1 NURSING-HOME CARE Suggestions for Lecturer -1-hour lecture-Use GRS slides alone or to supplement your own teaching materials. -Refer to GRS8 for further content and case vignettes in questions 51, 89, 172, 175, 231, and 261. -For strength of evidence (SOE) levels, see GRS chapter. -Supplement lecture with handouts.

2 The characteristics of the nursing-home populationOBJECTIVES Know and understand: The characteristics of the nursing-home population Risk factors for admission to a nursing home The requirements of the Omnibus Budget Reconciliation Act of 1987 The physician’s clinical, ethical, and legal responsibilities to nursing-home residents Topic

3 TOPICS COVERED The Nursing-Home PopulationNursing-Home Availability and Financing Staffing Patterns Factors Associated with Placement The Interface of Acute and Long-term Care Quality Issues Medical Care Issues Physician Practice in the Nursing Home The Role of the Medical Director Topic

4 THE NURSING-HOME POPULATION (1 of 2)Impairment in decision making 81% Need assistance with 3+ ADLs 80% Need assistance with 1–2 ADLs 22% Dementia 50%–70% Orientation and/or memory problems 66% ADLs = activities of daily living Topic

5 THE NURSING-HOME POPULATION (2 of 2)Communication problems 60% Bowel or bladder incontinence 40%–60% Visual impairment 39% Hearing impairment 36% Behavioral problems 33%+ Depression 20%–25% Common behavioral problems are verbal and physical abuse, social inappropriateness, resistance to care, and wandering. Topic

6 DEMOGRAPHICS (1 of 2) Almost half are 85 yearsThe majority are women, widowed, with limited social supports Topic

7 DEMOGRAPHICS (2 of 2) Black Americans 65–74 years old are more likely than white Americans to be admitted to a nursing home Hispanic Americans, Asian Americans, and Native Americans are underrepresented despite higher disability rates The percentage of black residents approaches the percentage in the general population Older adults with developmental disabilities constitute another unique population that is requiring increasing nursing-home care as their parents die. These people often require specialized care that many nursing homes have difficulty providing. Topic

8 NURSING-HOME BEDS AVAILABLE15,700 homes 1.7 million beds 2.5 million discharges 1.4 million residents Beds per home: Average 107 6% have 200+ About half of all nursing homes (56%) are part of a chain Topic

9 POSTACUTE CARE IN NURSING HOMESResponse to declining length of hospital stays and higher care needs of older adults Integrates features of acute medical care, long-term-care nursing, and rehabilitation Availability of services varies by locale: Dialysis Orthopedic care Ventilators Some limited studies suggest that, for selected patient populations, postacute care in the nursing home achieves outcomes equal to or better than those of postacute care in acute hospitals. Definitions as to what constitutes postacute care vary widely, however, as do regulatory standards, thus making comparison studies difficult. Post-operative care Rehabilitative care Wound care Topic

10 LENGTH OF NURSING-HOME STAYMany short-stay residents are admitted for rehabilitation, and some enter nursing homes for terminal care. Interestingly, longer-stay nursing-home residents often show improvement in function, which reflects the heterogeneity of this population. The number of nursing-home admissions continues to rise, reflecting the dynamic nature of this sector of the long-term-care continuum. Topic

11 FUNDING OF NURSING-HOME CARESpending > $120 billion Topic

12 MEDICARE PAYMENTS FOR NURSING-HOME CAREPredicated on patient’s functional needs and rehabilitative potential to help recovery from acute illness or injury Gains in function must be carefully documented to ensure reimbursement for rehabilitative services Requires 3-day qualifying hospital stay First 20 days in skilled-nursing facility: pays in full Days 21‒100 require co-payment On admission to a nursing home, almost one third of residents are eligible for Medicaid, and another third eventually qualify as financial resources are depleted. Although the prospective payment system has not conclusively limited access to skilled nursing care for Medicare beneficiaries, it has definitely forced nursing homes to be more diligent with regard to their admission policies. Not unexpectedly, physical, occupational, and speech therapies are commonly prescribed in the nursing home, with half of all nursing-home residents receiving at least 90 minutes of these rehabilitation services, according to one study. The prospective payment system requires nursing-home staff to carefully document gains in function to ensure reimbursement. Interestingly, declines in Medicare spending on home-health care since enactment of prospective payment may eventually force some individuals into nursing homes for lack of affordable home-health care options. Topic

13 STAFFING ISSUES — NURSESHigher quality of care correlates with: Total nursing hours Ratio of RNs to other nursing staff Turnover rates are >50% per year for Directors of Nursing, RNs, and LPNs and >70% for nursing assistants High turnover rates are associated with increased rates of hospitalization for nursing- home residents An Institute of Medicine report in 2001 recommended increasing nurse staffing levels to enhance the quality of nursing-home care and has spurred Congress to debate the merits of mandatory minimum staffing ratios. The Center for Medicare and Medicaid Services has refused to institute regulatory changes that would be based on current evidence but has rather called for additional research in this area. Even if significantly higher staffing ratios eventually are mandated, the financial resources to achieve them remain elusive. Recruiting and retaining staff, particularly nursing assistants, who constitute the bulk of the nursing-home workforce, also continues to be difficult. Topic

14 STAFFING ISSUES — PHYSICIANSThe typical nursing-home physician: Primary care internist or family practitioner Devotes 2 hours/week to nursing-home care The perception: Excessive regulations and paperwork Limited reimbursement Undesirability of long-term-care environment The reality: Challenging and fulfilling work requiring excellent clinical skills and sensitivity to a variety of ethical, legal, and interdisciplinary issues Topic

15 STAFFING ISSUES — “CULTURE”Closed-staff model may improve care by facilitating interdisciplinary communication and treatment Some evidence suggests lower hospitalization rates in nursing homes that employ a limited number of committed doctors In one study, quality of drug use in nursing homes correlated with enhanced nurse-doctor communication and regular interdisciplinary team discussions Topic

16 FACTORS ASSOCIATED WITH NURSING-HOME PLACEMENTIncreasing age Low income and low social activity Poor family supports (especially lack of spouse and children) Accepting attitude toward nursing homes Cognitive and functional impairment For patients with dementia, education and caregiver support have been shown to delay the need for nursing-home placement for up to 1 year. The range of long-term-care services that are now available (ie, skilled nursing, home care, assisted living) further increases the complexity of placement decisions, as the relative value and merits of available options have not been empirically tested. The use of formal (ie, paid- for) community services does not necessarily reduce the likelihood of nursing-home placement for patients with severe disabilities. Topic

17 INTERFACE OF ACUTE AND LONG-TERM CARE (1 of 2)Most nursing-home residents are admitted from an acute-care hospital Nursing-home residents have high rates of hospitalization, most commonly due to infection NPs and PAs working in concert with a primary care physician as a team: Often reduce hospitalization rates while maintaining cost of neutrality Nursing-home residents account for >2.2 million emergency department visits annually in the United States. Topic

18 INTERFACE OF ACUTE AND LONG-TERM CARE (2 of 2)Suboptimal information transfer is common: Missing or illegible transfer summaries Omission of prescribed medications Advance directives not documented Psychosocial issues and behavior problems not reported Topic

19 INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS (INTERACT)Developed with the support of CMS to improve early identification, assessment, documentation and communication about status changes in nursing home residents Goal is to reduce frequency of hospital transfers INTERACT II intervention’s communication tools, clinical care paths and advanced care planning tools reduced acute hospital admissions by 17% Topic

20 THE OMNIBUS BUDGET RECONCILIATION ACT (OBRA)Passed in 1987 to set training guidelines and minimum staffing requirements for nursing homes Bolstered residents’ rights: Limited use of restraints Limited use of psychoactive medications Initiated the Minimum Data Set (MDS) Requires documentation of the need for all medications, particularly psychoactive agents Topic

21 MEDICATION REGULATION (1 of 2)OBRA requires monthly evaluation of medications by a pharmacist Medications must be reviewed at regular intervals and include no unnecessary drugs Unnecessary drugs are defined as those given: In excessive doses For excessive periods of time Without adequate monitoring Without adequate indications for use In the presence of adverse consequences indicating the need for dose reduction or discontinuation Topic

22 MEDICATION REGULATION (2 of 2)OBRA requires that clinical documentation demonstrate the indication for all medications, especially psychoactive drugs For psychoactive medications, gradual dose reductions are mandated unless a clinical contraindication exists and is documented in the medical record Topic

23 THE MINIMUM DATA SET (MDS)Periodic comprehensive clinical assessment of all residents Used to compile nursing facility quality measures such as pain, pressure ulcers, weight loss, depression, rates of vaccination and restraint use Identification of current or potential problem triggers review of diagnostic and therapeutic protocols Topic

24 LEGISLATION IN THE NURSING HOME (1 of 2)Each federal regulation for long-term care is given a tag number, often called “F-Tags” Adherence to regulations is assessed by mandatory site visit surveys every 15 months, where facility procedures, quality of care, and quality of life are reviewed Failure to meet regulatory standards for care is cited in a “deficiency” A host of variables interact in nursing homes to determine the level of quality achieved. These include staffing levels, reimbursement rates, and processes of care. Although surveys of nursing facilities are mandated every 15 months, there is much debate as to whether the survey process can adequately identify quality practices and engender lasting improvements when deficiencies in care are found. The survey process, based on a deterrent regulatory paradigm, has been criticized for its inconsistencies, disassociation between outcome and process, surveyor subjectivity, and a failure to discriminate between trivial and important quality issues. Topic

25 LEGISLATION IN THE NURSING HOME (2 of 2)Penalties are imposed related to nature and severity of deficiency National set of quality indicators based on MDS allows facilities to compare their performance to local and national norms (www.cms.hhs.gov) Topic

26 CHALLENGES IN NURSING-HOME MEDICAL CARE (1 of 2)Heterogeneity of residents, necessitating individualized approaches to care Atypical and subtle presentation of illness Limited access to biotechnology Dependence on nonphysicians for patient evaluation High prevalence of cognitive impairment The care of nursing-home residents has become more complex over the past several years, commensurate with an increasing level of medical acuity in an environment continually constrained by lack of adequate resources. Problems in nursing homes that commonly require individualized diagnostic and treatment strategies include infections, falls, malnutrition, dehydration, incontinence, behavioral disturbances, the use of multiple medications, and prevention and screening. For example, determining the risks and benefits of tube feedings for frail nursing-home patients must be predicated not only on underlying illness but also on the resident’s and the family’s value system, the resources available in the nursing facility, and staff acceptance of the intervention. Given that the evidence for and against enteral feeding in nursing-home patients is controversial (ie, benefits are not well established), the practitioner must continue to individualize therapy. Topic

27 CHALLENGES IN NURSING-HOME MEDICAL CARE (2 of 2)The need to involve families in care plans and provide educational and psychosocial support for families Ethical and legal concerns, such as end-of-life care, feeding, hydration, and resident rights Intense regulatory oversight Many of the problems commonly encountered in the nursing home result when multiple comorbidities interact with a host of environmental factors, all of which may only be partially remediable. Unfortunately, expectations of family, as well as state regulators, often do not account for these complexities and commonly engender “risk-averse” behavior that is counter to autonomy and optimum quality of life. Topic

28 ENHANCING SATISFACTION WITH NURSING-HOME PRACTICESchedule and structure visits to benefit from efficiencies and to become better integrated into the health care team Act in concert with NPs and PAs Document the rationale for each medication and intervention, to protect against potential scrutiny Hold frequent discussions with the facility’s consultant pharmacist Topic

29 THE PHYSICIAN’S RESPONSIBILITIES (1 of 3)Comprehensive admission assessment, including history and physical examination, and review of available medical records Development of a care plan in concert with other team members, the resident, and the family that is consistent with the resident’s needs and goals Periodic monitoring of chronic health problems at appropriate intervals, using diagnostic testing, consultation, and interventions as warranted Topic

30 THE PHYSICIAN’S RESPONSIBILITIES (2 of 3)Prompt and thorough assessment of acute medical problems or change in function, instituting change in the medical treatment plan as indicated Communication with interdisciplinary team members, the resident, and the family concerning new diagnoses and treatment plans Periodic review of all medications, in concert with the consultant pharmacist, with regard to ongoing need, side effects, appropriate laboratory monitoring, and potential interactions Topic

31 THE PHYSICIAN’S RESPONSIBILITIES (3 of 3)Optimization of quality of life and function, with special attention to cognition, mobility, falls, skin integrity, nutrition, and continence Determination of each resident’s decision-making capacity and assistance in establishing advance directives Physical attendance to each resident, with documentation in the medical record in accordance with all state and federal guidelines Topic

32 QUALITY OF MEDICAL CARE IN NURSING HOMESStrategies for enhancing quality of care: Specific consultation services (eg, efforts to reduce falls) Interactive educational programs for physicians and nursing staff Discussions with residents about their preferences for care (eg, advance directives) Fewer than one in eight nursing-home residents has had a discussion with their health care providers about their preferences for care. In addition, there is often a lack of follow-up of do-not-resuscitate discussions in the hospital when the patient is subsequently admitted to the nursing home. Basic advanced directives such as do-not- resuscitate orders are present for 27% at admissions and 55% after 1 year of residence. Less than 5% of nursing home residents have do- not-hospitalize orders. When ethical dilemmas do present themselves, the availability of institutional ethics committees can provide important guidance. The multidisciplinary nature of these committees ensures a spectrum of opinion and insight critical for nursing-home residents, and they are particularly relevant to end-of-life issues. Topic

33 ROLE OF THE MEDICAL DIRECTORInfluences the quality of physician practice by: Setting quality standards and specific policies and procedures in concert with medical staff Ensuring compliance with government guidelines Working with the administrator and director of nursing to foster effective team care and appropriate continuing staff education Certification is offered by the American Medical Directors Association (www.amda.com) Every skilled-nursing facility must designate a licensed physician to serve as Medical Director (F501) Topic

34 SUMMARY There are 15,700 nursing homes in the US with 1.4 million residents and 2.5 million discharges per year Nursing-home care has evolved dramatically in recent years Federal law requires periodic comprehensive assessment of all residents Medical care of nursing-home residents is challenging and fulfilling because it demands excellent clinical skills and sensitivity to a variety of ethical, legal, and interdisciplinary issues Topic

35 CASE 1 (1 of 3) An 86-year-old man is admitted to the hospital for management of hip pain that began after a fall at home. Imaging studies show no fracture, and pain is controlled with regularly administered acetaminophen. He has moderately severe dementia but no other significant medical or neuropsychiatric conditions. His wife asks that he be transferred to a nursing home for physical therapy. She says she understands that Medicare will pay for 100 days in a nursing facility after a beneficiary is hospitalized. Her husband has Medicare Parts A, B, and D. Topic

36 CASE 1 (2 of 3) Which of the following is true of Medicare coverage?Medicare covers physical therapy in rehabilitation facilities but not in nursing facilities. Medicare may cover therapy in a nursing facility but only after a 3-day hospital stay. Medicare covers only the first 30 days of nursing- home care. Medicare may cover therapy if he stays in the hospital but not if he is discharged home. Topic Slide 36

37 CASE 1 (3 of 3) Which of the following is true of Medicare coverage?Medicare covers physical therapy in rehabilitation facilities but not in nursing facilities. Medicare may cover therapy in a nursing facility but only after a 3-day hospital stay. Medicare covers only the first 30 days of nursing- home care. Medicare may cover therapy if he stays in the hospital but not if he is discharged home. ANSWER: B Medicare Part A covers inpatient hospital care and, to a varying extent, nursing care, hospice, and home-health care. Medicare Part B contributes to physician and other provider fees, outpatient durable medical equipment, home-health care, and some preventive services. Medicare Part C (Medicare Advantage) is similar to HMO health plans and is provided by Medicare-approved private insurance companies. Medicare Part D helps cover the cost of prescription drugs and is administered by Medicare-approved private insurance companies. Medicare accounts for approximately 14% of payments to nursing homes. Reimbursement is available only for certain limited conditions for beneficiaries who require nursing or rehabilitation services. In general, Medicare Part A covers services that are rendered to help a beneficiary recover from an acute illness or injury. Such services must take place in a Medicare-certified nursing facility after a qualifying stay of ≥3 days in a hospital. In this case, the patient does not meet intensity-of-service criteria to remain in the acute hospital setting for 3 days. Some Medicare Part C programs waive the 3-day stay, but this patient does not have Part C. For qualified beneficiaries, Medicare pays in full for skilled services for the first 20 days in a nursing facility; a copayment is required for days 21–100. After days, Medicare payments for nursing-facility services cease. Outpatient or home physical therapy may be covered by Medicare Part B, depending on the patient’s diagnosis and functional status, whether the person is homebound, and the prognosis for improvement in function. Topic Slide 37

38 CASE 2 (1 of 4) A nursing facility has created a process improvement team to analyze and reduce the high prevalence of falls at the facility. Team members include the medical director, the director of nursing, the quality assurance director, a unit nurse, a nursing assistant, a member of the activities department, and a physical therapist. The team reviews the facility’s quality indicator report and confirms that the prevalence of falls in the facility is consistently higher than state and national benchmarks. Topic

39 CASE 2 (2 of 4) The quality assurance director presents additional data showing that many falls occur at change of shift, especially between 3:00 and 4:30 PM when the day shift is leaving and the evening shift is arriving. The nursing assistant suggests that, when the nurses and nursing assistants are in report, having a member of the activities department on the unit would engage residents, decrease wandering, and potentially decrease falls. Topic

40 CASE 2 (3 of 4) Which of the following is the best approach to determine the efficacy of this intervention? Introduce the intervention and monitor facility performance on quality indicator reports. Introduce the intervention and use a plan-do-study-act (PDSA) approach. Introduce the intervention and monitor facility performance on the Center for Medicare and Medicaid Services (CMS) Nursing Home Compare website. Hire a consultant to refine the intervention and help with implementation and measuring outcomes. Topic Slide 40

41 CASE 2 (4 of 4) Which of the following is the best approach to determine the efficacy of this intervention? Introduce the intervention and monitor facility performance on quality indicator reports. Introduce the intervention and use a plan-do-study-act (PDSA) approach. Introduce the intervention and monitor facility performance on the Center for Medicare and Medicaid Services (CMS) Nursing Home Compare website. Hire a consultant to refine the intervention and help with implementation and measuring outcomes. ANSWER: B The best choice based on consensus and recommendations from the Center for Medicare and Medicaid Innovation is a rapid-cycle approach using a method such as PDSA. This approach allows a small interdisciplinary group to plan an intervention based on available data, do the intervention quickly on a small scale, study the outcomes from the small study, then act to further modify the intervention if needed and repeat the PDSA rapid cycle. In this case, there is much historical data about falls to inform the process improvement team about the efficacy of having activities staff members available during peak time for falls. Data can be entered in an Excel or similar spreadsheet and the number of falls per day can be charted over a 2- to 4-week period. Quality indicator reports are generated for all nursing facilities in the United States based on information from the Minimum Data Set (MDS). Using the quality indicator report, the prevalence of falls can be compared with state and national benchmarks. However, the definition of “prevalence of falls” in the quality indicator report is the number of facility residents who have had ≥1 falls in the previous 30 days, not the number of falls. Monitoring the falls quality indicator is another way to track falls but does not provide the process improvement team with the information it needs about specific interventions, nor are the reports frequent enough to provide timely feedback about a PDSA cycle. Nursing Home Compare is a CMS Web site intended primarily for consumers. It does not provide specific information about falls. The process improvement team should not need a consultant at this point, because the PDSA rapid-cycle approach is a commonly used tool in health care. Topic Slide 41

42 Copyright © 2013 American Geriatrics SocietyGRS8 Slides Editor: Annette Medina-Walpole, MD, AGSF GRS8 Chapter Authors: Paul R. Katz, MD Suzanne M. Gillespie, MD, RD GRS8 Question Writer: Larry W. Lawhorne, MD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2013 American Geriatrics Society Slide 42