rather than shrugging them off and saying she’ll help them later, Heather puts an arm around their shoulders and helps them find someone who can help,” McNabb says.</div> <div> </div> <div>“Heather has helped grow our Bridges program into a top-notch program that provides the best, most compassionate care available for those with memory-related illnesses. In Berkshire County, Bridges at Melbourne is well-known and respected. Often when I tell people I work at Melbourne, they say that it’s such a great place and that their relative was in the Bridges program and received amazing care. </div> <div> </div> <div>Then they’ll ask if Heather still works there, because Heather was a big part of providing their loved one with a warm, welcoming home and the care they needed and deserved.”</div> <div> </div> <div>EPOCH Assisted Living at Melbourne is a community that prides itself on promoting each resident’s independence with “personal care packages” that are tailored to meet the individual needs of the residents. McNabb credits Lemoine with maintaining the community’s excellent reputation.</div> <div> </div> <div>“For many adult children, placing a parent with dementia or memory impairment into a senior living community is scary,” says McNabb. “Some, at least initially, even view memory care programs like Bridges as horrible, dark, dreary places. When they walk into Melbourne, they feel they’re giving their parents the death sentence. But when they meet Heather, the fear subsides. She takes the time to sit down with families, explain the program, and answer all of their questions. After talking to Heather, people realize that there is hope for their parents to maintain a quality of life and dignity through an obscure journey. They come to trust that Bridges is a quality program with caring, compassionate staff members who will provide their parents with a safe, comfortable home.”</div> <div> </div> <div>Lemoine believes that being helpful and fair, and her efforts to help staff “as much as I can,” are the reasons for her nomination to 20 To Watch. But those would be understatements, according to McNabb. “Her love and devotion to our residents is unmistakable and is a positive influence on all those who work and live here. Watching her interact so patiently and warmly with the residents is very reassuring to everyone, including me. I’d want my own mom to live here.</div> <div> </div> <div>“Heather demonstrates tireless compassion and an innate ability to radiate hope and love to families and their loved ones who are dealing with this difficult life transition. In addition, her staff clearly appreciate her responsiveness, clear direction, and leadership qualities, which shows in their work.<br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><img width="188" height="257" class="ms-rteImage-1 ms-rtePosition-1" alt="Tim Dressman" src="/Monthly-Issue/2013/PublishingImages/0313/TimDressman.jpg" style="margin:5px 10px;" />Tim Dressman</h2> <div>Chief Executive Officer (CEO)</div> <div>St. Leonard Senior Living</div> <div>Centerville, Ohio</div> <div> </div> <div>Like many who work in the profession, Tim Dressman’s devotion to it is rooted in his upbringing. “My dad told my brothers and me we were getting jobs in the nursing home, so we all worked in the same nursing home when we were young,” says Dressman. “Today, all my other brothers are in community service in one way or another.”</div> <div> </div> <div>Dressman, whose first job in that nursing home was as an elevator operator at 13 years of age, has held onto that lesson through every job he’s had. As a Navy man, he earned his degree in health care administration and then worked in a hospital as an auditor. After auditing a nursing home, he wondered if he could run it better than the administrator could. </div> <div> </div> <div>“So I got a nursing home license and was placed at a nursing home where I stayed for 11 years,” says Dressman. “It’s one of those jobs where you walk in and you know you were meant to be there.” Nursing home administration is not a job that you go to from eight to four and then leave, he says. “It’s truly a vocation. You have to love what you do.”</div> <div> </div> <div>“Tim has a quest for knowledge and a strong desire to improve processes and performance with knowledge, mentoring, and innovation,” says Debra Stewart, director of wellness at St. Leonard. “Tim’s spirit of innovation is what captures the attention of his employees, because they know that he will lead from a pivotal point and allow others to succeed on their own merit.” In the 12 years that Dressman has served as CEO of St. Leonard, he has implemented a number of innovative programs, including a behavior-based ergonomic dementia care program and a wellness initiative.</div> <div> </div> <div>Dressman also has taken advantage of local universities to garner interns and other fruitful partnerships. In addition, he teaches other individuals interested in becoming long term care administrators at a local college, Stewart notes.</div> <div> </div> <div>“The awards that Tim has won are too numerous to count, but the awards that he has written to nominate his employees are even more,” she says.</div> <div> </div> <div>Dressman enjoys his job immensely, but what he enjoys most is seeing employees and co-workers succeed. “I like to see all of our employees succeed and try to give them the credit they deserve,” he says. “I have a lot of great employees who give me a lot of great ideas. They all have great ideas, and if you listen they can open doors for you to new ways of doing things.”</div> <div> </div> <div>Among Dressman’s standout leadership qualities are humility, the ability to listen, a humble approach “that you don’t stand above the rest of your people and that we are all equal partners in providing care to our residents and others.” </div> <div> </div> <div>Dressman also prides himself in being open-minded. “I thank my dad for giving me the gift of being able to talk to all kinds of people of all socioeconomic levels,” he says. “He made us appreciate everyone as people.”</div> <div> </div> <div>Dressman also is grateful for his work with the American College of Health Care Administrators, the professional organization for long term care administrators. </div> <div>  </div> <div>As Stewart puts it: “Tim is a confident leader, who also projects a positive ‘can do’ spirit toward the various teams at St. Leonard. He has a quest for knowledge and a strong desire to improve processes and performance with knowledge, mentoring, and innovation.”<span style="display:inline-block;"></span></div> <span></span>The final seven of this year’s 20 To Watch illustrate the best of long term and post-acute care. In the third and final round of Provider’s inaugural 20 To Watch feature are two administrators, a director of health management, two chief executive officers, a dementia care program director, and an owner/administrator. 2013-03-01T05:00:00Z<img alt="" height="150" src="/Monthly-Issue/2013/PublishingImages/0213/20towatch2.jpg" width="150" style="BORDER:0px solid;" />Caregiving;Management;Quality;20 to WatchColumn3
One Community’s Successful Journeyhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0313/One-Community’s-Successful-Journey.aspxOne Community’s Successful Journey<div><span><span><span><img width="374" height="280" class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/FrancesBonAmi.jpg" alt="FrancesBonAmi.jpg" style="margin:5px 15px;" /></span></span></span>When Village on the Isle, Venice, Fla., redesigned its technology, company Chief Executive Officer Tom Kelly had a simple rule: no bosses allowed. “There were no managers in the meetings,” he says. “The vendors had to prove their works to our people. The only thing our staff was told was, ‘Pick out the thing that you think will work the best.’”</div> <div> </div> <div>The staff duly met with vendors and asked Kelly for … the most expensive system. “But because it was chosen by the staff and so enthusiastically endorsed, the people who chose it were their peers, we went with it,” Kelly says. “They went back and convinced everybody that this was the greatest thing since sliced bread.</div> <div> </div> <div><span></span>“Having been in the business for 37 years, I knew that if I had somebody telling me what to do, I’d resent it,” he says. “And I figured, if I resented it, why wouldn’t these people” as well?</div> <h2 class="ms-rteElement-H2">‘Money We Were Throwing Away’</h2> <div>Whatever hesitation Kelly and management had about spending $150,000 up front on new technology, they’ve since had their answer. “It’s worked beyond our wildest dreams,” he says. “The payback on it in improved revenue earned enough in the first 14 months that it totally paid for the rest of the EMR [electronic medical record] implementation. We didn’t realize how much money we were throwing away.”</div> <div> </div> <div>Village Administrator Elaine Boyer says that the new systems have not only improved staff morale and saved countless hours; it has also been “much safer for the residents.”</div> <div> </div> <div>“The nurse just scans the medication, and if it’s a wrong medication or a wrong time or anything, the computer alerts them to that,” she says. The computer displays pictures of both the appropriate medicine and the resident.</div> <div> </div> <div>“If there’s been a change in orders or something, they are visually alerted immediately by the computer,” Boyer says. “If there is a potential of a negative interaction between medications, the computer gives out strident warnings. It really enables the nurse to use the tools that are available but aren’t typically available in a nursing home.”</div> <h2 class="ms-rteElement-H2">Piecemeal Revolution</h2> <div>If what has happened at the Village is a tech revolution, it wasn’t an abrupt one, Kelly says. “We really quickly figured out that the first thing we needed to do is, we need to piecemeal this in so you don’t overwhelm anybody,” he says. </div> <div> </div> <div>Too many providers foist their technology on the staff, Kelly says. </div> <div> </div> <div>“They want to bring in a big, canned system and say, ‘Here it is. You’ve got a month, two months. Get confident,’” Kelly says of many long term care executives. “You’ve got management that thinks they’re smart. And I’ve told my colleagues that they’re not as smart as they like to think they are.”</div> <div> </div> <div>And the Village’s tech price tag could have been higher. But the company decided to keep its main operating system, instead seeking vendors that could integrate pharmacy, time and attendance, and other systems with the home’s operating system, Kelly says. </div> <div> </div> <div>“Nobody has the perfect system. There are a lot of different components that are really optimal,” he says.</div> <h2 class="ms-rteElement-H2"><div>High Tech At Low Cost</div></h2> <div>Cases like the Village prove that high tech doesn’t have to mean high cost, says Juli Ochs, engagement director at the auditing firm of Clifton, Larson, Allen. “I don’t know that I personally would advocate for a whole new system,” she says. </div> <div> </div> <div>One of the best tech solutions might come from the lowest tech resource: a human being, Ochs says. “I would argue for a full-time, experienced IT person,” she says. Companies are going to want “somebody who knows their needs and where they need help. My guess is, a lot of them are doing a lot of things right.”</div> <div> </div> <div>Privacy and compliance officers can also make life easier for homes, as well as drawing up a disaster recovery plan. “It’s the slow process of going through and assessing the risk, whether they hire somebody or they do it themselves,” she says. “Taking care of things on the front end will help make sure that there’s no panic at the back end.”</div> <h2 class="ms-rteElement-H2">Anchor Institutions?</h2> <div>There may even be ready cash for those providers that are ready to embrace modern technology, says Elaine Eshbaugh, associate professor of gerontology at the University of Northern Iowa. A home not far from her campus has just won a federal grant to buy computers for its residents. </div> <div> </div> <div>The Federal Communications Commission, in fact, has set aside millions in broadband grants for what it calls “anchor institutions”—schools, libraries. There is no reason that a community nursing home couldn’t be considered an anchor institution, experts say. </div> <div> </div> <div>“Until recent years, we’ve been just so concerned about meeting the minimal needs in the home,” Eshbaugh says. “With the baby boom generation coming up, we’re going to have to do better than that.”</div> <h2 class="ms-rteElement-H2">Culture Change</h2> <div>Back at the Village, the tech upgrades have led to a culture that’s increasingly open not just to new technology but to new ideas. Expensive ergonomic chairs, for instance, have slashed back injuries for the staff, Kelly says. “The changing future is going to require people to do business differently. I knew the technology existed. It was just a matter of making it happen,” he says.</div> <div> </div> <div>Elaine Boyer, the Village’s administrator, says that “when I saw the potential” of new technology, “I was tremendously excited.” But the staff response has exceeded even her expectations, Boyer says. </div> <div> </div> <div>“It brings the job into the current century,” she says.</div> Column3

April



 

 

Oral Health Gives People Something To Smile Abouthttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Oral-Health-Gives-People-Something-To-Smile-About.aspxOral Health Gives People Something To Smile About<div>One need only look around the majority of long term care facilities to see the prevalence of women residents. As women age, by age 85, they outnumber men at least two to one. Aging accounts for the loss of social support—including spouses, partners, friends, and family members—which may result in the need for help with daily care, including oral care. With aging comes a higher risk for oral diseases, regardless of gender. </div> <h2 class="ms-rteElement-H2">Men, Women Differ In Needs</h2> <div>Clinicians know that increased medications often mean a decrease in spit or saliva. Most people don’t realize or value the important role that saliva plays in protecting their teeth and mouths. Various chronic diseases, such as arthritis or stroke, can make it more difficult for elders to clean their mouths. These chronic diseases may result in residents needing assistance with their daily oral hygiene care.</div> <div> </div> <div>There are subtle differences in oral health between men and women as they age. Men have slightly higher levels of active oral disease, such as cavities (dental caries) and gum (periodontal) disease, when compared with people under the age of 65. However, the amount of dental care men and women receive over a lifetime is about the same. This mirrors the medical fact that in most studies, older women may have better health outcomes than men, even when treatment was the same or less.</div> <div> </div> <div>Women as a group, especially older women, make up the majority of adults living in poverty. Older women’s loss of social support combined with poverty may result in their entering long term care with poorer oral health. It is also important to know that most women, whether they have worked outside the home or not, have been called upon to be caregivers at some point in their lives. This role may spill over into how they choose to care for themselves and their oral health. </div> <div> </div> <div>Research shows that women are more likely to prefer prescription drugs over invasive treatment, and though the reasons are not clear, it suggests they may be making less stressful, less invasive choices in order to accommodate their daily lives. </div> <h2 class="ms-rteElement-H2">Providers Should Encourage Daily Care</h2> <div>There is a definite improvement to be seen in quality of life with a fresh, clean, and pleasant-smelling mouth. Women are more likely to embrace preventive and proactive care than men. This concept can be used to encourage patients or their loved ones to participate in daily care of the mouth. </div> <div> </div> <div>The benefits may have to be experienced for a resident to become a believer. And, frankly, it might have been a long time since someone has pointed out the needs and benefits of this often-missed daily ritual. </div> <div> </div> <div>Late-life depression is more common in women than in men in long term care facilities. Although this may superficially appear to have little to do with poor oral care, it can be a factor.</div> <div> </div> <div>If people do not have the energy or drive, and cannot see the benefits to cleaning their mouths every day, it can be an easy thing to forget to do. As people get older, this lack of daily care can actually increase oral disease even faster than in a younger person. </div> <div> </div> <div>Decreased saliva and recession of the gums that leads to more exposed tooth roots are more common in the elderly and can accelerate cavities and periodontal disease. Positive feedback regarding all the benefits of daily oral care is not only helpful, but it also provides encouragement for the woman who may be resistant. </div> <h2 class="ms-rteElement-H2">Be Mindful Of Meds</h2> <div>Since women are more likely to have osteoporosis, they may be taking bisphosphonate medications. These medications (such as Fosamax), which are often used to treat osteoporosis, can also increase the risk of causing a non-healing bone lesion to form in the mouth. </div> <div> </div> <div>These bone lesions, which are painful, open wounds in the mouth, are more likely to occur if invasive treatment like a tooth extraction is done. </div> <div> </div> <div>Dentists always need to know what medications a patient is taking prior to providing any dental treatment to avoid this possibility. </div> <div> </div> <div>Likewise, an intravenous form of the bisphosphonate drugs is sometimes used during the treatment for breast cancer and some lymphomas. Therefore, it is very important for women to tell their dentists if they have had treatments for cancer in the past and, if possible, supply the dentists with a list of the medications, even if the treatment occurred years earlier.</div> <div> </div> <div>Teeth were designed to last a lifetime, and many more adults are entering their senior years with the expectation of keeping their natural teeth for a lifetime. Older women benefit from good oral health through improved chewing, speaking, swallowing, and smiling, as well as enjoying the social benefits of good oral health. </div> <div> </div> <div>Regular dental exams and daily oral care remain vital pieces of a preventive strategy to maintain good health and function whether older women reside at home or in a long term care facility. </div> <div> </div> <div><em>Gretchen Gibson, DDS, MPH, is director of Oral Health Quality Group, VA Office of Dentistry and VA Health Care System of the Ozarks, Fayetteville, Ark., and Linda C. Niessen, DMD, MPH, is vice president and chief clinical officer, Dentsply International; and clinical professor, Department of Restorative Dentistry, Texas A&M University, Baylor College of Dentistry, Dallas.</em></div>Clinicians know that increased medications often mean a decrease in spit or saliva. Most people don’t realize or value the important role that saliva plays in protecting their teeth and mouths. Various chronic diseases, such as arthritis or stroke, can make it more difficult for elders to clean their mouths. These chronic diseases may result in residents needing assistance with their daily oral hygiene care. 2013-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0413/caregiving-thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn4
Effective Oral Health Care Requires Effective Collaborationhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Effective-Oral-Health-Care-Requires-Effective-Collaboration.aspxEffective Oral Health Care Requires Effective Collaboration<div>Health care experts are increasingly affirming the importance of oral health as an essential component of overall health. The need for quality-based mouth care does not diminish as a person becomes older, chronically ill, or placed within long term care settings. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Indeed, these individuals experience a disproportionate and debilitating amount of oral disease, which places them at higher medical risk; diminishes their quality of life; and, unless effectively addressed, may add significantly to the cost of care. </div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Plaque Key Culprit In Oral Health Problems</h2> <div> </div> <div> </div> <div> </div> <div>Inadequate daily oral hygiene will lead to a buildup of plaque (biofilms) in the mouth and is primarily responsible for the development of dental cavities, gum disease, and most other oral-related problems. </div> <div> </div> <div> </div> <div> </div> <div> <img width="298" height="213" src="/Monthly-Issue/2013/PublishingImages/0413/caregiving2.jpg" alt="lower, plaque covered teeth" class="ms-rteImage-2 ms-rtePosition-1" style="margin:10px 5px;" /><br></div> <div> </div> <div> </div> <div> </div> <div>Elders, in general, have an increased likelihood of developing oral health problems caused by poor oral hygiene, and older adults living in long term care settings are particularly vulnerable. Many nursing home residents have diminished oral hygiene due to deficits associated with their cognitive status, stroke, arthritis, vision, and other problems. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>In addition, they may have mouth dryness associated with their medications, their diet may be comprised of soft and sticky foods, and their remaining teeth may be poorly aligned, leading to food impaction.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Unmet dental needs can be quite substantial in long term care residents. For example, in a recent Massachusetts study, nearly 60 percent of nursing home residents had untreated dental cavities, compared with 35 percent of community-dwelling elderly, and 34 percent of these residents had major or urgent needs associated with these cavities. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Other studies have documented a high level of poor oral health found in nursing home residents:</div> <div> </div> <div> </div> <div> </div> <div>■ More than 40 percent had periodontal disease;</div> <div> </div> <div> </div> <div> </div> <div>■ Up to three-quarters aged 65 and older had lost some or all teeth;</div> <div> </div> <div> </div> <div> </div> <div>■ More than 50 percent of those over age 75 were edentulous (completely toothless); and</div> <div> </div> <div> </div> <div> </div> <div>■ Eighty percent of those who had lost all teeth had dentures, but nearly one in five did not use them.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><span><span><img width="309" height="261" src="/Monthly-Issue/2013/PublishingImages/0413/caregiving2_chart.jpg" alt="impact of tooth loss on nutrition" class="ms-rteImage-0 ms-rtePosition-2" style="margin:10px;" /></span></span>The consequences of dental infections from cavities or gum disease can be quite significant. Dental infections may lead to severe pain, as well as systemic health problems such as bacteremia, sinusitis, cellulitis, brain abscess, and/or airway collapse. <br><br></div> <div> </div> <div> </div> <div> </div> <div><span></span>Cavities and gum disease are responsible for the loss of natural teeth and can lead to chewing problems, which can impact nutritional health.<br><br></div> <div><div>Poor nutritional status has been shown to increase the length of hospitalizations, elevate infection rates, and even increase dependence in activities of daily living. </div> <p></p></div> <div> </div> <h2 class="ms-rteElement-H2"> </h2> <div> </div> <h2 class="ms-rteElement-H2">Studies Find Barriers</h2> <div> </div> <div> </div> <div> </div> <div>Studies looking at barriers influencing dental care in long term care facilities have identified several key issues that may inhibit satisfactory dental care. Nursing home administrators, unit charge nurses, and dentists have agreed that patient financial constraints, as well as lack of interest by the resident or by the resident’s family, are quite problematic. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>It is interesting to note, however, that administrators and unit charge nurses were generally more likely than dentists to cite unwillingness of dentists to see the resident at the dental office, as well as the nursing home, and nursing staff time constraints as significant barriers. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>On the other hand, dentists were more likely to attribute residents’ oral health problems to the apathy of nursing home administrators and staff, in addition to the lack of suitable portable equipment and inadequate space. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>These findings underscore the need for appropriate dialogue and, ultimately, the need to enhance teamwork between dental care providers and nursing home personnel. In some ways, these differing perceptions are like those of the three blind men trying to describe the elephant: Each may be correct from their individual perspective, but a more accurate picture only emerges when all three views are combined. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>In a white paper entitled, “Improving Dental and Oral Care Services for Nursing Facility Residents,” by the TRECS Institute (www.thetrecsinstitute.org/downloads/DentalCare.pdf), key factors were identified behind the poor response to addressing dental and oral health needs, as follows:</div> <div> </div> <div> </div> <div> </div> <div>■ A pervasive lack of knowledge of the importance of dental and oral health care on the part of residents, their families, and the nursing facilities’ staff;</div> <div> </div> <div> </div> <div> </div> <div>■ Difficulties faced by some residents in providing self-care due to physical limitations, despite the desire to maintain good oral health and the desire to remain independent;</div> <div> </div> <div> </div> <div> </div> <div>■ Providing good daily oral care to residents with dementia and/or behavioral problems can be extremely difficult for staff in spite of good intentions and efforts;</div> <div> </div> <div> </div> <div> </div> <div>■ Ageism prejudices are overtly evident among staff, families, and even the residents themselves; and</div> <div> </div> <div> </div> <div> </div> <div>■ A lack of or severely limited reimbursement for professional dental services results in significant access problems.</div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>Oral health is essential for the general health and well-being of nursing home residents. The challenges of meeting their diverse and sometimes complicated dental needs can be imposing, but it is very important to quality of care and quality of life for these individuals. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div>The team of multidisciplinary care providers essential to address the constellation of medical, psychosocial, emotional, financial, and spiritual needs of the long term care resident must place greater priority and emphasis on the significant oral health concerns of this population. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><a href="/Monthly-Issue/2013/Pages/0413/It-Takes-A-Village.aspx" target="_blank">Dedicated collaborative efforts</a> between nursing facility professionals and dental practitioners can be very helpful in better meeting the oral health needs of residents in long term care </div> <div> </div> <div> </div> <div> </div> <div>settings. </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div> </div> <div><em>Douglas Berkey, DMD, MPH, MS, professor, University of Colorado; dental director, InnovAge Greater Colorado PACE; member, National Elder Care Advisory Committee, American Dental Association. Berkey can be reached at <a href="mailto:%20douglas.berkey@ucdenver.edu">douglas.berkey@ucdenver.edu</a> or at (303) 907-5336.</em></div>Health care experts are increasingly affirming the importance of oral health as an essential component of overall health. The need for quality-based mouth care does not diminish as a person becomes older, chronically ill, or placed within long term care settings. 2013-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0413/caregiving3_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn4
Some States Moving To Innovative AL Survey Modelshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Some-States-Moving-To-Innovative-AL-Survey-Models.aspxSome States Moving To Innovative AL Survey ModelsThe national Center for Assisted Living recently released the 2013 edition of “Assisted Living State Regulatory Review,” finding that 18 states made changes to assisted living regulations, statutes, and policies during 2012. <br><img class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0413/News/survey.jpg" alt="" style="margin:0px 10px;" />Nine states—Colorado, Georgia, Michigan, Missouri, New Jersey, New York, Ohio, Oregon, and Washington—made major changes.<br><br>Adding to a growing number of states, Colorado and New Jersey started innovative survey models. Colorado has a one-year licensure term. However, under a new pilot program, Colorado would extend the one-year term if the residence meets specific requirements. <br><br>The community must have been licensed for three years. The residence’s record should not have a citation, an enforcement action, or a pattern of deficiencies and no major deficiencies that affected the life, health, or safety of residents in the three years prior to the survey. <br><br>In late 2012, Michigan’s licensing division for Homes for the Aged (HFA) and Adult Foster Care (AFC) also moved to a new renewal model for onsite inspections. Onsite inspections are required for all licensed facilities every two years for AFC homes and every year for HFA. The licensing division used to give AFC and HFA a few weeks’ notice before conducting the onsite inspection. <br><br>Now the state issues a one-day notice to HFA and AFC’s residences. Inspections consist of interviews and observations with licensees, staff, and residents to determine rule compliance plus resident care quality. Quality of care includes mental and physical health, welfare, and well-being, assessed through key indicators. <br><br>In the Garden State, New Jersey’s Department of Health (DOH) and the Health Care Association of New Jersey Foundation created a program called Advanced Standing, a voluntary program that requires participating assisted living communities to comply with all applicable regulations and submit quality data that meet benchmarks set by a peer review panel. <br><br>In 2012, several states added or changed disclosure and reporting requirements, including California, Florida, Ohio, Oregon, and Washington. In California, the Elder Abuse and Dependent Adult Civil Protection Act established procedures for the reporting, investigation, and prosecution of elder and dependent adult abusers. <br><br>The act requires certain persons, called mandated reporters, to report known or suspected instances of elder or dependent adult abuse. <br><br>If abuse occurs in a long term care facility—including assisted living—the act requires a mandated reporter and authorizes any person who is not a mandated reporter to report the abuse to the local ombudsman or the local law enforcement agency. <br><br>Failure to report physical abuse and financial abuse of an elder or dependent adult under the act is a misdemeanor. <br><br>Florida assisted living communities are now required to notify the state licensing agency within 10 days after the initiation of bankruptcy, foreclosure, or eviction procedures concerning the provider in which the controlling interest is a petitioner or defendant. <br><br>Oregon also required its residential care and assisted living providers to notify the licensing agency of bankruptcy or foreclosure.<br><br>In 2012, states also: <br>■ Changed life safety or physical plant standards (Missouri, North Dakota, Oregon, West Virginia);<br>■ Addressed tuberculosis testing requirements or infection control (Mississippi, Texas); <br>■ Revised or added admission/retention thresholds (Florida, Texas);<br>■ Changed rules relating to medication management (California, New Jersey);<br>■ Changed staffing requirements (Georgia, Ohio);<br>■ Changed resident assessment requirements (Georgia, Oregon); and<br>■ Addressed handling residents’ personal property or funds (Missouri, Oregon).2013-04-01T04:00:00ZColumn4
Survey Reveals Need For More Preventive Oral Carehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Survey-Reveals-Need-For-More.aspxSurvey Reveals Need For More Preventive Oral Care<div>A recent survey of nursing homes in Kansas revealed that one-third of residents had lost all of their natural teeth, according to the Kansas Bureau of Oral Health and Oral Health Kansas.</div> <div> </div> <div>“When a person loses all of their natural teeth, it affects their appearance and their ability to eat and speak,” the report said. “An additional 43.7 percent had lost some, but not all of their teeth. This is significantly higher than the 17.4 percent of seniors living independently in the community who have lost all of their natural teeth.”</div> <div> </div> <div>The survey, based on a nationally recognized protocol, included 540 Kansas elders living in 20 nursing homes and consisted of a clinical oral health screening and a resident questionnaire. <br></div> <h2 class="ms-rteElement-H2">Key Findings </h2> <div>■ Residents had significant dental care in the past, but now have untreated dental disease. More than one-third of nursing facility residents had untreated dental decay. “The screeners noted a large amount of past dental work (crowns, bridges, partial dentures) in the residents’ mouths. This indicates past access and investment in professional dental care,” the report said. “The presence of current untreated dental disease suggests that this level of care has not continued in their current life situation.”<br></div> <div><br>■ Residents had poor oral hygiene. Daily brushing and flossing removes the bacteria and plaque that irritates gums and leads to inflammation (gingivitis) and periodontal disease. Twenty-six percent of surveyed residents had severe gingival inflammation, meaning that the gums were swollen, bleeding, and/or painful. Twenty-nine percent had substantial oral debris on at least two-thirds of their teeth, and 15 percent of the residents had natural teeth that were loose. Taken together, these indicators suggest that many residents are not removing the plaque and bacteria from their teeth on a regular basis.</div> <div><br>■ Residents have limited financial resources for dental care. Medicare does not cover preventive and restorative professional dental services or dentures. Kansas Medicaid offers minimal dental benefits for adults. Sixty-six percent of the residents surveyed were on Kansas Medicaid. Professional dental care is an out-of-pocket expense for most seniors, and this is a barrier to care for many on limited incomes.</div> <div> </div> <div>Given these findings, the report recommends that residents receive daily preventive care, improved access to oral care be created via additional mobile programs in nursing homes, and the sustainability of the programs be ensured through a reliable payment source. </div> <div> </div> <div>“Nursing facilities must monitor residents to ensure they are receiving adequate daily oral care and to identify oral health needs that require professional attention,” the report said. “Access to dental professionals must be physically and financially feasible. All three components are necessary to see impactful and sustainable improvement in the oral health of this population.”</div> <div> </div> <div><em>Source: “Elder Smiles 2012: A Survey of the Oral Health of Kansas Seniors Living in Nursing Facilities,” Kansas Bureau of Oral Health, Kansas Department of Health and Environment, Topeka, Kan. </em></div> A recent survey of nursing homes in Kansas revealed that one-third of residents had lost all of their natural teeth, according to the Kansas Bureau of Oral Health and Oral Health Kansas.2013-04-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/senior_dental.jpg" style="BORDER:0px solid;" />CaregivingColumn4
VA Open To Long Term And Post-Acute Care Providershttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/VA-Open-To-Long-Term-And-Post-Acute-Care-Providers.aspxVA Open To Long Term And Post-Acute Care ProvidersThe Department of Veterans Affairs (VA) is weighing a rule that would allow non-VA companies to provide long term care and rehabilitation services to stricken vets. <br><br>The rules, which are expected to take effect, could well be an opportunity for providers, experts say. <br><br>“Veterans, who in some cases have had to travel hundreds of miles from their homes to find care in a VA facility, will now be able to play an active role in choosing the best care setting for their needs,” says Jack MacDonald, executive vice president for special projects and chief public affairs officer at Golden Living. “They will be able to receive this care in their communities where their families and support systems are located. It’s also important to note that the rule expands care choices to home health care, palliative care, and non-institutional hospice care—thereby expanding not only the locations in which our veterans may receive care, but expanding the options for choice as well.” <br><br>There are some 23 million Americans who rely on VA for health care, and the costs of VA’s major benefits programs are expected to rise 70 percent, to about $130 billion, by 2022. In fiscal 2007 alone, VA spent more than $4.1 billion on long term care for its patients. VA expected to spend some $108 million on nursing home care in fiscal 2009. <br><br>The proposed rules are the culmination of a lot of work, says Dough Burr of Health Care Navigator, who is also chair of the American Health Care Association Finance Committee. <br><br>“We have been working collaboratively with the VA for many years to get to the point where community nursing homes will now have the regulatory flexibility and reimbursement necessary to deliver high-quality outcome-oriented services to our nation’s veterans,” he says. “This is an example of how government and the private sector can effectively work together for the benefit of people who need post-acute and long term care.”2013-04-01T04:00:00ZColumn4
It’s A Matter Of Tastehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/It’s-A-Matter-Of-Taste.aspxIt’s A Matter Of Taste<div>A common complaint of most residents of senior living communities is food satisfaction. As an executive director (ED), it is one of the more challenging complaints to resolve.</div> <div> </div> <div> </div> <div> </div> <div>There are many times when an ED or chef is sampling the exact same dish about which a resident is complaining and having a completely different experience. For example, a resident might say a dish is lacking in flavor and is difficult to chew, while the ED or chef is finding it flavorful and easy to eat. </div> <div> </div> <div> </div> <div> </div> <div>As a result, the food and beverage departments often become demoralized as they find that no matter how hard they try, the level of satisfaction remains an issue. This article hopes to impart a better understanding of the complications related to taste in an aging population, categorize the type of complaints, and offer <br>some cooking suggestions that have brought about increased resident satisfaction.</div> <div> </div> <div> </div> <div> </div> <div>Those who oversee the food service in senior living communities will benefit from shifting their orientation and developing an approach that incorporates the common issues of diminishing taste sensations into their daily work.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Taste And Elders</h2> <div> </div> <div>When an individual reaches a particular age, the sense of taste deteriorates. Some studies have estimated that a person could lose 20 to 60 percent of their taste buds after the age of 60. </div> <div> </div> <div> <span></span></div> <div> </div> <div>A younger person’s threshold for tasting salt, sweet, bitter, and sour is much lower than an elder’s. This means that while elders’ senses are able to create a response to the flavor of salt, sweet, bitter, and sour, but their responses are not as strong as the younger person’s. </div> <div> </div> <div> <br></div> <div> </div> <div><span><span><img width="475" height="438" src="/Monthly-Issue/2013/PublishingImages/0413/mgmt_1.jpg" alt="What Impacts Taste" class="ms-rtePosition-1" style="margin:5px 10px;" /></span></span>At the same time, some elders’ main tasting abilities become relatively strong when their other abilities weaken as they age. For example, they may taste pronounced salt because other taste sensations have weakened.</div> <div> </div> <div> </div> <div> </div> <div>Taste is impacted by sense of smell, which also declines significantly as one ages. Thirty percent of people between the ages of 70 and 80 have a problem with their sense of smell. Smell that declines with age is called presbyosmia, and it is not preventable. </div> <div> </div> <div> </div> <div> </div> <div>The sense of smell, or olfaction, is part of people’s chemical sensing system, along with the sense of taste. Normal smell occurs when odors around in the vicinity, like the fragrance of flowers or the smell of baking bread, stimulate the specialized sensory cells, called olfactory sensory cells. The ability to smell these odors impacts taste.</div> <div> </div> <div> </div> <div> </div> <div>Dysgeusia is a distortion of the sense of taste and a common problem among elders. An alteration in taste or smell may be a secondary process in various disease states, or it may be the primary symptom. The distortion in the sense of taste is the only symptom, and diagnosis is usually complicated since the sense of taste is tied together with the individual’s other sensory systems. </div> <div> </div> <h2 class="ms-rteElement-H2"><div>Complaints Could Be Flags</div></h2> <div>It is common for residents to be unaware that their lack of enjoyment of the food may be caused by other factors unrelated to the community’s food service. It is therefore a challenge for the ED and director of food and beverage to discern the true source of the dissatisfaction. </div> <div> </div> <div> </div> <div> </div> <div>The first place to look is always the <a target="_blank" href="/Monthly-Issue/2013/Pages/0413/Ensuring-High-Quality-Food.aspx">quality and variety </a>of the food being offered, as well as its preparation. This should be relatively easy for the trained professional. If, on a daily basis, it is determined that the quality and food preparation are very good, then it can be hypothesized that the issue may be with the resident. </div> <div> </div> <div> </div> <div> </div> <div>Resident feedback on menu selection is very important, as is offering a variety of dishes and changes to the menu. Boredom with the menu can mimic changes in taste sensations. </div> <div> </div> <div> </div> <div> </div> <div>EDs should listen to all food complaints and work with the food and beverage department by keeping track of who is making the complaints and the types of complaints being made. Determine how many people are making the same complaint. A resident who complains on a daily basis that the food is lacking flavor is likely to be suffering from Dysgeusia but does not know it. </div> <div> </div> <div> </div> <div> </div> <div>Without a complaint/feedback log it is difficult to distinguish between food preparation errors and an aging palate. </div> <div> </div> <h2 class="ms-rteElement-H2">Educate Staff, Residents </h2> <div> </div> <div>Residents need to be educated on the things that impact one’s taste buds. Educational programs should be conducted to help create awareness for residents. </div> <div> </div> <div> <span></span></div> <div> </div> <div>Residents who are chronically dissatisfied with the food should be encouraged to speak with their doctor. Their level of satisfaction may return simply by changing a medication.</div> <div> </div> <div> </div> <div> </div> <div>There is little awareness and discussion of Digeusia. Doctors may not be aware of what impacts taste. It is therefore up to the residents and leaders in the field to encourage doctors to learn more.</div> <div> </div> <div> <span><span><img src="/Monthly-Issue/2013/PublishingImages/0413/mgmt_2.jpg" alt="Where does responsibility lie?" class="ms-rtePosition-4" style="margin:15px;" /></span></span></div> <div>The table above highlights the types of complaints received by residents and attempts to categorize them in two groups. The first group reflects possible issues with the food preparation and service. These complaints tend to be more specific and presented by residents who are generally satisfied with the food service. The second group is likely to be related to the resident’s sense of taste. These complaints tend to be more general, making it more difficult to pinpoint a solution. It is time for this type of discussion to become as common in senior living as other health-related topics are common to the older population. </div> <div> </div> <div> </div> <div> </div> <div>There is much to learn. These issues spark creativity and a challenge for food and beverage departments. </div> <div> </div> <div>Changing the orientation from one of expecting residents to complain to one in which a provider can make a difference may attract more chefs to the industry. </div> <div> </div> <div> </div> <div> </div> <div>Click here for some <a target="_blank" href="/Monthly-Issue/2013/Pages/0413/Menu-Development-And-Food-Preparation-Techniques.aspx">palette-pleasing recipes</a>. </div> <div> </div> <div> </div> <div> </div> <div><em>Robin Granat, LCSW, CALA, is executive director and Robert Derin is executive chef at Five Star Premier Residences of Teaneck, N.J., part of Five Star Senior Living. The research, opinions, and conclusions in this article do not constitute professional advice or advocacy of particular practices by the community and/or Five Star Senior Living.</em></div> ds Taste is impacted by sense of smell, which also declines significantly as one ages. Thirty percent of people between the ages of 70 and 80 have a problem with their sense of smell. Smell that declines with age is called presbyosmia, and it is not preventable. 2013-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0413/mgmt_thumb.jpg" style="BORDER:0px solid;" />Management;QualityColumn4
Livable Communities For Eldershttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Livable-Communities-For-Elders.aspxLivable Communities For Elders<img width="202" height="202" src="/Monthly-Issue/2013/PublishingImages/0413/News/communities.jpg" class="ms-rtePosition-2 ms-rteImage-1" alt="" style="margin:5px 20px;" />The best communities for elderly Americans provide “accessible and affordable housing options; transportation; walkability; safe neighborhoods; emergency preparedness; and support services like health care, retail outlets, and social integration,” according to a new report from the MetLife Mature Market Institute and the Stanford Center on Longevity.<br><br>According to the report, the most critical characteristics of an age-friendly, livable community can be measured using these indicators: <br><br>■ Housing. Accessible/visitable housing that is affordable. Zoning laws that permit flexible housing arrangements such as building assisted living facilities or private homes on relatively small lots.<br><br>■ Safe neighborhoods. Low crime rates and emergency preparedness plans that take the needs of older residents into account. <br><br>■ Transportation. Including mass transit, senior transport programs, walkable neighborhoods (safe for pedestrians), nearby parks and recreation, roads with visible signage, adequate lighting, and adequate vehicle and pedestrian safety at intersections.<br><br>■ Health care. An adequate number of doctors (primary care and specialists), hospitals, and the presence of preventive health care programs. <br><br>■ Supportive services. The presence of home- and community-based caregiving support services and the availability of home health care, meals-on-wheels, and adult day care.<br><br>■ Goods, services, and amenities. Retail outlets within walking distance, restaurants, grocery stores offering healthy foods, and policies supportive of local farmers’ markets.<br><br>■ Social integration. Programs and organizations that promote social activities and intergenerational contact. Places of worship, libraries, museums, colleges, and universities are often underutilized resources.<br><br>“We know people generally prefer to remain where they are as they age, connected to friends and family, and communities lose an economic and social asset when older people leave,” said Sandra Timmermann, EdD, director of the MetLife Mature Market Institute. “With that in mind, we supported the development of these indicators by studying the best existing tools and data. Communities can now make assessments and begin to implement change with readily available public data.”<br><br>According to Amanda Lehning, who collaborated on the report, “Every community is unique. Local governments should think about how to adapt these indicators to best meet the needs of their residents,” she says.<br><br>“Efforts to help older adults age in place can also potentially improve the community as a whole. For example, older adults can make valuable contributions as neighbors, caregivers, and volunteers. They also patronize local businesses and are a factor in tax revenue.”<br>See www.MatureMarket Institute.com.2013-04-01T04:00:00ZColumn4
Report: Holistic Approach Needed For Dementia Carehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Report-Holistic-Approach-Needed-For-Dementia-Care.aspxReport: Holistic Approach Needed For Dementia CareExperts seeking a holistic approach to health care for people with dementia have published a report that establishes the values, practices, and recommendations for person-centered dementia care.<br><br>“Overall dementia care in this country is impersonal and fragmented,” the authors wrote. “This paper is a call to action to change what is considered the gold standard.”<br><br>The report contains a framework for a holistic health care approach that considers the psychological, social, and spiritual aspects of individuals with dementia. <br><br>The expert group, called Dementia Initiative, came to consensus agreement on the framework and its contents. David Gifford, MD, MPH, senior vice president of quality and regulatory affairs for the American Health Care Association; Lindsay Schwartz, PhD, director of workforce and quality for the National Center for Assisted Living (NCAL); and Jane Clairmont, owner and chief executive officer of English Rose Estates, Edina, Minn., participated in the effort. <br><br>The white paper includes recommendations for the first steps in converting the country’s dementia care systems and practices to person-centered care.<br><br>It calls for the establishment of an advisory group that includes people with dementia. <br><br>This group would be expected to develop a plan for appropriate prescribing guidelines for the use of antipsychotic medications for people who have dementia.<br><br>The Dementia Initiative originally convened to discuss the overuse of antipsychotics for people with dementia. <br><br>“As discussion among the diverse group of dementia care experts got underway in the spring of 2011, it became quickly evident that focusing on one dysfunctional aspect of dementia care—in this case, the overuse of antipsychotics—was not possible without backing up and addressing the root cause of the dysfunction,” the authors wrote. <br><br>“This white paper provides a comprehensive guide to what person-centered care for residents with dementia encompasses and how to deliver that care, utilizing a holistic approach,” said NCAL’s Schwartz.2013-04-01T04:00:00ZColumn4
Sequester Hits Long Term Care Professionhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Sequester-Hits-Long-Term-Care-Profession.aspxSequester Hits Long Term Care ProfessionLong term and post-acute care professionals were girding themselves for massive Medicare cuts after the long-dreaded deadline for sequester came and went. <br><br>President Obama signed the so-called sequester order March 1, and the cuts will take effect beginning in April. Estimates vary on how big a bite the cuts will take—the Congressional Budget Office (CBO) has estimated that Medicare spending will fall by $9.9 billion through fiscal 2013; the White House Office of Management and Budget says that the cuts will equal $11.1 billion over the next 12 months. CBO has estimated that, if the cuts remain on the books for the next decade as scheduled, they’ll slice $123 billion from Medicare spending. <br><img src="/Monthly-Issue/2013/PublishingImages/0413/News/night_capital_thumb.jpg" class="ms-rtePosition-1" alt="" style="margin:20px 15px;" /><br>Debra McCurdy, an analyst with ReedSmith, says that things could be worse: The sequester caps spending cuts to providers by 2 percent; “this 2 percent Medicare cut compares to an almost 8 percent cut to non-exempt defense spending and about a 5 percent reduction in other non-exempt non-defense programs for the remainder of fiscal year 2013,” McCurdy says. <br><br>But those cuts may be the least of it for health care providers, said Rob Schile, a partner with the auditing firm CliftonLarsonAllen. <br><br>“The challenge for health care providers is that sequestration comes on top of other significant reductions taking place in reimbursement as a result of payment reform,” Schile said in a news release. “For these organizations, it isn’t necessarily the 2 percent reduction of sequestration that is so significant, it is the incremental impact of even more cuts on top of it.”<br><br>The cuts were inserted into the 2011 Budget Control Act as a kind of poison pill; congressional Republicans and the White House hoped that negotiators in each party would be able to concentrate on meaningful reforms with the sword of Damocles dangling above their heads. <br><br>As ReedSmith’s McCurdy drily notes, “It did not work out that way.”<br><br>Both parties are now apparently more focused on the public relations of the sequester, as opposed to the public policy of it. Democrats are working hard to portray congressional Republicans as hard-hearted reactionaries; Republicans, for their part, want Americans to see the Democrats as profligate demagogues. <br><br>However Washington moves in the short- and medium-term, experts say that it’s clear the Era of Austerity has begun for providers.<br><br>“In sum,” Schile said, “health care providers are experiencing a monumental shift in revenue cycles. How they meet the challenge of substantial reductions in the midst of a wave of change will determine how well they survive in the new environment.”2013-04-01T04:00:00ZColumn4
A Refresher On Social Media Policyhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/A-Refresher-On-Social-Media-Policy.aspxA Refresher On Social Media Policy<div>Social media is a vital part of everyone’s lives today on both a professional and a personal level. For human resource professionals, however, there exists some confusion about what constitutes a permissible social media policy or rule and what an employee can safely “post” on a social media website about his or her employer without being subject to discipline and/or termination. </div> <div> </div> <div>In fact, the National Labor Relations Board (NLRB) issued its first decision on this topic only last September. Providers should be aware of the latest NLRB developments when crafting their social media rules and/or policies.</div> <h2 class="ms-rteElement-H2">Costco’s Broad Social Media Policy </h2> <div>NLRB, in order to determine whether a work rule violates Section 8(a)(1) of the National Labor Relations Act (NLRA) and is thus an unfair labor practice, examines whether the rule tends to chill employees in the exercise of their Section 7 NLRA rights. Section 7 rights include the right to join unions, to bargain collectively, and to “engage in other concerted activities for the purpose of collective bargaining or other mutual aid or protection.” </div> <h2 class="ms-rteElement-H2">Board Makes First Policy Judgment</h2> <div>Last September, NLRB, in its first case directly addressing social media policy, held in Costco Wholesale Corp. that an overly broad social media policy promulgated by Costco violated Section 8(a)(1) of the NLRA and ordered Costco to rescind or modify that policy. </div> <div> </div> <div>The policy stated that “[e]mployees should be aware that statements posted electronically … that damage the company [Costco], defame any individual, or damage any person’s reputation, or violate the policies outlined in the Costco Employee Agreement, may be subject to discipline, up to and including termination of employment.”</div> <div> </div> <div>NLRB found that the “broad parameters” contained in the policy would result in employees refraining from engaging in certain communications (such as those that would be critical of Costco’s treatment of its employees) that are protected under Section 7 of the NLRA. </div> <div> </div> <div>NLRB noted that this broad rule did not contain language that would have restricted its application to conduct (malicious, abusive, or unlawful) that an employer can safely prohibit.</div> <div> </div> <div>The implication being, of course, that had it contained such restrictive language, the rule might have been found lawful. </div> <h2 class="ms-rteElement-H2">Firing Employees For Facebook Comments Found Unlawful</h2> <div>In Hispanics United of Buffalo, Inc., NLRB recently held that the employer violated the NLRA by firing employees for Facebook comments they wrote in response to a co-worker’s criticism of their job performances. </div> <div> </div> <div>One worker posted, on her Facebook page, that another employee had complained about her and her co-workers’ performances; she asked other employees to comment about this post on her Facebook page. </div> <div> </div> <div>The employer fired both the worker who made the initial post on her page and the four others who then posted comments. It contended that their remarks constituted “bullying and harassment” of a co-worker and violated the employer’s “zero-tolerance” policy of this conduct.</div> <div> </div> <div>NLRB held, however, that the employer violated the NLRA by firing the five employees, and it did not find the Facebook comments to be either a form of bullying or harassment.</div> <div> </div> <div>In a nutshell, the employees were engaged in concerted activities for the “purpose of mutual aid or protection,” and thus their conduct was protected. NLRB has long held that an employer cannot fire employees for engaging in discussions about job performance.</div> <h2 class="ms-rteElement-H2">NLRB’s Prior Reports Address Social Media Rules</h2> <div>Prior to the Costco Wholesale Corp. decision, NLRB’s acting general counsel issued three reports on social media. Some examples contained in the reports are as follows:</div> <div> </div> <div> ■ Policy provisions stating that, if an employee posted something about an employer, “you must also be sure that your posts are completely accurate and not misleading,” were found to be unlawful. The terms “completely accurate and not misleading” were found to be overbroad as they could apply to discussions of the employer’s policies and treatment of its employees, which, as long as they are not malicious, are protected activities.</div> <div> ■ A rule that prohibited “inappropriate postings that may include discriminatory remarks, harassment, and threats of violence or similar inappropriate or unlawful conduct” was found lawful as it prohibited plainly egregious conduct and there was no evidence that the employer had used it to punish employees for exercising their protected rights.</div> <div> ■ A rule that required employees to maintain the confidentiality of an employer’s trade secrets and confidential information was found lawful because: 1.) employees have no protected right to disclose trade secrets; and 2.) the rule contained sufficient examples of confidential information (for example, information regarding the development of systems, products, and technology) for employees to understand that the rule did not apply to “protected” discussions of working conditions. </div> <div> ■ Policy provisions stating “[t]hink carefully about ‘friending’ co-workers … on external social media sites” and “report any unusual or inappropriate internal social media activity to the system administrator” were both found unlawful because: 1.) the “friending” provision would discourage communication between co-workers and thus interfere with protected Section 7 rights; and 2.) the reporting provision could be reasonably construed to encourage employees to report to management on the union activities of their co-workers.</div> <h2 class="ms-rteElement-H2">Drafting Social Media Policies Tricky</h2> <div>Providers should draft their social media policies so that they do not contain broad prohibitions about workplace concerns that do not thereafter provide examples of activities that an employer may legitimately prohibit. </div> <div> </div> <div>Thus, if a provider has a rule such as “do not post comments that damage the company or an individual’s reputation” it should then give examples of conduct specifically prohibited by the rule, such as the disclosure of trade secrets or sexually harassing comments.</div> <div> </div> <div>Most importantly, a provider should ensure its policy is carefully reviewed by legal counsel. </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:%20andrewibart@gmail.com">andrewibart@gmail.com</a>.</em></div> Social media is a vital part of everyone’s lives today on both a professional and a personal level. For human resource professionals, however, there exists some confusion about what constitutes a permissible social media policy or rule and what an employee can safely “post” on a social media website about his or her employer without being subject to discipline and/or termination. 2013-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0413/legal_thumb.jpg" style="BORDER:0px solid;" />Legal;Workforce;ManagementLegal Advisor4
Be Prepared For Higher Acuity In Assisted Livinghttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Be-Prepared-For-Higher-Acuity-In-Assisted-Living.aspxBe Prepared For Higher Acuity In Assisted Living<div>Assisted living communities are caring for residents with more complex health care needs than just a few years ago and keeping staff realistic about their caregiving capacities, and implementing protocols to manage these higher-care needs can help lower the community’s liability risk and increase their capacity to retain residents, says an expert in nursing and clinical issues. </div> <div> </div> <div>Josh Allen, RN, C-AL, chair of the American Assisted Living Nurses Association (AALNA), presented these ideas during a recent webinar, sponsored by the National Center for Assisted Living (NCAL) titled, “Higher Acuity in Assisted Living: Risk or Reward?” </div> <div> </div> <div>Allen cited statistics from the 2010 National Survey of Residential Care Facilities. The survey revealed that 50 percent of the nation’s assisted living residents have three or more chronic conditions, and 42 percent of them have Alzheimer’s disease or other forms of dementia. </div> <div> <img src="/Monthly-Issue/2013/PublishingImages/0413/News/health_conditions.jpg" class="ms-rteImage-1 ms-rtePosition-1" alt="" style="margin:25px 10px;" /><br></div> <div>In addition, NCAL’s 2012 Performance Measures report found that of the respondents, 94 percent had access to a registered nurse. <br><br></div> <div>“We know acuity is on the rise. It sounds like a cliché, but many of the residents of assisted living today were in nursing facilities five years ago,” Allen says. “There is more direct caregiving being delivered.”</div> <div> </div> <div>To determine if the reward is worth the risk, Allen recommends that staff in an organization evaluate their caregiving capabilities and develop protocols for those residents with more chronic health care conditions.</div> <div> </div> <div>“Have you sat down as an organization and really talked about higher acuity?” he says. “Have you talked about who are the residents you are going to care for and what kinds of residents are you going to be able to accommodate?”</div> <h2 class="ms-rteElement-H2">Review The Top 10 Health Conditions</h2> <div>Allen suggested organizations review the top 10 chronic health conditions found in the national survey, evaluating their caregiving capacity by asking the following questions for each condition:</div> <div> </div> <div>1. Can we accommodate this condition?</div> <div>2. How are we managing this condition?</div> <div>3. Are we capable of addressing this condition?</div> <div>4. Are we prepared? </div> <div>5. Do we need to partner with a home health agency, physician, or physical or occupational therapist?</div> <div> </div> <div>Next, he encouraged communities to get nurses and marketers to work together to overcome any distrust between the departments.</div> <div> </div> <div>Often nurses believe marketers oversell staff’s caregiving capabilities, and marketers believe nurses curb their sales efforts. To counteract those perceptions, Allen recommends having sales and nursing staff meet daily to review each resident’s health care conditions—including residents moving in and those at risk of moving out. This daily meeting builds a relationship and trust amongst department members.</div> <h2 class="ms-rteElement-H2">Develop Elopement Checklist</h2> <div>Turning to specific health care conditions, Allen discussed managing residents with Alzheimer’s and other forms of dementia. </div> <div> </div> <div>Allen said research has found that the only true indicator of a resident being at risk of eloping is if the resident has actually wandered out of a community before. There are limited methods of determining which residents with Alzheimer’s disease who haven’t walked out of a building will, in fact, walk out of a building. </div> <div> </div> <div>Allen suggested all assisted living communities develop an elopement procedure checklist that includes steps for staff to complete when looking for a resident who has eloped. </div> <div> </div> <div>“Just like fire evacuation procedures, you want to have the same thing for an elopement, mainly because you panic,” he said. </div> <div> </div> <div>“Having that checklist helps focus your person’s energy on doing the steps.” </div>2013-04-01T04:00:00ZColumn4
Brooklyn Nursing Homes To Sandy: ‘We’ve Come Back’https://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Brooklyn-Nursing-Homes-To-Sandy-‘We’ve-Come-Back’.aspxBrooklyn Nursing Homes To Sandy: ‘We’ve Come Back’Two Brooklyn nursing homes were preparing to open their doors again, nearly half a year after Superstorm Sandy shuttered them. <br><br>“We went through these hard times, but just like the neighborhood, we’ve come back,” says Michael Schrieber, executive director of the Shoreview Nursing Home and the Sea Crest Health Care Center.<br><br>At Shoreview, in the Brighton Beach neighborhood, staff were a mere fire panel away from opening. Sea Crest, near Coney Island, would likely be ready by April, Schrieber says. <br><br><span><span><img alt="iStock_000004337210XSmall.jpg" src="/Monthly-Issue/2013/PublishingImages/iStock_000004337210XSmall.jpg" class="ms-rtePosition-1" style="margin:5px;" /></span></span>Like many in the long term care profession who suffered under Sandy’s wrath, Schrieber says he’s proud <span></span>that he and his staff were able to survive the challenge and come back. <br><br>“Everyone has been really superb throughout all of this,” he says.<br><br>But—also like many in the profession along the Eastern seaboard—the costs have been appalling. Some 100 residents from Sea Crest and Shoreview have died since the late October storm. <br><br>“It takes such a toll on these individuals who have this pretty standard, quiet life,” Schrieber says. <br><br>“And then this storm comes and they’re seeing things they haven’t seen and they’re in a place they don’t know, and it really upsets that stability.”<br><br>The buildings were gutted, Schrieber says. And the costs are still mounting. <br><br>“It has cost probably—and we’re not done yet because we don’t know what’s coming next, and we have all sorts of legal bills pending—but it probably has cost $10-$12 million,” he says. <br><br>But—adding insult to injury—the homes’ insurance company refused to cover employee costs, Schrieber says. Some 800 employees, including many who have worked at the homes for more than four decades, were laid off, Schrieber says. <br><br>“That, I think, was one of the biggest heartbreaks,” he says.<br>If anything else, though, it also steeled Schrieber and the staff, he says. “Getting that denial letter, that kind of solidified it for us,” he says.<br>“We were going to be able to get back up and running. We took personal loans and whatever we could because we felt an obligation to get back up and running.”<br><br>Schrieber says he’s hopeful that all the laid-off employees will be brought back. <br><br>For now, though, the focus is on getting the doors open. Staff and residents are counting the minutes, Schrieber says. <br><br>“I think, more than anything else, everyone’s excited to get back home,” he says. “We’re getting there.”2013-04-01T04:00:00ZColumn4
The QIS Expert: Can QIS Help Providers Comply With New QAPI Regs? Part 2 https://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Can-QIS-Help-Providers-Comply-With-New-QAPI-Regs.aspxThe QIS Expert: Can QIS Help Providers Comply With New QAPI Regs? Part 2 <img src="/archives/archives-2012/PublishingImages/Headshots/AKramer_rollup.jpg" alt="Andy Kramer, MD" class="ms-rtePosition-1" style="margin:5px 15px;" />This is the second column in a series of five addressing how QIS methods can be used in a Quality Assurance and Performance Improvement (QAPI) system by showing the parallels between QIS methods and the five elements of QAPI. <br><br>To better understand the QAPI regulation that will be enacted this year, go to <a href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf">www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf</a>. According to the QAPI at a Glance document, Element 2 of the five elements is Governance and Leadership: “The governing body and/or administration of the nursing home develops and leads a QAPI program that involves leadership working with input from facility staff, as well as from residents and their families and/or representatives.<br><br>“This includes designating one or more persons to be accountable for QAPI [and] developing leadership and facilitywide training on QAPI … They are responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover.<br><br>“The governing body and executive leadership are also responsible for setting priorities for the QAPI program and … setting expectations around safety, quality, rights, choice, and respect by balancing both a culture of safety and a culture of resident-centered rights and choice.”<br><br>This element stresses how QAPI is about creating a balanced organizational culture that permeates from leadership to every level of staff. This must start with the QAPI program being completely supported by the top leaders in the organization, through both interactions with staff and adequate resource planning. <br><br>Part of this leadership is to ensure that all of the participants in the delivery of services are contributors to the QAPI program.<br><br>This column has previously described guidelines from providers that have successfully used the QIS methods: Select a leader to guide the implementation effort; involve staff at all levels and in all disciplines; and use QIS every day and make it part of a daily routine, as in continuous quality improvement. <br><br>These methods lead to a system that derives much of the Stage 1 information from a wide range of sources involving residents, their families, and staff members.<br><br>There are two reasons that the QIS methods help to establish a system that is sustainable “despite changes in personnel and turnover.” <br><br>First, the QIS methods are embodied in standard procedures for assessment and investigation. A primary objective of QIS is that these processes are used the same way no matter who is conducting them, leading to consistency across staff changes. <br><br>Second, because so many staff members are involved in using the QIS methods rather than one or two individuals, the impact of personnel changes does not have to affect the collective knowledge of the system.<br><br>A fundamental aspect of the QIS methodology is to identify opportunities for improving care in cases of unacceptable levels of performance, up through above-average levels of performance. This can help guide a leader in “setting priorities” for a QAPI program.<br><br>Overall, the balance of resident safety and resident-centered care embodied in QIS methods can assist leadership in setting expectations for performance and improvement, thereby fulfilling this element of QAPI.<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>2013-04-01T04:00:00ZColumn4
Charting New Waters In Leadership Developmenthttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Charting-New-Waters-In-Leadership-Development.aspxCharting New Waters In Leadership Development<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div>Long term care and post-acute facility residents are individuals whose personalities and feelings must be considered in an effort to keep them safe and happy. </div> <div> </div> <div>That is the lesson of culture change, and facilities have embraced it in efforts to ensure quality care and resident satisfaction. Now facilities increasingly have begun to apply this lesson to staff development and motivation with similar results.</div> <div> </div> <div>Creative efforts to encourage and inspire staff, recognize and nurture potential leaders, and increase job satisfaction and reduce turnover are more widespread than ever. And facility leaders are pleased with the results. </div> <h2 class="ms-rteElement-H2">Residents As Educators</h2> <div>Leaders at Kindred Transitional Care and Rehabilitation of Brighton in Colorado discovered that they had the perfect staff trainer living right under their roof. When they discovered that resident Joan was a former nurse, they asked her if she would be willing to speak at new staff orientation programs, and she agreed. Director of Nursing Amy Szczepanski, RN, says, “We thought she would be a great asset to our program because she understands both the nursing and patient perspectives. We hoped that she could help our staff understand the multiple roles and how their words and actions affect residents personally.”</div> <div> </div> <div>Speaking to new staff, Joan shares the overall experience of being a nurse as well as what it is like to be a resident. “We conduct a survey after the orientation, and participants always say that Joan’s words are touching and moving to them. They say it gives them excellent insight and helps them appreciate what their work means to residents,” says </div> <div> </div> <div>Jerusha Siegel, facility administrator. Staff have an opportunity to ask questions, and they most commonly ask her what it’s like to make the move from the community to living in a facility.</div> <div> </div> <div>The opportunity to meet with staff is as rewarding for Joan as it is for them. As Szczepanski says, “It gives her a sense of purpose, something she can feel good about. She’s helping staff and benefiting other residents, and she enjoys that dual role.” </div> <div> </div> <div>Joan says, “For me, it’s an honor. When I speak to staff, I try to convey to them that this job is never going to be easy, but this is a great place to work.” She adds, “I never stopped being a nurse. The residents are very dear to my heart, and I want to help make sure that every one of them gets the care, support, and compassion they deserve.”</div> <h2 class="ms-rteElement-H2">Residents Want Involvement</h2> <div>Since Joan got involved in orientation, other residents have asked to participate, too. Siegel says, “It’s great to integrate residents in determining how orientation will go and what new employees will learn.” The facility actually has taken resident involvement to a new level. Siegel says, “We also have residents who lead various activities.” For example, one resident runs a Christian karaoke event.</div> <div> </div> <div>“He really loves it, and he is excited and proud to be doing something for his fellow residents. This reminds us that our residents like having independence and a sense of purpose. Having some control over their lives is huge,” says Siegel.</div> <div> </div> <div>As Joan observes, “People think you come to a nursing home to die. I don’t think that. You come here because you have needs to be filled. People often don’t realize the positive side of nursing homes.”</div> <h2 class="ms-rteElement-H2">Personal Connection</h2> <div>Encouraging new hires to get to know residents is a growing trend at today’s long term care and post-acute facilities. For example, at Exempla Colorado Lutheran Home, site orientation includes time for new caregivers to read the care plans for residents they will be working with on a regular basis.</div> <div> </div> <div>“We give them an hour of private time to review care plans and get to know their residents’ needs, preferences, history, and so on. This gets them thinking about how they will approach the residents, care for them, interact with them, and engage them in activities,” says Christie Wimmer-Christie, RN, MS, Exempla’s staff development coordinator. Later during neighborhood orientation and then regularly as they start their job, they have additional opportunities to review these plans. </div> <div> </div> <div>Because the plans are written in first person and provide details about each person’s history, communication style, preferred activities, and other information, caregivers can form a real picture of each resident as a person. “The care plans really humanize the residents. People really get wrapped up in the stories.”</div> <div> </div> <div>Not only does reading the care plans give caregivers information that they can use as icebreakers and conversation starters when they meet residents, they also give staff a head start on their work.</div> <div> </div> <div>“When they come back from reading the care plans during orientation, we have a debriefing time. Everyone has a chance to talk about something positive they found out or something that may present a caregiving challenge. Even before they start their job, they get started on critical thinking and problem solving,” says Wimmer-Christie. This contributes to the new employees’ job satisfaction and enhances their confidence.</div> <div> </div> <div>As for the residents, says Wimmer-Christie, “it means the world to them. It makes them feel a little more comfortable with new caregivers.” She adds, “They appreciate that the person has made the effort to get to know them, and this helps them feel a little less apprehensive about change.”<br><br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Motivating Through Culture Change</h2> <div>An assessment tool designed to measure and track culture change also can help facilities identify and implement practices that <a href="/Monthly-Issue/2013/Pages/0413/Motivating-Before-Hiring.aspx">motivate staff</a> and encourage teamwork and job satisfaction. The <a href="/Monthly-Issue/2013/Pages/0413/Charting-New-Waters-In-Leadership-Development.aspx?ControlMode=Edit&DisplayMode=Design">Artifacts of Culture Change</a> (www.artifactsofculturechange.org/ACCTool/) includes more than 25 items in six domain areas (care practice, environment, family and community, leadership, workplace, and staffing outcomes and occupancy). Some of these items are very specific to staff growth and development.</div> <div> </div> <div>For example, one item involves including frontline staff in care conferences. “I asked CNAs [certified nurse assistants] how they felt about this, and they blew me away,” says author and educator Carmen Bowman, who also is one of the developers of the Artifacts tool. She says, “They told me that they want to learn more about their residents and see the care conferences as a great way to do this. They know their residents behind closed doors, and they yearned to know people more fully and from the viewpoint of other team members.”</div> <div> </div> <div>Facility leaders who think that CNAs will balk at taking the time to participate in these conferences will be surprised, says Bowman. “We had talked about doing this at one facility but never formalized it,” she says. “We were having a care conference, and a CNA came rushing in with her lunch. She wanted to give up her lunch hour to attend this conference. It meant that much to her.”</div> <div> </div> <div>This story didn’t surprise Bowman, who says, “Research has shown that when CNAs attend care conferences, turnover goes down.”</div> <div> </div> <div>The Artifacts tool includes the concept of “guardian angels,” staff members who are matched with residents to be their special friends.</div> <div> </div> <div>“Most staff love this idea. One resident was dying in a rural facility, and she ended up passing away in her guardian angel’s arms. Her staff buddy wasn’t on duty at the time, but she wanted to be there for her special friend,” says Bowman. She notes that staff love the opportunity to really impact someone’s life, and being someone’s guardian angel makes them feel more connected and committed.</div> <h2 class="ms-rteElement-H2">Dress For Success</h2> <div>One item in the Artifacts tool that some considered somewhat controversial actually may really enhance staff morale, says Bowman. The idea that staff—including caregivers—wear street clothes instead of scrubs or uniforms is designed to encourage a more homelike atmosphere in facilities.</div> <div> </div> <div>“Some facilities are hesitant to implement this because it would require caregivers—who usually are on a tight budget—to spend more money on clothing,” Bowman says. </div> <div> </div> <div>Susan Black, administrator at Exempla Lutheran Home, admitted that she “got flack,” mostly from nursing staff, when she raised the idea of doing away with uniforms. “I told them that it’s not about what you’re wearing but what kind of relationship you have with residents.” Indeed, clothing cost was a factor, so Black initiated two ideas to ease the financial burden. First, she implemented the idea over six months so that staff could spread out their expenses for new clothing. She also had staff donate clothes and set up racks where staff could “shop” and pick out clothes for free.</div> <div> </div> <div>“We still have a dress code, and staff have to dress in a professional manner. They can only wear denim on Fridays. I think they all like it now,” says Black.</div> <div>Bowman suggests perusing the tool for ideas about ways to motivate and inspire staff. </div> <div> </div> <div>“The tool is educational, whether you complete it or not. And because these ideas are positive and designed to empower staff and improve the lives of residents, many are easy to implement and quickly embraced by management and staff alike,” she says.</div> <div> </div> <div>Even in a tight job market, it can be difficult to find the right people to fill challenging leadership positions—especially on short notice. </div> <h2 class="ms-rteElement-H2">Prepping Nurse Leaders For Future Opportunities</h2> <div>Kindred Healthcare Senior Vice President of Nursing and Clinical Services Barbara Bayliss and her team tired of scrambling to fill director of nursing services (DNS) positions in geographic areas where job opportunities are abundant and turnover is high. So they adapted an administrator training program for nursing staff to hire and mentor promising nurses to fill DNS positions.</div> <div> </div> <div>“We seek RNs with some supervisory experience who are interested in investing the time and effort to develop their leadership skills and move up in the organization,” says Bayliss.</div> <div> </div> <div>The six-month program involved full-time training, involvement on leadership work teams, and professional nurse supervisor-level pay. Participants learn how to recruit and retain staff, work with and educate nursing staff, implement quality improvement initiatives and achieve quality outcomes, and communicate and interact with residents and family members.</div> <div> </div> <div>On successful completion, they are offered a nurse leadership position at a Kindred facility within a 60-minute commute from the training site. “Participants go through an evaluation process every 60 days and have regular phone conversations with leadership to discuss their progress,” says Bayliss. </div> <h2 class="ms-rteElement-H2">Training Pays Off</h2> <div>Last year, Kindred had four nurses complete the program, and three of them were promoted within the organization. “Rather than scrambling to fill leadership positions, we had candidates who were trained nurses who know the organization,” says Bayliss.</div> <div> </div> <div>The nurse leaders who participated as mentors to the trainees also benefited from the program. “We equipped them with special training on how to be an effective mentor, and they participate with trainees in weekly training activities,” says Bayliss. They used customized training materials that involved eight modules addressing topics such as leadership development, performance improvement, Medicare/Medicaid, medical records and documentation, and clinical systems. The modules help track the program and identify gaps in knowledge and opportunities for learning.</div> <div> </div> <div>“Mentors feel privileged to be selected. They enjoy assisting another nurse to move forward,” says Bayliss. However, she discovered early on that it is important to clarify that the “new nurse is not there to take the mentor’s job. There had been some early confusion about that, so some were not readily welcoming. Once they understood how the program worked, they appreciated it and were pleased to be involved.” </div> <div> </div> <div>While the mentoring activities add to the DNS’ already busy schedule, having another nurse around also can be a huge benefit. “The trainee takes on various responsibilities such as handling immunizations or managing a unit. This reduces some of the burden and stress for the DNS,” says Bayliss.</div> <div> </div> <div>“Sometimes you get a limited amount of applicants for a position, and you have to choose the best of what you get. We realized that if we could develop our own people, we would never have to settle for anything less than the absolute best person for the job,” says Bayliss. “We could be better prepared to fill openings and more proactive in successful hiring.”</div> <div> </div> <div>It is useful to identify potential leaders from day one. However, this isn’t always easy, and the best leaders may not stand out right away.</div> <div> </div> <div>As David Farrell, one of the authors of <a target="_blank" href="/Monthly-Issue/2013/Pages/0413/Easing-The-Fear-Of-Change.aspx">“The Leadership Challenge in Long Term Care,”</a> says, “It’s not always the most talkative or outgoing people who make the best leaders.” Instead, he says, “In nursing homes, people follow the staff who are the nicest, most competent, and have the best attendance records. It’s the ones others go to for guidance and assistance. Sometimes, it’s the most quiet and humble people who are the best leaders.” </div> <div> </div> <div>Farrell suggests that managers always be cognizant of potential leaders among their staff. “You’re looking for a good mind and a good heart. You’re looking for someone with critical thinking and problem-solving skills. You’re looking for someone who is empathetic and can put themselves in others’ shoes and act accordingly,” he says. Farrell suggests identifying these people through rounding, meetings, and team huddles. </div> <div> </div> <div>“Watch how they interact with others, how they handle pressures and challenges, how they solve problems, and whether they are willing or eager to take the lead on projects and initiatives,” he says.</div> <div> </div> <div><div>When management identifies a potential leader, Farrell suggests having a formal sit-down. “Commend him or her on what you’ve observed and what of their behaviors and actions are especially helpful and positive. Ask them to do more.” He adds, “Give them some additional responsibilities, such as involving them in new staff orientation or presenting inservice programs.”</div></div>Long term care and post-acute facility residents are individuals whose personalities and feelings must be considered in an effort to keep them safe and happy. That is the lesson of culture change, and facilities have embraced it in efforts to ensure quality care and resident satisfaction. Now facilities increasingly have begun to apply this lesson to staff development and motivation with similar results.2013-04-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0413/cs_thumb.jpg" style="BORDER:0px solid;" />Management;WorkforceCover Story4
CMS Liberalizes Dining Standardshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/CMS-Liberalizes-Dining-Standards.aspxCMS Liberalizes Dining StandardsA “regular diet” should be the new standard for nursing facility residents, the Centers for Medicare & Medicaid Services (CMS) said in a recent memo to state survey agency directors. <br><br>Dated March 2, 2013, the memo advises clinicians and prescribers to make “a regular diet become the default, with only a small number of individuals needing restrictions.”<br><br>Following the recommendations of a task force consisting of 12 organizations representing “clinical professionals involved in developing diet orders and providing food service,” CMS noted that research had found “little benefit to many older individuals with chronic conditions from restrictions in dietary sugar and sodium, as well as little benefit from tube feedings, pureed diets, and thickened liquids.”<br><img src="/Monthly-Issue/2013/PublishingImages/0413/News/dining_standards.jpg" class="ms-rtePosition-2" alt="" style="margin:15px;" /><br>Although the new standards are based on the task force recommendations, the agency stopped short of requiring them for all nursing homes. They “do not represent CMS requirements,” and “surveyors should not issue deficiency citations simply because a facility is not following these particular recommended practices,” the memo says. <br><br>Providers that do follow these new standards “may rely on such adherence in response to questions regarding any changes from more restrictive diet protocols previously used,” the memo further says.<br><br>Go to www.cms.gov and search “dining standards” for more information.2013-04-01T04:00:00ZColumn4
Doc Fix Should Also Fix Therapy Caps For Good, AHCA Sayshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Doc-Fix-Should-Also-Fix-Therapy-Caps-For-Good,-AHCA-Says.aspxDoc Fix Should Also Fix Therapy Caps For Good, AHCA Says<img src="/Monthly-Issue/2013/PublishingImages/0413/News/therapy_caps.jpg" class="ms-rtePosition-1 ms-rteImage-1" alt="" style="margin:5px 10px;" />In a letter to the House Ways and Means and Energy and Commerce Committees, the American Health Care Association (AHCA) urged the chairman to include a permanent therapy cap fix in whatever legislative vehicle is created to permanently fix the formula for Medicare physician payments. <br><br>“We appreciate and strongly support your effort to find a permanent fix to the Sustainable Growth Rate” (SGR), which drives the update in physician rates, said the letter from Gov. Mark Parkinson, AHCA’s president and chief executive officer. “The medical directors of the 15,000 skilled nursing centers in the U.S. are doctors, and we appreciate your efforts to ensure that they are reimbursed at reasonable levels.”<br><br>Year after year, the therapy cap fix has been tied to the annual SGR fix. As a result, AHCA said it was concerned that if lawmakers enacted a permanent SGR resolution without doing the same for therapy caps, it would “leave millions of elderly patients without the care they require.”<br><br>Currently, Congress must pass an annual extension of the therapy cap exceptions process, “or face the consequence of residents in our centers not having access to necessary medical treatment,” Parkinson wrote. In the absence of an exceptions process, the cap imposes a limit of $1,900, “which does not come close to adequately covering the cost of needed treatment,” AHCA said.<br><br>The letter further asked lawmakers not to fund the permanent SGR fix with cuts to other providers.2013-04-01T04:00:00ZColumn4
Motivating Before Hiringhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0413/Motivating-Before-Hiring.aspxMotivating Before Hiring<br>One way to determine at the outset what you can do to motivate individual staff members and identify potential leaders is to conduct a Predictive Index (PI) assessment prior to hiring. The PI is a scientifically validated assessment that accurately predicts workplace behaviors, tendencies, motivators, and drivers.<br><br>“The PI tells you what makes a person tick and how he or she operates. Based on the information obtained in a PI assessment, I could motivate or demotivate a person in two minutes,” says Nancy Martini, president and chief executive officer of PI Worldwide, a company that works with companies and organizations to conduct and interpret these assessments.<br><br>The PI consists of a self-reported adjective checklist regarding how individuals view themselves and how they think others view them. It takes just five to 10 minutes to complete, and the results provide detailed information about a person’s behavioral drives. By matching a person whose drives are congruous with the job they will be performing, it can enhance retention, job satisfaction, team efficiency, and productivity.<br><br>“One goal of the PI is to determine who the person really is, because this is who managers, colleagues, and residents will have to interact with,” says Martini. This information is valuable, as many people—intentionally or not—hide their real personalities during the interview process. The PI helps managers determine in advance if a potential employee actually will fit in with the team and the facility’s culture and be an appropriate candidate for a leadership position.<br><br>Martini urges facilities that use the assessment to pay attention to the results. “What you don’t want to do is think that you will change someone to make them fit into a job. Instead, you should consider if someone is a fit for the job and how you will leverage his or her talents to get the best from his or her performance,” says Martini.<br><br>Jane Drury, vice president of human resources at Balfour Senior Living in Louisville, Colo., uses the PI as a recruiting tool. “We have each candidate complete a PI, then we match it to the profile of the characteristics required for the position,” she says. “This allows us to understand what motivates people and what their work style is so that we can address their needs when they are hired.” <br><br>Drury and company also use the tool to identify potential leaders and managers. “This not only helps us identify people who might be good leaders, but it also makes it more likely that the people we hire and promote will be more successful in those leadership positions,” she says.Column4

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Relationships Matter...Part 2https://www.providermagazine.com/Monthly-Issue/2013/Pages/0513/Relationships-Matter.aspxRelationships Matter...Part 2<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p></p> <div> </div> <div>Despite all the advances in equipment and technology to improve care, leaders should remember that it’s their staff and their relationships that have the greatest influence on organizations’ performance. </div> <div> </div> <div> </div> <div> </div> <div>Researcher Jody Gittell has documented that high-performing nursing homes have, as their foundation, high-quality working relationships among the staff. </div> <div> </div> <div> </div> <div> </div> <div>Gittell’s team found that residents’ experiences are powerfully shaped by relationships among staff and that the relationships among the staff who work closest to the residents matter most (<a href="/Monthly-Issue/2013/Pages/0213/Relationships-Matter.aspx">see February’s 2013 Management column</a>). The interdependent nature of caregiving work requires what Gittell calls relational coordination. </div> <div> </div> <h2 class="ms-rteElement-H2">Positive Chain Of Leadership</h2> <div> </div> <div>Systems that generate a dynamic of staff empowerment and engagement will take hold if leaders follow up with staff on what they share and adjust care and operations to meet needs that staff identify. </div> <div> </div> <div> </div> <div> </div> <div>The leadership abilities of charge nurses become so much more important because several of these systems support day-to-day decision making among staff closer to the problems and closer to the residents, where nurses set the tone through huddles and ongoing interactions. </div> <div> </div> <div> </div> <div> </div> <div>The more nurse leaders focus on good working relationships, the better everyone works together. </div> <div> </div> <div> <img width="284" height="189" src="/Monthly-Issue/2013/PublishingImages/0513/mgmt1.jpg" class="ms-rteImage-1 ms-rtePosition-2" alt="" style="margin:20px 5px;" /><br></div> <div>Some nurses come by these skills naturally, but very few have had formal leadership training. Nurses are better able to step into leadership when directors of nursing (DONs) focus on developing their leadership skills by giving them opportunities to take on new responsibilities and then sharpen the nurses’ skills by providing timely, accurate, problem-solving-oriented feedback in the context of a supportive relationship.</div> <div> </div> <div> </div> <div> </div> <div>For example, pilot testing implementation of daily shift huddles with the charge nurse most able to succeed, and helping the nurse step into the new role by providing support along the way, builds skills as the leader builds systems. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Stability Starts With Relationships</h2> <div> </div> <div>If a facility is experiencing daily instability, these relational practices may feel out of reach. However, systems to support good working relationships can actually help to stabilize an environment. In an atmosphere of instability, staff have often lost trust in their leaders. In restoring trust, actions speak louder than words. Action is most effective when it is systematic and consistent so that staff can count on it. </div> <div> </div> <div> </div> <div> </div> <div>The key is to reduce stress. National Research Corp. has consistently found in its My InnerView staff satisfaction surveys that the factors most affecting employees’ decisions to recommend their workplaces to others are that management cares, management listens, and management helps with job stress. </div> <div> </div> <div> </div> <div> </div> <div>A <a target="_blank" href="/Monthly-Issue/2013/Pages/0513/A-Trigger-For-Relational-Coordination.aspx">relational coordination</a> practice to reduce stress is an all-hands-on-deck approach, through which management supports staff at high stress times and staff are able to count both on management’s assistance and their accessibility during those times when they are most needed.</div> <div> </div> <h2 class="ms-rteElement-H2">All Hands On Deck A Successful Approach</h2> <div> </div> <div>When Susan Hawver became administrator at Bayberry Commons, the staff had had four administrators and four DONs in five years and had a bunker mentality, believing that they were on their own to address problems. </div> <div> </div> <div> </div> <div> </div> <div>Bayberry was a special-focus facility, with a one-star rating, a low census, and high rates of pressure ulcers and restraints. </div> <div> </div> <div> </div> <div> </div> <div>When Hawver began making daily rounds to check in on what people needed and to provide support, staff began to sense that they were not alone. </div> <div> </div> <div> </div> <div> </div> <div>The turning point came when the management team reviewed results from its family satisfaction survey and noted one bright spot among its dismal ratings: Despite not having staff respond in a timely manner to residents’ needs, families felt that when staff did come, they were kind and caring. </div> <div> </div> <div> </div> <div> </div> <div>The management team decided to take an all-hands-on-deck approach to meet residents’ needs during the busiest times of the day. Staff identified mealtimes and shift changes for this support. The management team members took assignments to help out and maintained their commitment every day. </div> <div> </div> <div> </div> <div> </div> <div>They were able to see the inner workings of their staff dynamics, identify simple ways to help work go more smoothly, role-model teamwork, and address staff who needed to step up. </div> <div> </div> <div> </div> <div> </div> <div>As staffing stabilized, the “all hands” approach allowed them to improve their customer service progressively. They dramatically improved in restraints and pressure ulcers, graduated from the special-focus list, achieved 100 percent census, and won a Silver Quality Award from the American Health Care Association. <br><span id="__publishingReusableFragment"></span><br></div> <div> </div> <h2 class="ms-rteElement-H2">Reducing Stress To Improve Results</h2> <div> </div> <div>Bayberry’s experience provided a road map for critical-access nursing homes involved in a four-state Advancing Excellence initiative in which 17 struggling homes stabilized over a one-year period. For many of the nursing homes, utilizing all hands on deck was a turning point. </div> <div> </div> <div> </div> <div> </div> <div>One DON said that as staff came to trust that they would have management’s help when needed, they became more generous in helping each other. He said it has created a “more nurturing” work environment and reduced conflict among staff. Now he has “more time to think ahead” and implement improvements because he’s not spending time on issues between staff members. </div> <div> </div> <h2 class="ms-rteElement-H2">Advancing Excellence Can Help </h2> <div> </div> <div>A Chicago nursing home participating in the Advancing Excellence initiative used huddles to stabilize. Each morning on each unit, nurses, nurse assistants, activities, social services, housekeeping, and management met to discuss what was going on and ensure everyone was working together to provide the necessary care and services the residents needed. </div> <div> </div> <div> </div> <div> </div> <div>Topics discussed were reported to the rest of the department managers at the morning meeting and addressed immediately. The group huddled again at the end of the shift to check in on whether needs had been addressed. As leaders were able to respond to staff needs, stress eased, staff stabilized, and care improved.</div> <div> </div> <h2 class="ms-rteElement-H2">Systems Drive Outcomes</h2> <div>Wherever a nursing home is in its improvement efforts, its systems shape its outcomes. The better staff work with each other, the better they can care for residents. </div> <div> </div> <div> </div> <div> </div> <div>It sounds so simple, but relational coordination doesn’t happen by itself. It occurs when leaders put the systems in place to generate “timely, accurate, problem-solving” communication; help staff to develop the skills needed to make the most of these systems; and create an environment that supports staff to talk issues through and problem-solve together. </div> <div> </div> <div> </div> <div> </div> <div>Whether struggling to improve from a one-star rating, focused on reducing antipsychotics or decreasing rehospitalization rates, or working on culture change, nursing homes succeed when using systems that support and foster relational coordination among the staff and with leadership who follow through and support what their staff need and have to offer. </div> <div> </div> <div> </div> <div> </div> <div><em>David Farrell, Barbara Frank, and Cathie Brady are co-authors of “Meeting the Leadership Challenge in Long-Term Care: What You Do Matters.”</em></div> <div></div> Some nurses come by these skills naturally, but very few have had formal leadership training. Nurses are better able to step into leadership when directors of nursing (DONs) focus on developing their leadership skills by giving them opportunities to take on new responsibilities and then sharpen the nurses’ skills by providing timely, accurate, problem-solving-oriented feedback in the context of a supportive relationship.2013-05-01T04:00:00Z<img alt="/archives/2013_Archives/PublishingImages/0513/mgmt_land.jpg" src="/Monthly-Issue/2013/PublishingImages/0513/mgmt_thumb.jpg" style="BORDER:0px solid;" />Management;CaregivingColumn5
Elopement: Assessment And Safety Essentialshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0513/Elopement-Assessment-And-Safety-Essentials.aspxElopement: Assessment And Safety Essentials<div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0513/caregiving1.jpg" class="ms-rtePosition-2" width="369" height="245" alt="" style="margin:5px;" />Nursing home and assisted living elopement highlights a provider’s duty to adequately protect those residents who suffer from cognitive deficits that result in poor safety awareness. </div> <h2 class="ms-rteElement-H2">Protecting Residents</h2> <div>After an elopement occurs, the immediate result is the frenzy of the search as well as various notifications, including of law enforcement, family members, the media, regulatory agencies, and the resident’s physician. But ultimately the onus will be on the facility to demonstrate whether adequate measures were instituted to protect the resident.</div> <div> </div> <div>Defending the care of a resident with documented cognitive impairment who elopes is challenging at best. A mere glance outside the front door of most long term care facilities brings to mind the frightening dangers that await a confused resident: extremes in temperature, bodies of water, busy thoroughfares, train tracks, expansive woods, uneven terrain, and wild animals. The consequences to the resident can be devastating. </div> <div> </div> <div>On the less-distressing end of the spectrum is a dementia resident with the anxiety of being lost; on the other end is the tragic—and often avoidable—loss of life. </div> <div> </div> <div>Although a facility’s responsibility to protect a resident from harm is clear, a screening assessment for elopement risk is often absent from the admission process. Because elopements generally occur in low volumes, the importance of this risk assessment is often overlooked, and even when facilities have an elopement screening tool available, the assessment is often conducted after staff observe that a resident is displaying wandering tendencies or has unsuccessfully attempted to elope. </div> <div> </div> <div>However, many elopements occur in the first few days after admission as the resident transitions to a new environment, and many occur as a consequence of a first wandering episode. As such, a reactionary, post-elopement assessment leaves those who are in most need of protection without any safeguards.</div> <h2 class="ms-rteElement-H2">Elopement Defined</h2> <div>Wandering refers to a resident with cognitive impairments moving aimlessly about inside a facility, without an appreciation of personal safety needs, while elopement is when a resident leaves a safe area unsupervised and unnoticed and enters into harm’s way. </div> <div> </div> <div>Residents who elope are differentiated from wanderers because they make purposeful, overt, and often repeated attempts to leave the nursing home and its premises. <br><br></div> <div>While wandering in a facility can present harmful situations for a resident if adequate protections are not in place, such as preventing resident access to chemicals and stairwells, the opportunities for injury multiply after a resident elopes from the nursing facility. </div> <div> </div> <div>Elopements remain among the most costly risk exposures in the long term care setting. According to CNA’s “Reducing Risk in a Changing Industry: CNA HealthPro Aging Services Claims Analysis 2004–2008,” the average paid claim for an alleged elopement in the for-profit skilled nursing setting was more than $325,000. </div> <div> </div> <div>According to the Briggs Corp., 10 percent of nursing home lawsuits deal with elopement, and 70 percent of these suits involve the death of a resident. In 45 percent of these cases, the elopement occurred within the first 48 hours of admission. </div> <div> </div> <div>When a resident has an impaired ability to make rational choices that will reasonably ensure his or her safety, the responsibility is on the facility to demonstrate that 1.) staff assessed the resident’s risk to elope; and 2.) staff implemented measures to protect the resident when that resident was no longer able to make sound decisions.</div> <div> </div> <div>It is nearly impossible to defend a process that leaves the responsibility for the safety of a vulnerable adult with that person. It is also difficult to defend a facility that admits residents whose needs it cannot manage, and yet neglects to perform an assessment that evaluates for these needs. Further, federal regulations prohibit the facility from admitting or retaining residents it cannot protect.</div> <h2 class="ms-rteElement-H2">Admissions Should Follow Assessment</h2> <div>A facility should base its admission criteria on its ability to protect residents, given the security systems in place, and elopement assessment findings must demonstrate that a resident’s level of risk is commensurate with the facility’s elopement-prevention strategies.</div> <div> </div> <div>Because an elopement risk assessment is used to determine if a resident has the safety awareness to remain in the facility, an objective, score-based risk assessment should include a defined parameter that indicates an increased risk for elopement and prompts the implementation of prevention strategies (<a href="/Monthly-Issue/2013/Pages/0513/Elopement-Prevention.aspx">see Elopement Prevention</a>).</div> <div> </div> <div>Because many residents in long term care have one or more conditions that compromise their decision-making ability, it is imperative that all residents be assessed on admission and at least quarterly thereafter. Further, if a facility’s admission criteria state that residents who are at risk for elopement are not admitted, the only method of demonstrating compliance with these criteria is by utilizing the admission risk assessment, which should clearly indicate the resident does not exhibit risk factors. </div> <div> </div> <div>A proactive risk assessment should be an adjunct to the resident and family orientation process. Families should be educated about admission and discharge criteria as well as the facility’s process for managing elopement risk. </div> <div> </div> <div>If the facility is equipped to care for residents who are at risk for elopement, the assessment should serve as a launching pad for a discussion about setting realistic expectations and the aging process. If the facility is not adequately equipped for this type of resident, the family should be informed that transfer to a suitable facility may be necessary. <br></div> <h2 class="ms-rteElement-H2">Reassessment Required</h2> <div>An additional risk assessment should be performed after there is any change in a resident’s condition. Although a resident may be admitted with adequate safety judgment and awareness, an alteration in cognition may occur subsequent to a change in condition. This could trigger risk factors that were not present on admission. </div> <div> </div> <div>Dimensions of the reassessment should include physical, psychological, and historical factors, as well as medications. Physical factors include any alteration in cognitive impairment; this is most commonly related to such conditions as Alzheimer’s disease and other dementias. Even mild cognitive impairment can weaken a resident’s ability to make sound decisions. A resident’s mobility and ability to communicate should be included in the reassessment. </div> <h2 class="ms-rteElement-H2">Contributing Symptoms</h2> <div>Psychiatric diagnoses, such as delusions, hallucinations, and schizophrenia, also place residents at high risk for elopement. Depression is known to mimic symptoms associated with dementia, and akathisia (motor restlessness characterized by pacing, standing and sitting, or rocking back and forth) may be caused by psychotropic and antidepressant medications. </div> <div> </div> <div>Medications that cause confusion and restlessness also contribute to elopement risk, while some medical conditions and their associated treatments can aggravate cognitive impairment. </div> <div> </div> <div>A resident’s history is of paramount importance in the assessment process. It should not only include prior attempts, wandering behaviors, and exit-seeking episodes, but also vocalized statements about wanting to leave the facility.</div> <div> </div> <div>Residents who are at risk for elopement often have a perceived need to go somewhere or attend to some activity that may once have been part of their daily routine, such as visiting a family member who is now deceased or caring for a pet they once had. These statements, urges, and activities should be recognized and addressed. </div> <div> </div> <div>Families often inaccurately portray a resident’s history regarding wandering and elopement because of fears about obtaining placement. Problems with definitions of “wandering” further cloud the responsible party’s ability to provide this essential information. Families who understand that objective criteria will be used to substantiate appropriate placement may be more forthcoming with their concerns. </div> <h2 class="ms-rteElement-H2">Watch For Danger Signals</h2> <div>Other factors that signal concern include finding a resident “lost” in the facility after admission. An unwilling admission or problem with adjustment to the facility, such as stating a desire to go home, or feeling confined, tricked, or imprisoned, contribute to an increased risk for elopement. Interference with prevention strategies, such as an expressed displeasure with a wandering-prevention bracelet or attempts to remove it, is also a warning sign. </div> <div> </div> <div>Additional behaviors that could precipitate elopement include those in which the resident is not easily redirected or managed. Some specific wandering behaviors may forewarn of an elopement, including shadowing staff or other residents; self-stimulatory behaviors, due to boredom; and exit-seeking behaviors, such as hovering near exits or waiting for the opportunity to leave with someone.</div> <div> </div> <div>In the end, all admission documents should serve as a basis for developing an individualized care plan, delineating the family and facility’s role in resident care, and documenting the corresponding safety measures the facility has put into place.</div> <div> </div> <div><em>Karen Struck, RN, MS, CPHQ, CPHRM, is a risk management professional, speaker, author, film writer, and independent consultant contracted with Pendulum. She can be reached at struckdown@aol.com or (805) 797-5840.<br></em></div><div><br><em></em></div> <p>References</p> <p>■ Algaier, Ted, “How Communication Technology Reduces Risk: Communications Update,” Nursing Homes, September 2002</p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ Turnbull, Gwen, “Feature: The Bottom Line on Wandering and Elopement,” Extended Care Product News 2002 83(5): 20-21</p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ Boltz, Marie, “Wandering and Elopement.” Assisted Living Consult, September/October 2006</p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ Boltz, Marie, “Wandering and Elopement: Litigation Issues,” The John A. Hartford Foundation Institute for Geriatric Nursing; NYU College of Nursing</p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ Federal Regulations 42 CFR Part 483, Centers for Medicare & Medicaid Services website, <a target="_blank" href="http://cms.hhs.gov/">http://cms.hhs.gov</a></p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ Futrell, M., and Melillo, K.D., “Evidence-Based Protocol: Wandering,” Iowa City, Iowa: The University of Iowa Gerontological Nursing Interventions Research Center. 6 M. Titler, ed., March 2002</p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ “National Institute on Aging Progress Report on Alzheimer’s Disease,” Washington, D.C.: U.S. Department of Health and Human Services, Public Health Services, National Institute of Health NIH Publication No. 99-3636. (1998)</p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ “Resident Elopement: Facts, Prevention, Responding, Tools and References,” Briggs Corp. Downloaded from the Internet January 2008. <a target="_blank" href="http://www.guideone.com/SafetyResources/SLC/Docs/elopementbrochure.pdf">www.guideone.com/SafetyResources/SLC/Docs/elopementbrochure.pdf</a></p> <span class="ms-rteThemeForeColor-8-4"> </span><p>■ “Transforming Aging Services,” CNA HealthPro Long Term Care Claims Study 2001–2006. CNA 2007</p> <div> </div>Defending the care of a resident with documented cognitive impairment who elopes is challenging at best. 2013-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0513/caregiving_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalSpecial Feature5
Digital Camera Surveillance: Friend Or Foe?https://www.providermagazine.com/Monthly-Issue/2013/Pages/0513/Digital-Camera-Surveillance-Friend-Or-Foe.aspxDigital Camera Surveillance: Friend Or Foe?<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div><img width="348" height="229" src="/Monthly-Issue/2013/PublishingImages/0513/tech1.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 10px;" />Skilled nursing and assisted living providers have a duty to monitor what happens in their facilities. Providers routinely use “smart” devices to enhance the staff’s capacity to meet resident needs. </div> <div> </div> <div>Examples of common “smart” devices utilized in nursing homes and assisted living communities are bed alarms to help staff members “observe” residents who are at risk of falling, infusion pumps to administer medications, and motion- activated night-lights. Some providers are also using digital recording video camera surveillance (DRVCS) systems to monitor the resident care environment. This article considers the practical and legal considerations surrounding the utilization of DRVCS.</div> <h2 class="ms-rteElement-H2">The Omnipresence Of Video Cameras </h2> <div>Historically, nursing home and assisted living providers and professional staff resisted the use of “granny cams”—camera systems that observe and record the facility. Opponents of DRVCS contend that video surveillance compromises residents’ privacy and dignity, invites staff resistance, and captures images that may be used by government agencies and plaintiff counsel. The installation, maintenance, and operation of DRVCS are also regarded as prohibitively expensive. DRVCS systems typically cost $3,000 to $12,000, though the price varies based upon the building characteristics, number of cameras installed, and digital storage capacity.</div> <div> </div> <div>Society’s attitude toward video camera surveillance has evolved in recent times, moving from resistance to tolerance, to acceptance, to, in many cases, preference.  <br><span><img src="/Monthly-Issue/2013/PublishingImages/0513/DavidGordon_tech.jpg" alt="David Gordon" class="ms-rteImage-1 ms-rtePosition-2" style="margin:15px 5px;width:137px;height:137px;" /></span></div> <div>In light of technological advancements, cameras are omnipresent. Surveillance takes place in stores, malls, restaurants, banks, hotels, elevators, parking lots, along streets, and at crosswalks. Homeowners install DRVCS systems and watch real-time images on their smart phones, tablets, and computers. </div> <div> </div> <div>Child daycare centers promote the use of DRVCS systems and encourage parents to view their children online, thereby increasing the level of trust between the daycare centers and families. Recording devices are readily accessible, as every person with a smart phone can capture photographs and audio and video recordings with the click of a button. </div> <div> </div> <div>State legislatures also recognize the benefits of DRVCS. At least 18 states have introduced legislation regulating electronic surveillance in nursing homes and assisted living settings, and several have adopted comprehensive regulations.</div> <div> </div> <div>In 2001, Texas was the first state to enact legislation permitting monitoring devices in skilled nursing and assisted living facilities. New Mexico, Maryland, and Virginia quickly adopted similar legislation. New Jersey is presently considering Senate Bill 669, mandating that nursing homes permit the use of electronic monitoring devices at a resident’s request. </div> <div> </div> <div>Most recently, the Oklahoma legislature proposed the Protect Our Loved Ones Act, mandating DRVCS system installation throughout skilled nursing and assisted living facilities, including resident rooms. A resident or a legal representative must affirmatively “opt out” of room monitoring by executing a waiver with the Oklahoma Department of Health. </div> <h2 class="ms-rteElement-H2">Benefits To Providers</h2> <div>The utilization of DRVCS provides benefits for providers as well. Camera surveillance may enhance security, verify proper care, and improve quality by identifying substandard practices for corrective action. Some believe that such devices help to deter abuse and neglect and promote a trusting relationship with consumers. </div> <div> <img src="/Monthly-Issue/2013/PublishingImages/0513/DanMoles_teck.jpg" alt="Daniel Moles" class="ms-rteImage-1 ms-rtePosition-1" style="margin:5px 10px;width:137px;height:137px;" />In fact, DRVCS systems may provide a marketing “edge” and be an additional source of revenue, if laws and regulations permit facilities to charge for this enhancement.</div> <div> </div> <div>In California, a family reported concerns of patient abuse to a skilled nursing facility for over a year. The family eventually installed a hidden video camera in the patient’s room. The footage showed a certified nurse assistant slapping the resident, pulling her hair, and treating her violently in a shower chair. The family sued, and the jury awarded a $7.75 million dollar verdict. </div> <div> </div> <div>The civil suit and sizable verdict may have been avoided had the facility installed a DVRCS system.</div> <div> </div> <div>A New York nursing home captured an occurrence of residence abuse and neglect through DRVCS monitoring that would have otherwise gone undetected. A nurse at the facility documented that she found an elderly patient with dementia on the floor near her wheelchair in the hallway. The patient sustained a broken hip and was hospitalized. </div> <div> </div> <div>The next morning the facility reviewed the DRVCS footage and learned the shocking truth. The recording revealed that the nurse abruptly spun the resident’s wheelchair, flinging her from the chair to the floor. Instead of offering the resident care and comfort, the nurse ignored her. She looked around the area, seemingly to confirm that there were no witnesses, and resumed pushing a medication cart down the hallway. Minutes later, a different staff member saw the resident, summoned help, and offered assistance.</div> <div> </div> <div>The facility reported the incident to the Department of Health and the police. The nurse was arrested and charged with abuse. The television news story, available at www.nursing homeexpert.net/videoindex.html, commended the facility for installing the DRVCS system, reviewing the footage, and promptly reporting the incident to the authorities.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Hidden Cameras Used Against Providers</h2> <div>DRVCS systems installed by law enforcement officials and families have similarly provided footage that resulted in civil litigation and criminal charges. After obtaining consent from the residences’ families, the New York State Attorney General’s Office of Medicaid Fraud placed hidden cameras in residents’ rooms. </div> <div> </div> <div>The footage obtained resulted in the arrest of a few dozen nurses, nurse assistants, and the facility’s medical director. Each employee was charged with the falsification of business records for documenting care that was not provided. </div> <div> </div> <div>The facility ultimately returned state funds for care and services that the managers should have reasonably known were not provided to the residents. Some employees faced additional charges of abuse and neglect. </div> <div> </div> <div>DRVCS systems can be used in common areas, such as lobbies, hallways, dining rooms, and dayrooms, where residents do not have a reasonable expectation of privacy. </div> <div> </div> <div>The provider should notify residents or their legal representatives of the surveillance monitoring upon admission and obtain written consent, to be retained in each resident’s record. Facilities should post conspicuous signs in common areas to inform residents, families, and visitors that the area is being monitored.<br><img src="/Monthly-Issue/2013/PublishingImages/0513/KLinsey_tech.jpg" alt="Katherine Linsey" class="ms-rteImage-1 ms-rtePosition-1" style="margin:10px;" />Cameras should not be permitted in areas where residents may have a heightened expectation of privacy, such as bathrooms, showers, and locker rooms. Under well-defined circumstances, DVRCS devices may be used in resident rooms, so long as the monitoring complies with state laws and regulations. DRVCS monitoring in patient rooms requires written, informed consent of the resident or legal representative. </div> <div> </div> <div>In a multi-bed room, consent of all roommates should be obtained, and the camera should be installed in a fixed position to ensure that it focuses upon the consenting patient. </div> <h2 class="ms-rteElement-H2">Approval Needed In Some Cases</h2> <div>With the exception of covert surveillance, the use of an in-room DRVCS system should be approved by the care planning team. In resident rooms, DRVCS may be especially helpful to monitor bedside care when the resident or family complains of abuse or neglect or when a resident sustains recurrent unidentifiable injuries. In addition, the camera system may proactively monitor residents who are unable to vocalize care-related concerns, such as those diagnosed with dementia. </div> <div> </div> <div>Providers planning to use DRVCS systems should formulate policy and procedure guidelines that:</div> <div>■ Address the scope, use, and capacity of the camera recording system; </div> <div>■ Note circumstances that warrant the use of covert cameras; </div> <div>■ Identify which staff members are responsible for maintaining the system and which are authorized to access the digital recordings; </div> <div>■ Specify how long the digital recordings will be preserved (usually seven to 21 days, based on the system’s capacity); </div> <div>■ Outline how the facility will safeguard and respond to footage that reveals substandard care;</div> <div>■ Describe the use of the recorded information to enhance quality improvement; </div> <div>■ Determine the nature and delivery of resident, family, and staff notifications; and </div> <div>■ Regulate off-site, Internet viewing by authorized staff members and families. </div> <div> </div> <div>The policies and procedures should define who owns the recorded images and the conditions under which residents, families, and others may view them. The guidelines should prohibit employees from watching or viewing the images absent a reasonable belief that the cameras may have recorded pertinent information. </div> <div> </div> <div>Oversight of the use of the DRVCS system may be assigned to the Quality Assurance and Performance Improvement Committee. Guidelines should be developed with the input of nurses and nurse assistants, an attorney, risk manager, insurance carrier or consultant, resident and family councils, the residents’ rights advocate or ombudsman, and in consultation with the state agency responsible for oversight of the facility’s compliance with federal and state regulations.</div> <div> </div> <div>The implementation of DRVCS systems to complement existing systems for monitoring care and improving quality may result in the timely, provider-friendly, cost-effective improvement of the patient care environment.</div> <div> </div> <div>Disclaimer: The information in this article is provided for educational purposes and does not constitute legal advice.</div> <div> </div> <div><em>Daniel Moles, RN, BBA, MPS, LNHA, president of TRANSITION HealthCare Consultants, can be reached at <a href="mailto:Dan@TransitionHCC.com">Dan@TransitionHCC.com</a>, (973) 464-2101. David L. Gordon, shareholder at Buchanan Ingersoll & Rooney, Princeton, N.J., and Philadelphia, can be reached at <a href="mailto:David.Gordon@bipc.com">David.Gordon@bipc.com</a>, (609) 987-6854. Katherine Linsey, RN, can be reached at <a href="mailto:Katherine.Linsey@bipc.com">Katherine.Linsey@bipc.com</a>, (203) 258-0766.    </em></div> <div> </div> In light of technological advancements, cameras are omnipresent. Surveillance takes place in stores, malls, restaurants, banks, hotels, elevators, parking lots, along streets, and at crosswalks. Homeowners install DRVCS systems and watch real-time images on their smart phones, tablets, and computers. 2013-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0513/tech_thumb.jpg" style="BORDER:0px solid;" />Column5
Federal Auditors Question Medical Necessityhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0513/Federal-Auditors-Question-Medical-Necessity.aspxFederal Auditors Question Medical Necessity<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div> <p></p> <div><img src="/Monthly-Issue/2013/PublishingImages/0513/coverstory1.jpg" class="ms-rteImage-0 ms-rtePosition-2" alt="" style="margin:5px 10px;" />The Centers for Medicare & Medicaid Services (CMS) proclaimed recently that its two-year-old Fraud Prevention System (FPS) is a fruitful investment with a high rate of return, but Congress is not as sanguine about the agency’s fraud-fighting efforts as the agency appears to be. </div> <h2 class="ms-rteElement-H2">CMS Praises New System</h2> <div>Following the FPS’ first year of operation, CMS found that the system has earned an estimated $3 for every $1 it has spent rooting out fraud. Peter Budetti, CMS’ deputy administrator for program integrity, explained recently to the House Energy and Commerce Subcommittee on Health that the FPS is a “highly sophisticated” system that prevented or identified more than $115 million in improper payments in its first year. </div> <div> </div> <div>In a December 2012 report to Congress, CMS says the FPS led them to take numerous administrative actions against providers. “Through these actions, CMS saved an estimated $115.4 million in payments, comprising $31.8 million in estimated actual savings and $83.6 million in estimated projected savings,” the report says. </div> <div> </div> <div>“The FPS also generated leads for 536 new <a target="_blank" href="/Monthly-Issue/2013/Pages/0513/Federal-Jimmo-Settlement-May-Have-Coverage-Implications,-Eventually.aspx">ZPIC</a> [Zone Program Integrity Contractors] investigations, augmented information for 511 pre-existing investigations, and prompted 617 provider interviews and 1,642 beneficiary interviews to verify legitimate provision of Medicare services and supplies.”</div> <div> </div> <div>Budetti’s testimony in front of the House panel touts the FPS as a “highly technical, highly sophisticated system that analyzes all Medicare fee-for-service claims using risk-based algorithms” and generates alerts that allow contractors to utilize a variety of methods to investigate them before they are paid. </div> <h2 class="ms-rteElement-H2">Congress Sees A Different Picture</h2> <div>The FPS figures may be impressive, but a bipartisan group of senators has been searching for solutions from sources other than CMS. In January, current and former members of the Senate Finance Committee released a report outlining <a target="_blank" href="/Monthly-Issue/2013/Pages/0513/Practical-Recommendations.aspx">recommendations</a> from more than 160 stakeholder groups on ways to improve the feds’ efforts to combat waste, fraud, and abuse in Medicare and Medicaid. </div> <div> </div> <div>Among the recommendations highlighted by the senators were: </div> <div>■ Eliminating duplication and redundancy in federal and state Medicare/Medicaid anti-fraud;</div> <div>■ Changing certain Medicare payment policies that, through disparate pricing issues, lead to fraud, waste, and abuse;</div> <div>■ Ensuring that provider enrollment policies are consistent and utilized </div> <div>effectively;</div> <div>■ Clarifying the circumstances in which use of care and the setting for care is appropriate such as when it is appropriate to use inpatient care versus outpatient;</div> <div>■ Making numerous process changes to how the various CMS audit contractors operate to ensure they are doing so efficiently and effectively;</div> <div>■ Balancing the incentives for Medicare contractors to identify overpayments with penalties for contractors whose findings are overturned on appeal through the CMS administrative process; and</div> <div>■ Creating an advisory panel to provide clinical input as a component of contractor oversight.</div> <div>The report and its recommendations are the result of a request made last spring by the senators to get input on the best ways to fight fraud. They called on stakeholders in the health care community to come up with their own ideas for battling fraud.</div> <div> </div> <div>“Last spring I joined with colleagues in asking members of the health care community to provide us with their best ideas for streamlining and strengthening federal efforts to curb waste, fraud, and abuse in Medicare and Medicaid,” said Sen. Tom Coburn, MD (R-Okla.). </div> <div> </div> <div>“Members of the health care community offered hundreds of pages of good, actionable, common-sense ideas, and I plan to continue working with my colleagues in a bipartisan manner to improve federal efforts in this area. </div> <div> </div> <div>“Evidence from the Government Accountability Office and the Inspector General’s Office has shown some federally funded program integrity efforts are failing to achieve the aims they were designed to achieve, while others are even losing money.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">CMS Invests Millions In Fraud System </h2> <div>Despite the senators’ apparent dissatisfaction with CMS’ efforts, the agency has invested millions of dollars in the FPS and appears to view it as a panacea to the age-old system of “pay and chase” that is now considered obsolete within the agency. The FPS report to Congress highlights the system’s projected and actual savings during its first year, which CMS estimates at $31.8 million and $83.6 million, respectively. </div> <div> </div> <div>Also in the report are costs associated with the FPS. During the first year of the program, costs were described in three categories: contractor costs, FPS-related CMS management costs, and ZPIC costs incurred in investigating and acting upon FPS-generated leads.</div> <div> </div> <div>Contractor costs amounted to some $30.5 million, while CMS management costs totaled $4.2 million, for a total cost of $34.7 million in the first year of implementation. </div> <div> </div> <div>One area of focus in the report is the FPS’ collaboration with law enforcement. “Mission rotations” are touted prominently as a key component in bringing together field investigations and predictive analytics.</div> <div>It works like this: “Multidisciplinary teams, including [ZPICs] and law enforcement, join CMS’ Center for Program Integrity in face-to-face collaborative mission rotations to develop consistent approaches for investigation and action,” the report says. </div> <div> </div> <div>This process compares with past approaches that included “numerous handoffs and required significant time,” while the FPS approach brings “experts and decision makers together in a pilot command center,” thus making the cycle time for making decisions on payment suspensions significantly reduced. </div> <div> </div> <div>With expanded law enforcement cooperation, FPS “provides investigators with the ability to access additional support information and analytic tools,” the report says. </div> <div> </div> <div>Multiple layers of law enforcement collaboration are further described in the report, including how Recovery Auditors (RAs) are able to refer cases in which they identify fraud to ZPICs for investigation. </div> <div>Also identified in the report are some “enhancements” to the FPS that CMS plans to implement over the next year. Among them is the expansion of “FPS capabilities and targeting fraudulent providers and claims” and the integration of the claims processing system and the FPS. </div> <div> </div> <div>This change will enable the FPS to “stop payment of certain improper claims, without human intervention, by communicating a denial message to the claims payment system,” the report says.<br><br></div> <div>This means that CMS will be able to deny improper claims that it describes as “medically unbelievable.”</div> <h2 class="ms-rteElement-H2">Medicare Auditors Press On</h2> <div>With the FPS in full force, CMS shows no signs of decelerating its fraud-fighting efforts. Providers continue to be surprised by audit letters and notifications in various pockets of the country, with the usual intensity aimed at Southern states such as Florida and Texas. And auditors appear to be targeting medically unnecessary care and providers’ use of high-level resource utilization groups (RUGs). Also under the microscope are billing errors, upcoding, and technical errors, and both ZPICs and RAs continue to lead the charge in pursuing skilled nursing facility (SNF) providers. </div> <div> </div> <div><img src="/Monthly-Issue/2013/PublishingImages/0513/Herschman_Gary.jpg" alt="Gary Herschman" class="ms-rteImage-1 ms-rtePosition-1" style="margin:5px 10px;" />“A lot of what we’re seeing is based on therapy levels, higher RUGs, and documentation,” says Gary Herschman, chair of the Health Care Practice Group at Sills Cummis & Gross and vice chair of the fraud and abuse practice group with the American Health Lawyers Association. “They’re going back and second-guessing SNFs, who will have to be prepared to defend their coding, medical necessity, and supporting documenation. The government is taking an aggressive stance.”</div> <div> </div> <div>So what’s a provider to do? “Being proactive with internal reviews, training and education, and other compliance measures could help providers avoid audits, or if audited, enable them to better defend and rebut audit findings,” says Herschman.</div> <h2 class="ms-rteElement-H2">Medical Necessity, RUGs Are Scrutinized</h2> <div>Much of the recent audits have centered on medical necessity, as well as technical findings, says Herschman, who has been working in this area for nearly 15 years. “Some of things we’re seeing, in letters from ZPICs, for example, focus on finding inconsistencies between the minimum data set [MDS] and the medical record and therapy notes,” he says.  Herschman cites as a common example the fact that SNFs may tend to poorly document physician signatures for orders or plans of care. “ZPICs are scrutinizing facilities on a 360 degree basis—consistency with MDS, medical record support for therapy, documentation of therapy provided, and RUGs coding. </div> <div> </div> <div>Herschman draws a connection between enhanced reviews and audits and the fact that a November 2012 Office of Inspector General (OIG) report found a 25 percent error rate among SNF claims. “They’re going to cast a wide net,” he says. “And they’re not just looking for clearly erroneous coding; they’re looking for anything questionable and small technicalities.”</div> <div> </div> <div>Also on ZPICs’ radars: a lack of restorative potential of therapy, in which the provider allegedly hasn’t demonstrated the patient’s progress with therapy.<br><br>(<a target="_blank" href="/Monthly-Issue/2013/Pages/0513/OIG-Targets-SNF-Billing-Practices.aspx">OIG Targets SNF Billing Practices</a>)<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Washington State Sees Uptick</h2> <div>Some providers in Washington state have seen a recent flare-up of RA audits, says Bill Ulrich, president and chief executive officer of Consolidated Billing, in Spokane. </div> <div> </div> <div>“This is new for Washington,” Ulrich says. “Historically, we have not seen a lot of auditor activity.” </div> <div>It began just recently, with RA letters to providers, asking for medical records for residents from three years ago, he says. </div> <div> </div> <div>“For a state with no activity for SNFs to get letters, up here, where we haven’t seen much, it’s got some people concerned,” says Ulrich, although he says he hasn’t found anything that says they are after a certain RUG category. </div> <div> </div> <div>SNF providers that are inclined to rely on the CMS appeals processes to save the day are best advised to recognize that a very small number of SNF Medicare claims denials are actually overturned on appeal. </div> <div> </div> <div><span><img width="176" height="200" src="/Monthly-Issue/2013/PublishingImages/0513/DianeDeLaMare.jpg" alt="Dianne De La Mare" class="ms-rtePosition-1" style="margin:5px 10px;" /></span>“Recovery Auditors are paid on a contingency fee basis,” says Dianne De La Mare, AHCA’s vice president of legal affairs. “But what happens if a provider wants to appeal—the appeals process is five stages long, and the administrative appeals process is the same for both MACs [Medicare Administrative Contractors] and RAs.” <br><br></div> <div>De La Mare contends that the complexity of the appeals process creates a disincentive for providers to pursue appeals. “CMS data show that only 12 percent of claims get appealed, and only 4 percent get overturned.</div> <div> </div> <div>According to Herschman, in light of reimbursement levels and other financial pressures, it’s hard for many SNFs to  invest resources and money into self audits and other proactive compliance measures. </div> <div>“As long as the government believes that there are overpayments, overbilling, wasteful spending, and fraud, they will continue to look for it,” he says.</div> <div> </div> <div>“The OIG studies give them internal support to throw more resources toward auditing. As long as they think investigations, reviews, and audits are going to result in recoveries well in excess of their enforcement and audit expenses, then they will continue to spend money on these endeavors.”</div> <div> </div> <div>As such Herschman and others advise providers and contracted therapy providers to be “super cautious. They need to self-review, conduct internal audits, and attempt to find out if there are major issues with their billing and documentation processes,” says Herschman. “If problems are identified, facilities need to change their policies and procedures, or better train their staff with respect to the implementation of the policies and procedures.” </div> <div> </div> <div><span class="ms-rteThemeForeColor-8-4">Resources</span></div> <div><span class="ms-rteThemeForeColor-8-4">Look for the CMS program integrity and auditor resources at the following links: </span></div> <div><span class="ms-rteThemeForeColor-8-4">■ Medicare Program Integrity Manual: <a target="_blank" href="http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html">www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html </a></span></div> <div><span class="ms-rteThemeForeColor-8-4">■ Recovery Audit Program: <a target="_blank" href="http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/index.html?redirect=/rac/">www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/index.html?redirect=/rac/ </a></span></div> <div><span class="ms-rteThemeForeColor-8-4">■ Provider Resources at CMS: <a target="_blank" href="http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Provider-Resource.html">www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Provider-Resource.html </a></span></div> <div><span class="ms-rteThemeForeColor-8-4">■ The American Health Care Association maintains resource pages and links on Medicare and Medicaid integrity programs for its members at the following link: </span><a target="_blank" href="http://www.ahcancal.org/facility_operations/integrity/Pages/default.aspx"><span class="ms-rteThemeForeColor-8-4"></span></a><a target="_blank" href="http://www.ahcancal.org/facility_operations/integrity/Pages/default.aspx"><span class="ms-rteThemeForeColor-8-4">www.ahcancal.org/facility_operations/integrity/Pages/default.aspx.</span></a></div> <p></p>The Centers for Medicare & Medicaid Services (CMS) proclaimed recently that its two-year-old Fraud Prevention System (FPS) is a fruitful investment with a high rate of return, but Congress is not as sanguine about the agency’s fraud-fighting efforts as the agency appears to be. 2013-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0513/coverstory_thumb.jpg" style="BORDER:0px solid;" />Policy;ManagementCover Story5
Leadership Rounds: A Trigger For Relational Coordinationhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0513/A-Trigger-For-Relational-Coordination.aspxLeadership Rounds: A Trigger For Relational Coordination<div><span><img width="311" height="207" class="ms-rtePosition-1" alt="health care staff" src="/Monthly-Issue/2013/PublishingImages/0513/mgmt1.jpg" style="margin:5px 15px;" /></span>Despite all of the advances in technology, health care is still a people business. It’s about the residents and their families. Therefore, nursing home leaders must regularly connect, face-to-face, with the people doing the work and delivering the care. And they need to visit with and talk to the residents and their families. </div> <div> Leaders’ ability to prioritize their time and get out of their offices and conduct frequent and effective rounds is critical to the success of the organization. </div> <div> </div> <div>Here are some tips to keep in mind in order to make more effective leadership rounds. <br></div> <h2 class="ms-rteElement-H2">1. Mood/Posture/Paradigm</h2> <div>Leaders need to understand that they are in the spotlight when they leave their offices and walk onto the nursing units. Everyone sees them, listens to what they say, and watches what they do. With this fact always in mind, all leaders need to flip a switch and put themselves in a proper frame of mind before they conduct their rounds. </div> <div> </div> <div>They need to conscientiously model the attitude and behavior they hope to see in their employees. Be a positive force. Leaders need to energize staff to perform better by their presence and influence—by what the leader says and does. Keeping employee morale up requires a constant effort. When leaders make consistent and sincere gestures of caring and listening to staff and the residents, it helps to put the staff at their best. <br></div> <h2 class="ms-rteElement-H2">2. Content—What Leaders Say And Do </h2> <div>Do answer call lights; hold doors open for people; hand out granola bars; smile; wave to residents; make eye contact with everyone; sit in the break room; sit on the end of a resident’s bed and talk with them; shake hands; kiss residents’ cheeks; rub shoulders; carry leftover food trays back to the kitchen; move a linen barrel to where it should be; look in utility rooms, shower rooms, resident bathrooms, kitchen, and break room.</div> <div> </div> <div>Say “thank you, can I help you with that, can I save you some steps, how’s staffing today, what’s frustrating you today, do you have all the supplies you need today, does all of the equipment work well today? I’m proud of you, how’s your son doing? Thanks a lot for helping her with that, thanks for being here today, thanks for all of your help today, I’m sorry about that, I’m worried about…. Is everyone treating you respectfully…” <br></div> <h2 class="ms-rteElement-H2">3. Timing Of Rounds</h2> <div>Rounds should be conducted a few times throughout the day. First rounds should be conducted as soon as the leader arrives. Never get trapped in the office looking at email. It’s less important than getting out and seeing what’s going on out on the units. Leaders should conduct rounds before the morning stand-up meeting. </div> <div> </div> <div>A second set of rounds is ideally conducted at the residents’ lunchtime hour. A third set of rounds is conducted at the change of shift from 2:30 to 3:30 p.m. At this time, shift hand-offs should be monitored and the day shift staff thanked, while welcoming the evening shift staff. Leaders should linger near the time clock and maximize their exposure to people. </div> <div> </div> <div>Finally, conduct a last set of rounds before leaving for the day. Also, go in on weekends and conduct rounds and visit at night at least twice per month. <br></div> <h2 class="ms-rteElement-H2">4. Keeping Notes And Following Up</h2> <div>Leaders should be making observations and receiving feedback during rounds that will require follow-up. Therefore, be sure to take along a pen and small piece of paper in order to make some notes. Don’t carry a cell phone during rounds. Be sure to follow up with people when necessary. </div> <div> </div> <div>To build organizational trust, people need to feel that the leader is listening to them. Be open and honest with staff.</div> <div> </div> <div>Even if every request cannot be honored, be sure staff know that thought was given to it. </div> <div> </div> <div>Nursing home employees are highly sensitive and responsive to the immediate context of their physical and social environment. </div> <div> </div> <div>Effective leaders positively influence staff by making specific changes that matter the most to employees and the residents. The key is to conduct more effective rounds. Be more conscious of how rounds are conducted. Adopt some of these tips, and self-reflect about your impact on people.</div> <div> </div> <div><em>Source: David Farrell, director of the Green House Project</em></div>Column5

June




 

 

Green House: Flexible, Low-Cost Funding Availablehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/Green-House-Flexible-Low-Cost-Funding-Available.aspxGreen House: Flexible, Low-Cost Funding Available<div><img width="405" height="305" alt="Green House residents share in each other's lives." class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0613/finance2.jpg" style="margin:5px 15px;" /><br>Long term care providers know times have changed. They know that boomers, even more so than their parents, will demand health care environments that look and feel like real homes, from private bedrooms to full control of their daily routines. </div> <div> </div> <div>So, why do most nursing homes still look like they did 20 or 30 years ago? Why aren’t providers building what they know consumers want?</div> <h2 class="ms-rteElement-H2">Foundation Offers Backing</h2> <div>As it turns out, the buck is stopping at the bank. It can be difficult for providers to <a href="/Monthly-Issue/2013/Pages/0613/How-To-Apply-For-Financing.aspx" title="How to apply for financing" target="_blank">find low-cost, flexible financing</a> sources, and that alone is a major reason why even the most forward-looking providers have not pursued major new construction. </div> <div> </div> <div>Even when providers have some of their own seed capital and can get additional financing from their local bank, they often lack the bridge financing necessary to complete a project. </div> <div> </div> <div>Obtaining flexible financing is a major barrier to progress. </div> <div> </div> <div>In 2011, the Robert Wood Johnson Foundation (RWJF), the nation’s leading health foundation, made a $10 million Program-Related Investment (PRI) in NCB Capital Impact and The Green House Project to make it easier for more providers to obtain flexible financing and build Green House homes. </div> <div> </div> <div>In making this investment, the foundation saw a unique potential for The Green House model to address the nation’s growing shortage of affordable, high-quality long term care options for low-income elders. </div> <div> </div> <div>For that reason, the foundation’s investment focuses on financing homes that will serve a population that is 40 percent Medicaid, at a minimum. RWJF has focused on The Green House model because of its track record for delivering high-quality care at roughly the same cost as a traditional nursing home. The foundation’s investment creates a pool of low-cost capital meant to fill an important void: the need for both subordinate debt and flexibly structured gap financing at below-market rates.</div> <div> </div> <div>RWJF and NCB Capital Impact also made sure that this new financing is flexible enough to help providers that want to take advantage of the New Markets Tax Credit. </div> <div> </div> <div>Because NCB Capital Impact is enlisting additional investors—like the Harry and Jeanette Weinberg Foundation and AARP Foundation—to leverage RWJF funding in any individual project by a ratio of four to one, the total financing opportunity is actually substantially larger than the foundation’s initial investment. </div> <div> </div> <div>Later this year, the first-ever Green House homes to use financing from the RWJF PRI will open in Mankato, Minn. </div> <div> </div> <div>They will also be the first Green House homes in that state, bringing the total number of states with Green House projects to 33. And even in states where Green House homes exist, untapped markets remain, full of consumers eager for the unique kind of nursing care the model offers.</div> <h2 class="ms-rteElement-H2">Higher Demand, Better Outcomes</h2> <div>RWJF’s bold investment is backed by consumer demand. In fact, the foundation surveyed 1,000 informal caregivers of all incomes to understand their long term care challenges better. When asked about their greatest fears for loved ones needing long term care, loss of dignity and loss of independence ranked highest on the list of concerns. </div> <div> </div> <div>When they learned about The Green House model and its central features—small size, private bedrooms and bathrooms, and the independence that elders retain—they were wildly enthusiastic.</div> <div> </div> <div>More than half of caregivers said they would pay more and drive further for a Green House option. Those with loved ones already under in-home care said they liked the Green House option “a lot better.” Nearly everyone wanted to see their local providers build more Green House homes. </div> <div> </div> <div>The Green House model comes with impressive clinical data that sets it apart in a crowded marketplace. </div> <div> </div> <div>According to a study published in 2007 in the Journal of the American Geriatrics Society, Green House caregivers have less turnover and more consistent assignments, leading to deeper relationships and better health outcomes for elders. Early research by Susan Horn and David Grabowski suggests that hospitalization rates for long-stay Green House residents are, on average, 7 percent lower than for traditional nursing home residents. The empowered, self-managed work teams in the homes are an important factor in preventing avoidable rehospitalizations as they can identify subtle changes in elders.</div> <div> </div> <div>Today, most nursing homes are still struggling with a 20 percent rehospitalization rate with their short-term-stay residents. The Leonard Florence Center for Living in Chelsea, Mass., with its three busy short-term rehabilitation Green House homes, has a rehospitalization rate under 10 percent. They are learning that the small size and personalized experience of the Green House model contributes to better outcomes. Private rooms and bathrooms contribute to less chance of getting an infection, plus better sleep. And the home-cooked meals lead to better appetites and more energy for therapy.</div> <div> </div> <div>The new financing opportunities available for Green House projects help to minimize the barrier of the upfront investment. The Green House Project also offers extensive technical assistance and can help providers identify other financing sources. </div> <div> </div> <div>Because the RWJF and NCB Capital Impact loan pool needs to be entirely distributed by 2014, interested providers should begin exploring the option as soon as possible. To find out more about tapping into RWJF and NCB Capital Impact financing for Green House projects, contact Maura Porcelli at (703) 647-2311 or <a href="mailto:mporcelli@ncbcapitalimpact.org" target="_blank">mporcelli@ncbcapitalimpact.org</a>. </div> <div><em> </em></div> <em> </em><div><em>David Farrell, MSW, LNHA, is senior director of The Green House Project. Prior to joining The Green House team, Farrell was director of organizational development and regional director of operations for a private nursing home management firm in California. A published author and member of the Pioneer Network’s board of directors, he has advocated for culture change using quality improvement practices for more than 25 years.</em></div>In 2011, the Robert Wood Johnson Foundation (RWJF), the nation’s leading health foundation, made a $10 million Program-Related Investment (PRI) in NCB Capital Impact and The Green House Project to make it easier for more providers to obtain flexible financing and build Green House homes. 2013-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0613/finance_thumb.jpg" style="BORDER:0px solid;" />Finance;ManagementColumn6
Under ACA, Employee Hours And Minutes Add Uphttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/Under-ACA-Employee-Hours-And-Minutes-Add-Up.aspxUnder ACA, Employee Hours And Minutes Add Up<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><br><img width="176" height="167" class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0613/HR_nurses.jpg" alt="" style="margin:5px 15px;" /><br>Health coverage changes in the Affordable Care Act (ACA) have a big impact on senior care employers. Providers are faced with choices, costs, and risks that need to be understood today in order to ensure compliance. </div> <div> </div> <div>While confusion and uncertainty do exist, it is imperative for employers to take steps today to understand what lies ahead. </div> <div> </div> <div>Health care reform is exacerbated by today’s realities in senior care that are already making it difficult to consistently provide high-quality care at lower costs. Reimbursement cuts that could reach $65 billion, workforce shortages, and an aging population are skewing the curves of supply and demand. </div> <h2 class="ms-rteElement-H2">Review Workforce Now</h2> <div>Adding to these complexities is an additional 32 million Americans who will enter health care by 2019 as more people become insured under ACA guidelines, according to data from the Henry J. Kaiser Family Foundation. In addition, 2014 will be a monumental year for the new law as changes and guidelines escalate. But, 2013 is the year to explore options, formulate a strategy, and embark on the path to compliance, all while focusing on high-quality care and lower costs. </div> <div> </div> <div>What’s more, look-back guidelines make 2013 a critical year for workforce calculations, making it even more important to get a plan in place today. </div> <div> </div> <div>One of the most critical areas for providers to examine is their workforce. Labor represents their top expense, and it is also a key indicator of the quality care and services provided to patients and residents. </div> <div> </div> <div>Examining labor management strategies is a top priority. Understanding and managing part-time and full-time employee status is foundational to determining the impact of the ACA to each and every provider (see graphic, page 40). </div> <div> </div> <div>Controlling labor costs is also key, as 40 percent of health care service employers expect costs to increase due to ACA requirements starting next year, according to Mercer in “Health Care Reform After the Decision, 2012.” </div> <h2 class="ms-rteElement-H2">Managing Part-Time and Full-Time Employees</h2> <div>Under the ACA, employers with 50 or more full-time employees must provide qualified health coverage to those full-time workers or face a penalty. A full-time employee is considered someone who works a minimum of 30 hours per week or 130 hours per month (see graphic, above) on average. </div> <div> </div> <div>Sounds simple enough, right? </div> <div> </div> <div>Now, consider the complexities in truly determining and planning for which employees are part-time and which are full-time. While it may seem manageable on paper, it is difficult to execute on a day-to-day and shift-by-shift basis. </div> <div> </div> <div>Employee absences, last-minute call-offs, and staffing shortages, for example, are common issues that senior care providers deal with each and every day. </div> <div> </div> <div>Filling shifts is often accomplished by scrambling to find replacements, resulting in overtime hours or additional PRN (as needed) hours. These issues now become more complex, as a part-time employee works over 30 hours, for example, just by picking up an extra shift here and there. </div> <div> </div> <div>In addition, employees often rack up additional minutes by simply clocking in early and clocking out late. These incremental minutes and hours add up significantly over the course of a week, month, and year. This, too, could easily become the tipping point for part-timers crossing over to full-time status. </div> <div> </div> <div>While a one-time overage will not cause a part-timer to enter full-time status, it is critical for providers to outline their plans for managing their part-time/full-time mix in order to avoid unplanned penalties. <br><br></div> <div><img width="189" height="237" src="/Monthly-Issue/2013/PublishingImages/0613/HR1.jpg" class="ms-rteImage-1" alt="" style="margin:5px;" /><img width="203" height="194" src="/Monthly-Issue/2013/PublishingImages/0613/HR2.jpg" class="ms-rteImage-1" alt="" style="margin:5px;" /><img width="210" height="210" src="/Monthly-Issue/2013/PublishingImages/0613/HR3.jpg" class="ms-rteImage-1" alt="" style="margin:5px;" /><br><br>Providers must consider the following workforce practices in light of impending ACA deadlines and requirements as part of the action plan to be compliant while maintaining quality care, operating efficiently, and managing costs. </div> <h2 class="ms-rteElement-H2">Consider The Best Fit</h2> <div>Many providers deal with two to three employee call-offs each day, leaving gaps in the schedule and risking quality care and services due to potential understaffing. That’s why most providers fill open shifts as fast as possible, with the first person who agrees. </div> <div> </div> <div>With the ACA part-time/full-time rule, the risks have increased with each and every open shift.</div> <div> </div> <div>Providers should put a plan in place for dealing with call-offs and unplanned open shifts. First, schedulers or managers should determine whether or not the shift needs to be filled, based on their hours per patient day targets or staffing level requirements. </div> <div> </div> <div>When shifts do need to be filled, identifying criteria for selecting a “best fit” replacement is important. </div> <div> </div> <div>For example, schedulers or managers filling the shift should understand how many hours potential, qualified replacements have worked to date and how many are scheduled. </div> <div> </div> <div>Managers must ask, what will be the impact of picking up this extra shift? Will it cause a part-time replacement to enter full-time status? Will overtime be incurred? What is the impact with regard to union requirements? </div> <div> </div> <div>With the new ACA requirements, evaluating part-time/full-time hours needs to be added to the list of criteria in determining best-fit candidates when filling an open shift.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Avoid Incremental Minutes</h2> <div>Early clock-ins and late clock-outs can add up, just minutes at a time, to significant overages. While there are plenty of times it may be necessary for a certified nurse assistant to stay late to help with a needy resident, there are also plenty of times when clocking out late can be avoided. </div> <div> </div> <div>While many providers have established a threshold for employee punch overages—commonly seven minutes—it is not enough. Providers should make sure that schedulers or managers are comparing employee punch data with schedules, and identifying variances, on a daily basis. </div> <div> </div> <div>With additional reporting, it is possible to project overages in advance, providing enough time to adjust schedules to avoid the unplanned extra hours. </div> <div> </div> <div>This not only controls costs, it also helps maintain the proper mix of part-time/full-time employees the provider has established. </div> <div> </div> <div>Providers need to equip schedulers with the proper tools and information for creating and updating schedules. <br><br></div> <div>They need to be aware of the organization’s goals and objectives in managing employee hours, not only for common things like overtime and hours per patient day requirements, but now for the full-time threshold. </div> <div> </div> <div>Schedulers need to check daily and weekly hour totals for employees and avoid building extra time into </div> <div>schedules. Short-staffing situations may make this difficult, but it is important to take the time to evaluate each potential overage ahead of time, so it can be avoided. <br></div> <h2 class="ms-rteElement-H2">Right-Size Staff</h2> <div>Balancing staff with resident census and acuity needs—each and every shift—goes a long way toward ensuring proper staffing. </div> <div> </div> <div>What’s more, it provides opportunities throughout the course of the day to determine where staff members are needed and where they are not. </div> <div> </div> <div>Equipped with information on upcoming admissions or move-ins, for example, schedulers can plan for bringing in extra staff ahead of time. Additionally, if census decreases, they have the opportunity to eliminate extra shifts to stay aligned with labor budget goals, while ensuring proper care. </div> <div> </div> <div>Schedulers should have employee-hours information, both incurred and planned, at their fingertips when deciding whose schedules to adjust. </div> <div> </div> <div>This ongoing focus on proper staffing, aligned with census and service needs or acuity, not only ensures quality care and services but also helps in the quest to manage part-time and full-time employee hours. </div> <div> </div> <div>In addition, providers who right-size their staff day in and day out find greater adherence to labor budgets and save money in doing so, while remaining properly staffed to provide quality care.</div> <h2 class="ms-rteElement-H2">Getting It Right From The Start</h2> <div>Prioritizing staffing and labor management is a critical step in preparing for health coverage changes in the ACA. Start by optimizing scheduling and labor management practices for visibility into and control over employee hours to maintain part-time/full-time goals. </div> <div> <span><span><em><img src="/Monthly-Issue/2013/PublishingImages/0613/MarkWoodka.jpg" alt="Mark Woodka" class="ms-rteImage-1 ms-rtePosition-1" style="margin:5px;" /></em></span></span></div> <div><span><div><em></em></div></span>And, consider how automating core processes can accelerate efforts in achieving objectives. These practices, along with efforts to control overtime and minimize turnover, can make significant strides in reducing costs in an already cash-strapped environment. <br></div> <div><em></em></div> <em><div> </div></em><div><em>Mark Woodka is chief executive officer of OnShift, a provider of Web-based staff scheduling and labor management software. He can be reached at mwoodka@onshift.com.</em></div>Health care reform is exacerbated by today’s realities in senior care that are already making it difficult to consistently provide high-quality care at lower costs. Reimbursement cuts that could reach $65 billion, workforce shortages, and an aging population are skewing the curves of supply and demand. 2013-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0613/HR_thumb.jpg" style="BORDER:0px solid;" />Workforce;ManagementColumn6
2013 Top 40 Largest Assisted Living Companieshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/2013-Top-40.aspx2013 Top 40 Largest Assisted Living Companies<div><span>Emeritus Senior Living edged out Brookdale Senior Living this year for the top spot, both companies having jostled for No. 1 over the past few years. Emeritus, however, made a leap of more than 20,000 in its occupant capacity in the past year, likely due to its fourth quarter 2012 lease and ownership acquisition of 138 communities. </span></div> <span><div> </div> <div>The remaining top contenders shuffled a bit, except for Sunrise Senior Living, Atria Senior Living, and Five Star Quality Care, which remained in slots Nos. 3, 4, and 5, respectively, again this year. No. 6 this year is Merrill Gardens, which switched places with Assisted Living Concepts, which comes in at No. 7. </div> <div> </div> <div>Newcomers to the Top 40 this year include BMA Management, Bradley, Ill.; Milestone Retirement Communities, Vancouver, Wash.; and Saber Healthcare Group, Foothill Ranch, Calif.</div> <h2 class="ms-rteElement-H2">Person-Centered Care Continues</h2> <div>A number of assisted living providers are taking on person-centered care models of care, including top dog Emeritus. The company says it is redesigning its memory care neighborhoods “to address stages of memory loss, incorporating new technology for resident socialization and family communication, including wireless technology, for operations and nursing.”</div> <div> </div> <div>Americare, No. 17, reported that it is “very active in many aspects of the Pioneer Network.” </div> <div> </div> <div>No. 2, Brookdale, is making ongoing renovations by adding units and revamping “physical plants and décor conducive to the needs of our resident and adult children populations.”</div> <div> </div> <div>Similarly, No. 18, Trilogy Health Services, says it will remove nurse stations from all facilities, and “we continually strive to make our facilities feel more homelike.” </div> <div> </div> <div>No. 21, Aegis Living, is “reviewing and updating our activities program and Life Skills Stations to increase benefit to residents and families.” </div> <h2 class="ms-rteElement-H2">Diversification On The Rise</h2> <div>Unsurprisingly, all of this year’s Top 40 providers offer dementia care among their services. What’s more, there are 36 that have independent living in their lineup of service/housing types, a jump of three from last year’s 33. </div> <div> </div> <div>Also similar to last year among the Top 40 providers, 23 this year also offer nursing home care, compared with 24 companies that had traditional nursing home care in their business lines. </div> <div> </div> <div>Last year’s Top 40 included 22 companies that offered post-acute care, compared with this year’s figure of 21. </div> <div> </div> <div>Outpatient therapy is offered by 16 companies in this year’s Top 40, mostly by companies that have post-acute care services and/or buildings as well. </div> <div> </div> <div>This year’s lineup represents a resident capacity of more than 240,000 and more than 2,900 buildings. </div> <div> </div> <div><em>Provider’s</em> 2013 Top 40 Largest Assisted Living Companies is ranked by occupant capacity as of Dec. 31, 2012.</div> <div> </div></span><div><span>Please click <a href="/reports/Documents/2013/Top40.pdf">here</a> for the list.<span style="display:inline-block;"></span><span style="display:inline-block;"></span></span></div> <span style="display:inline-block;"></span>This year’s lineup represents a resident capacity of more than 240,000 and more than 2,900 buildings. 2013-06-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/business_1.jpg" style="BORDER:0px solid;" />Quality;Quality ImprovementColumn6
2013 Top 50 Largest Nursing Facility Companieshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/2013-Top-50.aspx2013 Top 50 Largest Nursing Facility Companies<div>No matter what the moniker—seniors housing and care, long term care, long term and post-acute care, or aging services—the Top 50 companies are offering more consistent services. In fact, it may soon make more sense to call these annual rankings the “Top 50 Aging Services Companies,” given that the majority of this year’s largest nursing home companies offer a wide range of aging-like services to their customers. </div> <div> </div> <div>For example, all but two of this year’s top 50 offer both long term and post-acute care among their repertoire of services. The two companies that still offer traditional long-term nursing care are No. 50, HMR Veterans Services, based in Anderson, S.C., and No. 39, Complete HealthCare Resources, of Dresher, Pa. </div> <h2 class="ms-rteElement-H2">Dementia Care Ubiquitous</h2> <div>Dementia care—which is fast becoming a field of services on its own since many states require separate licensure for such providers—is offered by all but one of the Top 50 this year. </div> <div> </div> <div>Assisted living is another sector of seniors housing that is becoming part of the landscape of services offered by nursing home providers: Just 10 of the Top 50 do not have an assisted living component within their companies.</div> <div> </div> <div>Among the other services offered by this year’s roundup are 39 companies with outpatient rehab therapy services, 18 offering pharmacy within their facilities, 27 with home care, and 38 with hospice.</div> <div> </div> <div>Ventilator and dialysis care are offered by 19 of the Top 50 companies, while the number of companies offering bariatric-related services is climbing steadily: Thirty-eight companies offer it this year, compared with 23 last year and 20 the year before that.</div> <h2 class="ms-rteElement-H2">Top 10 Shuffle</h2> <div>This year’s Top 10 looks quite different from the preceding seven years or so, as Genesis HealthCare lands the No. 1 spot, having purchased Sun Healthcare Group (No. 7 in 2012) last year. The longtime top contender, HCR ManorCare, now takes over the No. 2 slot, while Life Care Centers of America maintains No. 3, as it has for several years. </div> <div> </div> <div>At No. 4 is Golden Living, which sank two spots from last year, while Kindred Healthcare fell one slot to No. 5 this year. SavaSeniorCare hung onto No. 6 again this year, while taking over the No. 7 spot this year is a newcomer to the Top 10: Consulate Health Care, based in Maitland, Fla. </div> <div> </div> <div>Slots No. 8 and 9 remain occupied by Extendicare Health Services and Evangelical Lutheran Good Samaritan Society, respectively. </div> <div> </div> <div>The No. 10 spot goes to a newcomer: Plano, Texas-based Preferred Care Partners. It pushed Ensign Group down two slots this year to No. 12. Skilled Healthcare Group jumped ahead of Ensign this year to land at No. 11. </div> <div> </div> <div>Two companies made their debuts this year to the Top 50: Fort Worth, Texas-based Creative Solutions in Healthcare and Saber Healthcare Group, based in Bedford Heights, Ohio, at Nos. 21 and 23, respectively. </div> <div> </div> <div><em>Provider’s</em> 2013 list of the Top 50 Largest Nursing Facility Companies is ranked by bed count as of Dec. 31, 2012.</div> <div> </div> <div><span>Please click <a target="_blank" href="/reports/Documents/2013/Top50.pdf">here</a> for the list.<span style="display:inline-block;"></span></span></div> This year’s Top 10 looks quite different from the preceding seven years or so, as Genesis HealthCare lands the No. 1 spot, having purchased Sun Healthcare Group (No. 7 in 2012) last year.2013-06-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/business_1.jpg" style="BORDER:0px solid;" />Quality;Quality ImprovementColumn6
Improving Outdoor Areas Raises Occupancy Levels, Researchers Findhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/Improving-Outdoor-Areas-Raises-Occupancy-Levels.aspxImproving Outdoor Areas Raises Occupancy Levels, Researchers Find<div>When residents’ satisfaction about their communities’ outdoor areas increased, their willingness to refer others to live in the community also increased, resulting in more word-of-mouth referrals that increased occupancy and lowered marketing costs for providers, researchers found. </div> <div> </div> <div>The study’s results were published in the Winter 2013<em> Health Environments Research & Design Journal</em>.</div> <div> </div> <div>Researchers conducted an assisted living survey at 68 communities in three regions of the United States to assess the relationship between satisfaction with outdoor spaces, time spent outdoors, and resulting improvements in mood. Using data from the survey, a financial analysis was developed to estimate potential benefits from improved outdoor areas that contribute to increased occupancy and decreased marketing costs associated with increased word-of-mouth referral.</div> <div> </div> <div>In communities with successful outdoor areas, the authors wrote, “residents typically expressed satisfaction with several features. Interestingly, the same features that were described as unsatisfactory at some communities were reported as highly satisfactory at communities where they apparently had been designed with the needs and preferences of residents in mind.”</div> <div> </div> <div>The features included attention to adequate shade, doorways, walkways, space, nature elements, and seating. </div> <div> </div> <div>“This finding emphasizes the importance of the location, layout, and detailed design of these features,” the authors wrote. “Seating, walkways, shade, and doorways appear prominently in comments showing satisfaction with outdoor areas; in addition, nature elements, social spaces, adequate space, and freedom of movement also appear to be important.” </div> <div> </div> <div>Satisfaction ratings of outdoor areas ranged from 29 percent to 96 percent. Researchers discovered that the higher the satisfaction rating, the more time the resident spent outdoors. In some cases satisfied residents were spending 90 more minutes a week outside than residents who were less satisfied. Previous research had found that residents spending more time outdoors improved their psychological well-being by 12 percent. The greater overall satisfaction leads to 8 percent more residents willing to refer potential residents to their community, the authors wrote.</div> <div> </div> <div>“Word-of-mouth referrals by current residents are a major factor in resident recruitment; improving outdoor areas leads to an estimated 4 percent increase in new residents, resulting in over $170,000 of increased revenue per year for a community of 100 residents,” wrote the authors. </div> <div> </div> <div>“Fortunately, it is not necessarily difficult or expensive to improve existing outdoor areas, or to design and construct new outdoor areas that support residents’ needs,” they wrote. “Problems with outdoor space often stem from simple issues that could be avoided by proper planning, or could be remedied fairly inexpensively after the fact.” </div> <div> </div> <div>Researchers estimated an investment of $5,000 per community in existing annual maintenance budgets would make it possible to make some changes that would improve the residents’ quality of life. For example, a door that is hard to open may only need to be adjusted so it doesn’t require as much pressure to open. Or providers could replace the door’s high threshold with one that is flatter, making it easier for residents with wheelchairs to roll over it. Shade above seating areas can be provided with inexpensive shade structures such as awnings, trees, or an arbor with vines growing over it.</div> <div> </div> <div>Adjusting a doorway closing mechanism could cost $100 or less, or an automatic door opener could be installed for $1,000 to $4,000, depending on the type. Walkway sections that had shifted could be repaired or replaced for $500 to $2,000, depending on the extent of the damage. </div> <div> </div> <div class="ms-rteElement-Callout1">Outdoor Evaluation Tool</div> <div class="ms-rteElement-Callout1">Researchers developed a user-friendly survey tool that providers can use to assess their community’s outdoor areas. This tool will identify which improvements are more likely to increase resident satisfaction. Visit <a href="http://www.accesstonature.org/resources.html" target="_blank">AccessToNature.org/resources.html</a>, look for “Seniors’ Outdoor Survey.”</div>When residents’ satisfaction about their communities’ outdoor areas increased, their willingness to refer others to live in the community also increased, resulting in more word-of-mouth referrals that increased occupancy and lowered marketing costs for providers, researchers found. 2013-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0613/outdoor_t.jpg" style="BORDER:0px solid;" />Management;DesignColumn6
NYC Providers Raise Bar On Disaster Preparednesshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/NYC-Providers-Raise-Bar-On-Disaster-Preparedness.aspxNYC Providers Raise Bar On Disaster Preparedness<br><span><span><img width="294" height="196" class="ms-rtePosition-2" alt="Disaster planning" src="/Monthly-Issue/2013/PublishingImages/0613/disaster2.jpg" style="margin:5px 10px;" /></span></span>On a recent sunny day in New York City, a hotel ballroom in Times Square was packed with nearly 150 attendees from some 90 nursing homes. The crowd consisted of staff members who had gathered for a two-day training on disaster preparedness. <br><br><span></span>Disaster, of course, is not new to the Big Apple and its denizens. But this training was new to many of the participants because it was on the <a href="http://cahfdisasterprep.com/NHICS.aspx" target="_blank">Nursing Home Incident Command System</a> (NHICS), a disaster preparedness system built on the national Incident Command System, a uniform management model that allows its users to adopt a standard approach to responding to incidents. <br><br>While the ICS has been around for nearly three decades, the NHICS program was created about seven years ago, and it has since been making its way across the country via training programs like this one. <br><br>The training was organized by the 1199SEIU United Healthcare Workers Labor Management Project, a program aimed at bringing workers together with their employers to collectively solve problems in their nursing homes. The goal of the program is to create “a positive work environment and improve patient care.”<br><br>So, with the memory of super storm Sandy still fresh in their minds—and just one day after the Boston Marathon bombing—frontline caregivers huddled with administrators and other managers to conduct table-top exercises based on a fictitious disaster befalling the city. <br><br>Leading the day’s training were Stan Szpytek, a former firefighter and battalion chief with the Chicago Fire Department, and Jocelyn Montgomery, clinical affairs program director for the California Association of Health Facilities. <br><br>Day-glow yellow vests, worn by the day’s “incident commanders” dotted the room. Clustered around the tables’ easel pads were scribes taking notes on how the nursing home would handle the day’s calamities.<br><br><span><span><img width="234" height="265" class="ms-rtePosition-1" alt="Disaster planning" src="/Monthly-Issue/2013/PublishingImages/0613/disaster.jpg" style="margin:5px 10px;" /></span></span>As the crowd worked the easels and made use of their new NHICS training, Szpytek interrupted periodically with a fire alarm bell to announce a status update. At the end of the day, tables reported on their work and discussed the pros and cons of the actions they had planned to take. <br><br>Although it’s universally acknowledged that New York nursing home providers did an excellent job of managing residents during and after Sandy, the aftermath was a wake-up call nonetheless. “We knew that we could still use more training and direction to prepare for the next disaster,” says Patricia Smith, vice president of 1199SEIU New York Nursing Home Division and co-chair of the event. <br><br>Four nursing homes in Smith’s division were severely damaged by Sandy (<a href="/Monthly-Issue/2013/Pages/0413/Brooklyn-Nursing-Homes-To-Sandy-‘We’ve-Come-Back’.aspx" target="_blank">see News story, April 2013 issue</a>). <br><br>“While staff did a wonderful job, this training came at the right time,” she says. “The disaster showed us that there were no titles when this happened. Everyone chipped in. This training today will help us to be ready for any type of disaster.”<br><br>The 1199 regions already had plans to meet separately to familiarize all staff members with the NHICS and the training. “We’ll introduce some of what took place today and bring them up to date,” says Smith. “We want to be more alert. There are so many things that can happen in a nursing home.”On a recent sunny day in New York City, a hotel ballroom in Times Square was packed with nearly 150 attendees from some 90 nursing homes. The crowd consisted of staff members who had gathered for a two-day training on disaster preparedness. 2013-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0613/disaster_t.jpg" style="BORDER:0px solid;" />Management;Workforce;QualityColumn6
Provider Taps Into University For New Designs For The Futurehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/Provider-Taps-Into-University-For-New-Designs.aspxProvider Taps Into University For New Designs For The Future<br>Virginia Tech’s School of Architecture and Design has partnered with Hollywood, Fla.-based Avante Group to craft a program that taps into the creative minds of the university’s design students “to bring a fresh approach that will enhance and improve the residents’ lifestyles and improve caregiver access,” Avante announced in a May press release. <br><br><span><img width="311" height="237" class="ms-rtePosition-1" alt="VA Tech School of Architecture & Design" src="/Monthly-Issue/2013/PublishingImages/0613/university.jpg" style="margin:5px 20px;" /></span>“We feel that the future design and innovation for our industry will come from a new source, and Virginia Tech is a leader in this area; however, they will need industry guidance,” said Steven Marhee, director of business development for Avante. <br><br>The projects, which began with the university’s spring semester this year, include the creation of a design plan for a senior care setting that gives a more homelike environment to the facility. “One that mirrors the technological advances in our world today yet creates an environment of familiarity and warmth that can improve the psychosocial well-being of residents,” the release said.<br><br>Avante at Roanoke, a skilled nursing facility near Virginia Tech, provides the students with a hands-on experience in a nursing home. <br><br>“We are pleased and excited to be working with Avante on this program,” said Lisa Tucker, chair of the interior design program. <br><br>“This project gives our students an opportunity to tackle a real-life challenge in a growing and important industry. <br><br>The experience they gain and feedback they receive while working with Avante will not only benefit them academically, but also their future career.”<br><br>Virginia Tech’s School of Architecture and Design has partnered with Hollywood, Fla.-based Avante Group to craft a program that taps into the creative minds of the university’s design students.2013-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0613/news18_thumb.jpg" style="BORDER:0px solid;" />Management;Quality;Caregiving;DesignColumn6
QAPI: Weaving The Old With The Newhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/QAPI-Weaving-The-Old-With-The-New.aspxQAPI: Weaving The Old With The New<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div> </div> <div><img width="260" height="302" class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0613/cs_image.jpg" alt="" style="margin:5px 15px;" /></div> <div> </div> <div>Waiting is hard. The questions, the anticipation, and the uncertainties can be frustrating, even exhausting. Long term care facility leaders and teams know this from experience. They have been waiting for months to learn what the regulatory requirements regarding Quality Assessment and Performance Improvement (QAPI) will be, only to hear as late as last month that the final regulations are still in the works. </div> <div> </div> <div> </div> <div> </div> <div>Still, many facilities and organizations are moving forward with QAPI initiatives. </div> <div> </div> <div> </div> <div> </div> <div>While these groups are unsure about the final regs, they are confident about their ability to implement QAPI. Some even see a little déjà vu in QAPI, as they see it reflected in many of their current quality improvement efforts. At the same time, those involved in the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) National Quality Award program see a parallel between the steps involved in the program and the five elements of QAPI. Whatever their approach, they make it clear quality assurance and performance improvement already are a priority.</div> <div> </div> <h2 class="ms-rteElement-H2">Unraveling The QAPI Mystery</h2> <div> </div> <div>Clearly, it doesn’t require a crystal ball to prepare for QAPI. As Ruta Kadonoff, vice president of quality and regulatory affairs for AHCA, says, “What is happening in nursing homes is modeled after what has been in place in other settings and follows the basic concepts of quality assurance—ensuring that you are in compliance with requirements about care and have systems in place to address failures as they arise.”</div> <div> </div> <div> </div> <div> </div> <div>To help facilities prepare for QAPI, the Centers for Medicare & Medicaid Services (CMS) recently released “QAPI at a Glance.” The document provides insights into the program and guidance on how facilities can prepare. For example, it clarifies the difference between quality assurance and performance improvement (<em>see table, below</em>). It emphasizes that QAPI involves team members “at all levels of the organization to: identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor effectiveness of interventions.”</div> <div> </div> <div> </div> <div> </div> <div>The CMS document stresses the rewards facilities will reap from QAPI, including competencies that will equip them to solve quality problems and prevent their recurrence; competencies that will allow facilities to seize opportunities to achieve new goals; fulfillment for caregivers, who are able to become active partners in performance improvement; and, ultimately, better care and quality of life for residents.</div> <div> </div> <h2 class="ms-rteElement-H2">Not A New Concept</h2> <div> </div> <div>QAPI isn’t entirely new, CMS stresses. It uses the existing Quality Assessment and Assurance regulation and guidance as a foundation. “QAPI at a Glance” reinforced the idea that many facilities already are implementing quality assurance and performance improvement in many ways, including creating systems to provide care and achieve compliance, investigating problems and attempting to prevent their recurrence, tracking and reporting adverse events, benchmarking and comparing quality with other homes, investigating complaints, seeking resident and caregiver feedback, and setting targets for quality.</div> <div> </div> <div> </div> <div> </div> <div>If a facility is performing some of the following tasks, it already is well on the way to QAPI:</div> <div> </div> <div>■ Using data not only to identify quality problems but also to uncover other opportunities for improvement, then setting priorities for action;</div> <div> </div> <div>■ Building on residents’ own goals for health, quality of life, and daily activities;</div> <div> </div> <div>■ Bringing meaningful resident and family voices into goal setting and progress evaluation;</div> <div> </div> <div>■ Incorporating caregivers broadly in a shared QAPI mission; </div> <div> </div> <div>■ Performing root-cause analyses to address problems; </div> <div> </div> <div>■ Developing Performance Improvement Project (PIP) teams with specific “charters;”</div> <div> </div> <div>■ Making systemic changes to eliminate problems at the source; and</div> <div> </div> <div>■ Developing feedback/monitoring systems to sustain improvement.</div> <div> </div> <div> </div> <div> </div> <div>“QAPI at a Glance” discusses the five elements of QAPI—design and scope, governance and leadership, feedback/data systems and monitoring, performance improvement projects, and systematic analysis and systemic action.</div> <div> </div> <div> </div> <div> </div> <div>It also offers several steps to effective QAPI implementation that addresses issues such as putting a personal face on quality issues, developing a deliberate approach to teamwork, conducting a self-assessment, identifying guiding principles, and conducting a QAPI awareness campaign.</div> <div> </div> <h2 class="ms-rteElement-H2">Baldrige Criteria, QAPI Go Hand In Hand</h2> <div> </div> <div>“Both QAPI and the AHCA/NCAL [National] Quality Award program are systematic processes to address quality. Both focus on leadership and responding to staff and customers. Both have a focus on performance improvement in a team-based context and on demonstrating results. They parallel each other pretty completely,” says Kadonoff, adding, “We believe that the criteria of the award program, which helps organizations do better as a mission-driven organization providing services, is aligned with the goals of QAPI.”</div> <div> </div> <div> </div> <div> </div> <div>The National Quality Award program is based on the core values and criteria of the Baldrige Performance Excellence Program, which promotes a sustainable business model based on the core values of delivering a consistently positive customer experience, valuing and empowering the workforce, thinking and acting ethically, and thinking and acting strategically. <br></div> <div> </div> <div> <br>Senior Baldrige Examiner Christopher <span><img width="539" height="202" src="/Monthly-Issue/2013/PublishingImages/0613/cs_qualityassurance.gif" class="ms-rtePosition-2" alt="Quality Assurance vs. Performance Improvement" style="margin:15px;" /></span>Laxton, CAE, agrees that award program participants are well on their way to QAPI success. He says that anyone who has been through a Baldrige process or cycle is extremely well prepared to implement QAPI. “Both take a systems approach to organizational performance,” he says.</div> <div> </div> <div> </div> <div> </div> <div>Laxton, executive director of AMDA—Dedicated to Long Term Care Medicine, says that Baldrige participants have already answered many of the questions QAPI will ask of them and that they already have undertaken PIPs as part of the award pursuit. “They already have been required to demonstrate cycles of learning and outcomes from those. These are the goals of QAPI,” he says.</div> <div> </div> <div> </div> <div> </div> <div>Laxton actually lined up elements of the Malcolm Baldrige Performance Excellence Program and QAPI and found <a href="/Monthly-Issue/2013/Documents/0613/CS_compreq.pdf">several specific commonalities.</a> For example, Baldrige begins (as does the AHCA/NCAL National Quality Award Program) with an organization profile, which is similar to the self-assessment outlined in “QAPI at a Glance.” Both of these sections, he says, address “how your leaders lead, how you manage your processes, data, etc. The questions posed are intended to cause the organization to think more deeply and precisely about what they do.”<br><br></div> <div> <img width="114" height="171" alt="Christopher Laxton" class="ms-rteImage-0 ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0613/ChrisLaxton.jpg" style="margin:10px 15px;" />While it is useful to compare what a facility has done for the Quality Award Program to what QAPI will require of them, Laxton advises, “Don’t get too hung up on one framework over another. All point to better patient care.” </div> <div> </div> <div> </div> <div> </div> <div>He suggests focusing on how the initiatives support each other and will help the facility move through the QAPI elements. “Begin with the end in mind—in this case, better patient care.”<br><br></div> <div> </div> <div>Based on his experiences with the Baldrige criteria, Laxton says he is “100 percent confident that facilities can do this well. There isn’t a single organization that can’t do performance improvement of some sort. They need to be committed and embrace it from the top down.</div> <div> </div> <div> </div> <div> </div> <div>“Even small organizations with as few as 25 employees have been award winners because they embraced a systematic approach to performance improvement and excellence.”</div> <div> </div> <div> </div> <div> </div> <div>He says he’s seen facilities of all sizes do this and show results that are extraordinary—not just in terms of patient outcomes but in reduced readmission rates well below national averages and financial strength well above. “It’s all about sustainability and making sure each organization is doing as well as it can to care for its patients and keep the organization moving forward.”</div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2">Don’t Let QAPI Make You Queasy</h2> <div> </div> <div>Jeri Reinhardt, RN, director of quality at Benedictine Health System in Minnesota, talks about how she and others are preparing for QAPI, despite the uncertainties about the regs. She says, “People are uncertain about the final regs and what the guidance to surveyors will be, and that creates unease. But we’ve been using quality assurance and performance improvement practices for years. We also have a facility in the QAPI pilot project. We currently use QI [quality improvement] in everything we do. We have already completed the self-assessment for the organization. Now we’re waiting for the regulations.”</div> <div> </div> <div> </div> <div> </div> <div>Uncertainties about the regs haven’t kept others from implementing QAPI. </div> <div> </div> <div> </div> <div> </div> <div>“We started doing this several months ago. When you really dig into this concept, it’s performance improvement—analyzing processes and systems and improving them in a proactive way—that is a game changer,” says Matthew Wayne, MD, CMD, chief medical officer for CommuniCare Health Services in Ohio. “We saw it as an opportunity. Using the five elements of QAPI, we started by determining what metrics we wanted to track as an organization and move the needle to improve quality.” <br><br></div> <div> </div> <div> <img src="/Monthly-Issue/2013/PublishingImages/0613/IMG_6731.jpg" class="ms-rtePosition-1 ms-rteImage-2" alt="Golden LivingCenter, Oakmont, Pa." style="margin:5px 15px;" />The devil is in the details, and “every single step needs definitions and clarity,” Wayne says. For example, he and his team spent time determining specifically how they would collect and review data. </div> <div> </div> <div>“We took time to teach people how to analyze information and conduct a root-cause analysis. This is a key step, because if you don’t understand data analysis, you can miss problems or see problems that don’t exist,” he says.</div> <div> </div> <div> </div> <div> </div> <div>“I feel good about what we’ve accomplished in the past several months,” says Wayne of his foray into QAPI. However, he stresses, “We could not have achieved this without buy-in from the top down. We work together with the interdisciplinary team each month. It’s important enough for us all to be there, and our success is due to that commitment.”</div> <div> </div> <div> </div> <div> </div> <div>Ed McMahon, PhD, national director of quality for Golden Living, says, “We started our real focus on QAPI over two years ago. We knew it was coming, and we knew it made sense. We had gotten into the Baldrige criteria before that, so it was an easy adaption for us.”</div> <div> </div> <img width="135" height="179" src="/Monthly-Issue/2013/PublishingImages/0613/EdMcMahon.jpg" alt="Ed McMahon" class="ms-rtePosition-2" style="margin:5px;" /><br><div>McMahon realized the need for widespread communication throughout QAPI’s implementation, so he published a QI newsletter to help everyone prepare and to get them on the same page. </div> <div> </div> <div> </div> <div> </div> <div>“We would look at a different tool and at a different Baldrige core value every month and talk about how these would be included in the QAPI process,” he says.</div> <div> </div> <h2 class="ms-rteElement-H2">The Team Challenge </h2> <div> </div> <div>“One challenge will be to get organizations to buy in to this as a team approach. Getting the whole team involved will promote actual quality assurance and performance improvement, instead of it just being another regulation,” says Karyn Leible, RN, MD, CMD, chief medical officer for Jewish Senior Life of Rochester, N.Y.</div> <div> </div> <div> </div> <div> </div> <div>Kadonoff agrees. She says, “This isn’t something that lives in the nursing department. It’s not the responsibility of one small committee, but something that involves the entire team.” Toward the end, leadership needs to embed QAPI in all aspects of the system, Kadonoff says. </div> <div> </div> <div> </div> <div> </div> <div>“QAPI doesn’t have to be something additional or different. The team needs to work together and identify where there are missing pieces.”</div> <div> </div> <div> </div> <div> </div> <div>In getting team members on board, says Leible, “You have to take the language of QAPI and put it into a context that CNAs [certified nurse assistants] and others can understand. You need to relate the steps in terms of things that they can relate to.” She adds, “It is important to emphasize that most of this isn’t much different from what they’re doing already.” </div> <div> </div> <div> </div> <div> </div> <div>Explaining root-cause analysis and tools such as fishbone diagrams is more effective when team members can see them in action, Leible says. “Once I was trying to figure out why a patient was falling, so I started doing a fishbone diagram. The staff saw what I was doing and started throwing out ideas. Before long, we had some good solutions, and the staff did it.” </div> <div> </div> <div> </div> <div> </div> <div>When staff understand how effective this process can be, people do participate, she says. “This is an opportunity for the team to get involved, dig deep, and generate ideas.”</div> <div> </div> <div> </div> <div> </div> <div>Maintaining momentum may be a challenge, especially when there is staff turnover. “When there is turnover, people don’t always see the results of QAPI,” says Leible. However, this will be less of a problem for facilities that have embraced culture change. “If you have a culture where everyone has an equal voice, you will have a leg up. People will feel comfortable speaking up and being heard,” she says. </div> <div> </div> <div> </div> <div> </div> <div>“If you get past the language, it makes sense to look at the processes you have and the tasks you perform every day. Then you can identify areas of concern and address QAPI in a proactive way.”<br><img width="157" height="188" src="/Monthly-Issue/2013/PublishingImages/0613/KarynLeible.jpg" alt="Karyn Leible" class="ms-rtePosition-1" style="margin:15px 10px;" /><br></div> Leible stresses that how much the team understands and buys into QAPI will depend in part on “how you present the tools. You need to do this and do it well. AMDA is working to develop a program for the team that presents a case study and uses QAPI tools to devise solutions to the problem. We will see more programs and materials such as this to help people get more comfortable using the tools,” she says. <div> </div> <div> </div> <div> </div> <div>Creating a culture where quality improvement focuses on processes rather than individual blame is more likely to result in positive, lasting change. Wayne says, “When the pressure ulcer rate is too high, let’s look at our process and not jump to blame CNAs for not turning patients frequently enough. When you eliminate the blame, you make it easier for people to be accountable for outcomes.” At the same time, he says, “Once the team is convinced that they won’t be blamed, it is easier for them to own problems and address them.”</div> <div> </div> <h2 class="ms-rteElement-H2">When Leaders Love QAPI</h2> <div> </div> <div>Of course, no QAPI program will work if leadership doesn’t embrace it. “Leaders need to take ownership and help remove obstacles,” says Baldrige examiner Laxton. </div> <div> </div> <div> </div> <div> </div> <div>One important role for leaders is to keep QAPI moving as their facilities work through the five elements. “If they get stuck on an element, leaders need to intervene to keep up the momentum.”</div> <div> </div> <div> </div> <div> </div> <div>The leadership also needs to get everyone on the same page. </div> <div> </div> <div> </div> <div> </div> <div>“Leaders need to talk about QAPI in the same way with everyone in the facility. They need to make sure that, as a team, everyone is speaking the same language,” says Laxton. </div> <div> </div> <div> </div> <div> </div> <div>They also need to ensure that everyone has appropriate access to data, not just for information purposes but to enable everyone to contribute to the collective knowledge. </div> <div> </div> <div> </div> <div> </div> <div>While leaders need to make sure that everyone is interpreting data objectively, Laxton stresses that they shouldn’t take the passion out of quality improvement. “It’s the passion that gets people up in the morning. You don’t want to minimize that.” </div> <div> </div> <div> <img src="/Monthly-Issue/2013/PublishingImages/0613/IMG_6171.jpg" alt="" style="margin:5px;" /><img src="/Monthly-Issue/2013/PublishingImages/0613/IMG_7121.jpg" class="ms-rteImage-2 ms-rtePosition-2" alt="Golden LivingCenter, Waynesburg, Pa." style="margin:5px;" /><br>He adds, “It’s easy to get data heavy with QI and to get overly analytical. Don’t dial this down, but make sure everyone understands that QI isn’t personal or about pointing fingers.” </div> <div> </div> <div> </div> <div> </div> <div>Be positive up front about the purpose of QAPI, he says, and “that lets you maintain the passion while addressing the quality.”</div> <div> </div> <div> </div> <div> </div> <div>Leaders have to “create a culture of transparency,” says Stacey Rose, vice president of quality management at Sava Senior Care Consulting in Atlanta. </div> <div> </div> <div> </div> <div> </div> <div>“They have to make it clear that it is okay to identify a problem or bring an error to light. Leaders need to help everyone understand that they can help prevent adverse events from happening if they identify and address problems promptly and effectively.”</div> <div> </div> <div> </div> <div> </div> <div>Finally, says Laxton, leaders need to practice and encourage patience. “QAPI, like any performance improvement [program], takes time. You can’t rush it. To do it right, give it time.”</div> <div> </div> <div> </div> <div> </div> <div>He observes that going through a full Baldrige cycle takes three to five years, and facilities can expect a similar time frame from QAPI. </div> <div> </div> <div> </div> <div> </div> <div>Laxton also notes that many practitioners are “high-touch” and that they may feel that asking them to get into data doesn’t fit their personality. However, he says, “Collecting and applying good data is the quickest way to make improvements. Leaders can use the clear effectiveness of good data to push past any resistance to collecting it.”<br><br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"> Size Doesn’t Matter </h2> <div>Even smaller facilities with limited resources can be QAPI-ready. They can start by looking at the five elements and how they relate to the current quality indicators they’re using, and they can try to simplify things instead of recreating the wheel. </div> <div> </div> <div> </div> <div> </div> <div>Additionally, they can look at the QAPI requirements and determine if the facility is meeting them with the current standards they’re using. If they are doing some type of quality improvement already—and most are—they simply may need to fill in some gaps, change the language to coincide with QAPI terminology, and implement some QAPI-specific tools.</div> <div> </div> <div> </div> <div> </div> <div>It may be challenging to get the board, employees, residents, and others to understand what QAPI is, compared with what they’re doing now. However, it is worth the effort to conduct training programs and have ongoing conversations about QAPI. With QAPI’s focus, more players than ever will be involved in quality initiatives, and this means more viewpoints, opinions, and input. The key is a lot of communication and the ability to dig into details and track trends. And, ultimately, staff will need to make decisions as a team. </div> <div> </div> <div> </div> <div> </div> <div>Creating a culture of quality improvement and teamwork takes time, but it is essential to make QAPI successful. Facility teams can’t operate in silos.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Filling a Toolbox That Builds Quality</h2> <div> </div> <div>As much as mechanics have a variety of tools in their toolboxes, facilities need to build a collection of tools for QAPI. “Tools are only effective if they are used in the appropriate circumstances,” says Wayne. Facilities need to use tools that help them conduct effective root-cause analyses and choose areas for improvement based on the highest priority.</div> <div> </div> <div> </div> <div> </div> <div>“They don’t teach root-cause analysis in school. So we need a structured way of looking at opportunities for improvement and identifying breaks in the system,” says Lisa Zeis, vice president of operational services for The Waters Senior Living in Bloomington, Minn. “There are lots of tools that help with this.” One useful tool for root-cause analysis is the fishbone diagram. This tool, which resembles a fish skeleton, helps categorize the many possible causes of a problem in an organized way.</div> <div> </div> <div> <img width="127" height="210" class="ms-rtePosition-2" alt="Lisa Zeis" src="/Monthly-Issue/2013/PublishingImages/0613/LisaZeis.jpg" style="margin:15px 10px;" /><br></div> <div>Four main steps are involved in creating a fishbone diagram. The “head” of the fish is the problem being analyzed. The larger “bones” closest to the head represent the most likely causes and the ones that have the greatest impact, while the smaller “bones” further from the head represent those having a smaller impact. The completed diagram helps the team identify what problems, or components of the process, they need to focus their attention on to effect positive change.</div> <div> </div> <div> </div> <div> </div> <div>Another popular tool is the “Five Whys Tool,” which starts with an effective problem statement that describes the current condition or issue. The team asks “why” to the problem statement and then asks why to the answer to that, then why to the answer to that, and so on. Like the fishbone diagram, this tool is designed to fix the system and not just remove the symptoms. </div> <div> </div> <div> </div> <div> </div> <div>Also useful for root-cause analysis is a Pareto Analysis, which employs the 80/20 rule, that is, 20 percent of causes generate 80 percent of results. A Pareto Analysis helps the team prioritize the changes most likely to improve a situation or process. “This tool helps you see where you will get the biggest bang for your buck,” says McMahon.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">More Helpful Tools</h2> <div> </div> <div>A flowchart is another useful tool. A diagram that represents a process, the flowchart shows steps as boxes and their order via connecting arrows. This tool can help the team diagram a solution to a specific problem. </div> <div> </div> <div> </div> <div> </div> <div>“Flow diagramming can help you look at your current process and identify where there is a potential breakdown, ” Leible says. To help ensure that everyone interprets data consistently across the board, a run chart can be helpful. This is a graph that shows data in a time sequence and enables the team to identify trends and detect outliers. </div> <div> </div> <div> </div> <div> </div> <div>“How data are presented makes a difference. You don’t want to chase numbers,” says Leible.</div> <div> </div> <div> </div> <div> </div> <div>When you identify an issue, you need to try to stratify what is causing it by identifying the most common reason for it, says Wayne. “This will help you decide where to prioritize your efforts.” However, he cautions, “You need to help the team to analyze the data properly. Only then can you choose and apply the appropriate tool.” He says that sometimes the team can spend time ineffectively if they don’t understand what the data are telling them.</div> <div> </div> <div> </div> <div> </div> <div>“If the only tool you have is a hammer, every problem looks like a nail,” says Reinhardt, who stresses the importance of having and using proven tools in a consistent, effective manner. “We have a toolbox that includes several items. No one tool will work in every situation.” It is important to have tools that are part of a systematic problem-solving process. </div> <div> </div> <div> </div> <div> </div> <div>She says, “If you really want to understand what is going on and determine root causes, you have to understand causal factors and come up with a plan to do something different and not just train people one more time or repeat another inservice. Then you need to make sure that whatever plan you implemented did what you intended it to do.”</div> <div> </div> <div> </div> <div> </div> <div>Benedictine has a “cheat sheet” for staff with tools they can use and where they can go for training on their use.</div> <div> </div> <div> </div> <div> </div> <div>“There are so many tools, people may be overwhelmed at first,” says Zeis. She says that facilities have good resources in the form of state Quality Improvement Organizations, state health care associations, and other organizations. These resources, says Zeis, can help facilities put tools into place.</div> <div> </div> <div> <img width="158" height="201" src="/Monthly-Issue/2013/PublishingImages/0613/MatthewWayne.jpg" alt="Matthew Wayne" class="ms-rtePosition-1" style="margin:15px 10px;" /><br></div> <div>McMahon is confident that team members will have little problem adapting to the use of various tools. </div> <div> </div> <div> </div> <div> </div> <div>“If you give them tools that enable better outcomes, they will jump on them because they want to do the right thing for their residents,” he says.</div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Cloudy Crystal Ball</h2> <div> </div> <div>As much as facilities would like to have a QAPI crystal ball, they can’t predict how the regulations are being written. </div> <div> </div> <div> </div> <div> </div> <div>“We had expected to see more rules by now, but we are likely to see some firmer regulatory guidance soon about what QAPI will look like from a reporting standpoint,” says Laxton. However, he suggests, “Don’t get caught up on second-guessing the rulemaking. QAPI is a journey, and every organization should be engaged on this at some level.”</div> <div> </div> <div> </div> <div> </div> <div>McMahon says that whenever a new regulation is promulgated, people panic. </div> <div> </div> <div> </div> <div> </div> <div>“They don’t know how surveyors will interpret them. They wonder about surveyor training. And they will stress until they have a survey showing that they are doing the right things. After that, they will become less fearful and more confident.” </div> <div> </div> <div> </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div>While these groups are unsure about the final regs, they are confident about their ability to implement QAPI. Some even see a little déjà vu in QAPI, as they see it reflected in many of their current quality improvement efforts. At the same time, those involved in the AHCA/NCAL National Quality Award program see a parallel between the steps involved in the program and the five elements of QAPI. 2013-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0613/cs_thumb.jpg" style="BORDER:0px solid;" />Quality;Quality Improvement;ManagementCover Story6
The QIS Experthttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0613/The-QIS-Expert.aspxThe QIS ExpertThis is the third column in the series of five addressing how QIS methods can be used in a QAPI system, by showing the parallels between QIS methods and the Five Elements of QAPI.<br><br>By breaking down “Element 3: Feedback, Data Systems, and Monitoring,” the parallels between QAPI and the QIS process are clearly apparent. <br><br>As the Centers for Medicare & Medicaid Services (CMS) says about Element 3, “The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate.”<br><br>While the QIS was designed for surveyors to use as a system for regulatory review, providers are able “to put in place a system to monitor care and services” using identical QIS methods. The six QIS assessments in Stage 1 “draw data from multiple sources,” including resident, family, and staff interviews; resident observations; and chart reviews for the short-and long-stay populations. Thus, feedback systems “actively incorporate inputs” from all those specified for QAPI.<br><br>CMS said Element 3 includes “using Performance Indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or targets the facility has established for performance.”<br><br>The Quality of Care and Life Indicators (QCLIs), which are rigorously defined in QIS, are “Performance Indicators.” The 80 QCLIs from the various Stage 1 assessments cover “a wide range of care processes and outcomes.” In addition, QIS also includes 21 Performance Indicators from MDS to calculate QCLI rates.<br><br>Where facility process Performance Indicators are required, the QIS Mandatory and Triggered Facility Tasks yield Performance Indicators relating to such critical processes as dining services and medication administration, which can be so critical to both quality of care and life. <br><br>For QAPI purposes, the “targets” set by the QIS Thresholds for regulatory purposes serve merely as a minimum performance standard.<br><br>QAPI appropriately demands that everyone work to perform better than they are, comparing themselves to benchmarks based on other facilities and their own past performances. Such benchmarks are increasingly available in large national databases or through repeated measures in individual facilities using a QIS-based system.<br><br>A final part of Element 3 is “tracking, investigating, and monitoring adverse events that must be investigated every time they occur and action plans implemented to prevent recurrences.”<br><br>Surveyors use the QIS to identify “adverse events” retrospectively during the survey. However, when used in real time in today’s health information technology systems, the QIS methodology identifies adverse events when they occur. <br><br>The Stage 2 Critical Element Pathways structure root-cause analyses can be used as the basis for “action plans.” <br><br>Thus, Element 3 is completely aligned with voluntary use of QIS methods by facility staff in a QAPI program. <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>This is the third column in the series of five addressing how QIS methods can be used in a QAPI system, by showing the parallels between QIS methods and the Five Elements of QAPI.2013-06-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/headshots/AndyKramer.jpg" style="BORDER:0px solid;" />The Quality Forum6

July



 

 

Collaboration Improves Carehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0713/Collaboration-Improves-Care.aspxCollaboration Improves Care<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div> <div><img height="220" width="294" src="/Monthly-Issue/2013/PublishingImages/0713/Caregiving_4641.jpg" class="ms-rteImage-2 ms-rtePosition-2" alt="" style="margin:10px;" /><br>In today’s fast-paced, economically burdened health care delivery system, long term and post-acute care providers often ask how to do more with less. With funding from a Johnson and Johnson Corporate Foundation block grant, Rutgers researchers and educators initiated the <a target="_blank" href="/Monthly-Issue/2013/Pages/0713/How-The-Collaborative-Worked.aspx">Rutgers Nursing Home Learning Collaborative</a> to test whether nursing homes could use insights from high-performance organizations to strengthen communication and improve staff satisfaction and better meet the needs of their residents.</div> <h2 class="ms-rteElement-H2">The Goal</h2> <div>Learning collaboratives bring together teams from multiple sites to focus on specific quality improvement topics and learn from technical experts and each other. This approach holds promise for many health care settings, including nursing homes.</div> <div> </div> <div>From 2009 to 2011, teams from nine central New Jersey facilities entered the collaborative. Drawing on learning organization principles and basic quality improvement processes, these teams implemented a range of changes. </div> <h2 class="ms-rteElement-H2">Survey Reveals Need</h2> <div>Effective communication is vital in providing high-quality care that respects and is responsive to the individual needs of residents. Diverse in size, ownership, and structure, the facilities in the collaborative generally performed successfully on surveys and tended to be involved in other quality improvement initiatives. </div> <p> </p> <p> </p> <div>However, surveys and interviews with their team members revealed that there isn’t much time in a normal day for managers and staff to exchange ideas, prioritize problems, or think about how to integrate new insights into facility routines. </div> <div> </div> <div>As one director of nursing explained, “Nursing homes are in survival mode.” </div> <div> <img height="183" width="245" src="/Monthly-Issue/2013/PublishingImages/0713/Caregiving_4667.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:15px 5px;" /><br>Over two cycles of the learning collaborative, a total of more than 400 nurses and nurse assistants responded to a one-page work environment survey covering a variety of issues, including supplies and resources; assignments; schedules; safety and health conditions; enforcement of policies; shift-to-shift communication; and relationships with managers, supervisors, and co-workers. </div> <div> </div> <div>The survey also included three open-ended questions that elicited hundreds of comments from nursing staff at each of the facilities. Each facility team used its survey results to identify areas in which its practices could be improved. </div> <div><br></div> <div>On the short-answer questions, nursing staff were most likely to disagree with the following statements: There is good communication between shifts, people on this unit find time to review how the work is going, assignments and schedules are fair, policies are enforced the same for everyone, and managers care about me as a person.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Staff Need To Communicate </h2> <div>In responding to the open-ended questions, nurse assistants were particularly likely to feel disrespected and unappreciated. Based on survey results and interviews with nursing staff who participated in the learning collaborative, these issues are interrelated. </div> <div><br></div> <div>Given the pace of demands, it is not surprising that staff report that bringing people together to “review how the work is going” is a rare event. </div> <div> </div> <div>Problems with bringing staff together extend to change of shift: Staff may not be able to respond to the current status of the residents they care for if the shift report is abbreviated or if the incoming staff do not have an opportunity to interact with outgoing staff, or if the report is not extended to nurse assistants before they plunge into their work.</div> <h2 class="ms-rteElement-H2">Results Of Poor Communication </h2> <div>Without opportunities to share information and discuss and resolve problems with co-workers, supervisors, and departmental leaders, nursing staff may feel like they have less control over their working conditions and feel less connected to the overall organization. </div> <div> <img height="200" width="266" src="/Monthly-Issue/2013/PublishingImages/0713/Caregiving_4675.jpg" class="ms-rteImage-2 ms-rtePosition-1" alt="" style="margin:10px;" /><br></div> <div>If staff do not understand how decisions are made, they may question the fairness of assignments and schedules and whether policies are fairly enforced.<br></div> <div>If managers are not visibly interacting on the floor, staff may not know that their efforts are seen and appreciated. </div> <h2 class="ms-rteElement-H2">Provide A ‘Safe’ Place To Communicate</h2> <div>From therapy and pharmacy communications to broken equipment and incomplete paperwork, participants in the Rutgers collaborative identified scores of problems that are “patched” or worked around as a result of the survey. </div> <div> </div> <div>How can nursing homes move more aggressively to recognize “systems problems” and learn from mistakes? Top leadership and middle managers need to acknowledge that organizational processes and practices are a work in progress that will always need to be refined.</div> <div> </div> <div>Feedback loops and face-to-face opportunities allowing staff to report problems and barriers and engage in problem solving are critical.</div> <div> </div> <div>However, managers must realize that asking line staff to share ideas and report problems may be perceived as involving more effort and risk-taking than muddling through and ignoring the wider systems flaws.</div> <div> </div> <div>Learning organizations require both accountability and psychological safety: Employees are accountable not only for performing their jobs well but for openly questioning ineffective organizational practices, sharing their ideas, acknowledging their mistakes, and taking risks by trying new approaches.</div> <div> </div> <div>For this to happen, they must feel psychologically safe, especially in interacting with their direct supervisor.<br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Lessons Learned</h2> <div>One of the most important lessons from the collaborative is that the biggest stressors for nursing home staff are closely related to barriers to providing the best possible care—whether the issue is not having the time, information, or resources needed to meet the needs of the residents or not having a supervisor who will listen to ideas for the best way to organize resident care  tasks. Each project used methods to strengthen the relationships and systems that allow information to flow across shifts, disciplines, and hierarchies.</div> <div> </div> <div>Although the starting point for process improvement was identifying system failures and stressors in each facility’s work environment—all of the projects had implications for improving resident care.<br></div> <div> <img height="165" width="243" src="/Monthly-Issue/2013/PublishingImages/0713/Caregiving_4645.jpg" class="ms-rteImage-2 ms-rtePosition-2" alt="" style="margin:10px 5px;" />“Residents can tell when staff do not work well together,” observed one nurse. “Happy staff, happy residents, happy families,” summarized another.<br><br></div> <div><a target="_blank" href="/Monthly-Issue/2013/Pages/0713/Definitions.aspx">High-performance</a> work practices used by learning organizations come at a cost: actively listening and cultivating honest and supportive relationships with staff at all levels. </div> <div> </div> <div>As one nurse manager said, “If someone has an idea, I will listen. If it won’t work, I’ll say ‘no’—but I’ll also explain the reasons why we can’t follow the suggestion and let my staff know how much I appreciate hearing from them.” </div> <div> </div> <div>This level of engagement among and between direct care staff, supervisors, and managers is exactly what is needed to create communities that are good places to both work and live. </div> <div> </div> <div><em>Michele Ochsner, PhD, is co-director of the Occupational Training and Elevation Consortium at Rutgers University, School of Management and Labor Relations. Lisa Slater, MSN, RN, is director of professional education at Francis E. Parker Homes.</em></div>Learning collaboratives bring together teams from multiple sites to focus on specific quality improvement topics and learn from technical experts and each other. This approach holds promise for many health care settings, including nursing homes.2013-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0713/caregiving_thumb.jpg" style="BORDER:0px solid;" />CaregivingColumn7
MDS 3.0: Looking Back, Looking Forwardhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0713/Looking-Back-Looking-Forward.aspxMDS 3.0: Looking Back, Looking Forward<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><img height="255" width="255" src="/Monthly-Issue/2013/PublishingImages/0713/feature.jpg" class="ms-rteImage-2 ms-rtePosition-2" alt="" style="margin:5px 10px;" /><br>The May 2013 update to the “Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual, Version 3.0” for the minimum data set (MDS) includes some notable changes for nursing home staff to be aware of, and the fiscal year (FY) 2014 prospective payment system (PPS) proposed rule and the upcoming Oct. 1, 2013, MDS technical specifications hint of more changes to come.</div> <div> </div> <div>More than 225 pages of the manual are affected by the May update. They include many inconsequential changes to wording, punctuation, and capitalization. But there are also a significant number of clarifications that affect facility staff who care for residents and interdisciplinary team members who code the MDS. </div> <h2 class="ms-rteElement-H2">Part A Transitions</h2> <div>One welcome update entails a situation in which a resident who was covered by a managed care (Medicare Part C) plan transitions to traditional Medicare Part A. Chapter 2 (page 2-45) of the manual now says that “if a resident goes from Medicare Advantage to Medicare Part A, the Medicare PPS schedule must start over with a five-day PPS assessment, as the resident is now beginning a Medicare Part A stay.” </div> <div> </div> <div>In this situation, the Medicare beneficiary continues in the same benefit period, but the PPS schedule is restarted with a five-day assessment and staff can begin submitting these assessments to the federal database.</div> <h2 class="ms-rteElement-H2">Skin Conditions</h2> <div>Pressure ulcer staging and management of skin condition are a key focus of the May update. More than 50 pages of edits were placed into section M, “Skin Conditions.” The edits begin by saying, “Pressure ulcer staging is an assessment system that provides a description and classification based on anatomic depth of soft tissue damage” (page M-4). </div> <div> </div> <div>The update puts an increased focus on pressure ulcer management as a “system” and prioritizes identifying the numerical stage of pressure ulcers and showing evidence of improvement and progress toward healing. </div> <div> </div> <div>“If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the patient’s overall clinical condition should be reassessed,” it says (page M-9).</div> <div> </div> <div>When a pressure ulcer either fails to show improvement or worsens, “the interdisciplinary care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer management principles are being adhered to when new pressure ulcers develop or when pressure ulcers worsen” (page M-25). </div> <div> </div> <div>National experts advise facility staff to utilize quality assurance and performance improvement (QAPI) principles to assess and analyze the development or worsening of pressure ulcers, conducting root cause analysis and developing performance improvement plans (PIPs) to address the issues. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">RUG Criteria Changes</h2> <div>Looking forward, both the FY 2014 proposed rule and the posted technical specifications for changes to the MDS item sets are targeted to become effective Oct. 1, 2014. One key change that will impact providers is that the Centers for Medicare & Medicaid Services (CMS) has proposed adding a new item to Section O, O0420. This item asks for the number of distinct calendar days of therapy that was provided in a given week (seven-day period). </div> <div> </div> <div>This change will impact the Rehabilitation Resource Utilization Group (RUG) categories, as determination of the level will include matching the current RUG criteria with the number of days indicated by this new item on the MDS. </div> <div> </div> <div>This new item is necessitated by the fact that the current RUG grouper does not capture distinct therapy days. CMS provided the following example:<br><br></div> <div>A resident receives 150 minutes of therapy in the form of physical therapy and occupational therapy on Monday (one session of physical therapy and one session of occupational therapy) and Wednesday (one session of physical therapy and one session of occupational therapy) and speech therapy on Friday. The intent of the Medium Rehab classification criteria is for such a resident not to classify into the Medium Rehab RUG category, since he or she only received therapy on three days (Monday, Wednesday, and Friday) during the seven-day look-back period. </div> <div> </div> <div>However, the MDS item set only requires the skilled nursing facility (SNF) to record the number of days therapy was received by each therapy discipline during that seven-day look-back period, without distinguishing between distinct calendar days. Thus, in the example above, the SNF would record the following on the MDS: two days of physical therapy, two days of occupational therapy, and one day of speech therapy. </div> <div> </div> <div>Currently, the RUG grouper adds these days together, allowing the resident described above to be classified into the Medium Rehab category even though the resident did not actually receive five distinct calendar days of therapy. </div> <div> </div> <div>This resident would not meet the classification criteria for the Medium Rehab category as they were intended to be applied. However, the MDS item set currently does not contain an item that permits SNFs to report the total number of distinct calendar days of therapy provided by all rehabilitation disciplines, allowing some residents to be classified into Rehabilitation RUG categories when they do not actually meet the classification criteria (Davis, 2013).</div> <h2 class="ms-rteElement-H2">Policy Manual Changes</h2> <div>With the addition of item O0420 to the MDS item set in October, facility staff will need to tighten up their rehabilitative service scheduling, while keeping in mind regulations in the Medicare Benefit Policy Manual (BPM). The BPM says that staggering the timing of various therapy modalities in an arbitrary fashion throughout the week to meet the requirement for “daily skilled need” does not satisfy the SNF coverage requirement for skilled care (CMS, 2006, chapter 8, section 30.6).</div> <div> </div> <div>This requirement is only met when there is a valid medical reason why both therapy services cannot be furnished on the same day. The basic issue here is not whether the services are needed, but when they are needed.</div> <div> </div> <div>Since accuracy of MDS coding is critical to quality measures, five-star ratings, survey management, and Medicare compliance, it is important that staff be well versed in the May “RAI User’s Manual” update changes. </div> <div> </div> <div>Take note, also, of all the changes that have been preliminarily posted for the MDS item sets for Oct. 1, 2013. The “RAI User’s Manual,” PPS rule, “Medicare Benefit Policy Manual,” MDS Technical Specifications, and other CMS clarifications all need to be pieced together to create a picture of success for facility staff action. Indeed, staff have their work cut out for them. </div> <div> </div> <div><em>Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, is vice president, curriculum development, for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em></div> <div> </div> <div><strong>References:</strong></div> <div>1. Centers for Medicare & Medicaid Services, May 2013, <a target="_blank" href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html">“Long-Term Care Facility Resident Assessment Instrument User’s Manual (Version 3.0)” </a><br></div> <div>2. Centers for Medicare & Medicaid Services (2006), <a target="_blank" href="http://www.cms.gov/Regulations-and-%20Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html">“Medicare Benefit Policy Manual” </a> </div> <div>3. Davis, C. (June 5, 2013). <a target="_blank" href="http://www.aanac.org/information-resources/article/2013/05/21/highlights-of-the-snf-pps-rule-detailed-at-may-snf-odf">Highlights of the SNF PPS rule</a> detailed in May SNF ODF. AANAC LTC Leader, 1–4. Retrieved June 5, 2013</div> More than 225 pages of the manual are affected by the May update. They include many inconsequential changes to wording, punctuation, and capitalization. But there are also a significant number of clarifications that affect facility staff who care for residents and interdisciplinary team members who code the MDS. 2013-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0713/feature_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn7
The Essentials Of Hospital Negotiatinghttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0713/The-Essentials-Of-Hospital-Negotiating.aspxThe Essentials Of Hospital Negotiating<div>Contracts with hospitals are today’s new reality. Already commonplace in markets such as California, they are sweeping across the country as Accountable Care Organizations (ACOs), bundled payment pilots, and capitated Medicaid programs take hold. </div> <div> </div> <div>They spring from a fundamental culture change in long term care: The Medicare world of “more is more” has been replaced with the managed care world of “less is more,” with an expectation of even better financial and clinical outcomes.</div> <div> </div> <div>Hospitals, ACOs, and managed care companies are increasingly contracting with post-acute partners who bring attractive, data-driven outcomes to the table. After these contracts are signed, these partners remain accountable for delivering competitive outcomes such as return to acute care, average length of stay, mortality rates, delivering a continuum of services, and better coordinated care. But opportunities—and competitive advantage—start with getting a contract on the table. </div> <div> </div> <div>Let’s look at how long term and post-acute care operations can best put the odds in their favor. <br></div> <h2 class="ms-rteElement-H2">First: Start With Value</h2> <div>Perhaps the most important guideline is to think beyond metrics and outcomes, into the broader value argument. The real goal is to provide value that would be expensive and time-consuming for networks to create on their own, in areas such as convenience, economies of scale, quality outcomes, and cost containment. </div> <div> </div> <div>Doing this well requires fresh thinking and a service mindset. This does not mean that data aren’t important; to the contrary, they are more important than ever today to own one’s own data story. The market is more competitive and more analytically driven than ever. <br><br></div> <div>ACOs have often done a surprising amount of due diligence on metrics such as length of stay, readmissions, and Five-Star data, and contracts routinely hinge on metrics-driven performance. And, on occasion, their information is incorrect. </div> <div> </div> <div>Get in front of this story by providing more granularity than partners can obtain from public sources, and consider portals and dashboards to share up-to-the-minute metrics with acute care partners.</div> <div> </div> <div>Today, some of the better long term care providers are starting to resemble logistics companies that happen to be in the health care business, with a broad range of services, new technology, a team of doctors on the ground, care transition coaches, and intake teams that can facilitate the full continuum of care. </div> <div> </div> <div>To build a value equation, be prepared to stretch, try things, and make mistakes. <br></div> <h2 class="ms-rteElement-H2">Second: Adapt To A Brave New World</h2> <div>The equation for profitable long term and post-acute care is quickly shifting from one of price to one of volume. This means that one of the biggest challenges is revenue compression, particularly due to downward pressures on length of stay. Adapting to this new environment—and convincing hospitals, networks, and ACOs to contract with a provider—is a multifaceted process that involves several factors, such as:<br><br></div> <div>■ Proactively reducing average lengths of stay through better disease management;<br><br></div> <div>■ Leveraging technology to work more efficiently, including selecting the right partners in areas such as electronic medical records and outcomes reporting;<br><br></div> <div>■ Protecting revenue by defining acceptable admissions processes and parameters up front;<br><br></div> <div>■ Creating a competitive advantage in getting patients home sooner and keeping them home longer;<br><br></div> <div>■ Managing a continuum of care rather than a silo of care; and<br><br></div> <div>■ Focusing on effective management-of-care transitions.</div> <div> </div> <div>This latter point has become an emerging, important metric, as care transition programs are increasing from 30 days toward 12 months. They are moving from isolated silos like acute or skilled nursing facility (SNF) environments to flat horizontal models focused on integration and efficiency of quality outcomes.</div> <div> </div> <div>A good future model for both the patient and a revenue-focused holistic approach will include coordinated services for a lifetime.<br><br></div> <div>Another important part of this brave new world is optimizing the use of physicians: While people talk about health care reform being about patient-centered care, it often feels more like physician-centric care. </div> <div> </div> <div>Patients follow their physicians, and as a result, the health care networks increasingly want their physicians and brands in the long term care partner’s building. It may make sense to rethink the traditional medical director model and evolve toward more of a “congress of resources” with managed care partners, competing specialists, SNFists, hospitalists, and more to promote dialogue among stakeholders. <br></div> <h2 class="ms-rteElement-H2">Third: Protect Your Interests</h2> <div>In a new world of contracting, providers need to look out for themselves before and after signing a contract, particularly in these three areas:<br><br></div> <div>■ Expertise. Steve Rodgers, chief executive officer (CEO) of AccentCare, a home health and hospice care company, said at the LTC100 Leadership Conference, “You must have some really good contracting people in your organization. Pick your partners well.” <br></div> <div>In a world where the people across the negotiating table can afford top talent, and often negotiate very big deals with much bigger partners, it makes sense to hire a contracting expert—and to get the best expertise available.<br><br></div> <div>■ Transparency. Providers are increasingly seen as a cost center nowadays, but long term and post-acute care operators need to know how their hospital partners control their costs, too, as part of a team that is dependent on each other to achieve bonus payments. Transparency is key across the network from a cost perspective; get agreements in writing, and hold partners accountable. Don’t assume there is mutual understanding and agreement about definitions for measurements, and providers should know their own cost structures in the moment.<br><br></div> <div>■ Holistic communications. Just because the hospital CEO signs a contract doesn’t mean that discharge planners always follow suit. One can deliver superior return-to-hospital rates, mortality rates, and length-of-stay and admissions numbers and yet find discharge planners who don’t understand why senior leadership is involved in the referral process. <br></div> <div><br>Bridge this internal communication gap by having clinical liaisons who can coordinate with hospital staff to facilitate referrals. <br></div> <div><br>Integrating technologies early will dramatically improve communications and help secure a provider’s place at the table as a partner. <br></div> <h2 class="ms-rteElement-H2">Contracts Are Here To Stay</h2> <div>There is lots of talk today about contracting strategies and positioning. Becoming a partner with acute-care stakeholders requires a balance of new ideas, new technology, and traditional values, such as providers that are direct with expectations and needs, clear about capabilities and weaknesses, transparent in sharing strategically important data, and, above all, trustworthy.</div> <div> </div> <div>The bottom line is that adverse selection is here to stay. While providers will be welcomed as partners at the negotiating table, they should offer value, plan to adapt to change, and protect their business interests before inking a deal. Referrals, revenue, expense levels, and reputation depend on it. </div> <div> </div> <div><em>Kenneth Lund is chief executive officer of Shea Family, a San Diego-based firm that provides comprehensive administrative services to senior care and rehabilitation businesses. Lund has 30 years of experience in industries ranging from banking and commercial real estate to nationwide distribution and has spent the last 15 years revitalizing senior living and skilled nursing companies using lifestyle and service-based approaches.</em></div> Contracts with hospitals are today’s new reality. Already commonplace in markets such as California, they are sweeping across the country as Accountable Care Organizations (ACOs), bundled payment pilots, and capitated Medicaid programs take hold. 2013-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0713/mgmt_thumb.jpg" style="BORDER:0px solid;" />ManagementColumn7
One Provider’s Quality Journeyhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0713/One-Providers-Quality-Journey.aspxOne Provider’s Quality Journey<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></div><div><img width="249" height="146" class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0713/luthernlogo.jpg" alt="" style="margin:15px;" /><br><br>A dozen or so years ago, Ted Goins Jr. had his road-to-Damascus moment. </div> <div> </div> <div>A veteran administrator at Lutheran Services Carolinas who had started his career as a nurse assistant, Goins, 55, had gone to a conference to hear Bill Thomas, MD, whom many regard as the chief evangelist of person-centered care. And Thomas talked about dogs. </div> <div> </div> <div>“I grew up, unfortunately, in the era where you wouldn’t let a dog through the door of a nursing home,” Goins recalls. “They might shed. You were a health facility. We mopped the floors all the time because there might be a hair somewhere on it. And then here was a guy standing up there on stage saying, ‘You should have a dog in the facility.’”</div> <h2 class="ms-rteElement-H2">Resident-centered Care</h2> <div>Goins had always considered himself receptive to the idea of treating residents as he would want to be treated. He had trained more than three decades earlier under a man who “was doing person-centered care before we called it that.” But, hearing Thomas, Goins realized that, for all of his self-supposed open-mindedness, he, too, was bound up in the Old Way of doing things. </div> <div> </div> <div>“All of a sudden, the light bulb switched on,” Goins says. “I remember thinking, ‘Maybe there’s a different way of looking at this.’”</div> <div> </div> <div>Goins grabbed Thomas after the speech. “I ended up sitting in the hall, on the floor, with him—just discussing some of the issues,” Goins says. </div> <div> </div> <div>He went a step further and invited Thomas down to North Carolina. “And he came and spent a day with our board of trustees and senior management staff and just helped ignite the passion,” Goins says. </div> <div> </div> <div>But it wasn’t until after Thomas had moved on that Goins realized that, while he had been honoring person-centered care with his lips, his heart was still far away from the ideal.</div> <div> </div> <div>Goins wants you to read his story. Because he thinks that the changes brought on by Thomas’ intervention have helped Lutheran Services not only survive but thrive, even as state and federal funds are drying up and so many providers find themselves staring at the prospect of extinction. </div> <h2 class="ms-rteElement-H2">Like An Obstacle Course</h2> <div>Goins had promised himself that he would incorporate the theory and practice of person-centered care, but he hadn’t realized that he had been harboring his own, stubborn doubts until he heard that one of his company’s maintenance men had solved a seemingly intractable problem. </div> <div> </div> <div>Employees at one of Lutheran’s homes found themselves flummoxed by how often residents were falling down. True to the principles of person-centered care, all the building’s workers were invited to a brainstorming session. The answer came from a seemingly unlikely source, Goins says. </div> <div> </div> <div>“And the maintenance man, who normally wouldn’t even be in a meeting like this—this was a nursing issue, not a maintenance issue—said, ‘Well, look at all the stuff in their way,’” Goins says. “‘There’s a call bell here, there’s an oxygen tube here, there’s a phone cord there—it looks like an obstacle course. Do you realize how many people are tripping over those cords?’”</div> <div> </div> <div>Having heard the story, Goins couldn’t un-hear it. </div> <div> </div> <div>“Those are the kinds of things that were starting to come out of those meetings,” Goins says of the unexpected wealth of wisdom Lutheran discovered in its front-line workers. “All of a sudden, things made sense. And now it feels like, ‘Why weren’t we doing this all along?’”</div> <div> </div> <div>He realized that, for all of his talk about patients first, he had been throwing away a pearl richer than his tribe by not seeking out his front-line workers. <br></div> <div><br>“The housekeepers spend the most time in the room. So we should be listening to those people,” Goins says. “I started as a nursing assistant, and it was almost like we weren’t allowed to have ideas.”</div> <div> </div> <div>The road to quality did not end there. But for Goins and Lutheran Services, those first, tentative steps have led to a road of riches. This year, Lutheran Services finds itself in a the midst of a five-year plan that will see two buildings remodeled and two brand new buildings opened. (In fact, ribbons have already been cut on three of the buildings.) </div> <div> </div> <div>Most of the rooms in the redone and new buildings already (or soon will) have private rooms, living rooms, dining rooms, spas, bistros, playgrounds for child visitors, computers (and computer classes), and libraries. There are lavender-scented bathrooms with towel-warming cabinets; residents routinely take twice-yearly trips to Carolina’s beaches (<em><a href="/Monthly-Issue/2013/Pages/0713/Beachin’-It.aspx">see Beachin' It</a></em>). Even as many providers find themselves collapsing (or barely holding firm), Lutheran Services is expanding. </div> <div> </div> <div>“It seems to me to all come back to that mission, vision, and values,” Goins says. “Because we’ve stayed true to that, we’ve got the reputation with the state, with the Medical Care Commission; they know we do good work. A lot of the not-for-profit groups have gotten out of the nursing home business, if you will. We’ve doubled down.”</div> <div> </div> <div>It is notorious that correlation doesn’t mean causality. But Goins is convinced that his company’s successes aren’t an accident. And his message is being heard. <br></div> <div><br>“We are encouraged and inspired by Ted’s growth,” American Health Care Association (AHCA) President and Chief Executive Officer (CEO) Gov. Mark Parkinson says. “It confirms what our most progressive members have proved: Even in tough times, person-centered care—whether it’s Eden, green houses, or some other alternative, works. It works for the patient, it works for the employees, and it works as a business model.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Postcards From The Apocalypse</h2> <div>In principle, no one disputes those findings, of course. </div> <div> </div> <div>The question is how to deliver on the promises? So many dispatches from long term care these days read like postcards from the Apocalypse. </div> <div> </div> <div>“As far as I’m concerned, quality of life is equally important,” Rhode Island Health Care Association President and CEO Virginia Burke says. “But given the regulatory scheme we operate under, it’s really difficult to operate.”</div> <div> </div> <div>The paradox, Burke says, is that the regulators themselves don’t seem to have learned the difference between lip service and real service. </div> <div> </div> <div>“The least expensive way to provide care is also the worst way to provide care: the assembly line. If you treat every patient as a widget waiting to be manufactured, then of course the quality isn’t going to be there,” she says. </div> <div> </div> <div>“Every blow to that funding just jeopardizes that further,” Burke says. “You just can’t go on. I don’t know if anyone’s giving much thought on how to innovate at the moment.”</div> <div> </div> <div>In late May, the Kaiser Family Foundation crunched the numbers and found that nearly half of America’s seniors may actually be poorer—because of rising health care costs—than official statistics show. In Rhode Island and 11 other states, the “supplemental” poverty numbers were at least twice as high as official numbers, Kaiser found. </div> <div> </div> <div>“The supplemental poverty measure indicates that elderly poverty rates overall and at the state level are much higher than indicated by the official poverty measure,” Kaiser researchers said.</div> <div> </div> <div>“At the national level, this result is largely due to the fact that the supplemental measure deducts health expenses from income, while the official measure does not.”<br></div> <div><br>In one of those 12 poor states, California, public retirees were recently told that their long term care insurance rates were going to explode by nearly 85 percent. Making matters worse, in 2011, California Gov. Jerry Brown signed legislation that cut Medicaid reimbursement to providers by another 10 percent. </div> <div> </div> <div>“Our providers are getting reimbursed $86 for every $100 in costs,” California Association of Health Facilities spokeswoman Deborah Pacyna says. “Because the costs are capped, there is no way to recoup that revenue.”</div> <h2 class="ms-rteElement-H2">Managed Care Crisis</h2> <div>To make matters worse, more than half of the states are, or will be, moving to managed care to handle the influx of new Medicaid enrollees after President Obama’s Affordable Care Act. </div> <div> </div> <div>Rhode Island is one of those states heading toward managed care. Burke is not pleased. </div> <div> </div> <div>“It’s just an extra hand in the process,” she says. “It’s an extra party that needs to be paid for services. Instead of the department just paying the providers, the department is now paying a health plan, which is going to pay the providers. It’s more money away from patient care.” </div> <div> <img width="222" height="207" class="ms-rteImage-2 ms-rtePosition-1" alt="Harvest Moon Ball" src="/Monthly-Issue/2013/PublishingImages/0713/HarvetMoonBall.jpg" style="margin:15px 5px;" /><br></div> <div>In June, AHCA issued a set of guiding principles that it hopes will blunt the worst effects of managed care (see box, page 30). Among the top concerns for providers was to make sure that managed care contracts had adequate long-term services and support programs. </div> <div> </div> <div>The supports “may be expensive in the short term,” AHCA’s Vice President of Medicaid and Long Term Care Policy Mike Cheek said in his report, “but they will provide long-term savings.”</div> <div> </div> <div>Burke says that culture change—and the investment that comes with it—has to seep beyond providers to regulators. </div> <div> </div> <div>“Ideally, under culture change, you’d have private rooms,” she says. “But I could never see our state Department of Human Services paying for private rooms. The quality people are never talking to the money people.”</div> <div> </div> <div>Goins says he understands how tough it is out there and that sometimes talk about quality can seem glib. But for him and Lutheran Services, it’s not a poster slogan: It’s a long-term investment that has paid off. “We have to prove to the public and our regulators that we’re worthy of adequate reimbursement and that it’s important to get what we’re owed.</div> <div> </div> <div>“And I know that’s a tough one in today’s world. If you’re sitting in a 50-year-old facility in Illinois—and they’ve got a notorious reimbursement rate—then it is hard to look beyond that. You’re just barely surviving, day to day.</div> <div> </div> <div>“But, then again,” he says, “you have to start somewhere. And you have to be willing to invest in quality. The days of that 120-bed facility that was all semi-private rooms with shared bathrooms is over. That means they’re going to have to invest, or they’ll be out of business.” <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Leap Of Faith</h2> <div>Lutheran Services’ employees will be the first to tell you that committing to quality is risky. And, perhaps worse, you can’t kinda do it. </div> <div> </div> <div>“Sometimes that’s easier said than done,” Lutheran’s Operations Director Jill Nothstine says. “We all talk about giving resident-centered care, but it’s really a battle every day to make that happen.” </div> <div> <img width="142" height="155" class="ms-rteImage-2 ms-rtePosition-2" alt="Jill Nothstine" src="/Monthly-Issue/2013/PublishingImages/0713/JillNothstine.jpg" style="margin:15px 5px;" /><br></div> <div>Nothstine knows of what she speaks. She signed on with Lutheran six years ago, when Goins’ massive cultural overhaul was just underway. </div> <div> </div> <div>“I thought they were really interested in providing resident-directed care, in culture change, and in empowering their staff. I know those are buzz words, but I find that they’re genuine here,” she says. “I was so impressed that I kind of casually asked if they needed a nurse consultant.” </div> <div> </div> <div>Her hunch about the place wasn’t wrong, Nothstine says. </div> <div> </div> <div>“I felt like, that from the minute I came here, it was a different place,” she says. “Those new buildings they’re building—that’s a leap of faith, when you think about it. But I think that’s shown our staff that we believe in what we’re doing.”</div> <div> </div> <div>But, like her boss, Nothstine was quick to discover that awkward, geographical relationship between one’s money and one’s mouth. </div> <div> </div> <div>“The whole electronic records, I didn’t think you could do it,” she says. “I have to admit, I had trouble at first really buying into that. I remember saying to our IT trainer … ‘I am a nurse. I’m not a technology person.’” </div> <div> </div> <div>Nothstine understands the fear of change. After all, the consequences of getting things wrong can be disastrous—not just for patients, but for companies. </div> <div> </div> <div>“I think a lot of it is fear of the state,” Nothstine says. “When you have a regulation that says there are so many hours between dinner and breakfast and you have to give medications before … and we’re saying, ‘No, we’re going to let Mrs. Smith sleep in until 10 a.m., so, yeah, we’re going to go over that 16-hour rule.’ </div> <div> </div> <div>“But we’re thinking differently,” Nothstine says.</div> <h2 class="ms-rteElement-H2">Not An Option </h2> <div>Scary, perhaps, but if you really think about it, Nothstine adds, you really don’t have a choice: “I can learn it now, or I can learn later, but not learning is not an option.” </div> <div> </div> <div>And it’s the focus on learning that has made all the difference, Lutheran Services folks say. About eight years ago, the company developed curricula that were a hybrid of the Eden Alternative/Wellspring models. The company calls its curricula “New Pathways.” </div> <div> </div> <div>Once per quarter (at least), Lutheran Services employees, from housekeepers to executives, are taken out of their homes or offices and sent off-site for continuing education. </div> <div> </div> <div>It runs the gamut of topics and people: Housekeepers, most recently, were given an in-service training on hygiene for the residents, Nothstine says. </div> <div> </div> <div>Once per year, select employees are sent out of town for lengthy seminars. There were some concerns the first year because the site didn’t have television sets in every room, “but it was all we could afford,” Goins says (<em>see </em><a href="/Monthly-Issue/2013/Pages/0713/Paying-For-It.aspx"><em>Paying For It</em></a>).</div> <div> </div> <div>“It sends a message to the staff, who love to get out of the building, that education is important and we’ll find a way to get it into the budget,” Nothstine says. “Because it matters.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Staff Respond To Training With Enthusiam</h2> <div>Lutheran Services Certified Nurse Assistant Gail House has been with the company for 26 years and has been to at least four of the training seminars. She recalls vividly a discussion on making bath-time more pleasant for residents. She was initially surprised to hear about towel-warming cabinets, lavender scents, and soothing music.</div> <div> </div> <div>“I hadn’t thought about it myself,” she says, “but I wish I had. It’s creating a spa-like atmosphere. Who doesn’t like to go to a spa?” </div> <div><br></div> <div>Meanwhile, House is a regular attendee at staff meetings, where employees aren’t just asked, but encouraged, to speak up about problems they’re seeing. <br><br></div> <div>“It really has worked,” House says. “I can’t see working anywhere else.”</div> <div> <img width="245" height="243" class="ms-rteImage-2 ms-rtePosition-1" alt="Ted Goins, Trinity resident" src="/Monthly-Issue/2013/PublishingImages/0713/TedGoins.jpg" style="margin:20px 5px;" /><br>Apparently, others agree. According to Lutheran Service’s numbers, the company’s turnover rate is barely above 29 percent, significantly below the national average for long term care. </div> <div> </div> <div>In a recent survey, 91 percent of the company’s employees said they were satisfied in their jobs. Lutheran Services’ resident satisfaction surveys are even better: 96 percent of residents and families agreed, or strongly agreed, that they were satisfied with their community, and 93 percent would recommend, or strongly recommend, the experience to others.</div> <h2 class="ms-rteElement-H2">‘University’ To Launch</h2> <div>Not satisfied with the quarterly seminars, Lutheran Services is now going digital. By September, the company hopes to launch what it is calling its “University,” Nothstine says. </div> <div> </div> <div>“It’s going to be an online, kind of one-stop shop for our staff members. It’ll be a place where they can log in and go,” she says. “They’ll have links to our online learning programs. We’ll also have an education calendar, things companywide like medication training or CPR training. What I think is interesting and fun about this setting is we can put links to outside training materials, for our lifts, for our incontinence supplies—any kind of training.” </div> <div> </div> <div>Goins himself was skeptical about the off-site training. “You know, penny-wise and pound-foolish,” he says. </div> <div> </div> <div>Because the plain fact is, Goins says, the more staff believed that they were key to effective care, the more they invested themselves personally in resident care; that, in turn, made it easier for Lutheran Services to invest in technology and training more efficiently, to make the employees’ jobs easier. That made it easier for the company to rack up rewards and recognition and get flexibility from regulators. Wash, rinse, repeat. <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">A Case In Point</h2> <div>Take a small example. Goins, like Nothstine, was a reluctant technocrat and wasn’t thrilled to hear about electronic records. “Because I remember the days when I said, ‘We don’t do technology. We take care of people,’” Goins says. Remembering the sapient maintenance man, Goins swallowed his misgivings and gave the gadgets a go. </div> <div> </div> <div>As has happened so often in the past decade, Goins says, he was thrilled to be wrong. </div> <div> </div> <div>“The [certified nurse assistants] can actually make that thing sing on the walls,” he says of the electronic records system. “If they document it in real time, they’re more likely to get it right. And it’s in a useable format. We are completely paperless in our medical records. The quality of care is better because we know what’s happening with that resident in real time, but also we’re making sure we’re getting paid right.”</div> <div> </div> <div>And, in melancholy retrospect, Goins says he wishes he’d jumped on electronic records sooner. </div> <div> </div> <div>“I remember the last 30 minutes of every shift that I worked as a nursing assistant, and it was just going over those huge notebooks about the residents,” he recalls. “It took so much time away from patient care. Plus, I’m not sure that everybody—including me—was as diligent about making sure they were putting information in the book. So you weren’t getting good information, and you were wasting a lot of time to get it.”<br></div> <div><br><img width="296" height="224" class="ms-rtePosition-2" alt="Lutheran IT" src="/Monthly-Issue/2013/PublishingImages/0713/LutheranIT.jpg" style="margin:5px;" />So, even as the scenery seems to be collapsing around long term care, how does a provider recommit to quality? </div> <div> </div> <div>“For once, I feel like I have an answer to that,” he says. “And the answer is, get a mentor or a coach right away.”</div> <div> </div> <div>A great mentor can be found keynoting a convention or cleaning the rooms in your building, Goins says. </div> <div> </div> <div>“We can all change,” Goins says. “It’s all learnable. You have to start with that mission and then bring people aboard who can support that.” </div> ​Employees at one of Lutheran’s homes found themselves flummoxed by how often residents were falling down. True to the principles of person-centered care, all the building’s workers were invited to a brainstorming session. 2013-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0713/coverstory_thumb.jpg" style="BORDER:0px solid;" />QualityCover Story7
New Reality: Data Trumps Allhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0713/New-Reality-Data-Trumps-All.aspxNew Reality: Data Trumps All<p>The majority of Shea’s volume is governed by a handful of contracts. The company has learned that it must have the information across the continuum—and both clinical and financial—in order to play ball.<br>The top outcomes measured are:</p> <ul><li>Five-Star data from the Centers for Medicare & Medicaid Services;</li> <li>Return-to-hospital rates of 10 percent or lower;</li> <li>Mortality rates;</li> <li>Lengths of stay;</li> <li>Number of appeals; and</li> <li>Ability to say yes to 95 percent of admissions in 15 minutes or less.</li></ul> <p>If the company falls outside of ranges for certain metrics, there are financial penalties, including a contract becoming null and void. Otherwise, they’ll go elsewhere. </p> <p>Demonstrating and measuring performance and outcomes is essential.</p>Column7

August




 

 

Arts And Imageryhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Arts-And-Imagery.aspxArts And Imagery<div><img src="/Monthly-Issue/2013/PublishingImages/0813/caregiving1.jpg" class="ms-rtePosition-2" width="276" height="206" alt="" style="margin:5px;" />Research has shown that interventions designed to provide a wide variety of stimuli can have a significant and positive impact on individuals with Alzheimer’s disease and other cognitive impairments. Additional research also supports multimodal approaches as being the most beneficial in both cognitive and social enhancement.</div> <div> </div> <div>One multimodal intervention, known as Therapeutic Thematic Arts Programming for Older Adults Method (TTAP Method), is an art/recreation group therapy process that engages creative recreation activity within a nine-step structure. The TTAP Method has been shown, in some cases, to inhibit and slow the progression of mild cognitive impairment and Alzheimer’s disease. It has also been shown to slow the deterioration process of those already diagnosed with Alzheimer’s disease. </div> <div> </div> <div>The TTAP Method has been researched in more than 11 studies in the United States, while further research out of Finland also supports it. <br></div> <h2 class="ms-rteElement-H2">Meeting Social Needs</h2> <div>The use of thematic approaches maximizes interaction among participants of all cultures, stimulates all aspects of brain functioning, addresses social and emotional needs, and integrates opportunities for life review. </div> <div> </div> <div>The TTAP Method provides the early intervention needed to assist older adults in retaining cognitive and psychosocial abilities, as well as a proven approach to enhancing engagement in community centers, assisted living communities, and long term care centers. </div> <div> </div> <div>In 2010, a pilot study of 18 patients on a geropsychiatric/dementia unit showed that when all staff were trained to use a thematic approach to conversation activities and activities of daily living, the unit saved $160,000 in nursing supervisory costs. <br></div> <h2 class="ms-rteElement-H2">How A Thematic Approach Is Used </h2> <div>Research into the brain is unlocking the understanding of how important the use of positive, rich language through recall and reminiscence really is to overall brain wellness. It is also known that long-term memory stays with people much longer than short-term memory, whether someone suffers from cognitive decline or not. </div> <div> </div> <div>The TTAP Method’s nine-step intervention directs the focus of therapy on helping cognition and the reinforcement and utilization of remaining strengths, such as accessing long-term memory or controlling motor coordination. </div> <div> </div> <div>The innovative approach of the TTAP Method instructs caregivers, health care professionals, and family members how to tap into this memory using themes of people’s lives, such as holidays, family traditions, vacations, and the seasons, to guide conversations and activities that are both positive and meaningful. </div> <div> </div> <div>The difference with this innovative approach is that all of the individuals surrounding the person diagnosed with Alzheimer’s may interact in concert, thus supporting and reinforcing conversations, memories, and activities during the sessions.</div> <div> </div> <div><span><img class="ms-rtePosition-1" alt="TTAP method" src="/Monthly-Issue/2013/PublishingImages/0813/caregiving_TTAP.gif" style="margin:5px 10px;" /></span>The TTAP Method utilizes all the creative arts in its nine steps, and sessions are structured in sequential order: group discussion, music/guided imagery, drawing/painting, sculpture, movement, poetry, food, photography, and a themed event (<em>see Table 1, left</em>). By utilizing the nine steps, the caregiver or therapist is facilitated in developing personalized programming. </div><br> <div>The second step is the most significant in assisting participants to identify their own personal needs. Step two brings music, body relaxation, and meditation into the session, allowing for a moment of introspection.</div> <div> </div> <div>Meditation has been linked to an increased likelihood of a later experience of “flow” in that it allows increased levels of concentration in the experience and a loss in awareness of the external environment. <br></div> <h2 class="ms-rteElement-H2">Brain Function Stimulated</h2> <div>Previous research on brain plasticity, neural regeneration, and the phenomena of cognitive reserve demonstrates that positive changes in neural activity can be activated by visual, auditory, and sensory stimulation. During the TTAP Method program, participants are provided with these types of stimulation, as well as stimulation to three distinct brain systems: the affective system, the strategic system, and the recognition system.</div> <div> </div> <div><span><img src="/Monthly-Issue/2013/PublishingImages/0813/caregiving2.jpg" class="ms-rtePosition-1" width="276" height="207" alt="" style="margin:5px;" /></span>Brain research now indicates that the brain can change in mass and density through increased stimulation in these three areas.</div> <div> </div> <div>The use of multiple forms of interaction is essential to the TTAP Method. Blooms’ Taxonomy of Learning is incorporated into the approach, and each of the nine steps is designed to stimulate the visual, musical, linguistic, interpersonal, intrapersonal, kinesthetic, and spatial learner responses in participants. </div> <div> </div> <div>Enhancing social interaction by stimulating all types of learners ensures a higher likelihood of full participation from each participant within the group experience and has a protective effect on the hippocampus, decreasing the likelihood that individuals with Alzheimer’s disease will show signs of further decline in language abilities and short-term memory.</div> <div> </div> <div>The integration of various artistic activities elicits an integration of higher cortical thinking, such as planning, attentiveness, problem solving, and emotional investment, in both the topic of discussion and in goal accomplishment. It thereby promotes faster cognitive and emotional processing and facilitates learning and memory. </div> <div> </div> <div>Guided imagery synchronized with music is one of the most unique and significant steps in the methodology, in that it allows the individual to access positive long-term memory.    </div> <h2 class="ms-rteElement-H2">Maximizing Interaction</h2> <div>Communication, in all forms, is a crucial aspect of social support, as it serves in “maintaining or retaining feelings of connectedness to one’s self and to the larger community of peers, friends, and family,” according to Linda Levine Madori, PhD, in her new book, “Transcending Dementia Through the TTAP Method: A New Psychology of Art, Brain, and Cognition.” </div> <div> </div> <div>The TTAP Method employs dynamic interaction by incorporating avenues for both nonverbal and verbal communication in a group context, which has been shown to regulate functions within the cerebral cortex, promoting brain wellness and skill retention among older adults. </div> <div> </div> <div>As a result of the nine-step structure, the TTAP Method naturally increases the total time a participant spends in programming by exposing the participant to longer levels of increased stimulation. <br></div> <h2 class="ms-rteElement-H2">Addressing Emotional Needs</h2> <div>Recent research suggests that when social and emotional needs are addressed, feelings of self-worth, self-esteem, mood, and overall quality of life are enhanced. The TTAP Method, in its thematic orientation, structures sessions in order to meet the specific needs of persons with Alzheimer’s, which includes the exploration of feelings of hope, love, grief, and sorrow, as well as fortitude.</div> <div> </div> <div>Cognitive difficulties, specifically short-term memory loss, are a defining feature of Alzheimer’s and are one of the central problems experienced on a daily basis. For an individual with early-stage Alzheimer’s, memory loss can have a major impact on daily living skills, which impedes self-confidence and can lead to anxiety, depression, and withdrawal from activities and other social involvements.</div> <div> </div> <div>Social withdrawal can result in a general increase in symptoms, including enhanced memory loss.</div> <div> </div> <div>This increase in symptoms beyond those attributable to the disease process is an example of what has been termed “excess disability.” TTAP, through its person-centered approach, naturally enhances feelings of self-worth, which has a direct correlation to motivation levels directed at creating enhanced social support systems, thus decreasing the likelihood of withdrawal among participants.</div> <div> </div> <div>Depression, coupled with feelings of hopelessness, can have a detrimental impact on cognitive functioning. Emotions directly affect cognition and, therefore, subsequent motor coordination, memory, self-esteem, and the perception of one’s own health. Cognitive evaluation tests show that cognitive performance is significantly impaired during depressive states, and 15 to 30 percent of individuals with Alzheimer’s disease have clinically significant levels of depression symptoms. </div> <div> </div> <div>Successful depression treatment, through the use of multimodal interventions such as the TTAP Method, has been correlated with significant alleviation of cognitive impairments and, therefore, an overall improvement in independent functioning.<em><br><br></em><em><img class="ms-rteImage-1 ms-rtePosition-1" alt="Linda Levine Madori" src="/Monthly-Issue/2013/PublishingImages/0813/caregiving_thumb.jpg" width="113" height="113" style="margin:5px;" />Linda Levine Madori, PhD, author of “Transcending Dementia Through TTAP: A New Psychology of Art, Brain, and Cognition (The TTAP Method),” is credentialed in both Therapeutic Recreation and New York state licensing in Creative Arts Therapy. Levine Madori has worked for the past 15 years at St. Thomas Aquinas College. Her dissertation research in Alzheimer’s disease, cognitive functioning, and psychosocial well-being is the basis for “Therapeutic Thematic Arts Programming for the Older Population (TTAP Method).” For more information, go to <a title="TTAP Method" target="_blank" href="http://www.ttapmethod.com/">www.TTAPMethod.com</a>. </em></div>Research has shown that interventions designed to provide a wide variety of stimuli can have a significant and positive impact on individuals with Alzheimer’s disease and other cognitive impairments. 2013-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0813/caregiving_thumb.jpg" style="BORDER:0px solid;" />Caregiving;Clinical;ManagementSpecial Feature8
Institute Centers On Person-Centered Carehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Institute-Centers-On-Person-Centered-Care.aspxInstitute Centers On Person-Centered Care<div>It is the fear of everyone who has parents or grandparents who might need special care as they approach old age: What if they are not able to remain active and involved? And as a result of their condition, what if they are not treated with dignity and respect? </div> <div> </div> <div>Person-centered care (PCC) began in response to precisely this situation in nursing homes, as a way to approach residents—particularly those with dementia—who might be disengaged and prone to react with fear or aggression to caregivers.</div> <div> </div> <div>Dementia care costs are projected to double by 2040, and new research from the RAND Corp., published in the New England Journal of Medicine, shows that with the aging baby boom generation, the country is unprepared for the coming surge in the cost and cases of dementia. By 2040 there will be an estimated 9.1 million people with dementia, compared with 3.8 million who currently have the diagnosis. This staggering number will cost billions in health care dollars as there will be fewer children to be informal caregivers for them. <br></div> <h2 class="ms-rteElement-H2">First Of Its Kind</h2> <div>Providers will need to be more educated in this specialist area, whether dementia care is provided in the community by a service entity, family member, friend, or in communal living. </div> <div> </div> <div>The University of Buffalo’s (UB’s) <a href="/Monthly-Issue/2013/Pages/0813/Institute-Objectives.aspx" target="_blank">Institute for Person-Centered Care</a>, working to further enhance this new method of caregiving through research and scholarship, is the first of its kind in the United States. </div> <div> </div> <div>The institute takes a collaborative, interdisciplinary approach, bringing together researchers, educators, health care providers, and community-based programs to develop new care and services and share them with the public. </div> <div> </div> <div>The institute began with interactions between UB and the Western New York Alliance for Person-Centered Care (WNYAPCC), a grassroots collaborative of skilled nursing and assisted living providers funded by the Oishei Foundation. Researchers as far away as the United Kingdom and Australia also contribute to the project. <br></div> <h2 class="ms-rteElement-H2">PCC Measures To Be Tested</h2> <div>According to Davina Porock, PhD, who directs both the institute and UB’s Center for Nursing Research, “[Person-centered care] differs from standard care of elders in that it does not just focus on illness and medical treatment and decision making. PCC considers the whole experience of everyday life, retaining a sense of self with meaningful interactions and purpose. … Delivering PCC is not only about providing high-quality physical care, but also ensuring that the emotional and psychological needs are met, particularly for the person who is unable to satisfy these needs independently.”</div> <div> </div> <div>Since this is an emerging field in health care, research is focused on defining and measuring its techniques and outcomes, a task that Porock is excited to lead. </div> <div> </div> <div>She writes, “Since there is little more than anecdotal evidence of outcomes and no strong theoretical understanding of how these techniques work, it is difficult to explain how to apply PCC into practice. Thus, our research focuses on these issues. So far, we have developed questionnaires from resident, staff, and family perspectives to measure dose of PCC, such as how much PCC is actually happening in a long term care facility. We used standard data collected in all long term care facilities to determine which resident outcomes might be sensitive to a PCC intervention,” she says, adding that some of that research was recently presented in a scholarly paper. </div> <div> </div> <div>An upcoming study this summer at two assisted living residences will further test PCC measures and procedures, with the hope, writes Porock, that this research will “explain the underlying mechanism for the positive outcomes of PCC approaches.” <br></div> <h2 class="ms-rteElement-H2">Partnerships Within The University</h2> <div>A university-wide initiative, the Institute for Person-Centered Care (IPCC) is housed in the UB School of Nursing, but partners as well with the Law School, Geography Department, School of Social Work, and all the health science schools, according to Porock. </div> <div> </div> <div>She adds, “We hold our trainings and outreach in the community at various long term care facilities throughout western New York and in various venues across the country.” The IPCC education and training mission is managed by Rhonda Rotterman, RN, who is board certified in gerontology and a licensed nursing home administrator with 25 years of experience with the geriatric population. </div> <div> </div> <div>Rotterman previously served for three years as the executive director of WNYAPCC.</div> <div> </div> <div>“I am excited about the opportunity to develop courses on person-centered care at UB and help develop the evidence base that supports what we already know is the right thing to do,” Rotterman says.</div> <div> </div> <div>“If we are to provide quality care and services to vulnerable individuals, it is paramount that we create a culture of ‘positive aging’ that focuses on how individuals can maintain autonomy and a sense of self-worth and purpose, despite physical or cognitive impairment. If we are healers, then taking care of the whole human being should be central to what we do, not just one facet of it. These issues will affect every one of us and those we love.”</div> <h2 class="ms-rteElement-H2">Research, Training, Support</h2> <div>With its partners both inside the university and beyond, the institute looks forward to heightening awareness and refining the techniques and outcomes of PCC for all stakeholders across the entire health care continuum, wherever services are rendered. </div> <div> </div> <div>The IPCC research program will work to develop evidence-based strategies of care based on and supported by scholarly research in the field. It will focus on education at the undergraduate and graduate levels, with the goal of eventually building PCC interdisciplinary programs of study in aging and gerontology. </div> <div> </div> <div>It also will provide training and specialist topics for staff in elder-care facilities, hospitals, community-based groups providing health care services, and the public.</div> <div> </div> <div>In addition, the IPCC will provide leadership training and practice development, as well as encouraging better delivery of services to frail and vulnerable people, and support for advocacy and public awareness efforts. </div> <div> </div> <div><em><strong>Davina Porock, PhD,</strong> professor and associate dean for research and scholarship, is executive director of the UB Institute for Person-Centered Care and director of the Center for Nursing Research at the University at Buffalo School of Nursing, Buffalo, N.Y. Porock can be reached at (716) 829-2260 or </em><a href="mailto:dporock@buffalo.edu" target="_blank">dporock@buffalo.edu.</a></div>Dementia care costs are projected to double by 2040, and new research from the RAND Corp., published in the New England Journal of Medicine, shows that with the aging baby boom generation, the country is unprepared for the coming surge in the cost and cases of dementia. By 2040 there will be an estimated 9.1 million people with dementia, compared with 3.8 million who currently have the diagnosis. This staggering number will cost billions in health care dollars as there will be fewer children to be informal caregivers for them. 2013-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0813/feature_thumb.jpg" style="BORDER:0px solid;" />Workforce;ManagementColumn8
The QIS Expert: Can QIS Methods Help Providers Comply With QAPI’s Performance Improvement Reg?https://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Can-QIS-Methods-Help-Providers-Comply_4.aspxThe QIS Expert: Can QIS Methods Help Providers Comply With QAPI’s Performance Improvement Reg?This is the fourth column in the series of five addressing how QIS methods can be used in a QAPI system, by showing the parallels between QIS methods and the Five Elements of QAPI. (See <a target="_blank" href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf">www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf.</a>)<br><br>By breaking down Element 4: Performance Improvement Projects (PIPs), the parallels between QAPI and the QIS process are clearly apparent. <br><br>The Centers for Medicare & Medicaid Services (CMS) calls a PIP “a concentrated effort on a particular problem in one area of the facility or facilitywide; it involves gathering information systematically to clarify issues or problems and intervening for improvements.”<br><br>Recognizing that the QIS was designed for surveyors to determine compliance with regulations rather than intervene to improve performance, conducting a PIP is not, per se, a part of QIS. However, when providers use QIS methods for QAPI, the tools available in stage 2 of QIS can be applied to “gathering information systematically to clarify issues or problems.” In fact, QIS is designed in two stages in order to concentrate effort on a particular problem.<br><br>Providers can use stage 1 of QIS to identify a problem area and then concentrate their efforts in stage 2 on clarifying the issues for that problem. The stage 2 protocols can be used as an adjunct in the process of root cause analysis, an essential step in PIPs, to complement other tools that examine care and service delivery systems.<br><br>Sometimes, with the combined stage 1 and stage 2 information, “intervening for improvements” is apparent to staff. But for the most part, a PIP carries the QIS process a step further with respect to determining and executing an intervention, with subsequent evaluation for measured improvement. <br><br>Element 4 is based on the premise that problems generally result from system breakdowns. Interventions, therefore, need to address how to change the system so it is not susceptible to failures. This is why PIPs are not universal; rather they are targeted to concerns in a specific organization and for specific services.<br><br>As CMS says about Element 4, “The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention,” areas that will vary “depending on the type of facility and the unique scope of services they provide.”<br><br>For this reason, stage 1 of the QIS process is an ideal starting point for identifying which quality issue to concentrate on and then start gathering data on it. The Quality of Care and Life Indicators (QCLIs), which are rigorously defined in QIS based on resident, family, and staff interviews, as well as observations and chart reviews for both short- and long-term residents, enable staff to identify “care or services in areas…needing attention.” Based on stage 1, areas can be prioritized for PIPs.<br><br>Thus, when used by facilities for QAPI, QIS processes provide a solid basis for Element 4, requiring expansion with respect to development of interventions, measuring results, and implementing improvements facilitywide.<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>By breaking down Element 4: Performance Improvement Projects (PIPs), the parallels between QAPI and the QIS process are clearly apparent. 2013-08-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/headshots/AndyKramer.jpg" style="BORDER:0px solid;" />Policy;Management;Survey and CertificationColumn8
Learn While You Workhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Learn-While-You-Work.aspxLearn While You Work<div>Through the years, skilled nursing center providers have grappled with the impact that shifting demographics and significant changes in health care delivery systems have had on staffing needs. According to the American Health Care Association, more than 50 percent of all Medicare beneficiaries who need post-acute care are admitted to one of the nearly 16,000 skilled nursing centers nationwide. </div> <div> </div> <div><img width="296" height="345" class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0813/HR_000015636897.jpg" alt="" style="margin:5px;" />On average, these individuals require a short rehabilitative stay of approximately 27 days before returning back into the community. Although today’s short-stay patients typically exhibit a higher level of acuity than that of “traditional” nursing home residents, recruiting the most qualified nursing staff into the skilled nursing environment can be challenging.</div> <h2 class="ms-rteElement-H2">Education Units Offer New Model </h2> <div>There are multiple reasons why registered nurses (RNs) gravitate toward working in an acute-care setting. In baccalaureate nursing education, gerontological nursing content about—and clinical practicum placements in—long term care have been minimal or relegated too often to a fundamentals entry-level nursing course. For a beginning baccalaureate nursing student, who may harbor less than favorable attitudes toward aging and older adults, this exposure can be misinterpreted as the typical experience for all older adults. </div> <div> </div> <div>Furthermore, students may be ill-equipped in an introductory course to appreciate the high-level nursing expertise necessary to fully address the needs for this population.</div> <div> </div> <div>What if today’s dynamic skilled nursing and rehabilitation center could have a more direct role in the education of new nurses? Would nurses in their formative training be more apt to choose a career in long term care? </div> <div> </div> <div>One answer to these questions may lie in the Dedicated Education Unit (DEU), an innovative clinical education model that provides meaningful academic experiences for students and promotes the development of select staff nurses in skilled nursing settings to serve as clinical teachers, while delivering high-quality care to patients. <br></div> <h2 class="ms-rteElement-H2">Partnership Improves Care</h2> <div>A DEU in Lowell, Mass., is the result of a successful academic-practice partnership between the University of Massachusetts Lowell School of Nursing and D’Youville Life and Wellness Community. </div> <div> </div> <div>Established with funding received from the Massachusetts Department of Higher Education, the DEU at D’Youville’s Center for Advanced Therapy operates within the skilled nursing setting and utilizes existing skilled nursing staff as clinical faculty. </div> <div> </div> <div>The nursing students work closely with their clinical preceptor, gaining direct exposure to, and a deep understanding of, the multiple challenges facing patients and staff in this setting. </div> <div> </div> <div>The designated university faculty member provides ongoing support and regular contact for the skilled nursing clinical preceptors to foster their teaching role with the assigned students.</div> <div> </div> <div>This model differs significantly from the typical clinical rotation site contract between an educational institution and a skilled nursing center. The typical model often includes one faculty to a group of six to eight students. <br></div> <h2 class="ms-rteElement-H2">Immersion Offers Rewards</h2> <div>In the DEU model, select center nursing staff members become an extension of the college or university. While they are working their usual shift and patient assignments, each center staff member also acts as preceptor to a nursing student in his or her third year of training. </div> <div> </div> <div>By working side by side, the nursing student gains unique insights, while the staff preceptor enhances her own credibility and confidence as a clinician. </div> <div> </div> <div>The presence of a DEU results in additional benefits to the skilled nursing center. The training of the center’s preceptors requires an ongoing direct relationship between center staff and the college/university faculty. </div> <div> </div> <div>As many experienced nursing home nurses do not have a baccalaureate degree themselves, this may be their first personal exposure to higher education and the catalyst for their own professional advancement. Preceptors have the opportunity to “train the trainer,” imparting the essence of their hands-on knowledge to the university faculty who may not have recent geriatric experience themselves. </div> <div> </div> <div>Also, the formal partnership between a skilled nursing center and an accredited college/university is a key element that can positively differentiate the center in the local marketplace. </div> <div> </div> <div>The process for establishing a DEU partnership includes considerable planning and coordination. Using this <a title="Academic Practice Partnerships Tool Kit" href="/Monthly-Issue/2013/Pages/0813/Academic-Practice-Partnerships-Tool-Kit.aspx" target="_blank">toolkit</a> as a guide can be helpful to academic and practice partners that wish to embark on such an endeavor. </div> <div> </div> <div>The positive rewards are well worth the effort. Nursing students whose formal education includes immersion in a geriatric-oriented rehabilitative unit could ultimately represent the future of the profession by improving quality of care and enhancing patient outcomes.</div> <div> </div> <div><strong>Long Term Care Dedicated Education Unit:</strong></div> <ul><li><em>Karen Devereaux Melillo, Ph.D., ANP-C, FAANP, FGSA, University of Massachusetts Lowell </em></li> <li><em>Lisa Abdallah, Ph.D., RN, CNE, University of Massachusetts Lowell </em></li> <li><em>Juliette M. Shellman, Ph.D, PHCNS-BC, University of Connecticut</em></li> <li><em>Ruth Remington, Ph.D, APRN-BC, Framingham State University</em></li> <li><em>Lea Dodge, MS, RN, University of Massachusetts Lowell </em></li> <li><em>Jacqueline Dowling, Ph.D., RN, CNE, University of Massachusetts Lowell  </em></li> <li><em>Stephanie R. Lane, MSW, Project Administrator, University of Massachusetts Lowell </em></li> <li><em>Naomi Prendergast, CEO/President of D’Youville Life and Wellness Community  </em></li> <li><em>Cynthia Thornton, Director, CAT, D’Youville Transitional Care Unit </em></li> <li><em>Andrea Rathbone, Administrator, D’Youville Senior Care</em></li></ul> There are multiple reasons why registered nurses (RNs) gravitate toward working in an acute-care setting. In baccalaureate nursing education, gerontological nursing content about—and clinical practicum placements in—long term care have been minimal or relegated too often to a fundamentals entry-level nursing course. For a beginning baccalaureate nursing student, who may harbor less than favorable attitudes toward aging and older adults, this exposure can be misinterpreted as the typical experience for all older adults. 2013-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0813/HR_thumb.jpg" style="BORDER:0px solid;" />Workforce;ManagementColumn8
Nurse Training Program Boosts Qualityhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Nurse-Training-Program-Boosts-Quality.aspxNurse Training Program Boosts Quality<div>Administrators are caught between a rock and a hard place. Among the rubs are reimbursement rate reductions of up to 15 percent, constant pressure to reduce hospital admissions, new battles to attract and retain core nursing staff in a shallow pool of nurses, and possible further cutbacks in Medicare and Medicaid payments, just to name a few. </div> <div> </div> <div> </div> <div> </div> <div>Like many since the 2008 economic crash, facility administrators have no choice. They must do more with less. </div> <div> </div> <div> </div> <div> </div> <div>At risk is care quality, which triggers a domino chain. Less quality equals less satisfaction. Eventually, this means fewer patients; fewer residents; and fewer referrals from hospitals, families, and from happy clients. </div> <div> </div> <div> </div> <div> </div> <div>At issue is prosperity—a survival of the fittest—in a rapidly changing, super-competitive, viselike </div> <div> </div> <div>marketplace. <br></div> <div> </div> <h2 class="ms-rteElement-H2">What’s A Provider To Do?</h2> <div> </div> <div>In tough economic times, three administrators—in Alaska, Massachusetts, and Nebraska—took a counterintuitive approach. They spent money on registered nurse (RN) training. They enrolled their nurses in a <a href="/Monthly-Issue/2013/Pages/0813/The-Program.aspx">unique gerontological certification course</a> based at the University of Nebraska Medical Center.</div> <div> </div> <div> </div> <div> </div> <div><img class="ms-rtePosition-1" alt="Bill Bogdanovich" src="/Monthly-Issue/2013/PublishingImages/0813/Bogdanovich.jpg" width="128" height="130" style="margin:5px 10px;" />Among facility operators who became involved in the course—known as Gero Nurse Prep (GNP)—early were Alaska’s Charlie Franz, Massachusetts’ Bill Bogdanovich, and Nebraska’s Roger Biens. What intrigued them? That higher-care quality also fosters lower costs.</div> <div> </div> <div> </div> <div> </div> <div>GNP was born with one purpose: improve quality in long term and post-acute care centers. It was created by the University of Nebraska Medical Center (UNMC) College of Nursing. </div> <div> </div> <div> </div> <div> </div> <div>“RN degree programs historically gave little attention to geriatric nursing,” says Catherine Bevil, RN, EdD, director of continuing nursing education at UNMC. “While that’s changing as the biggest generation in U.S. history ages, the fact remains that most RNs today—about two-thirds—have zero geriatric training.”</div> <div> </div> <div> </div> <div> </div> <div>GNP, she said, is solely focused on current, evidence-based clinical nursing skills for seniors. “The nursing profession has always been about health promotion, disease prevention, and symptom management. We take that to a new level for geriatrics. It’s niche nursing for long term and post-acute care.”</div> <div> </div> <div> </div> <div> </div> <div>Advanced geriatric knowledge and skills, says Bevil, mean measurably better care. Ten interactive learning modules train RNs to:</div> <div> </div> <div> </div> <div> </div> <div>■ Manage physical and mental aspects of aging;</div> <div> </div> <div>■ Quickly recognize symptoms, changes, and problems;</div> <div> </div> <div>■ Keep physicians, administrators, and the nursing team well informed; and </div> <div> </div> <div>■ Be attentive and compassionate in talking to residents and their families. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Training Promotes Patient-Centered Care</h2> <div> </div> <div>“Many seniors say they feel invisible,” says Bevil. “This course puts them front and center.”</div> <div> </div> <div> </div> <div> </div> <div>The learning program emphasizes prevention of adverse events, especially those with potential for lingering, time-intensive, and costly consequences. </div> <div> </div> <div> </div> <div> </div> <div>For example, falls, medication errors, and pressure ulcers are serious health risks for seniors in long term and post-acute care. “Proper nursing practice cuts risk substantially,” Bevil says. “In geriatric nursing especially, an ounce of prevention is better than a pound of cure—but RNs need sharper awareness and preemptive action steps.”</div> <div> </div> <div> </div> <div> </div> <div><img class="ms-rtePosition-1" alt="Catherine Bevil, RN, EdD" src="/Monthly-Issue/2013/PublishingImages/0813/Catherine.jpg" width="161" height="226" style="margin:5px 10px;" />Higher-quality care yields other benefits, she explains. It means happier residents and families, and that means happier nurses. Not only do RNs feel more competent, confident, and empowered, they also get more positive feedback and recognition, she says.</div> <div> </div> <div> </div> <div> </div> <div>That in turn feeds staff stability, with lower RN churn, which means fewer temp nurses, less recruiting time and expense, less new staff orientation, and less disruption of nursing care teams, Bevil says.</div> <div> </div> <div> </div> <div> </div> <div>GNP prepares RNs to pass the certification exam in gerontological nursing administered by the American Nurses Credentialing Center. To date, GNP alums have a 98 percent pass rate.</div> <div> </div> <div> </div> <div> </div> <div>As with physicians, “board-certified” is the gold standard of quality. “Only 1 percent of RNs are now certified in gerontological nursing, so providers with board-certified nursing staff really set themselves apart,” says Bevil. “That pays dividends in both patient and nurse recruiting and retention.” <br><br></div> <div> </div> <h2 class="ms-rteElement-H2">Training Earns Respect</h2> <div> </div> <div><a href="/Monthly-Issue/2013/Pages/0813/Gero-Prep-Nurse-Congrats.aspx" title="New graduates" target="_blank">Course alums</a> report that having RN-BC on their name badge earns them new respect. “Physicians look at me differently now,” says Maggie Spilker, RN-BC, with Heritage Care Center in Fairbury, Neb.<span><span><img class="ms-rtePosition-2" alt="Roger Biens" src="/Monthly-Issue/2013/PublishingImages/0813/Biens.jpg" width="143" height="178" style="margin:5px 10px;" /></span></span></div> <div> </div> <div> </div> <div> </div> <div>Roger Biens, administrator at Brookstone Meadows, Elkhorn, Neb., has a unique perspective, first serving as RN and director of nursing. Among the first GNP alums, he was promoted to administrator after becoming certified. Brookstone is part of Vetter Health Services, with more than 30 centers in five states and a systemwide GNP adopter.<span></span></div> <div> </div> <div> </div> <div> </div> <div>His 140-bed skilled nursing center depends on hospital referrals for about half of its occupancy. Referrals hinge on a 30-day rehospitalization rate, Biens notes. “We have to invest in the best RNs. We can’t afford not to.” <br></div> <h2 class="ms-rteElement-H2"> Nurses Step Up </h2> <div>For Charlie Franz, administrator at Heritage Place, Soldotna, Alaska, eight of 11 RNs completed the course and were certified on their first try. </div> <div> </div> <div> </div> <div> </div> <div><span><span><img class="ms-rtePosition-1" alt="Charlie Franz" src="/Monthly-Issue/2013/PublishingImages/0813/FranzCharlie.jpg" width="130" height="175" style="margin:5px 10px;" /></span></span>“In our [partner] hospital, there is a lot of emphasis on physician certification,” says Franz, “so we put emphasis on nursing certification. It was voluntary, they stepped up and did it, and I think they walk a little taller and a lot prouder.”</div> <div> </div> <div> </div> <div> </div> <div>He notes that the course helped his RNs improve resident assessments, interpret lab results, and communicate better with licensed practical nurse and nurse assistant staff. “The feedback I get is how effective the RN staff are at explaining situations, diagnoses, behavioral issues, and complications,” he says.</div> <div> </div> <div> </div> <div> </div> <div>What’s more, since GNP, Franz has seen use of off-label antipsychotics drop to zero.</div> <div> </div> <h2 class="ms-rteElement-H2">Program Attracts, Retains Good RNs</h2> <div> </div> <div>As a teenager, Bill Bogdanovich’s first job was at a nursing home. He rose to become chief executive officer and owner of diversified Broad Reach Healthcare, in Chatham, Mass.—and in 2013 won the American College of Health Care Administrators’ Facility Leadership Award. </div> <div> </div> <div> </div> <div> </div> <div>He, too, invited his RN staff to enroll in GNP, and all accepted. To date, 13 earned certification on their first try. Two more RNs are slated to be certified in 2013, achieving Bogdanovich’s goal of 100 percent RN staff certification. </div> <div> </div> <div> </div> <div> </div> <div>“I now hear a different level of critical thinking,” he says. He sees RNs engage the entire nursing team. “I see them asking questions and answering them—together and in depth.”</div> <div> </div> <div> </div> <div> </div> <div>An unexpected benefit: “Our state surveyors were quite impressed that we supported our RNs in this way, that so many enrolled and did well.”</div> <div> </div> <div> </div> <div> </div> <div>Bogdanovich’s bottom line? GNP helps retain good RNs. “Less turnover—the right staff longevity—makes it possible to focus on doing things you want to do. Otherwise, you’re constantly hiring and orienting brand-new people.”</div> <div> </div> <div> </div> <div> </div> <div>Voicing the position of long term and post-acute care operators nationwide, Bogdanovich puts it succinctly: “Despite increasing demands and declining resources, administrators are challenged to do at least as much, if not more, to provide scope and level of service.”</div> <div> </div> <div> </div> <div> </div> <div>Separated by thousands of miles, Franz and Biens drew the same conclusion, and each used GNP to help meet the challenge.</div> <div> </div> <div> </div> <div> </div> <div>For AHCA/NCAL Gero Nurse Prep details, go to <a title="Visit for details." target="_blank" href="http://www.geronurseprep.org/">GeroNursePrep.org</a>. </div> <div> </div> <div> </div> <div> </div> <div><em>Heidi J. Keeler, PhD, RN, is assistant professor, Community Based Health Department, nurse planner, continuing nursing education, University of Nebraska Medical Center College of Nursing, Omaha, Neb. Keeler can be reached at (402) 559-4524 or <a title="Email Heidi!" target="_blank" href="mailto:hkeeler@unmc.edu">hkeeler@unmc.edu. </a></em></div> Administrators are caught between a rock and a hard place. Among the rubs are reimbursement rate reductions of up to 15 percent, constant pressure to reduce hospital admissions, new battles to attract and retain core nursing staff in a shallow pool of nurses, and possible further cutbacks in Medicare and Medicaid payments, just to name a few. 2013-08-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Management;Survey and Certification;WorkforceHuman Resources8
Pallone Ponders Future Of Long Term Carehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Pallone-Ponders-Future-Of-Long-Term-Care.aspxPallone Ponders Future Of Long Term Care<div><img width="180" height="180" class="ms-rtePosition-1" alt="Frank Pallone Jr., Democrat, New Jersey" src="/Monthly-Issue/2013/PublishingImages/0813/Pallone.jpg" style="margin:5px 15px;" /><br>After the better part of three decades in Congress, New Jersey Democrat Frank Pallone Jr. finds himself facing the longest odds in his career. He’s running for Senate and will likely take on Newark Mayor Corey Booker in the special primary, a national figure whose fame reaches near-celebrity. </div> <div> </div> <div>Win, lose, or draw, though, it won’t be Pallone’s last fight: The Senate primary is a special election to replace former Sen. Frank Lautenberg, who died in June at the age of 89. It means that Pallone will keep his congressional seat—representing part of Jersey’s shore—even if he loses the Senate race. </div> <div> </div> <div>Whatever one feels about Pallone’s politics—and he is an unapologetic liberal—his willingness to fight makes him one to watch in Washington, says Greg Crist, senior vice president of public affairs for the American Health Care Association.</div> <div> </div> <div>“He has always worked to bolster Medicaid’s financial stability and opposed any efforts to impede the ability of providers to offer high-quality health care,” Crist says. </div> <div> </div> <div>If Pallone seems feisty, he’s come by it honestly: Born the day before Halloween in 1951, Pallone was the son of a cop. He was born and raised (and still lives) in Long Branch, on the Jersey Shore. He has spent most of his grown life in politics, first as a city councilman, then as a state senator, and then, in 1988, as a member of Congress.</div> <div> </div> <div>He has spent most of his career fighting for environmental protections and for health care expansion and reform. He chaired the House Energy and Commerce’s Health Subcommittee, making him one of the point men on what has come to be known as Obamacare. </div> <div> </div> <div>But, while he wants more care and more coverage, Pallone says reform can’t just be about spending money. You have to spend money wisely, he says. </div> <div> </div> <div>“We have to face up to the reality that health care is expensive,” Pallone said in a recent interview with <em>Provider</em>. “You have to figure out a way to pay for it, and you have to pay for it while you’re young.”</div> <div> </div> <div>The problem, he says, is that few in Washington seem to want to face those realities. “There’s not a lot of seriousness about the issue,” he said, sipping a cup of tea. </div> <div> </div> <div>Pallone says he understands that long term care is part of the future. </div> <div> </div> <div>He’s not sure that others have caught on to that yet. </div> <div> </div> <div>“We continue to rely on Medicaid to pay for nursing home care,” he says, his mouth slightly downcast. “I don’t think the system is sustainable.”</div> <div> </div> <div>He says he appreciates how much long term care has “evolved” down through the years. </div> <div> </div> <div>“People aren’t just warehoused there anymore,” he says. “It’s not just about efficiency. What [providers] have done and have continued to do is to focus on quality.” </div> <div> </div> <div>That will pay dividends, Pallone says—if Washington leaders will meet the profession halfway. </div> <div> </div> <div>In any case, he says he’ll keep fighting to make it happen. </div> <div> </div> <div> </div> <div class="ms-rteElement-Callout1">■ Thirteen-term congressman, currently representing New </div> <div class="ms-rteElement-Callout1">Jersey’s Sixth District</div> <div class="ms-rteElement-Callout1">■ Born: Oct. 30, 1951, in Long Branch, N.J.</div> <div class="ms-rteElement-Callout1">■ Education: Middelbury College, BA, cum laude, 1973; Tufts University, MA, international relations, 1973; Rutgers University, JD, 1978</div> <div class="ms-rteElement-Callout1">■ Family: Wife, Sarah (nee Hospodor), three children—daughters Rose Marie and Celeste Teresa and son, Frank Andrew.</div> If Pallone seems feisty, he’s come by it honestly: Born the day before Halloween in 1951, Pallone was the son of a cop. He was born and raised (and still lives) in Long Branch, on the Jersey Shore. He has spent most of his grown life in politics, first as a city councilman, then as a state senator, and then, in 1988, as a member of Congress.2013-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0813/Pallone.jpg" style="BORDER:0px solid;" />ManagementColumn8
States Partner With Assisted Livinghttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/States-Partner-With-Assisted-Living.aspxStates Partner With Assisted Living<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><h3 class="ms-rteElement-H3B" style="font-size:18pt;text-align:center;"><div>“In God we trust. All others, bring data.” </div> <div>—W. Edwards Deming, <br>American statistician and professor</div></h3> <div> </div> <div> </div> <div> </div> <div>Across the country, the years of budget crunches have taken their toll on many state-funded programs, not least of which is states’ investment in ensuring assisted living facilities (ALFs) are living up to quality standards. </div> <div> </div> <div> </div> <div> </div> <div>While nursing facility inspections are subsidized by the federal government through the Centers for Medicare & Medicaid Services, surveys of ALFs are entirely the state’s responsibility.</div> <div> </div> <div> </div> <div> </div> <div><img class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0813/coverstory_thumb.jpg" alt="" style="margin:5px 15px;" />Wisconsin, for example, found itself presented last year with an ever-growing number of ALFs to inspect but without enough funding to hire the people to inspect them. </div> <div> </div> <div> </div> <div> </div> <div>New Jersey’s funding of health department inspections had decreased to a point where ALFs were going almost three years between surveys.</div> <div> </div> <div> </div> <div> </div> <div>The associations representing ALFs in those states were also concerned about the issue. </div> <div> </div> <div> </div> <div> </div> <div>“Our fear,” says Paul Langevin Jr., president of the Health Care Association of New Jersey (HCANJ), New Jersey’s association for ALFs as well as nursing facilities, “is that like all other human beings, some people who operate assisted living facilities might lose their focus” on quality without someone outside the facility coming in regularly to inspect it and ensure its compliance with state regulations. </div> <div> </div> <div> </div> <div> </div> <div>Without regular inspection, the quality of care that residents receive could slip. That’s unacceptable in and of itself. Such a situation could also result in complaints that generate public outrage and cause legislators to decide they must address the issue, resulting in the kinds of onerous regulations nursing facilities contend with, Langevin says. <br></div> <div> </div> <h2 class="ms-rteElement-H2">New Connections</h2> <div>In Wisconsin and New Jersey, these concerns brought state ALF associations and health departments together to forge a new path to ensuring quality.</div> <p></p> <div> </div> <div> </div> And not quality just good enough to pass the standard health department inspection, but good enough to meet higher benchmarks and inspire ALFs to reach for ever-improving quality. <div> </div> <div> </div> <div> </div> <div>These programs also are not satisfied with a nebulous idea of quality. They are designed to collect hard data to demonstrate an ALF’s quality.</div> <div> </div> <div> </div> <div> </div> <div>“What we were looking for in New Jersey is a reliable indicator of services being delivered that consumers could look at that was based on empirical data collected routinely,” says Langevin.</div> <div> </div> <div> </div> <div> </div> <div>With an eye on those trends and an awareness of the increasing involvement of managed care in assisted living, the National Center for Assisted Living (NCAL) will be collaborating with the New Jersey Hospital Association Institute for Quality and Patient Safety to collect data so that providers and policymakers will have national benchmarks for important clinical quality measures. </div> <div> </div> <div> </div> <div> </div> <div>“Quality should be driven within the profession,” says Langevin, “so rather than follow the road nursing homes have followed, we’ve taken the bull by the horns and set higher standards for ourselves.” And soon they’ll have the concrete evidence to prove it. <br></div> <div> </div> <h2 class="ms-rteElement-H2">New Jersey’s Advanced Standing Program</h2> <div> </div> <div>In February of last year, HCANJ collaborated with New Jersey’s Department of Health and Senior Services to create Advanced Standing, the first such program of its kind in the nation. Advanced Standing encourages participating ALFs (and comprehensive personal care homes) to make a commitment to strive for an ever-higher quality of care and to demonstrate it by submitting quality data. Those ALFs able to prove that their quality outstrips state requirements won’t have a state surveyor showing up at their doors, barring a complaint or other such issue. </div> <div> </div> <div> </div> <div> </div> <div>But there’s a hitch: While any ALF in the state—it doesn’t have to be a member of HCANJ—may apply to join the program, it must first demonstrate that it’s already providing care that is among the highest quality available in the state. </div> <div> </div> <div> </div> <div> </div> <div>That’s accomplished through an application process that includes submitting quality indicator data to a peer review panel (made up of HCANJ and state health department representatives as well as an ombudsman). An ALF’s data will have to demonstrate that the facility is meeting quality benchmarks that go well beyond government health and safety licensing regulations. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Starting With A Clean Slate</h2> <div> </div> <div>Before any of that even begins, the facility must be in compliance with all applicable local, state, and federal regulations and be willing to submit an affidavit to that effect. It will also need to sign a contract with HCANJ that details the Advanced Standing criteria, and all fees (which vary depending on the size of the ALF) must be paid up front during the time period indicated in the application. The application fees pay for a consultant to perform an initial inspection and monitor the facility from there on. </div> <div> </div> <div> </div> <div> </div> <div>Once approved by both the Advanced Standing program and the state health department, the Advanced Standing consultants will continue to conduct annual surveys at the ALF and assist the ALF in resolving any quality concerns that arise. The ALF will provide quality data at regular intervals—as yet to be determined by a peer group.</div> <div> </div> <div> </div> <div> </div> <div>Those facilities awarded Advanced Standing status will no longer have annual health department inspections, and each participant will have the right to market itself as an elite Advanced Standing facility. </div> <div> </div> <div> </div> <div> </div> <div>“The good news as a consumer is that you can be assured the building is surveyed at least annually by a competent individual,” says Langevin. In fact, the program, in which about 75 ALFs are currently taking part, has engaged the master trainer of all assisted living surveyors in the state to perform this function.</div> <div> </div> <div> </div> <div> </div> <div>“The key element for me, anyway, is this is the profession seizing its own future and being responsible for the quality of care, rather than relying on an outside agency to tell it what to do,” says Langevin. <br><span id="__publishingReusableFragment"></span><br></div> <div> </div> <h2 class="ms-rteElement-H2">Wisconsin kicks Off Excellence Program</h2> <div> </div> <div>The agency within Wisconsin responsible for oversight of the assisted living sector, the Bureau of Assisted Living (BAL) in the Wisconsin Department of Health Services, found itself with a growing problem several years ago. </div> <div> </div> <div> </div> <div> </div> <div>The number of assisted living beds (including those in community-based residential facilities, residential care apartment complexes, and adult family homes) had been growing steadily since 1979. In fact, the phenomenal growth caused the number of assisted living beds to outpace those of nursing facilities in 2008, and every year saw the lead widen significantly. </div> <div> </div> <div> </div> <div> </div> <div>But the bureau was being required to operate on a static budget—money to pay for keeping tabs on all of these new ALFs was not being added to the budget.</div> <div> </div> <div> </div> <div> </div> <div>In 2009, as it became increasingly clear that soon it would be impossible for BAL to fund the provision of even adequate oversight for the burgeoning sector, concerned leaders began to search for a budget-neutral solution. </div> <div> </div> <div> </div> <div> </div> <div>BAL could find only one real option: to somehow find a way to safely relinquish most of the work of monitoring ALFs that were consistently high performers so that it could concentrate on those that weren’t performing up to snuff. <br></div> <div> </div> <h2 class="ms-rteElement-H2">The WCCEAL Initiative</h2> <div> </div> <div>After much networking and discussion, a group of representatives of several organizations met in November of 2009 and agreed to collaborate on an initiative they called the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL). The group was composed of representatives of the Wisconsin Department of Health Services, the state’s ombudsman program, the four assisted living associations working in the state, and the Center for Health Systems Research and Analysis (CHSRA). CHSRA is a collaboration between the Preventative Medicine and Industrial Engineering Departments at the University of Wisconsin-Madison. The organization’s researchers create performance measures and decision support systems and supply other information to improve long term care. </div> <div> </div> <div> </div> <div> </div> <div>Together they developed a program that would reduce BAL’s workload by removing the need for it to provide inspections to facilities whose quality was so good that the inspectors routinely turned up nothing of note. </div> <div> </div> <div> </div> <div> </div> <div>But that wasn’t all the program did. It also ensured participating ALFs would have both the incentives (reduced regulatory oversight) and the resources that would spur them to set that bar ever higher. </div> <div> </div> <div> </div> <div> </div> <div>The WCCEAL initiative was officially launched in November 2012. Currently, 218 ALFs (community-based residential facilities, adult family homes, and residential care apartment complexes) participate, according to Alfred Johnson, director of BAL, which licenses and certifies 3,384 ALFs in the state. </div> <div> </div> <div> </div> <div> </div> <div>ALFs eligible to participate in the WCCEAL program must be licensed by the state and belong to one of the four associations and enroll in its quality improvement/quality assurance program, for which the association charges a fee to cover expenses. </div> <div> </div> <div> </div> <div> </div> <div>The associations provide member facilities with quality improvement tools, networking opportunities, educational programs, leadership development, mentoring, consultation, and other resources. </div> <div> </div> <div> </div> <div> </div> <div>“After an assisted living community has enrolled into the WCCEAL program,” says Johnson, “the Bureau of Assisted Living will continue to conduct complaint and self-report investigations. For communities that qualify for our abbreviated survey, we will conduct less frequent abbreviated surveys.”</div> <div> </div> <div> </div> <div> </div> <div>In fact, adds Brian Purtell, executive director of the Wisconsin Center for Assisted Living (WiCAL), participating ALFs could “go as far as five years, possibly, without being surveyed.” Although avoiding inspections isn’t the reason why Purtell or his members are doing this, he says.</div> <div> </div> <div> </div> <div> </div> <div>To receive the abbreviated survey, the ALF must have been licensed for three years and within the last three years have had no substantiated complaints filed against it and no state enforcement brought to bear. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Quality Programs Weighed</h2> <div> </div> <div>But BAL wanted demonstrable proof of the participating facilities’ quality efforts. After talks with CHSRA, they agreed that the best measurement of the ALFs’ quality of care would be to gather data on a wide range of quality improvement variables that would measure a facility’s performance, customer satisfaction, and regulatory compliance. </div> <div> </div> <div> </div> <div> </div> <div>They also agreed that these variables should look at a facility’s structures, processes, and outcomes—the three components identified by Avedis Donabedian, a physician and health services researcher at the University of Michigan, as those that would most accurately evaluate a health care facility’s actual quality.</div> <div> </div> <div> </div> <div> </div> <div>So, every quarter the ALFs would submit to CHSRA, using a secure website, data on the facility itself and its residents, as well as on clinical processes, outcomes, and satisfaction levels. CHSRA collects and, along with the facility’s association, analyzes the data. Purtell points out that a firewall has been built into the system to ensure the health department doesn’t see data from individual facilities.</div> <div> </div> <div> </div> <div> </div> <div>“The provider associations work along with the community to address negative trends or issues that arise out of the regulatory surveys/investigations,” says Johnson. “There is accountability built into the quality improvement/quality assurance programs to ensure communities are addressing issues.”</div> <div> </div> <div> </div> <div> </div> <div>The facilities would be able to compare their efforts to peers, identify trends, and pinpoint areas needing improvement so that leadership can allocate resources appropriately and provide positive feedback to relevant staff. </div> <div> </div> <div> </div> <div> </div> <div>But the facilities wouldn’t be on their own as they worked to remedy a quality problem. CHSRA, in addition to identifying any problems in their individualized reports, would be able to help the facility come up with a strategy for improving the situation.</div> <div> </div> <div> </div> <div> </div> <div>In addition, the facility’s association would be there to offer assistance and advice. In fact, the associations were tasked with holding their participating members responsible for implementing the quality improvement/quality assurance program. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Collecting The Right Data</h2> <div> </div> Among the data Wisconsin ALFs would submit are demographics and quality improvement structure, process, and <a href="/Monthly-Issue/2013/Pages/0813/Fact-Finding.aspx">outcome indicators</a>, conforming to what is considered the most effective way to measure a health care facility’s quality—a model of evaluation developed decades ago by Donabedian.<img src="/Monthly-Issue/2013/Pages/0813/States-Partner-With-Assisted-Living.aspx?ControlMode=Edit&DisplayMode=Design" alt="" style="margin:5px;" /><span><span></span></span><div><div style="text-align:center;"><span><span><span><img src="/Monthly-Issue/2013/PublishingImages/0813/coverstory_Donabedian.jpg" alt="" style="margin:5px;" /></span></span></span></div> <div>BAL wanted to make sure ALFs were working to align their quality of care with recognized, evidence-based standards of practice. These standards are updated as appropriate, says Johnson. “As the internal group becomes aware of standards of practice, we post the information on a secure website for WCCEAL assisted living communities,” says Johnson. “The provider association’s quality improvement/quality assurance programs also incorporate the standards of practice.” </div></div> <div> </div> <div> <span></span></div> <div> </div> <div>WCCEAL, working collaboratively with CHSRA, created standards of practice and performance measures, along with related decision support systems.</div> <div> </div> <div> </div> <div> </div> <div>The standards of practice surround the following topics:</div> <div> </div> <div>■ Activities of daily living</div> <div> </div> <div>■ Diabetes</div> <div> </div> <div>■ Dementia</div> <div> </div> <div>■ Pain</div> <div> </div> <div>■ Pressure ulcers</div> <div> </div> <div>■ Person-centered care</div> <div> </div> <div>■ Abuse and neglect</div> <div> </div> <div>■ Falls</div> <div> </div> <div>■ Mental health</div> <div> </div> <div>■ Infection control</div> <div> </div> <div>■ Emergency management</div> <div> </div> <div>■ Medication</div> <div> </div> <div>■ Food safety</div> <div> </div> <div> </div> <div> </div> <div>While WiCAL’s ALFs aren’t yet submitting a lot of clinical quality data, the satisfaction data are very useful to them, says Purtell.</div> <div> </div> <div> </div> <div> </div> <div>“They can access it and slice and dice it, see how they stack up against other members and how they perform against the rest of the WCCEAL population,” he says. In addition, ALFs are able to access the comments section of the surveys almost immediately, Purtell says, so that they can address any issues early.</div> <div> </div> <div> </div> <div> </div> <div>“I was very strong about the first measurement having a standardized satisfaction tool,” says Purtell. It’s important to place “a big emphasis on resident and family satisfaction issues rather than just compliance issues.” <br><span id="__publishingReusableFragment"></span><br></div> <div> </div> <h2 class="ms-rteElement-H2">First Data Report In</h2> <div> </div> <div>WCCEAL ALFs were required to submit their first batch of quality data by April 15, and CHSRA has issued reports on it. </div> <div> </div> <div> </div> <div> </div> <div>“The first quarter of quality improvement variables report was available to the WCCEAL assisted living communities in May/June 2013,” says Johnson. </div> <div> </div> <div> </div> <div> </div> <div>CHSRA is still “in the early stages” of conducting performance analyses that will tell the individual ALFs how their quality efforts are doing, says Johnson, but has developed several different reports for ALF and provider associations to use. </div> <div> </div> <div> </div> <div> </div> <div>“Currently there are a number of reports available regarding the community and aggregate data that the community will be able to compare to,” says Johnson. “As we secure additional funding to continue the WCCEAL program, it is expected that the reports and analysis will increase.” </div> <div> </div> <div> </div> <div> </div> <div>At a later date, CHSRA will study the effectiveness of WCCEAL, providing BAL with reports on satisfaction and quality indicators for WCCEAL overall and for each provider association overall, as well as reports on various facility groups, such as those with similar demographics.</div> <div> </div> <div> </div> <div> </div> <div>“The part I’d like to get across,” says Purtell, is that the “unique and exciting part of this is the collaborative nature, with provider associations, academics, resident advocates, and regulators working as a team with the common goal of performance improvement.” <br></div> <div> </div> <h2 class="ms-rteElement-H2">NCAL Goes National </h2> <div> </div> <div>The National Center for Assisted Living (NCAL) is finalizing the details on a collaboration with the New Jersey Hospital Association Institute for Quality and Patient Safety, a patient safety organization (PSO), to collect and analyze data from across the country on clinical performance measures in ALFs, says Lindsay Schwartz, PhD, NCAL’s director of workforce and quality improvement programs. The organization hopes to launch the program this fall. Schwartz is excited about the prospect.</div> <div> </div> <div> </div> <div> </div> <div> “This is an amazing opportunity for our profession. “It’s an innovative [program] and something that’s never been done before.” It will be the first time national data on such items as fall rates will be available for assisted living. </div> <div> </div> <div> </div> <div> </div> <div>Most ALF operators would agree with her. NCAL conducted a survey of its board members to find out if such a program would be of interest to its members, and “they were unanimously excited to participate in this,” says Schwartz. </div> <div> </div> <div> </div> <div> </div> <div>As with the New Jersey and Wisconsin programs, ALFs will pay a fee to participate in a quality improvement program. The cost is still being negotiated, but NCAL is determined to ensure it will be affordable for small operators. The association will foot the start-up costs. <br></div> <div> </div> <h2 class="ms-rteElement-H2">Teaming With A Safety Group</h2> <div> </div> <div>Participating ALFs will submit <a href="/Monthly-Issue/2013/Pages/0813/NCAL-Data.aspx" target="_blank">quality data to be analyzed</a>. In return, the ALF will receive reports on how it measures up to its peers regionally or across the country, along with educational information and training around an array of issues. For an extra fee, ALFs can even receive root cause analyses in which experts look at specific incidents, drilling down to the heart of the problem and finding solutions, says Schwartz. </div> <div> </div> <div> </div> <div> </div> <div>NCAL developed the quality measures, which it calls the Tier II Clinical Performance Measures, making sure to include both process and outcome measure. Structural measures are not yet included in this list but may be in the future, although NCAL has been collecting structure measures through other surveys. It’s in the final stage of negotiating a contract with the New Jersey hospital safety group, which will collect and analyze data and help the facilities improve their quality. </div> <div> </div> <div> </div> <div> </div> <div>“The reason we’re going with the PSO,” says Schwartz, “is to protect the data. Under the federal Patient Safety Act, quality data submitted to PSOs are protected” from being mined by lawyers looking for an ALF to sue. </div> <div> </div> <div> </div> <div> </div> <div>In some states, assisted living facilities will not be protected under the Patient Safety Act of 2005 due to the definition of “health care provider” in the act and how a state has licensed assisted living. NCAL is working with outside legal counsel to develop a checklist for NCAL members to use to determine if their ALFs would be covered as a “provider” under the act. These members can still participate, even though they will not be covered under the protection of the Patient Safety Act. </div> <div> </div> <div> </div> <div> </div> <div>The act provides protection from legal discovery for data about quality and safety reported and shared by a health care provider, and the rule issued to implement the act authorized the creation of PSOs as the organizations that would safely collect and analyze that data. </div> <div> </div> <div> </div> <div> </div> <div>Purtell is also concerned about the possibility of WCCEAL data being used by lawyers in Wisconsin looking for a case. WiCAL is training members how to report data in such a way as to qualify for state statutory protections surrounding performance improvement efforts.</div> <div> </div> <div> </div> <div> </div> <div>“It’s ridiculous we have to worry about someone using something we’re doing to improve our quality to sue us,” says Schwartz. </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2">Data Collection Increasingly Vital</h2> <div> </div> <div>“The health care system is changing,” says Schwartz. Accountable Care Organizations are looking to partner with community providers, and they’re increasingly looking for these clinical measures” and data-based proof of quality to choose who they partner with.</div> <div> </div> <div> </div> <div> </div> <div>New Jersey’s Langevin agrees. “We think [quality data collection] is going to facilitate purchasing not only by consumers, but by managed care organizations in the state,” he says. </div> <div> </div> <div> </div> <div> </div> <div>As ALFs find themselves providing more medical services than in the past, collecting quality data is “changing the landscape of assisted living,” says Schwartz. And that ALFs are choosing to participate in these programs without regulation requiring it is to their credit, Schwartz says. “It’s amazing that an organization and its members have a vision of improving themselves,” she says. “It shows a commitment to excellence.” </div> <div> </div> <div> </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em> <br></div> With an eye on the trends and an awareness of the increasing involvement of managed care in assisted living, the National Center for Assisted Living (NCAL) will be collaborating with the New Jersey Hospital Association Institute for Quality and Patient Safety to collect data so that providers and policymakers will have national benchmarks for important clinical quality measures. 2013-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0813/coverstory_thumb.jpg" style="BORDER:0px solid;" />Cover Story8
Academic-Practice Partnerships Tool Kithttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Academic-Practice-Partnerships-Tool-Kit.aspxAcademic-Practice Partnerships Tool Kit<h2 class="ms-rteElement-H2 ms-rteForeColor-2">PLAYERS</h2> <h3 class="ms-rteElement-H3">A. Selecting partners</h3> <ol><li>How do you identify your partners? </li> <li>Why is this partner a good fit? </li> <li>How do you approach your potential partner? How do you make the appointment with the right person? Who is the right person? </li></ol> <ol></ol> <h3 class="ms-rteElement-H3">B. Preparing for your first meeting </h3> <ol><li>Where do you meet? </li> <li>What do you need to know about your potential partner and his or her organization? What does your partner need to know about you and your organization? <br></li></ol> <h2 class="ms-rteElement-H2 ms-rteForeColor-2">PARTNERSHIPS</h2> <h3 class="ms-rteElement-H3">A. Initial meeting</h3> <ol><li>What is the right partnership activity for you and your partner? </li> <li>What documents about your organization might be helpful to bring to the first meeting? </li> <li>What do you have to offer? </li> <li>What is the mutual benefit? </li> <li>What is your vision? </li> <li>Does your potential partner share this vision? </li> <li>What is the potential initiative/activity, and who else needs to be involved in both organizations? </li> <li>Who is the top leadership in the organization? Are you talking to them? </li> <li>What is the business case for the partnership? </li> <li>What are the next steps? Do you have a timeline established at the end of the first meeting? </li> <li>Be sure to send a thank-you note with next steps delineated. </li></ol> <h3 class="ms-rteElement-H3">B. Subsequent meetings</h3> <ol><li>Do you have clarity on goals and vision? </li> <li>What resources are needed? </li> <li>What are the details and timeline of the initiative? </li> <li>Whom can we call for expert consultation if need be? </li> <li>Will there be an official MOU? </li> <li>What are the expected outcomes of the activity? <br></li></ol> <h2 class="ms-rteElement-H2 ms-rteForeColor-2">ENVIRONMENT</h2> <h3 class="ms-rteElement-H3"><div>A. Time</div></h3> <ol><li>Is this the right time for this partnership? </li> <li>What are the issues that will facilitate or impede the development of the partnership? </li> <li>What is the time commitment for the partners? </li> <li>Whose time will be required? </li> <li>When will the meetings be scheduled? Are they on a regular basis and frequent?</li></ol> <h3 class="ms-rteElement-H3">B. Space</h3> <ol><li>What space is required for the activity? </li> <li>What equipment or supplies are needed? </li> <li>What funding is needed? </li> <li>Where are we meeting? </li> <li>Where will we present outcomes? </li></ol> <h3 class="ms-rteElement-H3">C. Regulation</h3> <div><ol><li>What are the policies or regulatory issues that will impede or facilitate development of the partnership on both sides? </li></ol></div> <h3 class="ms-rteElement-H3">D. Context</h3> <ol><li>How will the partnership be funded? </li> <li>What are the constraints of both partners? </li> <li>What history do the partners have with each other and each others’ institutions?     </li></ol> <div> </div> <div><em>Source: American Association of Colleges of Nursing (2012). “Academic-Practice Partnerships Tool Kit.” Retrieved May 4, 2013, from <a title="Tool Kit" target="_blank" href="http://www.aacn.nche.edu/leading-initiatives/academic-practice-partnerships/tool-kit.">www.aacn.nche.edu/leading-initiatives/academic-practice-partnerships/tool-kit.</a> Reproduced with permission.</em></div> <div> </div>Column8
Gero Prep Nurse Congratshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0813/Gero-Prep-Nurse-Congrats.aspxGero Prep Nurse Congrats<h3 class="ms-rteElement-H3 ms-rteThemeForeColor-6-4"><span>Congratulations to the following nurses that have completed the Gero Nurse Prep online training program and have passed the exam to become Board-Certified Gerontological Nurses. </span></h3> <br> <div>Lynne M. Alameda, RN-BC<br>Jill Albright, RN-BC<br>Nancy Amaya<br>Michelle A. Auger, RN-BC<br>Amy Bailey<br>Norma L. Benson<br>Catherine E. Benson<br>Karen Berg<br>Darci Branby, RN-BC<br>Theresa Burerkel<br>Maureen Hayden<br>Karen Castillo<br>Teresa Chin<br>Sandi Crawford<br>Amanda Dunkin<br>Claire Enright, BSN, RN-BC<br>Nancy T. Farrar<br>Ashley Flathers<br>Julie Fletcher<br>Debra Forss<br>Dianna Frickey, RN-BC<br>Virginia Girard, RNC<br>Christine Hangsleben, RN<br>Maureen Hayden, RN-BC<br>Lori Henry<br>Nancy M. Hilbrands<br>Judy Hollingsworth, RN-BC, CLNC<br>Kathleen Homan, RN-BC<br>Elizabeth Jensen, RN, MSN, RN-BC<br>Sally D. Jones, RNC<br>Joann Kapelos, RN-BC<br>Lucille Katzenberger<br>Marlene Kelly, RN-BC<br>Jeanette Klodt<br>Diane Lansing<br>Pepper Lippert, BA, RN-BC<br>Kate Lockyer<br>Janet Madison, RN<br>Alena Manaskova<br>Marcia Matsik<br>Debra McManus <br>Andrea Newgren<br>Lynzie Nilles, RN-BC<br>Rowena A. Norton, RN, BSN<br>Annette Nygaard<br>Pam O’Rourke, RN-BC<br>Kimberly A. Paradis, RN, BSN, M.ed, AHI <br>Emily Peaster<br>Selena Pevahouse, RN-BC, BSN<br>Diane Santos, RN-BC, MSN, CPEHR<br>Heather D. Schuette <br>Ellen Smitherman-Hinrichs<br>Joan M Sullivan<br>Suzie Temple, RN-BC BSN<br>Giuliana Varriano <br>Marsha Weatherholtz, RN - BC <br>Birgit Weisshuhn<br>Tiffanee A. Wittman<br>Melissa Woodyard, RN-BC<br>Patricia A. Young, RN-BC </div>Column8

September



 

 

Be Inspired to Learnhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0913/Be-Inspired-to-Learn.aspxBe Inspired to Learn<img width="281" height="409" class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0913/Saguaro_Sunset_AZ.jpg" alt="" style="margin:10px;" /><br>The 64th Annual Convention & Expo of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) is coming <a href="/Monthly-Issue/2013/Pages/0913/A-Day-Of-Special-Programming.aspx">Oct. 6-9</a> to Phoenix.<br><br>Following are a selection of the more than 60 CEU-credited symposia beginning on Monday, Oct. 7, and going on for three full days.<br><br><span class="ms-rteForeColor-10"><strong>Increase Opportunities For Person-centered Care Planning And Decision Making</strong></span><br><br>Leader: <em>Susan LaGrange, RN, BSN, NHA, director of education, Pathway Health Services, White Bear Lake, Minn.</em><br><br>Today the buzzwords “culture change” and “person-centered care” are on everyone’s lips. How can providers optimize their ability to really embed the process into their everyday planning and implementation of care? This session will provide tangible and practical tips on how to plan and communicate to caregivers the importance of integrating resident choice in everyday care.<br><br><span class="ms-rteForeColor-10"><strong>Reduce Direct Care Staff Turnover</strong></span><br><br>Leaders: <em>Jean Cannon, executive director, and Carmy Jerome, assistant director, Aspen House Memory Care Assisted Living, Loveland, Colo.</em><br><br>Hear how one facility reduced staff turnover from 77 percent to less than 20 percent with a few simple, cost-effective methods, including training, staff recognition, understanding staff’s personal situations, staff engagement in business decisions, and fun.<br><br><span class="ms-rteForeColor-10"><strong>Choosing the QAPI Methodology That Fits Your Organization</strong></span><br><br>Leaders: <em>Christine Boldt, vice president, long term care operations, Benedictine Health System, Red Wing, Minn., and Jeri Reinhardt, RN, director, quality, Benedictine Health System, Cambridge, Minn.</em><br><br>This session will introduce attendees to various types of process improvement methodologies, including Plan Do Study Act, LEAN, Six Sigma, and others. The presenters will also provide an overview of the tools available to support each methodology and learn how to select and apply the appropriate process improvement method to their organization.<br><br><span class="ms-rteForeColor-10"><strong>H</strong></span><span class="ms-rteForeColor-10"><strong>ow to Partner With Patient Safety Organizatio</strong></span><span class="ms-rteForeColor-10"><strong>ns</strong></span><br><br>Leader: <em>Marjorie Forgang, RN, MSN, New Jersey Hospital Association, Princeton, N.J.</em><br><br>This session will help attendees gain an understanding of what a patient safety organization (PSO) is and the role it has in improving quality in long term care. This will include an introduction to the laws and regulations governing PSOs and how long term care providers can take advantage of the confidentiality and privilege protections of a PSO for patient safety work products.<br><br class="ms-rteForeColor-10"><strong class="ms-rteForeColor-10">Discharge Should Not Mean Goodbye: Why Post-discharge Follow-up Plays a Critical Role</strong><br class="ms-rteForeColor-10"><strong class="ms-rteForeColor-10">In Achieving Your Hospital Readmission Goals</strong><br><br>Leader: <em>David Mills, chief operating officer (COO), Align, Wausau, Wis.</em><br><br>It is not an issue of whether hospital readmissions will have an impact on post-acute care but, rather, how should an organization be positioned to succeed in this ever-changing environment. The recipe for success is complicated. Experts agree that it takes strong transition support, coordinated discharge planning, superior communication skills, and education designed for the adult learner to truly impact readmission rates. While these areas are often addressed during a patient’s stay, the need for ongoing support remains after discharge. During this session, attendees will learn how to incorporate these and other best practices into the company’s post-discharge follow-up process.<br><br><strong class="ms-rteForeColor-10">Appreciative Inquiry: A Strength-based Approach To Leading Positive Change</strong><br><br>Leader: <em>Joanne Smikle, principal, Smikle Training Services, Ellicott City, Md.</em><br><br>Appreciate Inquiry (AI) turns the traditional paradigm of change on its head. Rather than focusing on how to fix what is perceived as broken, the process of AI creates a positive, affirming framework that asks, “What’s working, and how can we build on that to imagine and design a new future?” What a powerful tool for making culture change more than rhetoric. It is a tool leaders can use to identify the “positive core” that lies at the heart of the profession. It enables committed care organizations to harness the power within to launch change processes that inspire, motivate, and give energy to the people who have the power to drive and sustain positive organizational change.<br><br class="ms-rteForeColor-10"><strong class="ms-rteForeColor-10">Anatomy of an Assisted Living Lawsuit: Reducing Risk and Maximizing Quality Through a Formal Expectations Management Program</strong><br><br>Leader: <em>Rebecca Adelman, president and shareholder, Hagwood Adelman Tipton, PC, Memphis, Tenn.</em><br><br>The ever-increasing acuity of residents entering senior living leads to greater needs and service expectations. Residents are demanding to remain in the most independent options possible, redefining what it means to “age in place.” This new reality raises many questions for providers, including what litigation/claims risks they are facing and what strategies can be developed for minimizing risk and maximizing quality. The program will identify risk factor data, recommend policy and procedure changes, and offer training modules for various stages in a residency period where providers can set and manage expectations.<br><br><strong class="ms-rteForeColor-10">Payment Methodology: From SNF PPS to Bundled Payments</strong><br><br>Leaders: <em>James Michel, director, Medicare research and reimbursement, and Peter Gruhn, senior director, research, AHCA, Washington, D.C.; Doug Burr, vice president, Health Care Navigator, Roswell, Ga.; Joanne Powell, NA, RHIT, director of reimbursement strategies, Evangelical Lutheran Good Samaritan Society, Sioux Falls, S.D.; John Perticone, vice president, strategic partnerships, Golden Living, West Mifflin, Pa.; Henry Gordinier, vice president, strategic planning, Kindred Health Care, Louisville, Ky.; and Rachel Feldman, partner, The Moran Co., Alexandria, Va.</em><br><br>AHCA staff will provide a brief overview of the changes to skilled nursing facility (SNF) Prospective Payment System (PPS) for fiscal year 2014 and the relationship between SNF PPS and bundling. Key SNF PPS challenges must be met by providers in preparation for any transition to bundling. Then, a panel of AHCA members will engage in a discussion of their experiences and participation in the Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement initiative.<br><br><strong class="ms-rteForeColor-10">Discovering a Different Point Of View—The Leader’s Role in Creating a Culture of Innovation</strong><br><br>Leader: <em>Andre Boykin, managing partner, CAPITAL iDEA, Weston, Fla.</em><br><br>If organizations are to sustain viability over the long haul, leaders have to be able to effect meaningful change and innovation inside their organizations. The leader’s role is to create a culture of change and innovation, which will not come about when leaders are satisfied with the status quo. This program reshapes thinking about ways to establish a culture for new ideas and concepts.<br><br><strong class="ms-rteForeColor-10">The Nuts and Bolts of Survey Success</strong><br><br>Leader: <em>Mary Jann, RN, BA, director, regulatory affairs, California Association of Health Facilities, Sacramento, Calif.</em><br><br>Many excellent centers have experienced a bad survey, and few things are more discouraging to providers than to have their good work overshadowed by a damaging 2567. This session, taught by two former surveyors, will show attendees how to be survey ready every day by using a few simple fixes for big results. Through this interactive session, which includes role playing and case studies, attendees will learn techniques to assist them in their quality assurance and performance improvement efforts.<br><br class="ms-rteForeColor-10"><strong class="ms-rteForeColor-10">Stabilizing Staff Through Strengths</strong><br><br>Leaders: <em>Mitchell Elliott, chief development officer, and Patrick Fairbanks, COO, Vetter Health Services, Elkhorn, Neb.; and Lori Stohs, human capital consultant, Lori Stohs Consulting, Omaha</em><br><br>On average, only 29 percent of individuals are engaged in their jobs, with more than half considered disengaged and 17 percent considered “actively disengaged.” <br><br>These statistics can create serious flaws within a team. They can cost an employer time and money, but most importantly, quality of care and personal relationships. Understanding each individual and appreciating their strengths will enhance engagement. <br><br>This presentation will involve individual results from the Gallup StrengthFinder Assessment Tool. A case study involving this “strength-based” approach toward employee engagement at Vetter will serve as the core of this session.<br><br><strong class="ms-rteForeColor-10">From Administrator to Resident: Perspective From the Other Side</strong><br><br>Leader:<em> Phillip DuBois, faculty, St. Joseph’s College, Oxford, Maine</em><br><br>In April 2007, Phillip DuBois and his family were involved in a serious car accident. DuBois was seriously injured. After two weeks as a hospital in-patient, he became a skilled rehabilitation resident in his own nursing home for 2-1/2 months. <br><br>Today DuBois speaks of lessons he learned from that experience, such as patient perception of quality of care, how the demeanor of the caregiver impacts perception of quality, subjective factors that can impact quality scores, how to create an environment that promotes healing, and practical aspects of person-centered care from the perspective of someone who has been on both sides. <br><br>A selection of the more than 60 CEU-credited symposia beginning on Monday, Oct. 7, and going on for three full days.2013-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0913/conv_az_thumb1.jpg" style="BORDER:0px solid;" />Caregiving;Management;Policy;QualityColumn9
CMS Updates Expedited Appeal Regulationshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0913/CMS-Updates-Expedited-Appeal-Regulations.aspxCMS Updates Expedited Appeal Regulations<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div> <div><img width="244" height="344" src="/Monthly-Issue/2013/PublishingImages/0913/feature.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;" /></div> <div>It can be nerve-wracking for nursing home staff and management when a resident contacts the Quality Improvement Organization (QIO) using the expedited appeal process to appeal the nursing home’s decision to end Medicare coverage. Even more frustrating is a mandate of provider liability (non-payment days) because facility staff did not give proper notice to the beneficiary.</div> <div> </div> <div>It happens more often than providers care to admit. Facility staff fail to provide proper notice that Medicare coverage is ending. They might do this by giving less-than-required notice time; notifying the wrong representative; using the wrong forms; delivering incomplete forms; or, worst of all, not giving the notice at all. </div> <div> </div> <div>The expedited appeal process is also known as the Expedited Review or Expedited Determination and the Notice of Medicare Noncoverage (NOMNC). This process was established to allow skilled nursing facility (SNF) Medicare beneficiaries the right to appeal to a QIO regarding a pending discharge from Medicare-covered services. This is a separate and distinct process from the denial letters, or SNFABN (Centers for Medicare & Medicaid Services [CMS] form 10055), which allows the beneficiary to appeal the decision to the Medicare Administrative Contractor (MAC).</div> <div> </div> <div>Although nursing home providers have been grappling with the requirements for a long time, it seems there is still a lot of confusion surrounding the regulations. The “Medicare Claims Processing Manual,” Chapter 30, has been updated (effective date Aug. 26, 2013) with specific instructions for providers on how to manage the expedited appeal process; these are detailed in transmittal 2711. Understanding the instructions is the first step to compliance. </div> <h2 class="ms-rteElement-H2">Take The Proper Steps</h2> <div>■ Notify for the right reason. The NOMNC is required when a provider determines that Medicare will no longer pay for skilled services either under traditional Medicare Part A—skilled service provided by managed care—or under Part B when therapy services are ending. It is required regardless of whether the resident is being discharged or is staying in the facility for custodial care. Notice is not required when skilled service is being reduced but is not ending, when the resident exhausts benefits or self-elects to discontinue services, or when the resident transfers to the hospital or another SNF.    </div> <div> </div> <div>■ Use the correct form. The NOMNC is also called the “generic notice.” SNFs should be using CMS 10123-NOMNC with an approval date of 12/31/2011. The same form is issued for traditional Medicare A and for those residents accessing their skilled service through a managed care provider.</div> <div> </div> <div>■ Notify the correct person. The generic notice should be issued to the resident as the preferred option, or, alternatively, to the resident’s appointed or authorized representatives, designated by the resident to act on his or her behalf. If the resident has been deemed legally incompetent, the provider should follow state law for recognizing legal guardianships or properly executed durable medical power of attorney. There are times when the resident experiences “temporary” incapacitation and is not able to understand the facility staff’s explanation of the ending of Medicare benefits. Even if Mrs. Jones can sign that she received notice, if she doesn’t understand what she’s signing, it is an invalid notification. In such circumstances, the regulations state:</div> <div> </div> <div>“A person (typically, a family member or close friend) whom the provider has determined could reasonabl[y] represent the beneficiary, but who has not been named in any legally binding document, may be a representative for the purpose of receiving the notices described in this section. Such a representative should have the beneficiary’s best interests at heart and must act in a manner that is protective of the beneficiary and the beneficiary’s rights. Therefore, a representative should have no relevant conflict of interest with the beneficiary” (CMS, 2013, p. 11).</div> <div> </div> <div>Because the burden of proof for timely notification is on the provider, every effort must be made to provide timely notice to the correct person. <br></div> <div>■ Issue the notice in a timely manner. The NOMNC (generic notice) must be issued in person to the beneficiary at least two days prior to the end of covered services. If the notice is being issued to an authorized representative, the facility staff can issue the notice by phone and follow up with a certified, return-receipt-required letter or other verifiable delivery method such as FedEx or UPS. Faxed or emailed notification is allowed when the provider and representatives agree to that communication method, provided it meets the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security requirements. </div> <div> </div> <div>Additionally, the “notice delivery should occur within the normal operating hours of the provider;” CMS does not expect providers to “extend their hours or days of business solely to meet the requirements of the expedited determination process” (CMS, 2013, p. 12). </div> <div> </div> <div>Be warned, however, that timely notice is more important than respecting business hours. Even after business hours, facility staff who understand the notice process and can create, issue, and explain the NOMNC to residents or representatives should be available to ensure compliance with notice </div> <div>timing. <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">How To Fill Out The Form</h2> <div>■ Provide the correct information. When preparing the NOMNC, facility staff need to follow some specific requirements. The resident’s name, Medicare number, type of coverage (that is, Medicare A in the SNF), last day of coverage, and the QIO’s contact information should be either typed or clearly written on the government-approved form. The NOMNC must be two pages long and either double-sided or on two single pages. </div> <div> </div> <div>There is space on the government form for the provider’s logo and contact information, but the space is limited, and these cannot be placed in a manner that forces the standard information to shift to page two. There is an optional “additional information” section that can be individualized to the resident’s situation in order to explain the reason for ending Medicare services. </div> <div> </div> <div>■ Select the correct effective date. The notice-effective date probably creates the greatest confusion. For a Medicare A beneficiary in a SNF, the last day of coverage or effective date is the day before the discharge date. For example, Mr. Smith is in the facility for rehabilitative therapy following a hip replacement. Therapies will be ending on Friday, Sept. 13, and he is going home on Saturday, Sept. 14. In order to be in compliance, facility staff must issue the notice no later than Wednesday, Sept. 11, with an effective date on the NOMNC of Sept. 13. “Because a SNF cannot bill the beneficiary for services furnished on the day of (but before the actual moment of) discharge, beneficiaries may leave a SNF the day after the effective date and not face liability for such services” (CMS, 2013, p. 9). <br></div> <h2 class="ms-rteElement-H2">Resident’s Responsibility, QIO’s Role</h2> <div>Some providers have erroneously thought that the beneficiary has two days after the notice is given to call the QIO to request a review. In reality, once proper notice is provided, the resident has until noon of the day before the last covered day (the effective date on the notice) to call or write to the QIO and request the expedited review. This is helpful to the beneficiary in cases where the notice is given earlier than two days before the effective date. The QIO will conduct a review and make a determination within 72 hours. </div> <div> </div> <div>The QIO will notify the facility staff that a review of their coverage decision is underway. A facility’s first priority is to complete the “detailed notice” (form CMS-10124-DENC). Staff have until the end of the business day to complete and send the detailed notice, along with proof that the generic notice was provided and pertinent medical record information. <br></div> <h2 class="ms-rteElement-H2">References And Resources</h2> <div>■ Centers for Medicare & Medicaid Services. (2013, May 24.) Pub 100-04 <a href="http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2711CP.pdf">Medicare Claims Processing, transmittal 2711</a>.</div> <div>■ Centers for Medicare & Medicaid Services. (2012.) <a href="http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf">Medicare Claims Processing Manual, Chap. 30.</a> </div> <div>■ Centers for Medicare & Medicaid Services. (2011, December 31.) <a href="http://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFSEDNotices.html">Expedited determination notices. </a></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 <a href="mailto:jkulus@aanac.org" target="_blank">jkulus@aanac.org</a> or (800) 768-1880.</em></div> <div> </div> <div><img src="/archives/archives-2012/PublishingImages/0712/AANAC.gif" alt="" style="margin:5px;" /></div> <div> </div>It happens more often than providers care to admit. Facility staff fail to provide proper notice that Medicare coverage is ending. They might do this by giving less-than-required notice time; notifying the wrong representative; using the wrong forms; delivering incomplete forms; or, worst of all, not giving the notice at all. 2013-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0913/feature_thumb.jpg" style="BORDER:0px solid;" />Caregiving;PolicyColumn9
Dining Done Righthttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0913/Dining-Done-Right.aspxDining Done Right<div><div>There are so many options when deciding what is best for an entire community. For example, determining the right type of services for the community and changing them as the population changes will be the key to whether the dining program is outstanding or just serves meals. Understanding what flexibility the community can offer will only enhance the meal service, and it can be as simple as allowing a customer the option to sleep in a little before breakfast.</div> <h2 class="ms-rteElement-H2">Identify Facility Customer Needs</h2></div> <div>Before considering dining options, it is important to take a step back and <span></span>determine what types of customers are being served by the community. The most frequent customers in senior living are independent living, assisted living, health care (nursing facility), short-term rehab, and adult day care. </div> <div> </div> <div><span><span><img src="/Monthly-Issue/2013/PublishingImages/0913/mgmt_thumb.jpg" class="ms-rtePosition-1" alt="" style="margin:10px 15px;" /></span></span>Each of these groups has different needs and different expectations. </div> <div> </div> <div>Most health care residents lived through the Great Depression, while incoming independent living residents and rehab patients are more and more likely to be baby boomers.</div> <div> </div> <div>Knowing this can impact the service style. Start with the understanding that the more resident/patient types there are, the more certainty there is that one type of service will not provide excellent service to all. </div> <div> </div> <div>As the process begins, first examine the existing dining system. Take a good look at whether the residents appear to like it or if they were conditioned to accept it because there was no other option.</div> <div> </div> <div>Next, concentrate on what can be done with the current layout of the dining system and plan for the future. How can the physical design of the community support ways to meet the desires of current and future patients/residents? </div> <div> </div> <div><a href="/Monthly-Issue/2013/Documents/0913/Mgmt0913.pdf" target="_blank">This table</a> describes service options, along with a brief description and notes to consider when deciding on additional dining venues. Any one of these can be combined with others. <span>A <a href="/Monthly-Issue/2013/Documents/0913/Dining%20Equipment.pdf" target="_blank">chart outlining equipment </a>that will be needed for each dining option is available.<span style="display:inline-block;"></span></span><br></div> <h2 class="ms-rteElement-H2">Program Options </h2> <div>Changing the type of service the facility offers, or where it is offered, doesn’t mean that everything changes. The amount of food produced won’t change, nor will the number of customers. Food costs shouldn’t change. </div> <div> </div> <div>Staffing levels usually remain the same, although staff will do their work differently. Duties may change, but each staff member will still have a group of tasks that fills his or her work day.</div> <div> </div> <div>When considering the change to “open dining,” one recent senior living community client raised a very common question: “How do I get people to the dining room early when I have to get all my residents up by 7:00 a.m.?” The response to this was: “Why do you have such urgency to get everyone up by 7:00?” That response was: “Because they have to have breakfast early to meet the time frame for dinner.”</div> <div> </div> <div>But when she was reminded that there were five residents sitting around at 6:30 a.m. and how, if at least beverages and cereal had been offered to those who wanted it, breakfast had really started at 6:30 a.m., thus relieving the later morning breakfast rush by accommodating early risers.</div> <div> </div> <div>In the end, the spark lit, the client embraced the concept, and structured mealtimes are now a thing of the past in that community. This example shows how the thought process needs to change so that the benefits can be understood by all. <br></div> <h2 class="ms-rteElement-H2">Get Staff Support</h2> <div>The biggest change—and challenge—is how staff perceive the impact that changes will have on them. The buzzword is culture change.</div> <div> </div> <div>An important component for dining services is nursing staff understanding that food service is a component of patient/resident care. <br></div> <h2 class="ms-rteElement-H2">Involve Everyone</h2> <div>Nutrition status is a component of the same care plan that addresses medical and social care. The dining aide, hospitality aide, cook, and other staff members often have difficulty seeing themselves as part of the resident/patient care team. </div> <div> </div> <div>Changing mindsets is a culture change challenge that needs to be met. Planning changes so each group understands the full impact on them before implementation goes a long way to getting their support. This includes making as many changes as possible at the same time so staff are not always wondering, “What next?”</div> <div> </div> <div>During the consideration of options and plan development stages, keep everyone in the loop and explain options, and then plans, to the entire community. Take advantage of the change as a reason to address issues and areas that may not have been accounted for. Turn staff into marketing ambassadors by allowing them to feel like they are part of the process.</div> <div> </div> <div>There are many ways to provide dining service. These should be a starting place with thoughts and recommendations to help a company move toward its goals. Stay aware of how the center’s customer base is changing, and be ready with a plan of change to meet their needs. </div> <div> </div> <div>The age-old business proverb, “What was good enough to get you there isn’t good enough to keep you there,” should be the mantra for modern-day dining services. </div> <div> </div> <div><em>Wayne Toczek, chief executive officer of <a href="http://www.innovaservices.info/">Innovations Services</a>, Norwalk, Ohio, can be reached at (419) 541-7288. </em></div> <div> </div>Before considering dining options, it is important to take a step back and determine what types of customers are being served by the community. The most frequent customers in senior living are independent living, assisted living, health care (nursing facility), short-term rehab, and adult day care. 2013-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0913/mgmt_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ManagementColumn9
Market Looking Better All The Timehttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0913/Market Looking Better All The Time.aspxMarket Looking Better All The Time<div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div><img width="228" height="343" class="ms-rtePosition-1" src="/Monthly-Issue/2013/PublishingImages/0913/Finance1.jpg" alt="" style="margin:5px 15px;" /><br>Providers “ought to take a look” at refinancing their buildings, one of the nation’s leading long term care advocates says. </div> <div> </div> <div>Gov. Mark Parkinson, president and chief executive officer of the American Health Care Association (AHCA), says he’s not sure how much longer interest rates will be so favorable and that providers could save a lot of money if they refinance properly. </div> <div> </div> <div>“Regardless of what your financing is, if you haven’t refinanced in the last couple of years, you really ought to take a look at it,” he says. Parkinson is a former assisted living center operator as well as former governor of Kansas. </div> <div> </div> <div>“I’ve had members tell me that they have managed the impact of state and federal budget cuts by refinancing their debt and really harness their resources,” he says. </div> <h2 class="ms-rteElement-H2">Analysts Weigh In </h2> <div>Many analysts agree. <br><br></div> <div>“We’re anticipating rates to drop slightly over the next couple of weeks, but again, none of us has a crystal ball,” says Dan Biron, senior vice president of Berkadia, a company that helps providers obtain financing through the Department of Housing and Urban Development (HUD). “It’s still a very, very attractive interest rate right now.”</div> <div> </div> <div>Some providers are worried about whether refinancing may affect Medicaid reimbursement. But only “five or six states” have regulations that consider refinancing in reimbursement, Biron says. </div> <div> </div> <div>And HUD has learned the painful lessons of the past by focusing on streamlining its application process, Biron says. </div> <div> </div> <div>“There used to be a big queue of close to 400 applications sitting in the corner of someone’s office. And it basically took eight, nine months for someone to pick up the transaction and then start reviewing it,” he says. “What HUD did is hire outside underwriters, consultants, to help them in eliminating that queue.” </div> <div> </div> <div>Now, it can take less than six months from beginning to end to get their refinancing processed. </div> <div> </div> <div>HUD is one of the many vehicles for financing, but all lenders appear to be willing to be flexible with providers, experts say. <img width="226" height="280" class="ms-rtePosition-2" src="/Monthly-Issue/2013/PublishingImages/0913/finance3.jpg" alt="" style="margin:10px;" /><br></div> <div> </div> <div>For instance, HUD is now willing to work with providers to refinance even if they’ve recently done so and are in the so-called “lock-out” period of their loans, Biron says. And lenders have streamlined their reviews, so financing can go through in a matter of weeks or months, experts say. </div> <div> </div> <div>A handful of states measure mortgages when considering reimbursement, though, so it’s important to talk carefully with lenders, Biron and others say. </div> <div> </div> <div>“You can control the cost, but at the end of the day, there’s still a lot of savings,” says National Association of REITs (real estate investment trusts) Vice President Brad Case. </div> <div> </div> <div>“If interest rates go up, the value of a bond will fall. But that’s because a bond is a fixed-income instrument. Commercial property is not.” <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Long Term Care As Investment</h2> <div>Whatever happens with interest rates, it’s clear that long term care is emerging as a hot, long-term investment, experts say. </div> <div> </div> <div>“They’re buying it for the demographics,” says John Roberts, director of research at Hilliard, Lyons in Louisville. “There are a lot of positive demographics that are driving the industry: the aging, the baby boom generation. People are living longer. Supply is kept artificially low by the government, so you’ve always got a lot of demand for a limited supply.”</div> <div> <img width="149" height="170" class="ms-rtePosition-1" alt="John Roberts" src="/Monthly-Issue/2013/PublishingImages/0913/Roberts_John.jpg" style="margin:10px;" /><br>In fact, Roberts says that things are looking so good for long term care that many companies’ stocks may be over-valued. </div> <div> </div> <div>“The companies are, from an operating perspective, doing very well. I like the industry, longer term,” he says. “But as often happens, you might like the company, you might like the sector, but that doesn’t mean you like the stock.”</div> <div> </div> <div>Institutional investors have been drawn to long term care because of its big dividends, but “it’s an artificial market,” Roberts says, and it may not be a great buy for now. </div> <div> </div> <div>“I’m enamored with any stock at the right price. Rolls Royce is a great car, but I don’t want to pay $200,000 for it,” he says. “In my opinion, the group is priced too highly.”</div> <div> </div> <div>Nonetheless, some health care REITs are already taking an aggressive posture. LTC Properties, for instance, said at a conference in July that it had changed its focus from merely acquiring properties to developing new ones—particularly in homes that focus on dementia treatment. </div> <div> </div> <div>“We identified some unmet needs in the memory care area, and we started looking for operators to build new properties with,” LTC President and Chief Executive Officer Wendy Simpson said in July. “So we’re building some memory properties that are all memory care, we’re building some properties that are partly memory care, [partly] assisted living, and we’re also building skilled nursing properties.” <br></div> <h2 class="ms-rteElement-H2">Going Overseas</h2> <div>Demographics also have an international dimension. Griffin-American, a senior health care REIT, just announced that it will now head overseas, taking over a 44-facility portfolio in the United Kingdom. </div> <div> <br>“The demand for seniors housing in the U.K. is strong, and it’s certainly an attractive market,” Griffin-American Chairman and Chief Executive Officer Jeff Hanson told REIT.com. “Upon closing, our portfolio will exceed $2 billion, based on aggregate purchase price.” </div> <div><img width="145" height="184" class="ms-rtePosition-2" alt="Wendy Simpson" src="/Monthly-Issue/2013/PublishingImages/0913/WendySimpson.jpg" style="margin:10px;" />The U.K. deal was valued around $448 million, according to REIT.com. </div> <div> </div> <div>But it’s not just demographic trends that are making long term care a promising investment. LTC Properties’ Simpson says that President Obama’s health care reforms—particularly the creation of accountable care organizations (ACOs)—have plenty of promise for long term care investors. </div> <div> </div> <div>“We’re seeing that our operators are getting closer and closer to the hospitals in terms of developing networks,” she says. “They’re doing more direct contracting with managed care companies, which is a little different than what they had in the past. So I think the sophistication of what you’re going to have to do at the skilled nursing properties in terms of networking with other providers is going to increase.”</div> <div> </div> <div>Indeed, AHCA’s Parkinson, speaking at a panel discussion in July, said that ACOs may well be the path to the “Holy Grail” of his profession—delivering quality care at low prices. <br></div> <h2 class="ms-rteElement-H2">Breaking Into The Business</h2> <div>Cambridge Capital President and Chief Executive Officer Jeff Davis thinks that the Affordable Care Act may be a real opportunity for long term care. </div> <div> </div> <div>“The hospitals, under the new affordable care act, have strong incentives to get people out of the hospital settings,” he says. “The nursing homes should do well, as long as you have operators that are regionally focused and never losing sight of what their mission is, which is to deliver strong care to their population. It’s really just that simple.” Over the past several weeks, interest rates have gone up, but they’re still fairly low, Davis says. </div> <div> <img width="153" height="190" class="ms-rtePosition-1" alt="Jeffrey Davis" src="/Monthly-Issue/2013/PublishingImages/0913/JeffreyDavis.jpg" style="margin:10px;" /><br></div> <div>“Refinancing is always good if you can save money by refinancing or if it satisfies another need in your business plan,” he says. </div> <div> </div> <div>Still, providers may find themselves hemmed in by circumstances because the broader markets haven’t woken up to the potential in long term care, Davis says. </div> <div> </div> <div>“In senior living, which includes assisted living, memory care, and independent living centers, there are only so many ways to put long-term, fixed debt on your building. It’s not like commercial real estate,” he says. “There are only so many ways to skin the cat.</div> <div> </div> <div>“It’s just the markets have not really embraced seniors housing,” Davis adds. “Even though everybody reads the same publications and knows the demographics are super compelling, they’ve never really figured out how to properly underwrite it. It’s just been an ongoing, constant challenge.”</div> <div> </div> <div>Despite others’ opinions, Davis says that skilled nursing centers may be under-valued as an investment because they remain “challenging, intellectually.” </div> <div> </div> <div>Many analysts are put off by their own fear of aging and death, and that gets in the way of their analyses, Davis says. </div> <div> </div> <div>As a result, long term care seems to be sealed off from the bigger investing climate, Davis says. </div> <div> </div> <div>“At the end of the day, the people that are in the business typically specialize in the business,” he says. </div> <div> </div> <div>That can make it difficult for investors “to figure out” how they should approach long term care investments, Davis says. </div> <div> </div> <div>“But once they figure it out, they’re glad they did.”<br><br><a href="/Monthly-Issue/2013/Documents/0913/FinanceSupp0913.pdf" target="_blank">PDF version</a></div>Gov. Mark Parkinson, president and chief executive officer of AHCA, says he’s not sure how much longer interest rates will be so favorable and that providers could save a lot of money if they refinance properly. 2013-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0913/finance_thumb.jpg" style="BORDER:0px solid;" />Finance;ManagementColumn9
Med Recycling Aids Needy Californianshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0913/Med-Recycling-Aids-.aspxMed Recycling Aids Needy Californians<p>​Some 150 California nursing homes have donated $1.3 million worth of medications to Santa Clara Valley Medical Center, according to SIRUM (Supporting Initiatives to Redistribute Unused Medicine), a nonprofit social enterprise that connects skilled nursing facilities with community pharmacies. SIRUM aims to halt the destruction of valuable unused medicines and redirect them to Californians who cannot afford their medications.</p> <p>“We’re extremely grateful for donations of medicine from local nursing homes and facilities around<br>the state,” said Narinder Singh, director of pharmacy services or the medical center. “With medication costs rising year after year, these donations help us extend our resources and provide safe medications to people in our community in need of our service.”</p> <p>Instead of destroying unused medications, skilled nursing facilities in Santa Clara County joined the statewide movement to donate rather than destroy their meds.</p> <p>Among the donor centers participating in the program are: Villa Siena in Mountain View; Greenhills Manor in Campbell; Sunny View Manor in Cupertino; and Mt. Pleasant Nursing Center, Amberwood Gardens, and Lincoln Glen Manor in San Jose.</p> <p>The program uses “simple, efficient matchmaking technology” to make “hundreds of donations of unused medication.” SIRUM, which is supported by the California HealthCare Foundation and the Robert Wood Johnson<br>Foundation, hopes to bring 150 more California donors on board by the end of 2014.</p> <p>“Before we started donating our unused medicine, it used to be so upsetting knowing that we<br>were destroying this valuable medicine. It was the same medicine people in our community couldn’t afford.</p> <p>“Now, thanks to this program, it’s easy for us to donate medicine a resident doesn’t need any<br>longer, because she gets well, changes medicine, or leaves the nursing home,” said Rebecca Turner,<br>administrator at Lincoln Glen Manor and SIRUM board member. Lincoln Glen was the first in the state to join the effort to donate its unused medicine.</p> <p>SIRUM enables nursing homes across the state to set up bins for reusable medicine, just like a recycling bin for bottles and cans. Medicine that can be redistributed is shipped directly to pharmacies in Santa Clara County.</p> <p>Pharmacists check all donated medicine and dispense it free of charge to local patients who cannot afford their medications. “SIRUM has been able to leverage both new laws and smart technology<br>to make it easy for organizations to donate unused medicine from anywhere in the state,” said Santa<br>Clara County Supervisor Joe Simitian.</p> <p>“By pooling these donations, SIRUM has created a successful program that reduces environmental damage, saves taxpayers money, and improves the health of our most vulnerable citizens.” </p> <p>SIRUM Co-founder Kiah Williams lauded nursing homes’ efforts to make the program successful. “Nursing facilities around the state already do so much to care for their residents,” she said. “Our program enables them to multiply and extend their impact to thousands more Californians in need of medical help—with no additional cost or effort,” she said.</p> <p>“Our vision is zero waste, where we’re able to redistribute every safe, unused medicine in the state.”<br>SIRUM is planning to expand to at least one new state next year.</p>​Some 150 California nursing homes have donated $1.3 million worth of medications to Santa Clara Valley Medical Center, according to SIRUM (Supporting Initiatives to Redistribute Unused Medicine), a nonprofit social enterprise that connects skilled nursing facilities with community pharmacies. 2013-09-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/medications_1.jpg" style="BORDER:0px solid;" />ManagementColumn9
Phoenix: Urban Sophistication In The Midst Of Both Desert And Mountainshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0913/Phoenix-Urban-Sophistication.aspxPhoenix: Urban Sophistication In The Midst Of Both Desert And Mountains<div> </div> <div><img width="191" height="287" src="/Monthly-Issue/2013/PublishingImages/0913/Desert_Botanical_Garden_AZ.jpg" class="ms-rtePosition-1" alt="" style="margin:5px 10px;" /><br>From Oct. 6 to Oct. 9, American Health Care Association/National Center for Assisted Living (AHCA/NCAL) members from around the country will converge on Phoenix for the organization’s 64th Annual Convention & Expo.</div> <div> </div> <div>From culture to mountain climbing to professional sports events, Phoenix offers visitors a bountiful buffet of recreational and entertainment options. <br></div> <h2 class="ms-rteElement-H2">Enjoy The Unique Nature</h2> <div>Far from a bleak and arid wasteland, Phoenix’s Sonoran Desert boasts blooming cacti and hillsides carpeted with wildflowers that you can explore on your own or let Hike in Phoenix take you on a guided tour. </div> <div> </div> <div>Or hike without ever leaving the city by taking advantage of Phoenix’s more than 200 miles of hiking trails. In fact, TravelNerd has named Phoenix one of the Top 10 Urban Destinations for Nature Lovers. </div> <div> </div> <div>The largest municipal park in the United States, South Mountain Park and Preserve, provides 16,000 acres of hiking, biking, and horseback trails. Other notable spots for outdoor recreation include Camelback Mountain, Estrella Mountain Regional Park, and Superstition Mountains.</div> <div> </div> <div>A number of local organizations can help visitors create the perfect outdoor adventure. Take on Desert Dog Adventures’ 4X4 “desert stormin’” extreme adventure, or let Adventures Out West take you on an off-road Segway tour. Drive your own ATV through Box Canyon in the heart of the Sonoran Desert with Arizona ATV Adventure Tours, or do it yourself and rent your own ATV; jet ski; dirt bike; sports quad; kayak; or pontoon, wakeboard, UTV, or fishing boat at Arizona Outdoor Fun.</div> <div> </div> <div>If motorcycles are more your style, choose from a wide array of rental motorcycles at Arizona Street Eagle Motorcycle Rentals. Or Cave Creek Outfitters, Ponderosa Stables, and Cave Creek Trail & Horseback Rides will help you put together the perfect horseback experience.<br></div> <div><br>For those preferring a more “civilized” outdoor experience, choose from among Phoenix’s more than 200 golf courses. <br></div> <h2 class="ms-rteElement-H2"><div>Sports Abound</div></h2> <div>Plunge into Phoenix’s abundant professional sports venues and cheer on the NBA’s Phoenix Suns or its sister team the WNBA’s Mercury, the Arizona Cardinals NFL team, the Arizona Diamondbacks major league baseball team, or the Phoenix Coyotes of the National Hockey League.</div> <div> <span><img width="367" height="261" src="/Monthly-Issue/2013/PublishingImages/0913/Cardinal-Field.jpg" alt="Cardinal Field" class="ms-rtePosition-2" style="margin:10px;" /></span></div> <div>If college sports are more your thing, there’s always the Arizona State University Sun Devils or the Grand Canyon University Antelopes. Or cut loose and whoop it up at one of the city’s two NASCAR races at the Phoenix International Raceway. <br></div> <h2 class="ms-rteElement-H2">Museums And Entertainment</h2> <div>Then improve your cultural literacy with a visit to the Heard Museum of Native American Art and Culture or, for contemporary art, the Phoenix Art Museum and Scottsdale Museum of Contemporary Art.</div> <br> <div>Kids will love the Children’s Museum of Phoenix and the Arizona Science Center. To revel in nature’s diversity, visit the Phoenix Zoo or the Desert Botanical Garden.</div> <div> </div> <div>Live music thrives in Phoenix. In fact, during the days immediately surrounding the AHCA/NCAL convention, you can see live performances from Emmylou Harris and Rodney Crowell, the Indigo Girls with the Phoenix Symphony, John Mayer, The Lumineers, the Avett Brothers, or Depeche Mode.</div> <div> </div> <div>Or throw together a sampling of different cultural experiences and watch performances of The Diary of Anne Frank and take part in the 10th Annual Ales on Rails, the Arizona State Fair, or the Way Out West Oktoberfest. <br></div> <h2 class="ms-rteElement-H2">Casual To Fine Dining</h2> <div>And, finally, don’t miss some of Phoenix’s outstanding dining experiences, such as El Chorro Lodge at the base of Camelback Mountain or the nearby Elements at the Sanctuary resort, considered by some to be the most picturesque restaurant in the area with appropriately superior cuisine.</div> <div> </div> <div><span><img width="415" height="275" src="/Monthly-Issue/2013/PublishingImages/0913/Downtown_Streets_AZ.jpg" alt="Downtown Phoenix" class="ms-rtePosition-1" style="margin:10px;" /></span>For a dining experience reflective of Phoenix’s own history and culture, try Kai, the only five diamond Native American restaurant in the world. Or for something less formal, try the Pizzeria Bianco, said to make the best pizza in the country, or take the advice of locals, who say Mexican restaurant Los Dos Molinos is the city’s best-kept secret. <br></div> <div> America’s sixth-largest city, Phoenix, offers world-class restaurants, resorts, spas, stadiums, and arenas against a breathtaking mountain and desert backdrop with the Grand Canyon itself just around the corner. Don’t miss the opportunity to taste the American West at its best. </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em></div> <div> </div> <div><em>Author sources: Phoenix Convention and Visitors Bureau, the Phoenix Chamber of Commerce, and various individual websites listed below.</em></div> <div> </div> <div>For More Information</div> <div><ul><li><strong> <a href="http://www.visitphoenix.com/special-offers/coupons/index.aspx" target="_blank">Phoenix travel coupons</a></strong> </li> <li><strong><a target="_blank" href="http://www.visitphoenix.com/things-to-do/outdoor-activities/air-activities/index.aspx">Hot air balloon tours    </a>                                            <img width="279" height="209" class="ms-rtePosition-2" src="/Monthly-Issue/2013/PublishingImages/0913/Hot_Air_Balloons_and_Saguaro_AZ.jpg" alt="" style="margin:5px;" /><br></strong> </li> <li><a target="_blank" href="http://phoenix.gov/parks/trails/outdoor/familyhikes/index.html"><strong>Phoenix hiking trails</strong></a></li> <strong> </strong><li><a href="http://phoenix.gov/parks/trails/locations/camelback/index.html" target="_blank"><strong>Camelback Mountain </strong></a></li> <li><a target="_blank" href="http://www.hikeinphoenix.com/"><strong>H</strong><strong>ike in Phoenix</strong></a><strong> </strong></li> <strong> </strong><li><a href="http://http//phoenix.gov/parks/trails/locations/south/index.html" target="_blank"><strong>South Mountain Park and Preserve</strong> </a></li> <li><strong><a target="_blank" href="http://www.arizona-horses.com/">Ponderosa Stables</a></strong> </li> <li><strong><a target="_blank" href="http://www.azadventures.com/">Desert Dog Adventures</a></strong></li> <li><strong><a target="_blank" href="http://http//phoenix.gov/parks/trails/locations/piestewapeak/hikingmap/index.html">Phoenix Mountain Preserve</a></strong> </li> <li><strong><a href="http://www.phxart.org/" target="_blank">Phoenix Art Museum</a></strong></li> <li><strong><a target="_blank" href="http://www.azscience.org/">Arizona Science Center</a></strong> </li> <li><strong><a target="_blank" href="http://childrensmuseumofphoenix.org/">Children’s Museum of Phoenix</a></strong> </li> <li><strong><a target="_blank" href="http://www.dbg.org/">Desert Botanical Garden</a> </strong></li> <li><strong><a href="http://www.visitphoenix.com/where-to-eat/40360/pizzeria-bianco/details.aspx">Pizzeria Bianco</a></strong> </li> <li><strong><a>Kai restaurant</a> </strong></li> <li><strong><a href="http://www.visitphoenix.com/where-to-eat/40321/los-dos-molinos/details.aspx">Los Dos Molinos</a></strong> </li></ul></div> <div> </div>From culture to mountain climbing to professional sports events, Phoenix offers visitors a bountiful buffet of recreational and entertainment options. 2013-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0913/conv_az_thumb2.jpg" style="BORDER:0px solid;" />Caregiving;Management;Policy;QualityColumn9
ACOs: A Look At What Works for Nursing Home Providershttps://www.providermagazine.com/Monthly-Issue/2013/Pages/0913/ACOs-a-Look-at-What-Works-for-Nursing-Home-Providers.aspxACOs: A Look At What Works for Nursing Home Providers<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><img width="320" height="316" class="ms-rteImage-0 ms-rtePosition-2" src="/Monthly-Issue/2013/PublishingImages/0913/coverstory.jpg" alt="" style="margin:5px 15px;" />Inspiration can sometimes be found in unlikely places. For Shea Family, a long term and post-acute care provider in southern California, shipping giants FedEx and UPS sparked an idea that led to the company’s new admissions process. Although a seemingly improbable source of inspiration for Shea, examining the supply-chain experts taught them how to more efficiently manage their patient admissions. </div> <div> <br>“One thing we did was step back and say, ‘Who manages a continuum well?’ And, guess what? FedEx and UPS understand how to manage a continuum,” says Ken Lund, president and chief executive officer (CEO) of Shea. “It may be a package but it’s still following somebody or something through a life cycle, and that’s when we centralized our admissions.”</div> <h2 class="ms-rteElement-H2">Shea Makes Shift</h2> <div>Lund’s revelation helped to drive a key change in Shea’s operations: It shifted from managing admissions at each level within the company to managing the process via a centralized database. “All skilled, assisted living, home health, and transportation admissions go to our logistics center now,” Lund says. “So instead of a dozen phone numbers for prospective residents to call, they now call a single number.”</div> <div> </div> <div>Process changes and efficiency improvements like this one helped Shea position the company to become the primary post-acute care partner to the Pioneer Accountable Care Organization (ACO) in the San Diego area. </div> <div> It was not an easy feat.</div> <div> </div> <div>Lund says it’s taken years of slow, steady changes in everything from purchasing incontinence supplies to tweaking nurse hours to get to a balance of improved outcomes and efficiencies. </div> <div> </div> <div>“It’s been an expensive and painful learning experience for everyone—from ownership down to any level of the organization,” says Lund. </div> <div> </div> <div>It has been painful, he says, because they’ve had to find every way possible to change a multitude of processes that helped the company meet the needs of the ACO as well as the customer.</div> <div> </div> <div>Established by the Patient Protection and Affordable Care Act (ACA), ACOs are groups of doctors, hospitals, and other health care providers who combine their efforts to voluntarily give coordinated, high-quality care to Medicare patients. The goal of ACO programs, according to the Centers for Medicare & Medicaid Services (CMS), is to ensure that patients, especially those with chronic illnesses, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. </div> <div> </div> <div>If this model sounds a bit like managed care, it is. A number of ACOs are modeled after managed care. But there is a difference between the two: Medicare ACO patients must remain fee-for-service, which means they retain the ability to choose their own provider, regardless of any network that may exist. In a managed care model, networks are closed.<br><br></div> <div>There are three types of <a href="/Monthly-Issue/2013/Pages/0913/ACOs-In-Brief.aspx">Medicare ACO programs</a>: Shared Savings, Advance Payment, and Pioneer. <br></div> <h2 class="ms-rteElement-H2">Why The Fuss Over ACOs?</h2> <div>A recent study of ACOs by Oliver Wyman, an international management consulting firm, found that successful ACOs will be game changers. </div> <div> </div> <div>“They won’t just siphon patients away from traditional providers and attract the attention of payers, employers, and partner organizations. They will change the rules of the game in the regions where they operate, leading purchasers to expect lower costs, higher quality, and greater patient satisfaction,” the study says. “As that happens, there will be a race to adopt the best models. Providers that fail to do so—or that commit halfheartedly to real change—will stand no chance.”</div> <div> </div> <div>Backing up its claims, the Wyman study found that about 14 percent of the population—almost one in seven Americans—is now in an organization with an ACO arrangement. What’s more, more than 40 percent of Americans live in areas with at least one ACO, while 28 percent of the population lives in a community with two or more ACOs in it. </div> <div> </div> <div>“The shift to accountable care is a massive opportunity, and many providers, payers, and enablement companies have already invested millions of dollars in transforming, becoming, incentivizing, and supporting ACOs,” Wyman said. “We cannot ignore how the ACO movement has already earned the confidence of these sophisticated players across the health care system.</div> <div> </div> <div>“For those who intend to be part of tomorrow’s market, it is time to move quickly, even for organizations that have already given up the chance to be first. The data are clear: The fight for tomorrow’s health care market has already begun.”</div> <div> </div> <div>Adding to the quantity argument are some data on quality. In July, CMS announced “positive and promising results” from the first performance year of the Pioneer ACO model “that have the potential to impact post-acute care providers in a major way.”</div> <div> </div> <div>The results are impressive: higher-quality care and lower Medicare expenditures. </div> <div> </div> <div>“ACOs, including the Pioneer ACO Model and the Medicare Shared Savings program, are one way CMS is providing options to providers looking to better coordinate care for patients and use health care dollars more wisely,” CMS said in a press release on the results.</div> <div> </div> <div>“These results show that successful Pioneer ACOs have reduced costs for Medicare and improved the quality of care for their patients,” said CMS Administrator Marilyn Tavenner. <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">ACOs And Post-Acute Care</h2> <div>Why are ACOs important to post-acute care providers? At the center of a successful ACO is care coordination throughout the continuum of care, and in order to succeed, ACOs will have to determine continuum-wide, cost-effective care pathways; implement best practices in transitions; and engage patients and families in their own care, said Jared Landis, senior consultant for the post-acute care collaborative with the <a href="http://www.advisory.com/" target="_blank">Advisory Board Co</a>., during a webinar on the topic this past March.</div> <div> <img class="ms-rtePosition-1" alt="Jared Landis" src="/Monthly-Issue/2013/PublishingImages/0913/JaredLandis.jpg" style="margin:10px;" /><br></div> <div>“The ACO model is no longer a mythical concept,” Landis said. “I think for so long it was a bit of a unicorn in the health care space, where we heard lots of talk about it but had very little idea what it actually looked like practically. That’s no longer true. ACOs are cropping up in nearly every market in the U.S.” Since ACOs are responsible for keeping the total cost of care for their patients under a predetermined threshold, Landis said, they are likely to want control of the spectrum of care in some manner. </div> <div> </div> <div>“Hence, the mindset shift from managing episodes of care to managing the full gamut of care,” Landis said. </div> <div> </div> <div>Although some hospitals have acquired post-acute care provider groups, “most will be looking at tighter integration, not acquisition.” </div> <div> </div> <div>Landis pointed to the Michigan Pioneer ACO, which includes Detroit Medical Center, as an example of what’s in store with regard to innovative arrangements. The medical center recently contracted with Hospice of Michigan to support patients with advanced illnesses in its system. The hospice will provide customized care and will share in some of the savings.</div> <div> </div> <div>“This reflects a broader theme in the market where ACOs are turning to post-acute care organizations to provide geriatric care management—a new skill for many ACOs, but where post-acute providers have significant experience,” said Landis. </div> <div> </div> <div>In addition, hospitals will continue to develop affiliations to create tighter referral networks, he added. </div> <div>In Massachusetts, where there are five Pioneer ACOs, there exists a very close collaboration between post-acute providers and ACOs, but across the country relationships between the two entities run the gamut, says James Michel, director of Medicare research and reimbursement at the American Health Care Association (AHCA).</div> <div> <br>“We’ve seen in Massachusetts a very close collaboration with ACOs, in which they have jointly developed expectations. It encompasses not only what the ACO requires of the SNF [skilled nursing facility] provider, but what the SNF requires of the ACO.”</div> <div> </div> <div>This kind of two-way conversation is the more preferred, more sophisticated kind of approach, says Michel. “But we’ve seen, on the other hand, ACOs that just send applications to SNF providers in their referral markets saying, ‘You need to get your length of stay to this, you need to get readmissions down to this,’ with no basis, no collaboration, no anything,” he says.</div> <div> </div> <div>“In some cases, they have said, ‘If you don’t do this, you’re not in the network.’ Because we’re seeing those extremes, we know there’s a lot of in between happening. But it isn’t defined.”</div> <div> </div> <div>To avoid this issue, Michel suggests that providers would be wise to proactively engage ACOs in discussions around performance expectations early. <br></div> <h2 class="ms-rteElement-H2">In Massachusetts, Lots To Do </h2> <div>The ACO environment in the Bay State may be highly collaborative but post-acute providers nonetheless have their work cut out for them. </div> <div> </div> <div>Tara Gregorio, vice president of government relations for the <a href="http://www.maseniorcare.org/" target="_blank">Massachusetts Senior Care Association </a>(MSCA), estimates that at least 40 percent of the state’s Medicare beneficiaries are part of a federal ACO, whether it be one of the five Pioneer ACOs in the state or 12 Shared Savings ACOs. </div> <div> </div> <div>“This number will only grow,” she says, noting that she and her colleagues are engaged in an ongoing effort to educate and assist member providers about ACOs. </div> <div> </div> <div>“There will continue to be increased pressure for skilled nursing centers to be clinically prepared to care for higher-acuity patients for a shorter period of time,” says Gregorio. “In addition, facilities will need to provide data to ACOs, hospitals, and payers to demonstrate high quality, efficiency, and customer satisfaction.”</div> <div> </div> <div>Provider groups in the state have convened a Payment Reform Task Force that meets at least monthly in an effort to work with the Pioneer ACOs and skilled nursing centers to develop strategies for quality post-acute care, says Gregorio. “This month, we will begin the difficult work of developing measurements for the skilled nursing facility strategies, and we expect the Pioneers to initially focus on developing rehospitalization and length-of-stay measures.”<span></span></div> <div> </div> <div>Also on the agenda for MSCA is the development of model legal principles to give providers the background they need to make informed decisions regarding contracting with ACOs for payment or quality initiatives. MSCA will release the document as a series of education programs this month. </div> <div> </div> <div>Gregorio points to analytics as another key component of their work with ACOs. “Data is certainly king in this evolving health care system,” she says. MSCA has contracted with both Tufts University and PointRight on “critical data analytics that we need to inform health policymakers.” </div> <div> </div> <div>Tufts provided MSCA with data on the potential savings that could be realized by eliminating the Medicare three-day stay rule. “The data show that eliminating this nearly 50-year-old policy could save more than $450 million,” Gregorio says. “PointRight provided important data for us on length-of-stay drivers, which will be enormously helpful in our discussions with the Pioneer ACOs on a length-of-stay measurement.”</div> <div> </div> <div>To that end, Gregorio says MSCA is in the process of organizing an analytical education program in the fall to assist its members in measuring critical data elements that are important to ACOs, hospitals, and payers. <br><span id="__publishingReusableFragment"></span><br></div> <h2 class="ms-rteElement-H2">Smells Like Managed Care</h2> <div>Managed care is not new to Arizona. In fact, it has become ubiquitous within the Grand Canyon State, and so the entry of ACOs is not sounding alarm bells, but it has been eyed with both optimism and caution. </div> <div> </div> <div>“The state has been operating in an ACO-like environment for some period of time, and this is just another overlay to a very complex managed care environment serving dual eligibles,” says Kathleen Collins Pagels, executive director of the <a href="http://www.azhca.org/" target="_blank">Arizona Health Care Association</a>.  </div> <div> <img width="139" height="182" class="ms-rtePosition-1" alt="Kathleen Collins Pagels" src="/Monthly-Issue/2013/PublishingImages/0913/KathleenCollinsPagels.jpg" style="margin:10px;" /><br>“ACOs have a lot of similarities to managed care, and it creates a competitive environment as well as a climate of preferred partnerships. And our concern is that all our members are able to benefit from the existence of ACOs. I would say we consider it an opportunity as well as a challenge here in Arizona because it is a new framework for care delivery.”</div> <div> </div> <div>In terms of preparing her members to contend with ACOs, “for us it’s more like business as usual than in other states because there is already a climate in Arizona of preferred partnerships with hospitals and post-acute providers,” she says.</div> <div> </div> <div>Some ACOs have aligned with providers to create more of a system, so the organization is working with providers to protect the choice of beneficiaries to go to any skilled nursing center. <span><span></span></span></div> <div> </div> <div>“Our concern is protecting resident choice,” Collins Pagels says. </div> <div> </div> <div>California is another state that has a history of managed care. “ACOs are another component of managed care initiatives that will change the post-acute care industry,” says Nancy Hayward, assistant director of reimbursement for the <a href="http://www.cahf.org/">California Association of Health Facilities </a>(CAHF). “This is just another name for similar models that are currently operating in California.” <br></div> <h2 class="ms-rteElement-H2">California Providers Take It In Stride</h2> <div>To that end, CAHF is focused on helping its members get in touch with local managed care health plans as opposed to the large ACOs, says Deborah Pacyna, director of public affairs. “Although the same strategies apply.” </div> <div> </div> <div>For providers who need help with contract negotiations, CAHF has a dedicated Web page that includes contact information for health plans, a contract checklist, and a contract toolkit to help them with their individual negotiations. </div> <div> </div> <div>Hayward is also relatively calm about the impact of ACOs on providers, but that may be because she’s prepped her members. “For the past two years, we’ve been telling members to prepare for managed care that will be implemented by multiple initiatives. And at the local level, individual skilled nursing centers are being quietly invited to the ACO tables,” she says. “They are entering into a competitive market that will be data-driven, so we’ve asked them to get to know their average length of stay for different types of patients, readmission rates, and costs to provide care so that they can negotiate adequate rates.” </div> <div> </div> <div>Hayward also advised her members to work on improving their Five-Star ratings, upgrading their centers’ appearances, and to prepare to accept admissions 24/7. In short, ACOs are data-driven and looking for partnerships with skilled nursing centers that have “outstanding performances,” she says.</div> <div> </div> <div>Shea’s Lund recognized this fact several years ago and has prepared his company accordingly. “Hospitals are very sophisticated in terms of data management,” he says. “The big systems—the Sharps and Kaisers of the world—they know their data.”</div> <div> </div> <div>And while Shea is not as sophisticated as the big hospital systems, Lund says the company is getting there. “We’re much more sophisticated than we were,” he says. And because we’re more sophisticated, we’re able to drill down on multiple indicators.” <br><span id="__publishingReusableFragment"></span><span><span><span></span></span></span><br></div> <h2 class="ms-rteElement-H2">Data & Efficiencies: Getting The Right Balance</h2> <div>All of the process and preparation has made Shea a better company, especially in terms of managing resources, Lund contends. But it hasn’t been easy. “A lot of industries have benchmarks that you can point to, but those aren’t available in long term care; it doesn’t necessarily exist in our industry. So you have to develop your own benchmarks,” he says. “Why would a company do this? Because if nothing else, you say ‘here’s where we are today, we’ve got to do better.’ And you start implementing some processes and techniques for a quality improvement process. So whatever the metric is, you say, ‘if it’s $2.00 day, let’s make it better tomorrow.’ But the minute outcomes are slack or go south, you’ve pushed too hard. The really, really good thing about this is we’ve become intensely more efficient. We’ve been able to balance outcomes and efficiencies.”</div> <div> </div> <div>Meeting customers’ needs is another theme that Lund and Shea Family have embraced. Lund also believes the customer has changed dramatically, “seemingly overnight,” he says, “even though the writing has been on the wall for decades.” </div> <div> </div> <div>Over the past three years, he and his team have been prepping for this new customer. In addition to centralizing admissions, Lund describes a slew of other initiatives that have primed his company’s entry into the world of ACOs. </div> <div> </div> <div>In a strategic customer-oriented move, Shea boosted its ACO curb appeal by diversifying. “When I joined in 2010, we were skilled nursing, period,” says Lund. “Today, my single largest operation is in-home services.”</div> <div> </div> <div>For Shea, in-home services include retrofitting homes for Americans With Disabilities Act compliance and similar modifications that enable individuals to stay in their homes longer. “We’ll put ramps in, we’ll put grab bars in, we’ll widen doorways, those types of things,” says Lund. “That’s not a service that skilled nursing provides.”</div> <div> </div> <div>Indeed, it is not a typical skilled nursing service, but it is a service that has served Shea well, especially with regard to its involvement in the local ACO. <span><span><span><span></span></span></span></span></div> <div> </div> <div>“We don’t mind where a patient goes within our system; we want what’s best for our patient. And so, what we’re saying is that the physician and the family need to make a decision about where the patient should go, and whatever decision they make, we can create that solution,” Lund says. To that end, Shea also created a transportation company that takes residents where they need to go from any of its buildings. </div> <div> </div> <div>“So in-home services means more about learning to say yes and filling a need than it is about providing health care,” says Lund. “And health care becomes a menu option in that business.”</div> <div> </div> <div>Lund’s advice for post-acute providers: “Develop some thick skin, be patient, and know that your numbers and your revenue model change because it goes from being a sales process in a transaction to a sales process based on a systems approach.” </div> <div> </div> <div>It goes from being focused on individual buildings to more of a logistic model to managing someone through a continuum rather than an episode, Lund explains.</div> <div> </div> <div>Lund also cautions that the model providers have used for decades won’t work in the future. “Maybe one of the most interesting things I’ve learned in this process is to look outside our industry [a la UPS and FedEx]. There are enormous lessons to be learned by looking at industries that have been forced into consolidation, such as agriculture and banking. There are lots of non-health care industry examples that we looked into.”</div> <div> </div> <div>The results speak for themselves: “We’ve proven in our ACO partnership that we can deliver equal or better outcomes based on CMS’ definition of reduced length of stay and reduced readmissions,” says Lund. “And on a limited number of quality indicators, we delivered equal or better outcomes and reduced the readmission rates from the mid-20s down to the 10 percent range.”</div> <div> </div> <div><div>Also notable is that Shea cut its patients’ average length of stay down to 12 or 13 days from about 30. </div> <h2 class="ms-rteElement-H2">Advice For Providers: Know The ACO Landscape</h2></div> <div>It’s not too late for post-acute providers to get into the game. In order to do so successfully, they need to be paying attention to what’s happening in their referral markets, says AHCA’s Michel. “They need to know their own landscape with ACOs in their states.”</div> <div> </div> <div>Michel advises providers to do the following to prepare for ACO involvement: “Identify which providers in your market are in ACOs, find out what they’re looking for, and set up internal processes to be able to track data against what they’re looking for,” he says.</div> <div> </div> <div>“We know, based on members’ experiences, what most hospitals are looking for: rehospitalization/<br>readmission rates and lengths of stay.”</div> <div> <span><span><span><span><span><img width="134" height="193" class="ms-rtePosition-2" alt="James Michel" src="/Monthly-Issue/2013/PublishingImages/0913/JamesMichel.jpg" style="margin:10px;" /></span></span></span></span></span></div> <div>The percent of patients in ultra-high Resource Utilization Groups (RUGs), or RUGs distribution; sophisticated staffing and turnover data; ease of access; and admissions are some other key areas that ACOs are considering. </div> <div> </div> <div>Providers interested in prepping for ACOs should have conversations with their referral sources, Michel suggests. “Ask them what they want to see. Think about how you can make yourselves attractive. And if hospitals are thinking about it but haven’t come to you, maybe go to them with reports and say, ‘this is how we’re doing relative to our competitors,’” says Michel. </div> <div> </div> <div>Lund believes that ACOs aren’t an end in and of themselves. </div> <div> </div> <div>“They are the beginning,” he says. “People need to get that ACOs are just a point in the journey. Two years ago no one wanted to talk about managed care, and now ACOs have hit the Holy Grail. It’s just a point on the journey; it doesn’t matter whether ACO as an entity or concept survives, it’s still managed care.”</div> <div> </div> <div>For Gregorio in Massachusetts, the road ahead has its share of challenges and unknowns, she says. “Particularly when we begin thinking about global payments and the state’s Jan. 1, 2017, mandate that all health care providers have interoperable electronic health records.” </div> <div> </div> <div>But there is also great opportunity. </div> <div> </div> <div>Skilled nursing facilities continue to demonstrate high-quality patient care at a lower cost and are focused on safe, appropriate discharges to the community, Gregorio says. </div> <div> </div> <div>“This will ultimately save the system money, improve patient access to quality care, and improve satisfaction, thus meeting the goals of the ‘Triple Aim’ of better care, better health, and lower cost.” </div> <div> </div> <div>For more information on ACOs, go to <a href="http://www.cms.gov/aco/" target="_blank">www.cms.gov/aco/</a></div> <div>To find the 23 Pioneer ACOs, go to:<a href="http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/index.html" target="_blank">http</a><span>://innovation.cms.gov/initiatives/Pioneer-ACO-Model/index.html</span></div> <div>ACO resource for AHCA Members: <a href="http://www.ahcancal.org/advocacy/Pages/AccountableCareOrganizations.aspx" target="_blank">http://www.ahcancal.org/advocacy/Pages/AccountableCareOrganizations.aspx</a></div>Established by the Patient Protection and Affordable Care Act (ACA), ACOs are groups of doctors, hospitals, and other health care providers who combine their efforts to voluntarily give coordinated, high-quality care to Medicare patients. The goal of ACO programs, according to the Centers for Medicare & Medicaid Services (CMS), is to ensure that patients, especially those with chronic illnesses, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. 2013-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/0913/cs_thumb.jpg" style="BORDER:0px solid;" />Management;Quality;Quality Improvement;Policy;CaregivingCover Story9

October



 

 

Zeroing In On Incontinence Care Managementhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/1013/Zeroing-In-On-Incontinence-Care-Management.aspxZeroing In On Incontinence Care Management<p></p> <div> </div> <div> </div> <div><span><img class="ms-rtePosition-1" alt="achieving continence" src="/Monthly-Issue/2013/PublishingImages/1013/caregiving_incontinence.jpg" width="435" height="316" style="margin:5px 15px;" /></span>Post-acute care providers are functioning in a world of regulatory acronyms: QAPI, QIS survey, ZPIC, PPS, CERTs, UPICs, ACOs, and more, including programs to improve transitions of care and reduce rehospitalization rates. </div> <div> </div> <div>Operational managers and clinical leadership in nursing homes are evaluating services, training, risks, and outcomes, as well as database content, on a daily basis to monitor outcomes for the elders they serve. </div> <div> </div> <div>The issue of incontinence management and treatment related to incontinence is central to most of these activities and must be properly identified, treated aggressively, and monitored continuously to eliminate unnecessary cost and negative outcomes. This focus requires participation from operations, clinical staff, therapy, social services, direct caregivers, and families.</div> <h2 class="ms-rteElement-H2">Continence Care Must-Haves</h2> <div>The issue of incontinence management is not new at all and has been a frequent topic of discussion for interdisciplinary team members in care conferences, team meetings, and when discussions of risk management and outcomes arise. </div> <div> </div> <div>The current environment in post-acute care requires a more specific approach and understanding of the definitions in the minimum data set 3.0 (MDS), as well as coordination between related departments, to work to reverse levels of incontinence, when possible, and to minimize the negative outcomes for elders, including rehospitalizations and deterioration in quality of life. </div> <div> </div> <div>Facilities are now more accountable for the data they transmit on the MDS because of the data references used by state surveyors, policy processes, and payment programs. This is a very expensive and common issue that facilities need to strive to understand, properly manage, and document, especially with regard to the impact of their interventions and programs.</div> <div> </div> <div>When looking at the definition of continence in the resident assessment instrument (RAI) manual, May 2013 revision, it does not match the working definitions found in the majority of facilities. According to the MDS 3.0, continence is “total control of the release of urine or stool.”</div> <div> </div> <div>This means that an elder who has stress or effort-related incontinence (urine leakage with a cough or change in position) should be coded as incontinent on the MDS.</div> <div> </div> <div>The current Centers for Medicare & Medicaid Services (CMS) MDS frequency reports for the first quarter of 2013 show that 23.9 percent of all elders in skilled nursing facilities are totally continent. </div> <div> </div> <div>This is a statistic that is just simply not true.</div> <div> </div> <div>A review of F-Tag 315 uses the same definition and then goes on to explain the negative impact that any level of incontinence has on elders in the skilled nursing environment, with a focus on the identification of the type of incontinence, its cause, and treatment. Quality of life and quality of care are the goals, with an individualized approach that is undertaken by the entire team, as well as the family, when possible. </div> <h2 class="ms-rteElement-H2">Restorative Program Required</h2> <div>Today, a significant number of facilities do not have active restorative programs that include toileting and retraining. Many have very little coordination between nursing and therapy for bladder and bowel retraining, while some have poor documentation of in-depth quality assessments at the time of admission to determine the true level of continence prior to hospitalization and after-hospitalization. </div> <div> </div> <div>These are all important factors in the development of an active program to identify and reverse incontinence whenever possible. Elders must also be asked if they want to be continent and have control of their elimination. </div> <div> </div> <div>According to an 80-year-old resident, newly admitted to a nursing home for rehab after a hip repair surgery, “I know I needed to have my hip repaired, but I did not sign up for this .... [having to wear a brief because of functional incontinence after urinary catheter removal]. I want my rehab to include help with my incontinence.”</div> <div> </div> <div>The demographics of customers are changing, and the programs need to be there to meet their needs. These are elders who want to go back to their active, positive lives in the community—without incontinence. Nursing centers need to have excellent assessment programs and documentation at the time of admission and be open and interactive about the status of continence. </div> <div> </div> <div>It is important to initiate retraining or scheduled toileting programs, as well as involving therapy, with strengthening and activities of daily living programs, combined with resident and family education, to support the goals and interventions in the plan. <br></div> <h2 class="ms-rteElement-H2">Assessment Essentials</h2> <div>Careful assessment and identification of the cause(s) of incontinence are the essential first steps for appropriate and successful management. This assessment needs to involve several disciplines, including therapists, nurse practitioners, nurse assistants, nursing staff, medical directors, and dietary staff. </div> <div> </div> <div>Assessment should be done at the time of admission to the facility and at any change in bladder and bowel status. The first step is determination and documentation of incontinence history on or before the time of admission. Staff should determine the resident’s continence status prior to admission or determine whether it occurred with the present illness, since urinary incontinence (UI) could be of several years’ duration. This requires a conversation with the elder or family</div> <div>members. </div> <div> </div> <div>Although UI is not a normal part of aging, there are age-related changes in the lower urinary tract, such as that the greatest volume of urine is excreted at night, with two-thirds of daily fluid intake being produced by the kidneys at night. Bladder capacity is diminished with poor bladder emptying, and bladder sensations changes with age, causing a delay in desire to void, leading to bladder frequency. </div> <div> </div> <div>Mental, functional, and environmental assessments are vital to the success of a restorative program. Cognition should be assessed to determine the ability of the resident to comprehend voiding needs. Knowing when the onset of lower urinary tract symptoms occurred, including urgency, frequency, nocturia, dysuria, post-void dribbling, and episodes of urine leakage, is important. The relationship between UI and medication use and medical diagnoses, such as diabetes, neurologic diseases, such as Parkinson’s or multiple sclerosis; prostate problems in men, such as cancer or benign prostatic hyperplasia; and chronic urinary tract infections, especially in women, should be detailed. </div> <div> </div> <div>Facility nurses should perform a thorough bowel history of the resident to determine symptoms of constipation, fecal incontinence, and the use of laxatives, stool softeners, suppositories, and enemas. Per the MDS 3.0, an elder’s voiding and bowel pattern and frequency of incontinence should be assessed, so observation of toileting can be helpful. </div> <div> </div> <div>In addition, nurses should perform a general examination to determine peripheral edema and gait abnormalities that may impact toileting, while an inspection of the genitalia should also be done to determine skin breakdown. </div> <div> </div> <div>Assessments should lead to a plan of care. The classification of continence, as seen in Figure 1 (see page 63), outlines components of continence management. Centers should have well-defined policies and procedures to initiate and document toileting programs with nursing and therapy. <br></div> <h2 class="ms-rteElement-H2">Determine Staff Knowledge</h2> <div>Facility staff members need to address their knowledge of the topic and develop appropriate documentation skills to identify the type and frequency of incontinence at the point of admission, or before, as part of the key information they need to care for the elder. </div> <div> </div> <div>Using the appropriate definitions for all staff and transmitting the accurate data into the MDS 3.0 database is the first step to create an accurate facility record.</div> <div> </div> <div>Reading the facility database reports on the initial levels of continence, followed by subsequent changes in levels of continence as rehab and nursing services improve the resident’s function, gives the manager access to reportable outcomes. </div> <p></p> <p></p> <div> </div> <div>The outcomes of an active continence management program are very easy to identify and document. </div> <div> </div> <div>If the MDS data are accurate, then tracking levels of success with toileting, ambulation, and balance programs—along with the goal of safely going to the bathroom; getting on and off the commode; control of muscles involved in elimination; and improved dignity, strength, and function—should  be straightforward.</div> <div> </div> <div>Changes in ADL (activities of daily living) scores and symptoms of depression, as well as reduced rates of falls, can all be outcomes that are reportable and desirable in the data-driven world providers work in today. More independence decreases the stress on staff and lessens product use or the type and cost of products. </div> <div> </div> <div>With regard to payment in case-mix states, restorative programs have a positive impact on Medicaid rates and support Part A rates with the use of the low rehab category after high- intensity rehab is completed.</div> <h2 class="ms-rteElement-H2">Incontinence Products</h2> <div>Nursing homes need to evaluate their current products and the variety of sizes and types of products they use. It is essential to have incontinence products that are properly sized, with a variety of types available as the retraining program progresses. <br></div> <div><br>Staff education and training is also essential to delivering toileting programs, documenting outcomes, and elders’ responses. A toileting or retraining program should never be done to an elder, it should be done with the elder. </div> <div> </div> <div>Scheduled toileting programs can be designed and delivered for elders with memory loss to diminish the number of incontinent episodes and develop a habit of voiding that matches the elder’s intake and activity patterns. </div> <div> </div> <div>Proper reporting and documentation should include the outcome of a toileting program and the types and sizes of products used so that the care is consistent and connects with the plan. This will have a positive impact on survey outcomes. </div> <div> </div> <div>Remember, the goal here is increased quality of care and quality of life for the elder, as well as a reduction of risk of falls, behavioral outbursts, moisture-associated skin damage, skin breakdown, and dignity issues. <br></div> <h2 class="ms-rteElement-H2">How To Get Started</h2> <div>It’s a good idea to begin with the CMS definitions and the staff’s knowledge base about continence and incontinence. Use the RAI Manual May 2013 definitions and the October 2013 updates. Assess bladder control issues at the point of admission, and inquire about the level of continence prior to taking a resident to the hospital. Focus on an accurate three-day voiding diary, and build toileting programs from that documentation. Involve the resident and family when appropriate, remembering that it is a matter of involving the resident with the program and not forcing it upon them.</div> <div> </div> <div>Develop policies and processes for toileting programs, and include education for all clinical staff so programs can be delivered on all shifts with accurate documentation. Include the toileting program and need for muscle strength and retraining with rehab services. Analyze the data, and know what the database says about the issues and outcomes. Look for cost savings, improved outcomes, and increased customer satisfaction. </div> <div> </div> <strong> </strong><div><em><strong>Leah Klusch RN, BSN, FACHCA, </strong>executive director, the Alliance Training Center, Alliance, Ohio, can be reached at <a target="_blank" href="mailto:leahklusch@sbcglobal.net">leahklusch@sbcglobal.net</a>. <strong>Diane Newman, DNP, ANP-BC, FAAN,</strong> co-director of the Penn Center for Continence and Pelvic Health, can be reached at <a href="mailto:diane.newman@uph5.upenn.edu">diane.newman@uph5.upenn.edu</a>.</em></div> <p></p>Facilities are now more accountable for the data they transmit on the MDS because of the data references used by state surveyors, policy processes, and payment programs. 2013-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/1013/caregiving_thumb.jpg" style="BORDER:0px solid;" />Caregiving;ClinicalSpecial Feature10
How To: No-Fear Surveyshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/1013/How-To-No-Fear-Surveys.aspxHow To: No-Fear Surveys<br><p><img width="164" height="217" class="ms-rtePosition-2" alt="Kevin McElroy" src="/Monthly-Issue/2013/PublishingImages/1013/Kevin_mgmt.jpg" style="margin:10px;" />There are good surveys and not-so-good surveys. But one thing is true: Good surveys don’t happen by accident. They are the result of continuous planning, ongoing education, and keeping a razor-sharp focus on quality outcomes.<br><br>Especially with regard to the Centers for the Medicare & Medicaid Services Five-Star rating system, a good or bad survey can greatly impact a nursing center’s reputation in the community. And while it may not be rocket science, following some basic steps can help long term and post-acute care providers achieve their desired outcomes: good annual surveys. <br><br>Following are some tips for making this happen:<br><br><strong class="ms-rteForeColor-1">1. </strong>There is no such thing as “time to get ready for survey.” If a nursing home’s survey window is open and staff are just starting to review plans, they are already behind the eight-ball. Communities need to be ready for a survey 365 days a year. Think about it—the facility could be surveyed at any time (such as a complaint investigation). A good mantra for the team is, “Doing the right thing for our residents, every day!” Focusing on doing the right thing every day, 365 days a year, and not just because a “survey is coming,” puts the community one step ahead of the rest. <br><br><span class="ms-rteForeColor-1"><strong>2.</strong></span> First impressions matter. If the surveyors have a good first impression when they walk in the door, it can help set the tone for the entire survey. But if they walk in and the team is not prepared, there are odors, the community is not clean, and the team is not smiling and friendly, that will set the mood for a disappointing survey. <br><br><span class="ms-rteForeColor-1"><strong>3.</strong></span> Have the survey book updated and ready to go. This is a book that has everything in it the surveyors would want when they walk in the door, such as med pass times, activity calendars, and resident demographics. Unsure about what goes into a survey book? Check with the state nursing home association for a guide. Being prepared and organized will go a long way to starting off on the right foot. Grab a new three-ring binder; get an index together; and make sure the book is neat, organized, and easy to follow.<br><br><strong class="ms-rteForeColor-1">4.</strong> Review the center’s quality indicator/quality measure data. Surveyors are using these data to see where the center is and which residents will be picked for their survey sample, before they even walk through the door. But all nursing homes have access to the exact same information anytime they want it (usually, the minimum data set coordinator can print out copies). Consider pulling and reviewing, on a monthly basis, and as a team, the facility-level and resident-level quality measure reports. They clearly indicate where the weak areas are and which residents may trigger more quality measures that could cause them to be chosen by the survey team for review.<br><br><span class="ms-rteForeColor-1"><strong>5.</strong></span> Set and communicate goals. Ask 10 people what their idea of a good survey is and there would likely be 10 different answers. In order for a team to move in the same direction, they all have to have a clear picture of what they need to accomplish—be it reducing tags by 50 percent, compared with the previous year; having no quality-of-care or G-level tags; or a deficiency-free survey—set goals that are clear, measureable, and can be understood by everyone on the team. And once the goals are set, beat that drum every moment possible, such as in staff meetings, newsletters, or on banners in the break room. It can’t just be the flavor of the month. If the team sees it is important and not going away, they will notice.<br><br><strong class="ms-rteForeColor-1">6.</strong> Provide year-round education and not just the “minimum requirements” that mandate what must be done. Consider offering continuous-return demonstrations on medication passes or incontinence care. Ensure that the team knows what quality measures are. Consider educating nurse assistants about how to communicate with surveyors. It may sound like a cliché, but it’s true: Knowledge is power. Arm the team with the knowledge they need to reach their survey goals.<br><br><strong class="ms-rteForeColor-1">7. </strong>Audit, Audit, Audit. The entire team should be continuously looking at systems and outcomes. The only way to know how things are going is to look. Give each department head an audit to complete monthly for review during QI meetings. Also, consider holding QI meetings monthly instead of quarterly. Have a “mini mock survey day” where each member of the team focuses on a particular area and reports back at the end of the day. Ask other members of the team (such as the consultant pharmacist) to assist with checks and audits. The idea is to constantly be digging and looking to make sure the systems and procedures are working properly. And remember, using the excuse that there is no time to do this works until there is a deficiency, after which the excuse will no longer work.<br><br>These may not be earth-shattering suggestions, but if these basic steps are followed, the entire team will be well on its way to achieving good—and maybe even excellent—survey outcomes. And don’t forget to lean on each other. <br><br>While these are just some tried and true tips, other administrators may have their own best practices as well. <br><br>If the team is focused on good quality outcomes, it will not only have good surveys, it will also feel good knowing the residents are receiving great care at their community. <br><br><em>Kevin McElroy, CNHA, CASP, is the administrator at Evergreen Living Center in St. Ignace, Mich. He can be reached at </em><a title="Email Kevin!" href="mailto:kmcelroy@mshosp.org" target="_blank">kmcelroy@mshosp.org.</a><br></p>There is no such thing as “time to get ready for survey.” If a nursing home’s survey window is open and staff are just starting to review plans, they are already behind the eight-ball. Communities need to be ready for a survey 365 days a year. 2013-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/1013/mgmt_thumb.jpg" style="BORDER:0px solid;" />Management;Survey and CertificationColumn10
Technology And Readmissionshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/1013/Technology-And-Readmissions.aspxTechnology And Readmissions<div><div>A key element of health reform is introducing new ways to reward hospitals for good outcomes and penalize hospitals for poor outcomes. In this new environment, hospital strategies may influence referral patterns and significantly impact the business of post-acute providers. </div> <div> </div> <div>Two of the most impactful changes to a hospital’s bottom line—30-day readmission penalties and bundled payments cov<span></span>ering the entire continuum of care—are significantly affected by what happens to patients when they leave the hospital. These market forces will demand that hospitals develop stronger relationships with long term and post-acute care organizations that provide effective and efficient care post-discharge. </div> <div> </div> <div>This is especially true for preventable conditions such as fall-related injuries and complications from undetected urinary tract infections (UTIs). </div> <h2 class="ms-rteElement-H2">Improving Relationships With <span></span><span></span>Hospital<span></span>s</h2> <div>Accountable care requirements are causing shifts in the industry, making collaboration and partnership across the spectrum of care more prevalent. This trend is already affecting long term and post-acute care providers. </div> <div><span> <div><span><span><span><span><span><span><img width="409" height="153" class="ms-rtePosition-2" alt="Falls and Hospitalizations" src="/Monthly-Issue/2013/PublishingImages/1013/tech_falls.jpg" style="margin:5px;width:495px;height:185px;" /></span></span></span></span></span></span>The traditional business model of long term care facilities focuses on providing a place of residence for someone who needs support with daily living. In the future, that model will not lead to market leadership. Already, long term care facilities are shifting the way they operate to provide services for those older adults who want to age in place. </div> <div> </div></span></div> There is greater appetite for innovation, including long term care providers that distinguish themselves with new approaches and services to become a provider of choice when hospitals look to develop patient referral networks. <div> </div> <div>Providers may be hesitant to rewire a business model that has been successful, yet those that do not take a new approach will almost certainly lose market share.</div></div> <h2 class="ms-rteElement-H2"><span><span><span><span><span><span></span></span></span></span></span></span>Standing Out</h2> <div>There are a few key characteristics hospitals will most likely assess when deciding which long term or acute-care providers should be part of their preferred network for referrals. Hospitals will choose long term care facilities that have some level of clinical services to provide support for residents who leave the hospital. <span><span><span><span><img width="471" height="282" class="ms-rtePosition-2" src="/Monthly-Issue/2013/PublishingImages/1013/tech_cautionarytale.gif" alt="" style="margin:10px;" /></span></span></span></span></div> <div> </div> <div>Facilities that are <span><span><span></span></span></span>innovative in how they care for residents, show an expertise in understanding the needs of newly discharged patients, and provide 360-degree care will be in a good position to succeed.</div> <div> </div> <div>Technology can be a useful tool as long term and post-acute care providers develop strategies to differentiate and make themselves more attractive to hospitals. </div> <div> </div> <div>For example, smart sensor technology provides information to staff that can help facilitate the right care at the right time and help improve patient health and well-being. The technology, which is already being used in senior living communities, can help mitigate potential readmission risks, such as falls and UTIs, to improve quality of care and safety. </div> <div> </div> <div><span><img width="263" height="305" class="ms-rtePosition-1" alt="A Mutual Benefit" src="/Monthly-Issue/2013/PublishingImages/1013/tech_benefit.jpg" style="margin:5px 10px;" /></span>UTIs are the second leading cause for hospitalization in seniors age 65 and older. Detecting a UTI early can be the difference in being hospitalized or treated as an outpatient, which could potentially save a hospital from financial penalties. <br></div> <div>Early signs include frequent urination at night. Long term or acute-care facilities that have smart sensor technology can detect if a resident used the restroom an unusually high <span></span>number of times in one night, and the technology sends an alert to a staff member. That staff member could check on the resident, test for a UTI, and, if it came back positive, treat it before it becomes more serious and requires hospitalization.</div> <div> </div> <div>Falls are another example of where smart sensor technology may help prevent hospital admissions. </div> <div> </div> <div>Thirty-three percent of seniors fall every year, causing 662,000 hospitalizations. Additionally, the rate of falling after a hospitalization is four times as likely within the first two weeks after discharge, compared with the first three months.</div> <div> </div> <div>Smart sensor technology can detect when there is a different pattern or inactivity in a patient room and will send an alert to a staff member. If a resident falls in the bathroom and smart sensor technology recognizes that there has been no movement for 30 minutes, a caregiver is alerted to check on him. </div> <div> </div> <div>While smart sensor technology cannot detect a fall, it can measure the activity within a patient’s room and help detect differences. </div> <div> <span><em><img class="ms-rtePosition-2" src="/Monthly-Issue/2013/PublishingImages/1013/tech_sources.gif" alt="" style="margin:5px;" /></em></span><br>Helping a patient after a fall within the golden hour increases the patient’s survival rate and may allow the long term or acute-care facility to care for the patient before complications arise that require hospitalization. </div> <h2 class="ms-rteElement-H2">Moving The Industry Forward</h2> <div>Strong partnerships between hospitals and long term care providers are a relatively new idea, and there is no set formula for success. What will this shift in care look like? What amount of care should be provided at a nursing home, and what role should it play in coordinating care? How can long term and acute-care facilities shift their business models to partner with hospitals? These questions have yet to be answered, but they will be in time. And first movers will have the most influence and reap the biggest rewards as hospitals and health systems look for dependable and innovative partners. </div> <div> </div> <div><em>Julie Cheitlin Cherry, RN, MSN, director of clinical services, Intel-GE Care Innovations, can be reached at <span class="baec5a81-e4d6-4674-97f3-e9220f0136c1" style="white-space:nowrap;">(408) 835-8716<a title="Call: (408) 835-8716" href="#" style="border-width:medium;border-style:none;border-color:-moz-use-text-color;margin:0px;width:16px;bottom:0px;display:inline;white-space:nowrap;float:none;height:16px;vertical-align:middle;overflow:hidden;right:0px;top:0px;left:0px;"><img title="Call: (408) 835-8716" alt="" style="border-width:medium;border-style:none;border-color:-moz-use-text-color;margin:0px;width:16px;bottom:0px;display:inline;white-space:nowrap;float:none;height:16px;vertical-align:middle;overflow:hidden;right:0px;top:0px;left:0px;" /></a></span> or at </em><a title="Email Julie!" href="mailto:julie.cherry@careinnovations.com" target="_blank"><em>julie.cherry@careinnovations.com</em></a><em>. </em></div> <span></span><span></span><span></span><span></span><span></span><span></span>Two of the most impactful changes to a hospital’s bottom line—30-day readmission penalties and bundled payments covering the entire continuum of care—are significantly affected by what happens to patients when they leave the hospital.2013-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/1013/tech_thumb.jpg" style="BORDER:0px solid;" />Technology;Management;Quality ImprovementColumn10
2013 AHCA/NCAL Annual Awardshttps://www.providermagazine.com/Monthly-Issue/2013/Pages/1013/2013-AHCANCAL-Annual-Awards.aspx2013 AHCA/NCAL Annual Awards<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><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a><a href="/ReusableContent/4_.000">a</a></div><div>The American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) have announced the individual and group winners of their annual awards.</div> <div> </div> <div> </div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Edgemoor Distinct Part Skilled Nursing Facility</span><br>Not-For-Profit Program of the Year</h2> <div><span><span><span><em>Sarah Langmead<span style="display:inline-block;"></span></em></span></span></span></div> <div> </div> <div><br><img width="329" height="248" class="ms-rteImage-1 ms-rtePosition-1" alt="Edgemoor District SNF" src="/Monthly-Issue/2013/PublishingImages/1013/Edgemoor.jpg" style="margin:5px 15px;" /><br>Nearly two years ago, Edgemoor DP SNF in Santee, Calif., created Sierra Stroll, a multidisciplinary therapeutic behavioral activation program. Five days a week, Sierra Stroll enables residents to engage in social and physical activities outdoors, like walking, listening to music, dancing, or playing cards.</div> <div> </div> <div>Many Sierra Stroll participants suffer from dementia, mental illness, apathy, or aggression. The program was designed specifically to address these populations, and since it started, staff have seen great improvements in their residents’ attitudes and behaviors. </div> <div> </div> <div> </div> <div> </div> <div>“This program has sustained the interest and positive engagement of residents with severe behavioral problems and has served to enhance peer-to-peer interaction and to decrease aggression and other negative behaviors,” said Alfredo Aguirre, director of the Behavioral Health Services Division of San Diego County, in his nomination letter.</div> <div> </div> <div> </div> <div> </div> <div>Specifically, Edgemoor DP SNF reported that Sierra Stroll has resulted in psychoactive medication reductions, improved behavior and tolerance, reduced aggression, and improved staff skills, as well as staff fitness.</div> <div> </div> <div> </div> <div> </div> <div>“Sierra Stroll is special because it adapts more traditional outpatient behavioral activation to [skilled nursing facility] residents with significant cognitive, physical and interpersonal limitations,” said Walter Hekimian, Edgemoor administrator. “We’re so proud of the positive impact we’ve had on our residents.”</div> <div> </div> <div> </div> <div> </div> <div>Richard Brown, president of the Volunteer Association at Edgemoor, agreed. </div> <div> </div> <div> </div> <div> </div> <div>“I have seen the change in [the residents’] behaviors,” he said. “They are more relaxed, less stressed, less confrontational and combative, smile more often, and seem interested in their surroundings. This is a program that takes place a couple times a week so that the residents can count on outings.”</div> <div> </div> <div> </div> <div> <span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Lorraine Oakes</span><br>Adult Volunteer of the Year</h2> <div><div><span><span></span><span><em>Sarah Langmead</em><span style="display:inline-block;"></span></span><span style="display:inline-block;"></span></span></div></div> <div>  </div> <div><img class="ms-rtePosition-1" alt="Lorraine Oakes" src="/Monthly-Issue/2013/PublishingImages/1013/LorraineOakes.jpg" style="margin:5px 10px;" />Lorraine Oakes has been a celebrated volunteer of Kindred Healthcare, Elizabeth City, N.C., a short-term rehabilitative and long term care facility, for the past 22 years. She enjoys sitting with residents and getting to know them each on a more personal level. Oakes has created and significantly impacted multiple programs at Kindred. Fifteen years ago, Oakes played a major part in developing the facility’s thriving dining assistance program. She also created a popular Bible studies program. </div> <div> </div> <div> </div> <div> </div> <div>“Lorraine is truly dedicated to our residents,” said Tonia Bryant, executive director of Kindred Transitional Care and Rehabilitation - Elizabeth City. “Her cheerfulness and generosity make her a true asset to our facility.”</div> <div> </div> <div> </div> <div> </div> <div>Though Oakes currently serves as the volunteer coach at the facility, advising all volunteers, her passion for serving others extends outside of Kindred Healthcare: She is also an active volunteer at local assisted living facilities and elementary schools.</div> <div> </div> <div> </div> <div> </div> <div>“Lorraine always has a kind word to say to everyone she meets,” said Bryant in her nomination. “We’re proud to have her as part of our team!” </div> <div> </div> <div> </div> <div> </div> <div>Described by many as a “fireball of energy,” Oakes volunteers nearly every day of the week. One resident’s family member said that “her compassion and love for the elderly is unmatched.” In an environment where many residents have few or no visitors, Oakes is always there to offer encouragement and hope, a smile, or a simple prayer.</div> <div> </div> <div> </div> <div> </div> <div>“She adopts families and helps them out however she can,” said Lori Chepan, activities director, in her nomination of Oakes. “She remembers birthdays and special occasions of staff and family members, as well as residents. You never know when she might pop in with a trinket of some sort and say, ‘this reminded me of you!’ Those little things make residents feel so special.”</div> <div> </div> <div><div> </div> <div><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Josh Sosebee</span><br>Young Adult Volunteer of the Year</h2></div> <div> </div> <div><em>Sarah Langmead</em></div> <div> </div> <div> </div> <div> </div> <div><img width="179" height="222" class="ms-rtePosition-1" alt="Josh Sosebee" src="/Monthly-Issue/2013/PublishingImages/1013/JoshSosebee.jpg" style="margin:5px 10px;" /><br>Though only 16 years old, Josh Sosebee has been a notable volunteer of Life Care Center of East Ridge, Tenn., a 130-bed long term care facility, for the past four years. During his time at Life Care Center, Sosebee has cultivated strong relationships with residents and has developed several programs to better address their needs.</div> <div> </div> <div> </div> <div> </div> <div>Sosebee created Canning for a Cause, a weekly program to can vegetables and other items to raise money for organizations that residents support. He also formulated a men’s discussion program and organizes activities like poker and model car events. Residents particularly enjoy helping with the local animal shelter’s adoption events through Sosebee’s Pet Adoption Program. </div> <div> </div> <div> </div> <div> </div> <div>“Josh’s intention is to better the lives of men and women who may feel as if society has passed them by,” said Beecher Hunter, president of Life Care Centers of America, in his nomination of Sosebee. “He acknowledges the residents’ importance by his gifts of time, attention, compassion, and kindness. He is a builder of intergenerational bridges.”</div> <div> </div> <div> </div> <div> </div> <div>Sosebee has impacted the volunteer pool at Life Care Center of East Ridge. Whenever the facility holds a special event, he brings a friend, and more often than not, those friends continue to volunteer. “Josh contends that his ‘pay’ is delivered to him in the encouragement of folks who have endured hardships along the way, but who assure him the journey is worth it,” said Hunter.</div> <div> </div> <div> </div> <div> </div> <div>In addition to volunteering approximately 20 hours per week, Sosebee maintains excellent grades in Advanced Placement and Honors classes and works a part-time job. Despite a busy schedule, he continuously prioritizes his time with the residents and their families. </div> <div> </div> <div> </div> <div> </div> <div>“There is no one better than Josh at sitting one-on-one with residents,” said Ben Zani, LNHA. “We will often send him in to speak with our more difficult residents, as he can reach them in a way that no one else can.”</div> <div> </div> <div> <br><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Helen Cherry</span><br>ID/DD Hero of the Year</h2> <div> </div> <div><em>Sarah Langmead</em></div> <div> </div> <div> </div> <div> </div> <div><img width="149" height="173" class="ms-rtePosition-1" alt="Helen Cherry" src="/Monthly-Issue/2013/PublishingImages/1013/Helen.jpg" style="margin:5px 10px;" /><br>Helen Cherry’s dedication, innovative thinking, and compassion are just three reasons why she was selected as the 2013 Intellectual/Developmental Disabilities Hero of the Year Award.<br></div> <div> </div> <div>Cherry is an active employee of New Hope Services, a division of Medicalodges in Pittsburg, Kan. New Hope Services provides community living options and supportive services for persons with intellectual and developmental disabilities. </div> <div> </div> <div>“Since joining this challenging yet rewarding field 22 years ago, Helen has helped to forge meaningful relationships between her clients and local businesses,” said Cindy Luxem, president and chief executive officer of the Kansas Health Care Association. “She has successfully developed her clients’ skill sets and facilitated their integration into various work and social environments where they can not only contribute, but thrive.”</div> <div> </div> <div>Cherry has created several programs for her clients, including the New Hope Bulldogs Special Olympics team, which, with 56 coaches and 124 athletes, is one of the largest Special Olympics chapters in the state of Kansas. </div> <div> </div> <div>“Helen has made extraordinary contributions to the lives of the clients at New Hope,” said Fred Benjamin, chief operating officer at Medicalodges New Hope in his nomination. “She builds her clients’ self-worth, dignity, and their inner spirit to strive to be the best they can be.”</div> <div> </div> <div>Cherry founded Extremely Outrageous Creations—a business designed to offer job choices to adults with intellectual challenges. She also instituted the Legacy Fitness Center and the BIKE 4 LIFE program that together have positively impacted hundreds of special needs athletes in Pittsburg.</div> <div> </div> <div>“Helen always begins by asking prospective clients and families, ‘What are your dreams?’ She then sets about making them come true,” said Benjamin. “With her encouragement, clients live, work, and participate in their community on their own terms. Based on a client’s dream, she organized an annual ocean cruise that now serves 30 clients per year. </div> <div> </div> <div>“Helen’s giving spirit and positive attitude radiate and motivate our entire company to face the challenges in their lives with determination and a brave heart.”</div> <div><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Helensview High School </span><br>Group Volunteer of the Year</h2> <div><div><em>Sarah Langmead</em></div></div>  <div>Anne Frank once wrote, “How wonderful it is that nobody need wait a single moment before starting to improve the world.”</div> <div> </div> <div>Students at Helensview High School in Portland, Ore., not only understand this adage, they live by it.</div> <div>Since 2009, Helensview, an engaging environment designed to help students with needs that have not been met in other educational settings, teamed with Porthaven Care Center, a 99-bed long term care and rehabilitation center, to create a volunteer program. </div> <div> </div> <div>Students in the volunteer program enjoy playing board games and making crafts with residents. Recently, the group proposed, developed, and implemented a special design area in the facility to display resident art projects. </div> <div> </div> <div>“Not only do the students come on their volunteer day, but many found time in their busy lives as young single parents, working and going to school, to drop in on the birthday of their ‘buddy’ and surprise them with a card or balloon,” said Porthaven Administrator Sarah Murk in her nomination of the group. “One student organized a birthday party for a resident who was in hospice care. The resident described the day as his ‘best birthday ever.’”</div> <div> </div> <div>Porthaven staff have noticed that Helensview students have assisted in improving resident behaviors, as well.</div> <div> </div> <div>“One resident said, ‘These kids are so special, and they treat me like I am special,’” said Jodi Burroughs, Porthaven activities director, in her nomination. </div> <div> </div> <div>“This resident has developmental disabilities and a serious seizure disorder, which presented some challenges. After he began participating in activities with [the students], he not only developed confidence in himself, but his behaviors improved!”</div> <div> </div> <div>“It’s so exciting to watch our student volunteers connect with Porthaven residents,” said Kris Persson, principal at Helensview High School. “We hope that this program inspires students to continue volunteering throughout their lifetimes.” </div> <div><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Robin Moran</span><br>Noble Caregiver in Assisted Living</h2> <div><em>Lisa Gluckstern</em></div> <div> </div> <div><img width="184" height="202" class="ms-rtePosition-1" alt="Robin Moran" src="/Monthly-Issue/2013/PublishingImages/1013/RobinMoran.jpg" style="margin:5px 10px;" /><br>Robin Moran, recreation assistant for The Chelsea at Tinton Falls, N.J., makes it her life’s purpose to get to know each resident as well as possible. That desire is one of many factors that led to Moran being named the recipient of the 2013 NCAL Noble Caregiver In Assisted Living Award. </div> <div> </div> <div>She loves getting to know each resident and becomes a trusting friend to the residents. In one recent instance, a resident confided to Moran about his memory lapses and asked if his repetitive questions annoyed her. Moran reassured him that they did not, explaining that he wasn’t the only person with this condition and telling him, “This could be me some day, and I hope people will be kind when that day comes.”</div> <div>Moran’s kindness is demonstrated through visits to residents who have been hospitalized. She reaches out to residents who are shy or unhappy and is often rewarded with a smile and newfound friendship. </div> <div> </div> <div>She recruits her own friends and acquaintances to give talks to the residents on a variety of subjects. For example, she convinced her husband to give a lecture on the Hindenburg event and then a 10-week series on “The Pacific.” She arranged for people to arrive in costume on Halloween to deliver treats to residents. She runs the book club, bakes cookies, brings her pets in, and takes residents to monthly events at her church. </div> <div>Moran was hired by the community four years ago.</div> <div> </div> <div>“She took to the role like a duck takes to water,” wrote Kathie Deak, executive director of The Chelsea at Tinton Falls. “Her outgoing personality, love of people, strong nurturing skills, and a positive outlook on life had an immediate effect on residents, families, and co-workers alike.” </div> <div> </div> <div>Whenever anyone in the community is going through a rough patch, she uses her spirituality to give them strength, and she has set up a quiet area in the community’s sun room where someone can go to reflect, said Deak. </div> <div> </div> <div>“She is a very modest unsung hero who loves what she does and makes what she does look easy,” Deak wrote.</div> <div> </div> <div><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Julie Taylor</span><br>NCAL Administrator of the Year</h2> <div><em>Lisa Gluckstern</em></div> <div> </div> <div><img width="190" height="257" class="ms-rtePosition-1" alt="Julie Taylor" src="/Monthly-Issue/2013/PublishingImages/1013/JulieTaylor.jpg" style="margin:5px 10px;" /><br>Julie Taylor, administrator of Gilman Park Assisted Living located in Oregon City, Ore., is not afraid to clean, dig, paint, or do anything she asks of others. </div> <div> </div> <div>The pride she takes in the assisted living community is contagious to her staff members. She encourages them to make their own decisions and trains them to take care of resident issues in a timely fashion. Those are just a few of the accomplishments of Taylor, who is the recipient of the 2013 NCAL Administrator of the Year Award. </div> <div> </div> <div>Her support of staff members encourages the delivery of person-centered care to residents. In her five years at Gilman Park, she created an awards program for the community’s volunteers and reduced staff turnover while increasing census. Last year, Gilman Park won four company awards at Frontier’s annual meeting, among them was having the highest average occupancy. In 2012, Taylor was named Frontier Management’s Executive Director of the Year.</div> <div> </div> <div>But that’s not all. Taylor also raised the profile of Gilman Park Assisted Living to the surrounding community. For example, she created the ABC Award pencil program for the local elementary school. Every quarter, 500 pencils with the words “I AM Brilliant” or “I am Awesome” are distributed to students who earn good grades or do good deeds. </div> <div> </div> <div>Then, once a month, Gilman Park residents go over to the school and become lunch buddies to a group of school children. </div> <div> </div> <div>Four years ago, Taylor created the Volunteer of the Year Award for Oregon City, which recognizes a senior who worked on behalf of others in the city. Every year the assisted living community hosts an award ceremony. The mayor attends and makes the presentation.</div> <div> </div> <div>Taylor stays busy with projects. She is currently designing and planning to build a koi pond for the community after designing, planning, and building Gilman Park’s dog run, which allows residents to be outside while their dogs roam freely without their leashes. </div> <div> </div> <div><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Cheryl Hopkins</span><br>NCAL Assisted Living Nurse of the Year</h2> <div><em>Lisa Gluckstern</em></div> <div> </div> <div><img width="204" height="228" class="ms-rtePosition-1" alt="Cheryl Hopkins" src="/Monthly-Issue/2013/PublishingImages/1013/CherylHopkins.jpg" style="margin:5px 10px;" /><br>Cheryl Hopkins, RN, resident care manager at the Kansas community Vintage Park at Paola, personifies the community’s mission: Make a difference, every day, every time. </div> <div> </div> <div>The 2013 NCAL Assisted Living Nurse of the Year is described as compassionate and committed. Hopkins’ leadership inspires staff and conveys concern and great care to the residents and their family members. </div> <div> </div> <div>For an example of her dedication and personal commitment, her nominator Christina (Tina) Dick, Vintage Park director, cited how Hopkins works long hours to make sure a resident who is close to the end of life is “not alone” and is comfortable. “Cheryl displays integrity and a high standard of ethical behavior by leading staff to standards, which she sets above and beyond expectations. She rolls up her sleeves and works side by side with the staff, teaching and reviewing their skill competencies,” she said.</div> <div> </div> <div>Hopkins has led the community to deficiency-free surveys for the past five years. In 2010, she guided staff to achieving Silver in the AHCA/NCAL National Quality Award program. </div> <div> </div> <div>Not resting on her laurels, she helped reduce resident hospital readmission rates, and employee satisfaction ratings of excellent rose to 70 percent. </div> <div> </div> <div>She has been resident care manager for the past six years and has a total of 25 years of experience in long term care.</div> <div> </div> <div>“Cheryl takes great pride in the communication between her and the physicians, family members, and other stakeholders,” said Dick. “She will not leave until she is satisfied that all is going well with the residents, staff, and family members.”</div> <div><span id="__publishingReusableFragment"></span></div> <div> </div> <h2 class="ms-rteElement-H2"><span class="ms-rteThemeForeColor-8-4">Summer’s Landing of Warner Robins</span><br>NCAL National Assisted Living Week Programming Award</h2> <div><em>Lisa Gluckstern</em></div> <div> </div> <div><img class="ms-rtePosition-1" alt="Summer's Landing of Warner Robins" src="/Monthly-Issue/2013/PublishingImages/1013/Summerlanding.jpg" style="margin:5px 10px;" /><br>The team at Summer’s Landing of Warner Robins in Georgia planned events based on the 2012 National Assisted Living Week theme, Art for the Ages, with the Spiritual, Physical, Intellectual, Creative, and Emotional (SPICE) needs of the residents at the forefront of their programming design.</div> <div> </div> <div>This was a winning strategy that created engaging and fun events for residents, staff, families, and the surrounding neighborhood community. The Summer’s Landing team: Kim Pitsenbarger, executive director, Allison Gatliff, senior living advisor, Melissa LaFave, human resources, and Lany Puckett, dietary director, are recipients of the 2013 National Assisted Living Week Programming Award. </div> <div> </div> <div>These four individuals designed programming that celebrated the creativity of everybody, inside and outside the assisted living community, such as a nearby daycare center, a local elementary school, and experts who conducted interactive presentations that helped empower residents to create art either collectively as a group or individually. </div> <div> </div> <div>The highlight of the week was the Summer’s Landing Art Gallery, which contained work created by residents, family members, and staff, who displayed their ceramics, needlework, woodworking, oil paintings, and puzzle art in the dining rooms and the halls of the community. The team also posted various creative works of art from across the globe, along with facts about them, throughout the community. User-friendly cameras were available for residents and staff to take candid photos of life in the community, which were then displayed in the lobby. </div> <div> </div> <div>One of the residents taught a class on the Art of Flower Arranging. And a local expert taught residents about Japanese Ikebana—the art of creating elegant beauty with ordinary objects found in nature. </div> <div> </div> <div>The Art of the Spoken Word was celebrated by having a resident recite from memory the Frank Stanton poem, “Keep A Goin’ ” during a wine and cheese social. The Landing’s food and beverage team shared their knowledge of wine production, and a local bluegrass band performed original music, as well as country and Western music.</div> <div> </div> <div>The Art of Dining Well included four dining rooms decorated with flower and Ikebana arrangements and filled with carefully drizzled plates of julienned vegetables and Atlantic salmon; for dessert, flaming peaches jubilee. </div> <div> </div> <div>A local photographer instructed residents about the composition elements of taking photos and shared his stories and prize-winning photos taken while traveling.</div> <div> </div> <div>The Art of the Everyday featured a rotating art gallery of puppets made by the daycare center children. </div> <div>Finally, The Art of Thankfulness featured a photo contest and a Tree of Gratitude. The residents and staff members each wrote one good thought on a paper leaf and attached it to a tree drawn on an oversized poster board. One leaf contained the following touching thought:</div> <div> </div> <div>“Thank you to all of you who keep us going and make us feel like we belong.”</div> <div> </div> <div> </div>The American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) have announced the individual and group winners of their annual awards.2013-10-01T04:00:00Z<img alt="" src="/Monthly-Issue/2013/PublishingImages/1013/special_thumb.jpg" style="BORDER:0px solid;" />Quality;CaregivingColumn10
The QIS Expert: Can QIS Methods Help Providers Comply With QAPI’s Systematic Analysis And Action Regs?https://www.providermagazine.com/Monthly-Issue/2013/Pages/1013/Can-QIS-Methods-Help-Providers.aspxThe QIS Expert: Can QIS Methods Help Providers Comply With QAPI’s Systematic Analysis And Action Regs?This is the final column in A series of five addressing how QIS methods can be used for Quality Assurance & Performance Improvement (QAPI). The previous four columns (in <a target="_blank" href="/Monthly-Issue/2013/Pages/0213/The-QIS-Expert.aspx">February</a>, <a target="_blank" href="/Monthly-Issue/2013/Pages/0413/Can-QIS-Help-Providers-Comply-With-New-QAPI-Regs.aspx">April</a>, <a target="_blank" href="/Monthly-Issue/2013/Pages/0613/The-QIS-Expert.aspx">June</a>, and <a href="/Monthly-Issue/2013/Pages/0813/Can-QIS-Methods-Help-Providers-Comply_4.aspx">August</a> 2013 issues) have shown the parallels between QIS methods and the first four of the Five Elements of QAPI.<br><br>These first four columns showed that QIS is consistent with where the Centers for Medicare & Medicaid Services is heading on QAPI from a regulatory standpoint. More importantly, QAPI is a voluntary means to continuously improve care. (See <a target="_blank" href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf">www.cms.gov/Medicare/ Provider-Enrollment-and-Certification/Survey CertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf)</a>.<br><br>Element 5: Systematic Analysis and Systemic Action provides the framework that providers can use to voluntarily conduct QAPI.  <br><br>CMS says that Systematic Analysis involves the following: “The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered.” <br><br>Just as surveyors use the multifaceted Stage 1 investigation of the QIS process to determine when in-depth analysis is needed, providers can use those same assessments, but with a different type of reporting. “Understanding the problem, the causes, and the implications for change” involves drilling deeper into the QIS data than is required for the survey process. <br><br>For example, it is not sufficient for QAPI to determine that a resident’s preferences are not being honored by staff. Instead, staff must understand specifically what choices are not being honored; whether it is just a single resident, a unit, or the facility as a whole; and what must be done to improve accommodation of resident preferences. <br><br>Thus, provider QAPI systems that use QIS methods must go beyond the work of surveyors in Stage 1. Staff must go beyond the typical questions on resident satisfaction surveys. Fortunately, the QIS questions can provide much of the necessary drill-down when broken down and structured in a QAPI tool. <br><br>Element 5 also says that, “Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement.” <br><br>Once again, QIS contains tools, when properly restructured, that take aspects of the surveyor investigation process and “look comprehensively across all systems.” This involves advancing the investigation that surveyors conduct a step further—to correcting system failures that are identified. It also requires that providers do not use the QIS methods in a “mock survey” or external consulting model; rather, they use the methods continuously for “learning and continuous improvement.”<br><br>In recent years, working with providers, I have observed numerous examples of staff using these QIS tools for QAPI with extraordinary success. So what are you waiting for? <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><br>Just as surveyors use the multifaceted Stage 1 investigation of the QIS process to determine when in-depth analysis is needed, providers can use those same assessments, but with a different type of reporting2013-10-01T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/headshots/AndyKramer.jpg" style="BORDER:0px solid;" />Policy;Survey and Certification;ManagementColumn10
Climbing The Mountain Of Health Care Reformhttps://www.providermagazine.com/Monthly-Issue/2013/Pages/1013/Climbing-The-Mountain-Of-Health-Care-Reform.aspxClimbing The Mountain Of Health Care Reform<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><p>When the Treasury Department announced in early July that employer penalties under the Affordable Care Act (ACA) would be delayed for a year, until 2015, the news came as a relief to long term care providers, regardless of how prepared they were for the transition.<br><br>“Delay of the employer mandate meant the delay of both uncertain and actual cost increases,” says Phil Fogg Jr., president and chief executive officer of Marquis Cos. in Milwaukie, Ore. <br><br>Marquis had already begun offering an ACA-compliant health plan when the announcement was made. By July, the self-insured organization was preparing its initial communications with employees and was on the brink of offering reduced cost-sharing in the health plan as an incentive for employee participation in wellness initiatives targeting obesity and other costly health problems. </p> <p><img width="430" height="175" class="ms-rtePosition-2" alt="Variable Affecting Employer Costs" src="/Monthly-Issue/2013/PublishingImages/1013/coverstory_employercosts.jpg" style="margin:5px 20px;" />Marquis has about 3,500 employees and operates skilled nursing facilities, assisted living communities, and other long term care services in 26 locations, mostly in Oregon. With a qualifying plan in place, “we are 98 percent of the way there,” Fogg says of Marquis’ readiness for ACA compliance. <br><br>He’s less certain, however, about the number and cost of employees who will opt into the health plan, especially as they face the ACA’s individual mandate requiring all adults to obtain insurance for themselves and their children in 2014, or pay a penalty.</p> <p></p> <div>Some workers are expected to choose to pay the individual penalty of $95 or 1 percent of household income rather than incur the cost-sharing required by the health plan. Nevertheless, participation in Marquis’ insurance program is expected to spike, adding an estimated $1.5 to $2.5 million a year to benefit costs, Fogg says. </div> <div> </div> <div>“That’s a big hit for us,” he adds.</div> <div> </div> <div>Despite the delay in ACA penalties, Marquis’ health coverage will remain intact, along with its commitment to the wellness goals of reducing costs and promoting a healthy workforce. The company has taken a step back, however, from linking wellness participation with financial incentives in the health plan. </div> <h2 class="ms-rteElement-H2">Cost Tops List Of Provider Concerns</h2> <div>The ACA requires businesses that are deemed “large employers” to provide health coverage to full-time staff. The coverage must be “affordable” for employees, whose share of premium payments cannot exceed 9.5 percent of their household income. It must also offer “minimum value,” by achieving at least 60 percent actuarial value, meaning the plan can be expected to pay 60 percent of an insured’s health expenses.</div> <div> </div> <div>Projections of exorbitant cost increases tied to ACA compliance, as well as uncertainty about the magnitude of the increase, and the inability to offset costs by raising prices in a profession dominated by government payers, top the list of long term care providers’ concerns about the ACA.</div> <div> </div> <div>There are no estimates of how much ACA implementation is likely to cost the profession. Financial exposure will vary based on factors unique to each provider and organization, experts say. These include the level of baseline coverage, staff composition and wages, and the number of employees who choose to participate in their employer’s plan.</div> <div> </div> <div>Providers’ concerns are driven by “two recurring themes,” says Emmett Reed, executive director of the Florida Health Care Association. “It’s going to cost more money, and in some cases a lot more money, to continue operating.” </div> <div> </div> <div>The second theme is the unknown, he says. Providers don’t know who is going to join the plan and how much more it’s going to cost. As a result, organizations “can’t properly plan their business strategy.” </div> <div> </div> <div>Some large organizations have estimated as much as a $7 million cost increase, Reed says. “That’s a big number and a huge concern given nursing facilities’ razor-thin margins.” Smaller providers are even more fearful of the impact, he adds. “It’s a frightening time.”<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">The California Experience</h2> <div>In California, providers are “stepping back and seeing what’s reasonable and what they can afford,” says James Gomez, president and chief executive officer of the California Association of Health Facilities. Unlike Florida, California is integrating the ACA’s optional Medicaid expansion, to 138 percent of the federal poverty level, which will result in the addition of more than 1 million beneficiaries, Gomez says. In addition, the state is running its own Health Insurance Exchange, as opposed to defaulting to the federal government for that function. The Web-based portal could be deluged by 3 million to 4 million registrations for insurance coverage, Gomez says.<br></div> <div><br>“This is a very rapid program that we’re trying to do. It will be difficult everywhere in the nation.”</div> <div> </div> <div>From providers’ perspective, the effort is draining state and federal resources from quality improvement and the payment of adequate Medicaid rates, he adds.</div> <div> </div> <div>“We lose money every time we serve a Medicaid participant,” Gomez says. As more people gain eligibility, there is widespread fear across all provider types of further rate erosion.</div> <div> </div> <div>Under California law, federal and state mandates must be reimbursed, he says. “We’ve let [lawmakers] know this is an issue.”</div> <div> </div> <div>Craig Robinson, president of Gulf Coast Health Care in Pensa-cola, Fla., says the ACA compounds the uncertainty that long term care providers face from perpetual reimbursement and regulatory changes.</div> <div> </div> <div>“The [ACA] penalties are being put off, but we need to move forward with health insurance as if it’s going to happen,” he says. “We need to do what we have to by law.” But it’s difficult to do that with “unknown costs” that have to be budgeted, he adds.</div> <div> </div> <div>“There’s uncertainty in our environment all the time,” stemming from potential payment cuts and regulatory changes, Robinson says. </div> <div> </div> <div>“The ACA is just like that.”</div> <h2 class="ms-rteElement-H2">Gearing Up For Compliance</h2> <div>The year-long reprieve from penalties gives providers additional time to get their arms around the complexities of the ACA, develop health coverage that best fits their organization, and test out their programs before they are exposed to penalties for compliance failures, experts say. </div> <div> </div> <div>“We’re recommending that employers proceed as if the ACA is going into effect in 2014 and that they use the transition time to work out the kinks, while there are no financial implications from penalties,” says Tiffany Downs, a partner and head of the employee benefits group in the Atlanta law office of Ford Harrison. This gives businesses time to develop Plan B if their initial program isn’t compliant, she adds.</div> <div> </div> <div>“If you don’t offer coverage at all [during the transition], it takes more time to get up and running.” </div> <div> </div> <div>Most importantly, the delay should not be mistaken for the demise of the ACA, say legal and health benefits professionals who, like Downs, are advising clients to use the transition time to plan for implementation.</div> <div> </div> <div>Next year should be treated as “the dry run for employers to see whether the benefits they intend to provide, are going to be compliant in 2015, when ACA penalties kick in,” says Toni Fatone, member services liaison with the American Health Care Association (AHCA), who has worked with insurers and a broker to create the AHCA/National Center for Assisted Living Insurance Solutions Program, which gives members of the organization access to discounted health plans.</div> <div> </div> <div>“It’s really important that [providers] don’t take their foot off the gas” next year, says Nicole Fallon, a health care consultant at CliftonLarsonAllen (CLA), a national consulting firm based in Minneapolis. </div> <div> </div> <div>“Employers should use 2013 employee data to simulate how the 2015 requirements will impact their organization, because we believe 2014 data will be used as a measurement period to determine which employees are full-time and which employers are considered ‘large’ and subject to the law,” she says.</div> <div> </div> <div>It is not clear if the federal government will offer employers the same flexibility in 2015 as it did in 2014, to synchronize the launch of new ACA plans with the start of their existing health plan year or use shorter measurement periods to determine full-time status of employees, says Fallon. If they do not get the same leeway, employers will have to hit the ground running with a compliant plan on Jan. 1, 2015. </div> <div> </div> <div>“The ACA is not going to go away,” says Nancy Taylor, an attorney with the Miami-based law firm Greenberg Traurig and co-chair of the firm’s health and FDA business practice. “It’s wishful thinking to believe it could be delayed forever.” </div> <div> </div> <div>Providers wrestling with ACA compliance must also wrestle with math. The law is stacked with formulas and measurements that determine whether a provider is subject to penalties for failing to offer health coverage, whether workers are counted as full-time and must therefore be offered coverage, whether health benefits meet value and affordability tests, and whether a provider and its workforce would be better served by compliance or penalty payment.</div> <div> </div> <div>These often dizzying calculations are staples of ACA webinars, workshops, and presentations being conducted nationwide for long term care and other employers, by legal and benefits experts who are steeped in details of the law. </div> <div> </div> <div>ACA calculus begins with staffing. Only businesses with 50 or more full-time employees and “equivalents” are deemed to be large employers, subject to the ACA’s health coverage requirements and at risk of penalties for failing to comply.</div> <div> </div> <div>Counting staff, however, is not as simple as it sounds. The ACA defines full time as 30 hours per week, measured as 130 hours of service in a month, says Taylor, who also serves as legal counsel to AHCA and has conducted several ACA webinars and presentations for the organization and its state affiliates. </div> <div> </div> <div>For the purpose of determining whether a business is a large employer, however, the count includes the total hours worked by all part-time staff in a month, up to a maximum of 120 hours per employee, divided by 120, Taylor explained in a July webinar for AHCA. The sum of that equation is the number of “full-time equivalents,” which must be added to the number of actual full-time workers. If the final tally is 50 or more, the business meets the definition.<br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Look-Back Period</h2> <div>For staff whose full- or part-time status is unclear due to their variable or seasonal schedule, the ACA creates a “look-back” period. <br><br></div> <div>This measurement tool allows employers to track an employee’s hours over a three- to 12-month period to determine whether they average 30 hours per week/130 hours per month, says Downs. If so, the person is deemed full time and must be offered health coverage during a “stability period” of six months, or the duration of the look-back, whichever is greater, Downs says.</div> <div> </div> <div>Employers may designate an administrative period up to 90 days between the look-back and stability periods, in which they “crunch numbers and offer enrollment,” Downs says. At the end of 90 days, the stability period must start immediately, and employers must provide health coverage to those workers deemed full-time, even if their hours no longer rise to the level of full-time status, Downs says. </div> <div> </div> <div>A look-back period can only be used when “it’s not clear that an employee works 30 hours a week,” Downs says. “It cannot be used to delay coverage. There has to be a determination that hours really are variable.” </div> <h2 class="ms-rteElement-H2">The ACA And Quality Care </h2> <div>As employers develop strategies for managing ACA costs and meeting compliance challenges, one of the available options is to create more part-time positions, reducing the number of staff to whom insurance coverage must be offered. </div> <div> </div> <div>While the approach might be useful in retail or other settings, long term care providers are not embracing part-time employment as a solution.</div> <div> </div> <div>At Mission Health Services in Ogden, Utah, the philosophy of care is rooted in the belief that “the resident has to be well-known,” says Gary Kelso, president and chief executive officer. “That means we have to have consistent staffing.”</div> <div> </div> <div>By having “the same individuals caring for people every day, even if there is a slight change in condition, the employee will see it,” Kelso says. </div> <div> </div> <div>The need for consistency and familiarity means that reducing work hours to create more part-time staff who don’t have to be offered health coverage under the ACA is not an option for Mission Health, a nonprofit with four facilities and 375 employees. The organization, which is partially self-insured, put an employee insurance plan in place five years ago. It covers 100 percent of employees’ premium cost, has a small copay after the deductible is met, and needs no modifications to comply with the ACA. </div> <div> </div> <div>Since the plan was implemented, Mission Health’s workers’ compensation costs have dropped dramatically, and staff turnover has plummeted from 60 to 70 percent, which is typical in the long term care sector, to under 10 percent for the past three years, Kelso says. All facilities have four or five stars from the Centers for Medicare & Medicaid Services, and two have had deficiency-free surveys for the past 18 months.</div> <div> </div> <div>Other factors have likely contributed to these trends, including the fact that all Mission Health facilities are Eden-registered, Kelso says. While he believes the ACA is “bad policy” that will lead to “losses in business and losses in the economy,” he’s not expecting to reduce employees to part time.</div> <div> </div> <div>“I don’t think that’s a valuable or good policy,” he says.</div> <div> </div> <div>Kelso says he’s not stressed about the ACA, as there’s nothing the organization needs to change to be compliant. The acquisition of 12 facilities, with 475 employees, is on the horizon, however, and the move may add as much $1 million a year to the health benefits rate structure. </div> <div> </div> <div>“That’s significant,” Kelso says. “We may have to ask employees to pay a small amount” for their premiums, though it would probably not be as much as the ACA’s benchmark for affordability, which is 9.5 percent of household income.</div> <div> </div> <div>“That’s still too high in my perspective when you have lower-paid employees,” he says.</div> <h2 class="ms-rteElement-H2">Creating A Workable Plan</h2> <div>At Opis Management Resources in Tampa, Fla., the company is working closely with a health insurance broker to understand the ACA, the changes that it would have to make to come into compliance, options for redesigning the current benefit program, and the associated costs.</div> <div> </div> <div>“We’ve always provided coverage and have a generous plan,” which is “extremely affordable” and has a good participation rate, says Jennifer Ziolkowski, senior vice president of finance. Adding staff who work 30 hours a week, as opposed to the current 32-hour threshold for full-time status, will be the biggest cost, she says.</div> <div> </div> <div>Opis manages 10 Florida skilled nursing facilities and one assisted living community. With about 2,300 employees, the company recognizes the need to remain competitive, and that means keeping up with the benefits that other providers and other types of businesses are offering. Opis plans to come into ACA compliance, and doing so will require closer management of staff hours, Ziolkowski says.</div> <div> </div> <div>In looking closely at monthly reports on “flex staff,” who are supposed to be part-time, for example, Opis found that some of those employees were in fact working 40 hours a week.</div> <div> </div> <div>“We were calling them as needed, but we needed them all the time,” Ziolkowski says. “Our mindset isn’t on having more flex-time workers, but on having permanent staff,” she says. </div> <div> </div> <div>As the organization focuses more closely on hours, it will have to be vigilant about defining full-time, part-time, and flex staff, she says. <br><br></div> <div>“We need to make sure that if we have flex staff working more than what we consider flex time, we address that by approaching staff to become full time, or by spreading the hours over more people,” she says. </div> <div> </div> <div>Next to managing the cost of ACA compliance, the greatest challenge faced by long term care providers will be the time and effort it takes to track employee hours and other data required by the ACA, says CLA’s Fallon. </div> <div> </div> <div>“A large organization with a couple of hundred employees and on-call staff now has to closely track all those hours.” <br><span id="__publishingReusableFragment"></span></div> <h2 class="ms-rteElement-H2">Pay Or Play: That Is The Question</h2> <div>Among the most critical ACA calculations employers have to make is the decision to offer health coverage or pay a penalty.<br></div> <div><br>Many factors go into this consideration, says Fallon, including staff composition and wage levels, premiums charged by the Health Insurance Exchange, and the cost of providers’ options.</div> <div> </div> <div>Under the ACA, providers that don’t offer any health coverage to full-time workers are subject to a $2,000 penalty for every full-time worker in their employ, excluding the first 30. </div> <div> </div> <div>Employers that offer insurance that fails to meet the ACA’s affordability or minimum value test are