1 Competencies for Post-Acute and Long-Term Care MedicinePaul Katz MD, CMD Matthew Wayne MD, CMD Jonathan Evans MD, CMD

2 Speaker Disclosures: Paul Katz MD, CMD has disclosed that he has no relevant financial relationship(s). Matthew Wayne MD, CMD has disclosed that he has no relevant financial relationship(s).

3 Physician Competencies for post acute and long term care medicineSetting the Stage Physician Competencies for post acute and long term care medicine

4 The Physician Value PropositionShould physician worth be predicated on financially based measures? Number of patients seen per unit time Number of times sued Optimization of billing codes

5 The Physician Value PropositionShould physician worth be based on measures that exemplify a special skill set and how it’s application at the bedside? Accuracy of medication reconciliations Use of antibiotics based on established guidelines Number of hospitalizations avoided Time spent with staff teaching at the bedside Documentation and comprehensiveness of advance care planning discussions

6 Rationale for Establishing Competencies for Physicians Practicing in the NHNursing Home practice demands a unique skill set Competencies linked to relevant clinical outcomes/quality Credibility of physicians predicated, in large part, on specialization Impetus to set the bar independently or allow government to determine performance metrics Helps inform new curriculum development which aligns with educational mission of AMDA

7 More NH residents Sicker NH residents Workforce ConstraintsIncreasing Need More NH residents Sicker NH residents Workforce Constraints

8 Current Reality Number of older adults with two limitations in ADLs will grow by 1/3 over the next 25 years 40% chance of NH admission after age 65 Number of NH beds likely to rise to accommodate population growth and increase in frailty The number of LTC beds in Canada is projected to increase from 280,000 (2008) to 690,000 by 2038 (Rising Tide: The impact of Dementia on Canadian Society. Alzheimer Society of Canada, 2010

9 Increasing Acuity of NH Residents: North AmericaNHs in BC reported an increase of the highest acuity residents from 4-38% between 1996 to 2006 (Statistics Canada. No XPE. Health Reports 21(4), 1-7.) In 2008, Ontario reported that more than 85% of NH residents required high levels of care (Sharkey S, MOHLTC 2008) In US, share of residents requiring extensive assistance or who were considered totally dependent to transfer or walk increased from 51% to 60% between pg 170

10 Can NH’s Accommodate Increased Acuity?Inadequate staffing Geriatric training lacking at all levels Few nurses or physicians have adequate training in geriatrics or a meaningful long term care experience before graduation Misaligned incentives The consumer expects a systems approach to care despite the fact that acute and long term care systems operate under different funding paradigms and priorities The “silo” approach negatively impacts quality of care as responsibility for the patient shifts with the venue of care Elements of an Effective Innovation Strategy for LTC in Ontario. Conference Board of Canada. Jan 2011

11 The Nursing Workforce www. aacn. nhceThe Nursing Workforce Clear link between nurse staffing ratios, educational level and quality of care Nurses are aging (avg age = 46yrs old in 2008) 55% of nurses reported an intention to retire between Very high turnover (10-30% per yr) with over 19,000 vacancies in LTC settings reported in 2008 Limited training in geriatrics (<1% of RN’s certified in geriatrics;23% of BA programs require geriatric course)

12 NH Staffing Standards and Staffing Levels in Six Countries J Nursing Scholarship 44 (1): 88-98, 2012Recommended level of hprd (hrs/resident/day) Nursing hours worked per resident day in US = 3.91 Staffing standards in US State to state variability LN standards ranged from 0.14 hprd to 1.08 RN standards ranged from 0.08 hprd to 0.32 Direct care (RN+LN+CNA) to resident ratio required in 18 states with highest standards = 1:5 during the day, 1:10 in evening and 1:15 at night

13 NH Staffing Standards and Staffing Levels in Six Countries J Nursing Scholarship 44 (1): 88-98, 2012Comparisons of nurse staffing between countries difficult as models of care differ and staffing data not consistently reported British Columbia: hprd Ontario: 3.12 hprd England: 4.26 hprd Sweden: 5.19 (includes all staff although most are nursing)

14 Physician Practice and QualityWorkforce Linkages

15 Three critical dimensions… A Model for Nursing Home Physicians Ann Intern Med 2009; 150: Three critical dimensions… Commitment conceptualized as percentage of the physician's practice devoted to NH care and the amount of time, on average, spent per NH patient encounter. Physician NH practice competency defined by specialized training and experience necessary to handle the complex medical care in a highly regulated, interdisciplinary care context that is the contemporary NH. Organizational structure reflects the cohesive integration of the medical providers into the culture of the facility.

16 Improving Medical CareThe framework suggests quality of care can be improved by progressing along one or more of three paths— Enhancing training and credentialing (competency) Increasing reimbursement (commitment) Developing new regulatory mandates and organizational models (closing medical staffs)

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18 The Physician WorkforceIn the U.S. only one in five primary care physicians engages in the care of nursing home residents (JAGS 45: 911, 1997) The majority spend 2 hours or less per week in NH care In Ontario (2005), 1190 physicians engage in NH care out of 10,317 (12%); of these 628 (53%) cared for 90% of all residents. Internationally, the “physician led model of care” is in the minority Surveys suggest continued difficulties with recruitment and/or exodus of physicians practicing in LTC

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21 Nursing Home Medical Staff OrganizationClinical and Nonclinical Factors Associated with Potentially Preventable Hospitalizations Among Nursing Home Residents in New York State (JAMDA 12: , 2011) 147 randomly selected NHs Outcomes derived from DON survey, MDS and SPARCS (patient level data related to hospitalizations) SPARCS=statewide planning and research cooperative system

22 Nursing Home Medical Staff OrganizationResults Four factors significantly associated with reduction in ambulatory care sensitive (ACS) conditions Nursing staff trained to effectively communicate with physicians regarding a resident’s condition Physicians treat residents within the nursing home and admit to hospital as a last resort NHs that provide better information and support to nurses and aides surrounding end-of-life care Easy access to stat lab results in <4hrs on weekends ACS= dx’s or chronic conditions that can be prevented or are treated safely and on site if a qualified professional is available. These ininclude convulsions, angina, asthma, cellulitus, COPD, CHF, dehydration, Diabetes, gastroenteritis, epilepsy, HPN,hypoglycemia, UTI, PNA,nutritional deficiencies, TB, and severe ear, nose and throat conditions

23 Survey of US and Dutch physicians caring for NH residentsThe Importance of Physician Presence in NHs for Residents with Dementia and Pneumonia JAMDA 12:68-73, 2011 Survey of US and Dutch physicians caring for NH residents 31% response rate in US (N=24) vs 38% in Netherlands (N=38) Treatment of pneumonia in residents with dementia was explored as well as “Nursing Home Presence” Calculation based on percentage of practice in NH and frequency of visits to a typical NH resident 82% of Dutch physicians spent more than 75% of practice time in NHs vs 88% of US physicians who spent less than 50% of practice time in NHs

24 The Importance of Physician Presence in NHs for Residents with Dementia and Pneumonia JAMDA 12:68-73, 2011 Results Physicians with lower NH presence were more likely to order a chest x-ray, hospitalize and treat with rehydration and oxygen Physician presence not related to decision to treat with antibiotics or certainty of the pneumonia diagnosis After adjusting for country, only significant finding was higher physician presence and certainty of family preferences

25 Bottom Line More physicians needed with requisite skill set and experience to care for an increasingly frail NH population Need to specifically define competencies for attending physicians in post acute and long term care as a first step in designing a curriculum and possible certification

26 Framework, Principles and ScopeCompetency Development Framework, Principles and Scope

27 2010 Board approval of White Paper defining rationale for establishing competencies

28 Rationale Lends credibility to the practice of post-acute and long-term care medicine Acknowledges the need to set the “bar” independently vs allowing government or other professional organizations to determine performance metrics Helps inform new curriculum development which aligns with educational mission of AMDA Sets the stage to explore the link between competencies and clinical outcomes/quality

29 2011 Work group charged with developing framework and specific competencies

30 Framework for CompetenciesBased on ACGME Outcome Project’s General Domains Foundational (Ethics, Professionalism and Communication) Medical Care Delivery Process Systems Nursing Home Medical Knowledge Personal QAPI

31 Process of Competency DevelopmentDACUM (developing a curriculum) process utilized by 25 member AMDA workgroup Initial draft of competencies reviewed by 450 AMDA members via survey methodology

32 2012 Draft of competency statements reviewed by organizations representing professions and industry engaged in long term care ACP, AAFP, AGS, SHM, ACHA, Leading AGE, ACHCA, NADONA

33 Principles Guiding Competency DevelopmentThe practice of post-acute and long-term care medicine requires a knowledge base and skill set that can be defined within a specific set of competencies that reflects expertise found in a number of other specialties: Family Medicine, Internal Medicine, Hospital Medicine, Palliative Care, Rehabilitation, Geriatric Medicine and Psychiatry

34 Principles While necessary for effective practice, none of these discipline-specific competencies are, alone, sufficient to describe the full range of post-acute and long-term care medicine competencies

35 Principles Rather, they must reflect a mix of many of the skills unique to each of these disciplines which must then be operationalized within a unique care setting with it’s unique regulatory requirements while incorporating the full skill set of the entire interdisciplinary team

36 Scope Setting: SNF and NFClinical Focus: Post-Acute patient and Long-Term Care resident Clinician: Attending Physician (These are not medical director competencies)

37 Foundation 1.1 Addresses conflicts that may arise in the provision of clinical care by applying principles of ethical decision-making 1.2 Provides and supports care that is consistent with (but not based exclusively on) legal and regulatory requirements 1.3 Interacts with staff, patients, and families effectively by using appropriate strategies to address sensory, language, health literacy, cognitive, and other limitations

38 Foundation (cont.) 1.4 Demonstrates communication skills that foster positive interpersonal relationships with residents, their families and members of the interdisciplinary team (IDT) 1.5 Exhibits professional, respectful and culturally sensitive behavior towards residents, their families and members of the IDT 1.6 Addresses patient/resident care needs, visits, phone calls and documentation in an appropriate and timely fashion

39 Medical Care Delivery Process2.1 Manages the care of all post-acute patients/long-term care residents by consistently and effectively applying the medical care delivery process including recognition, problem definition, diagnosis, goal identification, intervention and monitoring progress 2.2 Develops, in collaboration with the IDT, a person-centered, evidence-based medical care plan that strives to optimize quality of life and function, within limits of an individual’s medical condition, prognosis, and wishes

40 Medical Care Delivery Process (cont.)2.3 Estimates prognosis based on a comprehensive patient/resident evaluation and available prognostic tools, and discusses the conclusions with the patient/resident, their families (when appropriate) and staff 2.4 Identifies circumstances when palliative and/or end-of-life care (e.g., hospice) may benefit the patient/resident and family 2.5 Develops and oversees, in collaboration with the IDT, an effective palliative care plan for patients/residents with pain, other significant acute or chronic symptoms, or who are at the end of life

41 Systems 3.1 Provides care that uses resources prudently and minimizes unnecessary discomfort and disruption for patients/residents (e.g. limited nonessential vital signs and blood sugar checks) 3.2 Can identify rationale for, and uses of key patient/resident databases (e.g., the Minimum Data Set), in care planning, facility reimbursement, and monitoring quality 3.3 Guides determinations of appropriate levels of care for patients/residents including identification of those who could benefit from a different level of care

42 Systems (cont.) 3.4 Performs functions and tasks that support safe transitions of care 3.5 Works effectively with other members of the IDT, including the medical director, in providing care based on understanding and valuing the general roles, responsibilities, and levels of knowledge and training for those of various disciplines 3.6 Informs patients/residents and their families of their healthcare options and potential impact on personal finances by incorporating knowledge of payment models relevant to the post-acute and long-term care setting

43 Medical Knowledge 4.1 Identifies, evaluates, and addresses significant symptoms associated with change of condition, based on knowledge of diagnosis in individuals with multiple comorbidities and risk factors 4.2 Formulates a pertinent and adequate differential diagnosis for all medical signs and symptoms, recognizing atypical presentation of disease, for post-acute patients and long-term care residents 4.3 Identifies and develops a person-centered medical treatment plan for diseases and geriatric syndromes commonly found in post-acute patients and long-term residents

44 Medical Knowledge (cont.)4.4 Identifies interventions to minimize risk factors and optimize patient/resident safety (e.g. prescribes antibiotics and antipsychotics prudently, assesses the risks and benefits of initiation or continuation of physical restraints, urinary catheters and venous access catheters) 4.5 Manages pain effectively and without causing undue treatment complications 4.6 Prescribes and adjusts, medications prudently, consistent with identified indications and known risks and warnings

45 Personal QAPI 5.1 Develops a continuous professional development plan focused on post-acute and long-term care medicine, utilizing relevant opportunities from professional organizations (AMDA, AGS, AAFP, ACP, SHM, AAHPM), licensing requirements (state, national, province) and maintenance of certification programs 5.2 Utilizes data (e.g. PQRS indicators, MDS data, patient satisfaction) to improve care of their patients/residents 5.3 Strives to improve personal practice and patient/resident results by evaluating patient/resident adverse events and outcomes (e.g., falls, medication errors, healthcare acquired infections, dehydration, return to hospital)  

46 Next Steps