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JANUARY 2018 • VOLUME 19, NO. 1www.CaringfortheAges.com

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See CHEERLEADING • page 12

Tattoo YouThere’s one permanent option to make your end-of-life wishes known, but can you change your mind? 2

Dear Dr. JeffAmid ethics confl icts, the decision for continued survival in long-term care should be to gain the highest attainable quality of life. 4

Bipolar Diagnoses ChallengedStudy raises doubts about the use of antipsychotics in demented patients who may be inappropriately diagnosed with bipolar disorder. 6

A Post-Jimmo LandscapeKnowing the complexities of therapy services for Medicare benefi ciaries will help practitioners avoid allegations of improper billing. 8

Teen EntrepreneurNoah Krieder brings Generation Z tech savvy to elders in assisted living. 16

Well-Meaning Cheerleading Can Throw the Game for PA/LTC Residents Joanne Kaldy

When Sen. John McCain announced his cancer diagnosis, the internet

was fl ooded with messages of support and encouragement: “You can beat this!” “You’re a fi ghter!” “You’re a survivor.”

Hopeful, upbeat messages about health care are everywhere — ads for medica-tions, health plans, hospital networks, and elsewhere. These often show smiling

patients, interacting happily with physi-cians and other practitioners, laughing with friends and family, and celebrating positive outcomes. Although such mes-saging is designed to inspire confi dence in patients and encourage them to place their trust in the product or provider, they also can lead to unrealistic expectations, anger, and damaged relationships. It is

important for practitioners and caregivers to balance cheerleading with realistic and focused support to help patients deal with serious diagnoses, disappointments, and outcomes that fall short of goals.

Mary Lou Dallam, a woman in her 70s battling lung cancer, appreciates

Cheryl Phillips, MD, CMDR, took the title of her keynote address for

AMDA — the Society for Post-Acute and Long-Term Care Medicine’s 2018 Annual Conference from a Hopi prayer that speaks to the importance of having the knowledge, strength, and wisdom to face the challenges we encounter rather than relying on someone else to res-cue us. Her presentation, “We Are the Ones: The Future of PA/LTC and Our Role in Leading the Change,” is designed to empower post-acute/long-term care practitioners to be strong leaders moving into a world of value-based, high-tech medicine. “We are the ones we’ve been waiting for,” she said. “We who are the experts in this setting; we know the resi-dents, family, care teams, and regulatory environment better than anyone. If we don’t guide decisions and policy moving forward, outside forces will devise solu-tions for us that work for them but not necessarily for our patients or us.”

As a Society past president and a long-time leader in PA/LTC medicine, Dr. Phillips has worn many hats and navi-gated numerous changes and challenges over the years. Caring sat down with her to refl ect on the past, present, and future of the profession and the Society that represents it.

She started by noting, “In some ways, I’m no longer of the Society. I’m not a medical director anymore; I’m on the out-side looking in, and I have an outsider’s appreciation of the complexity of systems of care and the changes faced, not just by PA/LTC facilities but also hospitals, payers, insurance companies, and others.

Everyone is trying to a do a piece of the work, but there is little coherence or coordination. Being an outsider, I under-stand these components better now; and I understand that the cohesion is much more diffi cult than I realized.”

We Are the Ones: Keynoter Promotes Collaboration in Times of Change Joanne Kaldy

2018 ANNUAL CONFERENCE

TO REGISTER VISIT paltc.org/annual-conferenceRegister by January 17 to Save $200!

MARCH 22-25, 2018

Society Past President Cheryl Phillips (l), pictured here with Verna Sellers (c) and Joseph Ouslander (r) at the 2016 Society Annual Conference, now says she has an “outsider’s appreciation” for the work of PA/LTC providers.

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2 CARING FOR THE AGES JANUARY 2018

Many of Caring’s readers will re-call the November letter to

the New England Journal of Medicine (2017;377:2192–2193) that recounted the case of an unidentifi ed 70-year-old man who presented, unconscious and very ill, to an emergency department and was found to have a large “DO NOT RESUSCITATE” tattoo on his chest. Beneath that tattoo was a second tattoo, a representation of his signature. The pa-tient received moderately aggressive life-sustaining treatment in an intensive care unit to address acidosis and hypotension, and the treating ICU team elected not to honor the tattoo initially.

Before discussing the outcome of this case, it is worth reviewing some of its instructive and controversial aspects. The published case was reported on widely in the media, and I encourage interested readers to go online and read some of the comments on those articles, which are mostly from lay people but also from medical and legal professionals (for example, see Washington Post, Dec. 1, 2017; http://wapo.st/2ic5jfu). These comments are quite interesting and refl ect a variety of opinions — although most seem to agree that these greedy doctors only wanted to make money off the dying man’s suffering, despite his clear wishes. Many also believe the doc-tors didn’t care what the patient’s wishes were — they just wanted to avoid being sued. In fact, some of the comments on various websites about this DNR tattoo story are downright disturbing in their vitriolic, simplistic hate.

Regrets, I Have a Few The authors of the case cited a couple of reasons for electing not to honor this seemingly unambiguous expression of the patient’s wishes. First, tattoos serving as a medical directive have no legal prec-edent, regardless of how clear they may be. Moreover, a tattooed DNR is not a physician’s order, so certainly paramedics would not be able to follow it without an order from a base station physician. Second, and certainly worth contemplat-ing, is that the authors adhered to the “principle of not choosing an irreversible path when faced with uncertainty.” Or, as some of us say, when in doubt, err on the side of life.

But really, where was the uncertainty here? People do, indeed, change their mind. There has been a single case report of a patient with a DNR tattoo who changed his mind — but obviously he was conscious and able to articulate that. If someone with a legal, written, properly executed DNR order comes in unconscious, what possible reason

would there be to suspect a change of heart? How is the case with the tattoo any different?

And what about the possibility of tat-too regret? I still remember my basic pathology text by Robbins and Cotran noting that tattoos have a nasty habit of becoming permanent reminders of tran-sient poor judgment — as more recently illustrated by the “No Regerts” tattoo of internet notoriety. (My apologies here to my nephew and all our millennial readers who are proud of, even thrilled with, their multiple tattoos. They aren’t my generation’s cup of tea, but I don’t begrudge them.) If a person who has a DNR tattoo has a change of heart, wouldn’t the fi rst thing to do be to slash out the “NOT”? Or make some other arrangement to clarify that DNR was no longer the desired course of action? After all, this is potentially a life-and-death matter.

And what of those who get a DNR tattoo just because they lost a bet? Well, I think the same applies — people know

what it means: it removes a chance to receive aggressive medical treatment. A responsible adult takes action to remedy mistakes like this.

Facing the Final Curtain With those caveats in mind, I think the overwhelming majority of people who opt to get a DNR tattoo are quite serious about their wishes; they’re suffi -ciently determined and passionate about their choice to opt for the expense, pain, and lifetime commitment of having it inscribed onto their skin. I know the patients I’ve seen with these take them very seriously, and they would be very upset (on the off chance they survived) to fi nd themselves successfully resusci-tated against their clearly, cutaneously memorialized wishes.

I’ve seen a few DNR tattoos in my day on fi rst responders and other health care providers as well (all of whom were conscious at the time), but they also all had the corresponding legal documents. Another local friend and colleague who’s a longtime hospice physician and oncol-ogist, a healthy, athletic man in his 60s, says he has seriously contemplated get-ting a DNR tattoo because he truly does not want cardiopulmonary resuscitation under any circumstances; ultimately he decided to execute a Physician Orders for Life-Sustaining Treatment (POLST) form and to be sure all of his loved ones had access to it. By now he’s prob-ably uploaded his POLST to one of the cloud-based registries that house such advance directives and medical orders about wanted and unwanted treatments — which I believe is the wave of the future. (However, as I often remind our

readers, POLST forms are not generally meant for people in good health; they are for people in the last year or so of life, or those with serious, chronic illnesses and strong feelings about their treatment preferences.)

When There Was Doubt Clearly, even the best-laid plans can go awry for anyone; as we are fond of telling our patients and their families, no POLST form or advance directive can envision every possible scenario. If you don’t want chest compressions or defi brillation, and you are unfortunate enough to have your cardiac arrest in a public place (say, a restaurant or hos-pital), a Good Samaritan is probably going to pound your chest or pull down the automated external defi brillator. MedicAlert bracelets or other medallions have legal standing in some jurisdic-tions, and electronic copies of POLST Paradigm forms are legally actionable in many states, so if you have a picture of your POLST on your smartphone (and someone can access it), you may not be subjected to these unwanted incursions on your body for as long as you other-wise might.

Registries are on the rise, and some states (such as Oregon) have a manda-tory registry to which all POLST forms are uploaded. But even that is not going to stop a well-meaning bystander from doing what is normally considered the right thing to do.

Some of the comments online about the tattoo case called for the use of micro-chips or other technology, which also seems like a good idea if the privacy aspects can be worked out. R. Blake Kessler, a former classmate of mine, has sug-gested that the tattoo should instead have read, “Notarized DNR in my wallet” — which, again, to be valid requires a phy-sician or other practitioner’s signature. Which brings up a related question: would the DNR in the New England Journal of Medicine case have been valid if the tattooed signature had been a doctor’s instead of the patient’s?

Blake went on to say, “Where is the voluntary unifi ed national online medi-cal records repository for emergencies? It could include signed and notarized MOLST [Medical Orders for Life-Sustaining Treatment], etc. Fifty-seven different systems by 57 wannabee dot-com millionaires (the direction we’re heading) won’t do.” I heartily agree. It’s precisely that kind of corporate greed that landed us in the stinking morass of non-interoperable electronic health records we currently are trying to dig out of. I’m not saying that everyone offering

ON MY MINDKarl Steinberg, MD, CMD, HMDC

No DNR Tattoo for Me, Thanks

Copies of POLST are valid. Would this be a better tattoo to ensure your wishes are honored?

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If someone with a legal, written, properly executed DNR order comes in unconscious, what possible reason would there be to suspect a change of heart? How is the case with the tattoo any different?

CARINGFORTHEAGES.COM CARING FOR THE AGES 3

online, cloud-based advance care plan-ning documents, advance directives, and medical orders like POLST and MOLST is in it for greed, because that’s clearly not the case. But it would be lovely to have a national registry along the lines of what Oregon has, especially for those who have strong feelings about their wishes (in either direction).

Unfortunately, state laws vary sub-stantially, and I don’t foresee any feasible national solution to this problem — especially given the current political cli-mate. I urge our readers to follow what’s going on in their states with respect to documenting wishes for potentially life-sustaining treatment and for designating surrogate decision-makers, which is much more important for the public at large.

Even though there are those who seem to believe all medical decisions should be made in a court of law, and that every-body’s life should be prolonged until the last possible instant achievable by medical technology, it is clear that most

people want to make their own decisions as long as they can, or have a trusted surrogate make those decisions if they should lose decisional capacity, and not have extraordinary measures visited on them — especially when they are near-ing the end of life, regardless of what is or is not done.

In the case study, an ethics committee was convened, and ultimately the social worker found a previously documented DNR from a local nursing home. The patient’s condition worsened, and he

died the day after admission without having been intubated, defi brillated, or subjected to chest compressions. The study’s authors felt that the case “neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated” and the DNR tattoo produced “more confu-sion than clarity.” Apparently they were still concerned that the tattoo may have represented a “permanent [reminder] of regretted decisions made while … intoxicated.”

To my thinking, there’s nothing con-fusing about a DNR tattoo. But whether it can be legally followed is clearly an issue. So my New Year’s resolution is to be sure my loved ones know what I want in the event of serious medical decompensation, and be sure they have copies of my advance directive. In the meantime, a DNR tattoo — or any other tattoo — is not on my resolution list, or part of my immediate or remote agenda. But to each their own.

Dr. Steinberg is chief medical offi cer for Mariner Health Central in Califor-nia, and a longtime nursing home and hospice medical director. He is editor in chief of Caring and chairs the Public Policy Committee for the Society. The views he expresses are his own and not necessarily those of the Society or any other entity. He may be reached at karlsteinberg@MAIL.com and he can be followed on Twitter @karlsteinberg .

The Centers for Medicare & Medicaid Services released a fi nal rule on the

Medicare physician fee schedule (PFS) for 2018 and other revisions to Medicare Part B policies. Policies in the fi nal rule took effect on Jan. 1, 2018.

Before 2015, the annual update to the PFS conversion factor (CF) was previously calculated based on a statutory formula (the Sustainable Growth Rate methodol-ogy that was largely overridden each year by Congressional action). The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the update for calendar years 2015 through 2025. The CF for 2018 is $35.9996. For 2018, the specifi ed update is 0.5%, before applying other adjustments.

In addition to the update, the CF calculation for 2018 takes into account two other factors: the Relative Value Units budget neutrality adjustment and the target recapture amount (the pro-posed CMS estimate of the net reduc-tion in expenditures resulting from proposed adjustments to relative values

of misvalued codes as compared with the 2018 statutory target of 0.5% net reductions in expenditures).

Here are some highlights of the fi nal rule:

PQRS and MU Quality Reporting CMS revised CY2016 Physician Quality Reporting System (PQRS) and Meaningful Use (MU) quality reporting requirements to only require physicians to report six measures with no domain or cross-cutting measure requirements. CMS fi nalized this change, which aligns the CY 2016 PQRS and MU quality reporting requirements with the new quality reporting requirements for phy-sicians under the Merit-Based Incentive Payment System (MIPS). CMS estimates that this change will result in approxi-mately $22 million in reduced penalties for physicians.

To further align with the MIPS requirements, CMS fi nalized making the Consumer Assessment of Healthcare Providers and Systems for PQRS survey

optional under GPRO for practices of 100 or more eligible clinicians in 2016.

Value Modifi er (VM) CMS fi nalized several changes to better align the VM program with the MIPS program including:

• Holding all groups and solo prac-titioners who met 2016 PQRS reporting requirements harmless from any negative VM payment ad-justments in 2018.

• Halving penalties for those who did not meet PQRS requirements to -2% for groups with 10 or more eligible professionals, and to -1% for smaller groups and solo practi-tioners.

• Reducing the maximum upward payment adjustment to two times an adjustment factor that is set at the rate needed to keep penalties and bonuses budget neutral.

• Dropping its earlier proposal to publicly report 2016 value modi-fi er data on its Physician Compare web site.

The Society joined several other phy-sician specialty societies in advocating for these changes during a meeting with former Health and Human Services Secretary Tom Price, MD. The Society welcomed these changes and continues to advocate for more appropriate qual-ity and cost measures in the Quality Payment Program.

Patient Relationship Categories MACRA directed CMS to create new patient relationship codes that physi-cians would be required to report on claims starting in 2018 for the purposes of determining which physician would be held accountable for a patient’s cost

of care. CMS fi nalized the use of Level II Healthcare Common Procedure Coding System (HCPCS) modifi ers as the patient

relationship codes. The HCPCS modi-fi ers may be voluntarily reported begin-ning Jan. 1. CMS notes that by allowing for a voluntary approach to reporting, it will gain information about patient rela-tionship codes and allow for education and outreach to physicians on the use of the codes.

Evaluation and Management (E/M) Documentation Guidelines In the 2018 proposed rule, CMS asked for comments on revisions to the E/M documentation guidelines that would reduce administrative burden to physi-cians. CMS relayed that commenters did not agree on how the current standards should be changed, and different special-ties expressed different challenges and rec-ommendations regarding the guidelines. However, the agency also noted that it continues to believe revised documen-tation guidelines could reduce clinical burden, and it is considering the best approach for collaboration to develop and implement potential changes going for-ward.

CMS Releases 2018 Medicare Physician Fee Schedule Final Rule

CodeTotal 2018RVUs

2018 Payment Rate

(CF=35.9996)

Total 2017RVUs

2017 Payment Rate

(CF=35.77510)

Percentage Change

2017-2018

99304 2.58 $92.88 2.58 $92.30 0.63%

99305 3.69 $132.84 3.69 $132.01 0.63%

99306 4.72 $169.92 4.69 $167.79 1.27%

99307 1.26 $45.36 1.25 $44.72 1.43%

99308 1.96 $70.56 1.94 $69.40 1.66%

99309 2.59 $93.24 2.57 $91.94 1%

99310 3.87 $139.32 3.85 $137.73 1.15%

99315 2.06 $74.16 2.05 $73.34 1.12%

99316 3 $108.00 2.99 $106.97 0.96%

99318 2.72 $97.92 2.71 $96.95 1.00%

CMS revised the PQRS and MU quality reporting requirements to only require physicians to report six measures with no domain or cross-cutting measure requirements.

My New Year’s resolution is to be sure my loved ones know what I want in the event of serious medical decompensation, and be sure they have copies of my advance directive. ©

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4 CARING FOR THE AGES JANUARY 2018

Dear Dr. Jeff: Our nursing home ethics committee is occasionally faced with diffi cult decisions regarding end-of-life decisions for residents who lack the capacity to make decisions for themselves. Family and friends disagree, at times quite bitterly. The staff caring for the resident accepts the committee decisions, but often not very happily. Although we try to make each decision in accordance with our best understanding of the resident’s wishes in order to respect patient auton-omy, the process leaves many disgruntled or unsatisfi ed. What do you suggest?

Dr. Jeff responds: Last month I approached this question through a discussion of the limitations of a medical ethics process that treats autonomy as the sole ethical principle to be honored. Certainly, the rights of individuals who retain decision-making capacity must be a paramount consider-ation, as adults of any age should make their own decisions regarding their lives and their bodies. However, the numerous problems regarding advance directives — including the inevitable diffi culty of identifying in advance how medical deci-sions might present and how preferences might change over time — make a blind obedience to these directives problematic at best.

The notion that designated proxies will make decisions when patients lack the ability to make them for themselves frequently falls short ethically, particu-larly in the typical situation when the designated proxies have no direct know-ledge of how patients would, in fact, have made choices in their altered con-dition. Unfortunately for geriatricians, very few families discuss “Would you want to be on dialysis if you are already demented?” at the dinner table between “What’s for dessert?” and “What’s on TV tonight?”

Although the designation of health care proxies or agents defi nitely simplifi es problems for the providers and provides a legal framework for decision making without resorting to the courts, the actual ethical basis for this process is rather doubtful. State laws typically authorize certain documents, such as durable pow-ers of attorney for health care, or create a formal hierarchy of decision makers authorized to give or refuse consent on the patient’s behalf. But we should not confuse what is legal with what is ethical.

Using the theory that health care deci-sions made in accordance with a resi-dent’s prior values demonstrate respect for the personhood of the resident, many ethics committees make seri-ous efforts to explore what a resident’s

actual values were to attempt to clarify the resident’s probable decision-making process. Often the designated proxy and other friends and relatives can be use-ful sources for information regarding a value structure that may be complex and nuanced.

For example, simply identifying the religious denomination with which an individual identifi ed does not necessar-ily mean that the resident accepted all the teachings of that religion regarding health care and end-of life decisions, or even knew what they are. The world’s major religions — Islam, Christianity, Buddhism, Hinduism, Judaism — are all divided into different denomina-tions and movements with signifi cant differences in practice. Even when a comparatively unifi ed set of theological teachings is widely accepted — such as the Roman Catholic Church’s Ethical and Religious Directives for Catholic Health Care Services, a work that is widely disseminated and periodically updated — the interpretation of the circumstances creating an obligation to accept a feeding tube has varied from diocese to diocese.

A Life of Confl icts Most of us simultaneously embrace contradictory values. We prize our independence and also our relation-ships with friends and family. We are concerned with preserving our lives and health but make frequent exceptions as needed for our pleasure or convenience. We try to minimize stress yet celebrate holidays with our families — including those relatives we can’t abide. We want to share our bounty with the less fortu-nate while still protecting our assets. We seek less clutter and more simplicity in our lives, but buy lottery tickets. Values frequently manifest most clearly when in confl ict, as individuals demonstrate their priorities. Unfortunately, this often makes decision making based on respect for a resident’s values diffi cult, if not impossible.

Both the principle of substituted judgment, which underlies the use of proxy decision makers, and the attempt to derive current choices through the creation of a retrospective values history are attempts to extend the ethical prin-ciple of autonomy into regions where individual autonomous decisions are no longer possible. However, autonomy is not the sole basic ethical principle.

Benefi cence, the obligation to do good to others, is an underlying principle of ethics for professionals, and it is a key concept in medical and nursing eth-ics. Financial and pension advisors may

have no obligation to provide advice designed exclusively for their client’s best interest, but for health care professionals benefi cence is not a choice — it is an obligation.

Benefi cence is often portrayed as a bland instruction to do the right thing and is often regarded as simply the equivalent of non-malefi cence (“above all do no harm”). However, this prin-ciple also extends to avoidance of actions that neither help nor hurt a patient — particularly when an act is done primarily to benefi t the professional. For instance, nurses ethically should not advise a patient to choose a wound dressing that is less likely to promote healing merely because it is easier for the nurse to apply. And the presence of health insurance is not an indication for a surgical proce-dure. Increasingly, pay-for-performance guidelines have attacked the principle of benefi cence by rewarding practitioners for testing that is not medically indicated for particular patients.

Caring the Root of Treatment The great Walsh McDermott, one of the original editors of the Cecil-Loeb Textbook of Medicine and a pioneer in population health, argued that the con-cept of benefi cence should be expanded to “Samaritanism” — the professional expectation to actually care for the patient. We should not defi ne ourselves as health care providers, as though we are owners of a medical store that sells medical services based on the patient’s preferences (even if we are honest sales-people of quality goods). If that is all we are, a corner drug pusher could be considered a “provider” of medications as well. Rather, we are suppliers of medica-tions and caregivers, as indicated by our professional judgment.

The New Testament parable of the Good Samaritan is the foundational story of Samaritanism, and hundreds of hospitals and medical awards have been named in its honor. In this story, a man has been beaten by robbers and left half-dead beside the road from Jericho to Jerusalem. Several travelers of rank pass him by, but a Samaritan (then a despised ethnic group) stops to help; he then washes and binds the man’s wounds. If the tale stopped here, it would encourage simply an obligation to provide emergency assistance to the injured — as enshrined in the Good Samaritan laws that protect practitio-ners from lawsuits when they help in emergencies. But many forget that the story does not stop here. The Samaritan places the injured man on his donkey, transports him to a nearby inn, pays

the innkeeper to provide care for the man, and promises to return later to pay any additional expenses required for his care.

Aspects of this tale are particularly salient for those of us involved in long-term care. The parable suggests to us an obligation to go beyond immediate medical care, to concern ourselves with the lives of our residents in an active way. This obligation may require much more than providing care in accordance with advance directives. Rather, it means participating in the formation of those directives, relieving suffering where we can, and helping to guide our patients and their families away from options that will only increase suffering, whether physical or existential.

Martin Luther King Jr. took this a step further: “On the one hand we are called to play the Good Samaritan on life’s roadside; but that will only be an initial act. One day we must come to see that the whole Jericho road must be trans-formed so that men and women will not be constantly beaten and robbed as they make their journey on life’s highway.” This is a Christian formulation of the foundational Jewish ethical imperative tikkun olam — to heal the world. For those of us in long-term care, this process should begin where we work.

Any discussion regarding end-of-life choices is in part a discussion of the risks and benefi ts of various alternatives. One of the stressful aspects of ethics commit-tee discussions is the participants’ aware-ness that none of the choices is likely to produce a good outcome — and with the extraordinary risk of choices that can produce signifi cant suffering. Although the nature of disease and modern tech-nology may control the benefi ts that the alternatives offer, we must fi nd ways to minimize the risks.

The goal of our Quality Assurance Performance Improvement (QAPI) proj-ects should go beyond improved statistics. The decision for continued survival in a long-term care facility despite an impaired condition and additional medical proce-dures should still be a decision for the highest attainable quality of life. The decision to forgo interventions should be a choice for a fi nal period marked by comfort and respect, and for a painless death with dignity, surrounded by those who love and care for you, whether they are family, facility staff, or both.

Dr. Nichols is past president of the New York Medical Directors Association and a member of the Caring for the Ages Editorial Advisory Board.

DEAR DR. JEFFJeffrey Nichols, MD, CMD

The Path to Doing the Right Thing

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How Poor Gait Can Predict Dementia Randy Dotinga

Which patients are heading into de-mentia? Cognitive tests are one

way to detect changes, but there is an-other that is less obvious: tests of how patients walk.

There is growing evidence that poor gait is an early indicator of potential dementia, especially when it’s combined with thinking diffi culties. “Any older patent without dementia presenting with slow gait and cognitive complaints is a high-risk patient, someone you should target in clinical and research practice,” said Joe Verghese, MBBS, MS, of the Albert Einstein College of Medicine, who spoke at the 2017 World Congress of Gerontology & Geriatrics meeting in San Francisco.

Dr. Verghese, director of the Jack and Pearl Resnick Gerontology Center, has studied gait in the elderly for more than 15 years. In a 2016 systematic review and meta-analysis, Dr. Verghese and colleagues exam-ined 12 studies and linked poor gait performance to a 1.53-fold higher risk for any dementia, with a 1.79-fold higher risk for vascular dementia and 1.89-fold higher risk for non-Alzheimer’s dementias (J Am Med Dir Assoc 2016;17:482–490). They found only a weak connection between poor gait performance and Alzheimer’s dis-ease dementia.

In 2014, Dr. Verghese led a study that described a “motoric cognitive risk syndrome” in the elderly “char-acterized by the presence of cognitive complaints and slow gait in older indi-viduals without dementia or mobility disability.” The researchers found signs of the syndrome in 9.7% of 3,128 adults 60 years and older (Neurology 2014;83:2278–2284).

How can gait and cognitive skills be tested to detect early signs of trouble? Manuel Montero-Odasso, MD, PhD, said that evidence now suggests that a “dual-task gait test” is “easy to per-form, low-tech and economical.” He led a 2017 study that tracked 112 older adults (mean age 76.6, 49.1% women) with mild cognitive impair-ment (MCI) for up to 6 years from 2007 to 2016. Although they did not fi nd a link between general slow-speed gait velocity and later dementia, those whose gait declined at a high level while they counted backward or named ani-mals were more likely to progress to dementia (JAMA Neurol 2017;74:857–865). “Dual-task gait testing is easy to

administer,” the researchers noted, and “may be used by clinicians to decide further biomarker testing, preventive strategies, and follow-up planning in patients with MCI.”

In an interview, Dr. Verghese pointed out it is not necessary for caregivers to use a specialized gait test for patients. “Ask patients and caregivers about

cognitive concerns or complaints,” he advises. “Gait speed can be simply and easily measured by timing gait over a fi xed distance. It does not require much time or specialized equipment.”

If the tests show signs of dementia risk, he recommended checking the patient for any potentially reversible causes of dementia: “Encourage a healthy lifestyle

that includes participating in cognitively stimulating activities, regular physical exercise, diet and control of vascular risk factors such as blood pressure and cho-lesterol.”

Randy Dotinga is a San Diego-based freelance writer.

“Any older patent without dementia presenting with slow gait and cognitive complaints is a high-risk patient.”

6 CARING FOR THE AGES JANUARY 2018

Dr. Phillips acknowledged that “we are still working on how to fi t all of the pieces together.” She noted that PA/LTC practitioners have always felt out-side of the mainstream, and they are struggling for a sense of purpose and to fi nd their place in this strange new world. Nonetheless, Society members have a head start on succeeding in a world where they must interact effec-tively with many partners.

“We have long embraced teamwork, and the Society has invited team mem-bers beyond physicians — nurse practi-tioners, physician assistants, pharmacists, dietitians, and others — into its mem-bership,” Dr. Phillips told Caring. By embracing all team members, she said, the Society puts them on the same page with consistent data, news, and informa-tion, as well as a common understanding of everyone’s roles and the possibilities

for collaboration and partnerships. “The success of PA/LTC is driven by team-based care delivery,” she said.

Although the Society is appropriately no longer just about medical directors, said Dr. Phillips, the organization’s ori-gin was appropriate and necessary. “We needed to start with medical directors because it was a competency that wasn’t recognized or valued, and it needed to be defi ned,” she said. “We don’t want to lose our legacy, and we don’t want to abandon it. The medical director still plays a vital role. But as an organization we need to be bigger than that.

“When each discipline is creating its own curriculum and training programs, everyone comes in seeing themselves as experts, but without understanding what others do or how they can work together. This just serves to fragment care delivery further,” she told Caring. By bringing various disciplines and practitioners to the table, giving everyone a seat and a voice, “we create a stronger community of care. I’m excited about that.”

The Society and its members have made much progress over the years. Through the efforts of the organization and its members, the Centers for Medicare & Medicaid Services, the Medicare Payment Advisory Commission (MedPAC), and many legislators have gained a greater understanding of long-term care medi-cine. However, Dr. Phillips noted, there still is a lack of awareness about the com-petencies necessary in this care setting. “We have to differentiate our expertise. Payers are beginning to understand the value of specially trained practitioners on quality care in this setting, but the public and health care system at large are still struggling to understand this role.”

There are challenges ahead, of course. “Personally, I’m worried about what is happening with Medicaid,” said Dr. Phillips. Clearly, these concerns are not unfounded. In their efforts to repeal and replace the Affordable Care Act ear-lier this year, House Republicans pro-posed a fundamental change in the way the government has fi nanced Medicaid

for more than 50 years — calling for caps on how much states get per Medicaid enrollee, based on how much the state spent on the program in 2016. Later, the Senate’s health care reform efforts, called the Better Care Reconciliation Act of 2017, also included proposals for signifi -cant reductions in Medicaid. The Senate’s

Keynoterfrom page 1

Cheryl Phillips discusses policy at the 2015 Society conference in Orlando, FL.

Accuracy of Bipolar Diagnoses in Nursing Home Residents ChallengedWhitney McKnight

A new study calls into question the accuracy of bipolar diagnoses in

nursing home residents, since about three-quarters of residents with the di-agnosis also had a previous dementia diagnosis.

“This pattern suggests that the bipolar disorder diagnosis may represent mood symptoms in dementia,” wrote the study’s coauthors, Ryan M. Carnahan, PharmD, and Elena M. Letuchy, MS.

Spurred by the 2012 decision by the Centers for Medicare & Medicaid Services to remove bipolar disorder as an exclusion criterion for the long-stay Minimum Data Set (MDS) assessment, the two researchers from the University of Iowa cross-referenced data sets for 22,000 long-stay nursing home residents from 437 facilities in Iowa. They found that not only is bipolar disorder often diagnosed after dementia, but that the change in exclusion criteria negatively impacts the antipsychotic use measure generally — especially in facilities with larger proportions of residents with bipolar disorder, regardless of the avail-ability of mental health-specifi c care in that facility.

“These fi ndings are affected by the way in which bipolar disorder is diag-nosed and documented in the MDS,” wrote the coauthors. “However, the accuracy of both appears questionable.”

They conducted an analysis of fi rst-quarter 2014 MDS data on antipsy-chotic use and bipolar diagnoses for their selected population, prior year Medicare claims, and Chronic Condition Warehouse (CCW) data “ever” bipolar disorder indicators and their condition

onset dates, to determine the number of residents diagnosed with bipolar disorder after a dementia diagnosis.

Nearly three-quarters of the entire population studied were women with an average age of 83.4 years. According to the MDS, 2.56% had bipolar disor-der. The average proportion per facil-ity receiving antipsychotics was 19.6% when individuals with bipolar disorder were included, and 18.3% when they were excluded. The positive predictive value of MDS bipolar diagnoses was 80.2% vs. CCW lifetime indicators and 74.6% vs. CMS claims. The positive pre-dictive value decreased by 27.1% when “bipolar, unspecifi ed” and “other bipo-lar disorders” diagnoses were excluded. About three-quarters of all residents with bipolar disorder also had dementia.

More than half of dementia residents had the diagnosis prior to a bipolar dis-order diagnosis, according to CCW data, although the more specifi c the bipolar diagnosis or bipolar indicators, the lower the proportion became at each respective facility.

The coauthors acknowledged their study raises doubts about the valid-ity of some bipolar diagnoses, and the extent to which antipsychotic use is justifi ed. They point to their fi nding that the positive predictive value of an MDS bipolar disorder diagnosis did not ever exceed 82% in any Medicare-based standard references. More than two-thirds of MDS bipolar disorder diagnoses were comorbid with one for dementia, with nearly 58% of these having been made prior to when CCW bipolar disorder indicator criteria were

met, meaning that 42% had the demen-tia diagnosis fi rst.

“If these represent mood disorder symptoms in the context of dementia, there is no clear reason to consider these differently than other BPSD [behavioral and psychological symptoms of demen-tia] for quality measures,” the coauthors wrote.

In addition, often, neither claims nor CCW data indicated any record of bipo-lar disorder in the MDS records of many residents, suggesting that care plans do not include proper management of bipo-lar disorder. There currently is no federal indication for the use of antipsychotics in behavioral and psychological symp-toms of dementia.

The admitted drawbacks of the study were that it was based on the adminis-trative data of only one state, although the researchers suggested that their fi nd-ings could help determine optimal treat-ment in this patient subgroup.

“If bipolar disorder arising within dementia is truly a unique syndrome, then it would be useful to evaluate drug therapies in this subgroup of patients to determine if their effectiveness and safety differs from what has been estab-lished in dementia,” the coauthors wrote.

Whitney McKnight is Washington, DC-based medical writer and reporter.

EDITOR’S NOTE

Many of us balked at CMS’ decision in the early 2010s to exclude bipolar disorder — a condition for which treatment with antipsychotic medication is FDA-approved — from the list of diagnoses that would not penalize a nurs-ing home for antipsychotic use on their quality measures. CMS’ decision was based on concerns that prescribers, or nursing homes, would game the system by assigning a bipolar diagnosis to patients who simply had BPSD. One of the Society’s concerns was that patients who really needed antipsychotics to control severe manic symptoms and psychosis would not get them, or that they would be inappropriately discontinued, because of concerns about the quality measures.

This study is interesting in that it appears some inappropriate labeling of dementia patients as bipolar may be occurring despite having no direct impact on the quality measures. Perhaps this is to reduce scrutiny from surveyors or issues of consultant pharmacist concern; it probably “looks better” to use these meds for bipolar disorder than for dementia-related behaviors. On the other hand, it’s probable that some of these patients did indeed have a history of bipolar disorder and the diagnosis simply was delayed in making it into the records. Whether or not these Iowa-specifi c fi nd-ings refl ect national practices, they are concerning enough to prompt further review.

—Karl Steinberg, MD, CMD, HMDCEditor in Chief

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CARINGFORTHEAGES.COM CARING FOR THE AGES 7

2 0 1 8 A N N U A L C O N F E R E N C E AMDA — THE SOCIETY FOR POST-ACUTE AND LONG-TERM CARE MEDICINE

Navigating a Changing Landscape in Post-Acute & Long-Term Care

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plan would have phased out the enhanced federal funding for Medicaid expansion and limited federal Medicaid funding through a per capita cap or block grant. The Society has formally opposed all such attempts to place caps on Medicaid or create a block-grant system.

Although these repeal and replace efforts ultimately failed, both House and Senate Republicans have signaled that Medicaid cuts are on the table. At press time, a tax bill being supported and pro-moted by congressional Republicans and President Donald Trump could end up cutting spending for programs including Medicaid. As this program covers more than 70 million Americans, many of them elders, such deep cuts would have widespread implications. “As Medicaid is negatively impacted, it will in turn affect the quality of and access to long-term care for those who need it most,” said Dr. Phillips.

Another key concern, said Dr. Phillips, is how providers are measured and assessed. This brings up a plethora of questions. What are the measures of qual-ity? What do we need to be reporting? Who do we need to be collaborating with? How will all this impact how we practice? “Quality measurement is messy and complicated, and it’s not going away. The measurement discussion of late is huge,” she said. “The Society’s role is crit-ical in interpreting this for post-acute and long-term care practitioners and ensuring we have a voice in these discussions mov-ing forward.” She further noted, “I worry that those without a voice will get lost in all of the quality measurement discus-sions, so our voice is essential. We need to be able to measure what matters and not just what impacts costs — such as resource utilization and lengths of stay.”

Technology has improved the ability to document and, to some degree, share data, but Dr. Phillips stressed the need to ensure that care remains high-touch even as it becomes increasingly high-tech. “EHRs [electronic health records] are signifi cant and have provided a wealth of information, triggers, and compli-ance reminders. They have become an important platform for extracting information for quality measures. But they also have created a cut-and-paste phenomenon, where everything is car-ried over from prior input.” In reality, she pointed out, “people are dynamic, and lives are dynamic; but often when I look at EHRs, everything looks static.” Strategies to use technology to encourage engagement with patients and popula-tion health strategies are needed, “so we can spend more time one-on-one with the people we care for,” she said.

The changes in the PA/LTC world have been signifi cant over the years. Dr. Phillips said the Society’s founders would hardly recognize their profession and practice today. “Billy Dodd [the Society’s founder and fi rst president] was an old-style physician who worked hard, saw lots of patients, and did fee-for-service billing. He worked in a world where regulations were just starting to address

quality. He never worked in population-based health, and I don’t think he would recognize the PA/LTC environment today.” However, she added, “he would appreciate the value of recognizing the physician’s role and would embrace the team approach to care and involvement of nurse practitioners and others as vital.”

James Pattee, MD, CMD, an early Society leader and father of the certifi ed medical director and core curriculum programs, “picked up where Dr. Dodd left off,” she said. “He believed that we needed competencies and the curricula to support them. He would value the quality measurement work being done today, but he would be frustrated that it doesn’t measure what good quality in a nursing home looks like.” She noted that both Society pioneers would be “distrustful of payment strategies that only look to reduce costs but don’t have quality embedded in them.”

So even though the founders might not recognize the industry they once had supported, “They would be proud of how the Society and its members have built on what they started and our com-mitment to continuing and expanding on their early visions,” Dr. Phillips said. And she believes they would be pleased that commitment to patients and pro-viding the best possible care pervade and guide “everything we do.”

She said it is important to refl ect on and learn from history, but “wanting the world to go back to the way it was is not the strategy for success. The biggest value of our Society is helping people navigate tumultuous practice in a rapidly chang-ing world,” Dr. Phillips said. “We need to get back to the idea that you can’t do this alone. More than ever, we need each other.”

Dr. Phillip’s keynote address is scheduled for 8 a.m. on Friday, March 23.

Joanne Kaldy is a senior contributing freelance writer in Harrisburg, PA.

A HOPI PRAYER

Let me walk in beauty, and make my eyes ever behold the red and pur-ple sunset.

Make my hands respect the things you have made and my ears sharp to hear your voice.

Make me wise so that I may under-stand the things you have taught our people.

Let me learn the lessons you have hidden in every leaf and rock.

I seek the strength, not to be greater than my brother/sister, but to fi ght my greatest enemy — myself.

Make me always ready to come to you with clean hands and straight eyes.

So that all that we do now must be done in a sacred manner and in celebration.

We are the ones we’ve been wait-ing for.

8 CARING FOR THE AGES JANUARY 2018

The Department of Justice (DOJ) ac-tively pursues fraud not only in the

housing and mortgage industries but in other industries as well — including among health care providers. The False Claims Act (FCA) allows the federal gov-ernment to recover funds from improp-erly received reimbursements or billing to governmental programs, including those by health care providers: the DOJ recovered $19.3 billion in health care fraud claims from January 2009 through September 2016.

Health care providers are frequently alarmed by the DOJ announcements of large fi nes and settlements from FCA cases. In recent years, FCA allegations have often involved the provision of unnecessary medical care — specifi -cally, skilled therapy services provided to Medicare benefi ciaries. As the DOJ’s vigorous enforcement efforts continue to prevent abuse of governmental funds in the health care space, we should examine how the Jimmo v. Sebelius settlement slightly shifted the legal focus in the skilled therapy area.

Jimmo v. Sebelius A brief discussion of the history of Medicare benefi ts as applied to skilled therapy may be helpful to begin. In the years before the Jimmo settlement, health care providers and Medicare ben-efi ciary advocates protested the restric-tive interpretation by the Centers for Medicare & Medicaid Services of skilled therapy, which would be covered only if the delivered therapy was produc-ing continuing improvement in the patient’s condition. In January 2011, Medicare benefi ciary advocates fi led suit against CMS in the case known as Jimmo v. Sebelius, and a settlement was reached in 2013. As part of the agreement, CMS was required to issue new information about skilled therapy coverage: therapy to prevent further deterioration or to preserve current capabilities would be covered as well. The previous requirement that continu-ing improvement was a necessity had been eliminated, and benefi ciaries who were unable or unlikely to improve were no longer denied coverage.

CMS has posted a webpage on the Jimmo settlement (www.cms.gov/Center/Special-Topic/Jimmo-Center.html) that provides extensive information about the case and the maintenance coverage stan-dard. After the suit was settled, Medicare benefi ciaries received maintenance cover-age therapy, and providers received reim-bursement for those types of services.

False Claims Act Enforcement In recent years both corporations and individuals have been pursued by the DOJ for FCA activities, and the DOJ continues to announce new cases and settlements almost every day. Some of these cases have included therapy ser-vices, although they usually pertain to services delivered before 2013, the date of the Jimmo settlement agreement.

Among the recent examples of health care providers making the news, the chairman of the board and a senior vice president of reimbursement of North American Health Care Inc. (NAHC) paid $1.5 million (collectively) and the corporation paid a total of $28.5 million

to settle FCA allegations brought by the DOJ. The NAHC allegedly delivered medically unnecessary rehabilitation therapy to inpatients at skilled nurs-ing facilities between January 2005 and December 2011.

The Life Care Centers of America settlement also occurred in 2016. Life Care and its owner, Forrest Preston, agreed to pay $145 million to settle a DOJ lawsuit. The allegations included Life Care’s corporate policy of push-ing SNF inpatients into the ultra-high reimbursement category for Medicare Part A services. “Ultra-high” is based upon 720 minutes involving at least two types of therapy (physical, speech, or occupational) delivered 5 days a week. This was alleged to be excessive, unnec-essary therapy for residents that was not based upon their individual needs. The government rewarded the former employees who had brought these prac-tices to light with a total of $29 million as whistleblowers.

Only time will tell whether the DOJ’s FCA actions related to therapy services

LEGAL ISSUESJanet K. Feldkamp, JD, RN, LNHA

Medicare Therapy Services: Finding the Right Balance

Palliative Specialists Urge Collaboration With Geriatric Care Randy Dotinga

Palliative care and geriatric care share plenty in common, but the two

fi elds aren’t always on the same page. It’s time for a better relationship to improve patient well-being toward the end of life, palliative specialists told colleagues at the 2017 World Congress of Gerontology & Geriatrics, presented by the Interna-tional Association of Gerontology and Geriatrics.

“I do not feel the specialties are the same. There’s a lot in geriatrics about valuing old people, and there’s a lot in palliative care about the progression and complexities of symptom management. It’s about respecting the differences as well the similarities,” said Irene J. Higginson, PhD, director of the Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation at King’s College London.

Diane E. Meier, MD, FACP, director of the Director of the Center to Advance Palliative Care, explained that palliative care doesn’t just focus on those who are dying. “It now encompasses the care of all people with serious and chronic ill-ness that affects quality of life,” she said.

Palliative care is especially impor-tant because chronically sick people are responsible for so much of health spend-ing in the United States, Dr. Meier said.

She pointed to a study by the Agency for Healthcare Research and Quality that found that 22% of health care spending — an average of $90,061 per person — was attributable to 1% of the population in 2008. People in poor and fair health made up a large percentage of health care spending overall (“The Concentration and Persistence in the Level of Health Expenditures over Time,” Statistical Brief 354, January 2012; https://goo.gl/zEuvQV).

Many people assume that much of this spending goes to care for dying people, but that’s a “widely held myth,” Meier said. She pointed to a 2012 Institute of Medicine report that notes that “not all deaths result in high spend-ing, and not all high spending occurs near death.” Indeed, the report esti-mates that only 13% of $1.6 trillion in health spending goes to care in the last year of life (Health and Medicine Division, National Academy of Sciences, “Dying in America,” 2014; https://goo.gl/4S3nwC).

Research proves that palliative care works, said Dr. Higginson. She led a 2014 study that linked early palliative support for breathlessness in respira-tory patients to a higher likelihood of survival compared with a control

group. “A short-term burst of pallia-tive care helped,” she said, at no over-all increase in cost (Lancet Respir Med 2014;2:979–987).

Dr. Higginson coauthored a 2013 Cochrane Library review that exam-ined 23 studies and found that “home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without impacting on caregiver grief ” (Cochrane Database of Syst Rev 2013;6:CD007760).

A more recent Cochrane Review of seven studies found that “early pallia-tive care interventions may have more benefi cial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone” (Cochrane Database Syst Rev 2017;6:CD011129).

Despite research fi ndings like these, palliative care isn’t always embraced as a crucial part of helping the ill, not just the dying, said Luc Deliens, PhD, director of the End-of-Life Care Research Group at Vrije Universiteit Brussel and Ghent University in Belgium. “Palliative care is often still terminal care in many coun-tries in Europe,” he said. “Many of the palliative needs of residents throughout

their illness are not addressed in a timely manner.”

What can be done? “Early integra-tion of palliative care alongside life-prolonging treatments needs to be the model in nursing homes,” Dr. Deliens said. “Everyone should have basic skills in general palliative care. If there are symptoms or other needs, you might need specialized palliative care services. In order to implement that kind of care at nursing homes, you need to change the culture.”

Randy Dotinga is a San Diego-based freelance writer.

“Early integration of palliative care alongside life-prolonging treatments needs to be the model in nursing homes. Everyone should have basic skills in general palliative care.”

CARINGFORTHEAGES.COM CARING FOR THE AGES 9

APRN Gerontological Specialist Certification Exam

will decrease in the post-Jimmo settle-ment era. Now that the published CMS interpretation permits maintenance therapy for inpatient and outpatient Medicare benefi ciaries, the benefi ts for the SNF residents themselves have been positive. Many providers now are delivering needed physical, speech, and occupational therapy to individuals to prevent their further decline, maintain their current capabilities, and provide the strengthening and other needed therapies to decrease falls and regain activities of daily living.

Recommendations for Facilities A review of the reported FCA settle-ments and cases highlights several com-mon factors. For instance, the policies/practices of these companies consis-tently focus on reimbursement rather than on individual benefi ciary needs; to this end, they encourage that thera-pies continue even when the therapists recommend otherwise. The following recommendations may assist facility leadership in avoiding allegations of excessive therapy.

• Therapy plans of care must be based upon an individual’s needs as determined by a thorough evalua-tion. One component of the facil-ity quality review process should be a periodic review of the therapy services and needs for each therapy recipient.

• Before approving the plan of care, the attending physician must re-view the therapy plan to ensure that it reasonably meets the needs of the individual. Attending phy-sicians can be an active partner to ensure the delivery of appropriate therapy services and ensure that without a signed order the care should not be delivered.

• Therapy services must not be driven by a percentage of revenue needs rather than the specifi c needs of individuals. When health care services are based on revenue rather than health care need, the regulators will apply heightened scrutiny.

• The professional judgement of the therapy and nursing staffs should be heeded. These staff have been pro-fessionally trained to understand the needs and tolerances of patients.

• Any fi nancial incentives that an outside contracted therapy compa-ny may receive to increase therapy services should be required to un-dergo periodic review for quality data with a company leader.

• The appropriate checks and bal-ances must be in place before bill-ing for the rendered therapy oc-curs. If the therapy was part of a Part A stay, the required Minimum Data Set (MDS) must be locked and submitted before billing.

• Periodic pre- and post-billing audits must ensure that billing is complet-ed in an accurate and timely man-ner, and within the requirements.

• The clinical documentation must be reviewed on a periodic basis to ensure that the documentation sup-ports the services rendered and the billing submitted for such services.

Understanding the complexities of therapy services for Medicare benefi cia-ries — and particularly for benefi ciaries in the skilled nursing setting — will ensure compliance with the require-ments and avoid allegations of improper billing. Skilled therapy must support, maintain, and assist in the individual’s

rehabilitation through an understand-ing of their abilities and expansion of their current capabilities. Medicare therapy must be medically necessary, with supportive documentation of ser-vice delivery.

Post-acute care leaders must advocate for the needs of the individual benefi -ciaries in their care, while balancing the complexities of medical necessity and billing requirements. Again, time will be the test of whether the FCA cases turn the focus away from the unnecessary

therapy area for services that have been provided since 2013.

This column is not to be substituted for legal advice. Ms. Feldkamp practices in various aspects of health care, including long-term care survey and certifi cation, health care acquisitions, physician and nurse practice, managed care and nurs-ing related issues, and fraud and abuse. She is affi liated with Benesch Friedlander Coplan & Aronoff LLP of Columbus, OH.

10 CARING FOR THE AGES JANUARY 2018

While I was participating in an inter-professional course being taught

at my university, I came across an ar-ticle by Thomas Bodenheimer, MD, and Christine Sinsky, MD, that expanded on the goals of the Triple Aim — improving patient experience, improving population health, and reducing costs — which has been widely accepted as a compass to optimize health system performance. They proposed instead the “Quadruple Aim,” which adds an additional goal: Improving the work life of health care providers, clinicians, and staff. The authors emphasized the widespread problems of burnout and dissatisfaction among physicians and other health care providers (Ann Fam Med 2014;12:573–576). As I read their article, I considered the impact of this fourth aim for providers and staff in the post-acute and long-term care setting.

Expectations of Nursing Staff As I described in my earlier column regarding the diffi culty of meet-ing Quality Assurance Performance Improvement (QAPI) benchmarks (Caring for the Ages 2017;18:14–15), nursing staff in long-term care are required to do more with less. As with physicians in their practices, the tools for meeting the benchmarks are not always available to accomplish the goals. The focus on reducing hospital readmissions also has had an impact on successful implementation of QAPI initiatives.

In many facilities, short-term residents with complicated medical conditions have become a priority. Consequently, the focus for many facilities has shifted to how to meet the staff ’s educational needs for managing these complex residents and preparing them for safe

discharge to the community. Licensed nurses, particularly in smaller centers, must now wear many hats, including QAPI leader. Not only are the expecta-tions high, but they also are accompa-nied by increased pressure to meet the benchmarks with little formal training on the process.

Staff Burnout Burnout in nursing has been exam-ined over the years by studies in both acute-care and long-term care settings. However, in working on this column I found little published research from the past 5 years that has addressed long-term care staff.

John F. Schnelle, PhD, and col-leagues from the Division of Geriatrics in Vanderbilt University’s School of Medicine in Nashville, TN, used a dis-crete event simulation (DES) model to

describe the relationship between the workload involved with helping resi-dents perform their activities of daily

living (ADL) in a consistent, timely manner and the level of nurse aide staffi ng reported by nursing homes (J Am Med Dir Assoc 2016;17:970–977). The Minimum Data Set information related to the level of dependency on

NURSES’ NOTESNina Flanagan, PHD, GNP

The Quadruple Aim: Improving Working Conditions for Health Care Providers

Speed of processing training, a meth-od of cognitive training that involves

computerized exercises, is associated with a 29% reduction in dementia risk at 10 years when compared with a control group, according to a subanalysis of the Advanced Cognitive Training for Inde-pendent and Vital Elderly (ACTIVE) trial.

“Greater risk reduction was evident among those who completed more ses-sions of training,” said Jerri D. Edwards, PhD, of the University of South Florida, Tampa, one of the study’s investigators. Their research has now demonstrated that an intervention can lower the risk for dementia [Alzheimers Dement (NY), Nov. 7, 2017; doi:10.1016/j.trci.2017.09.002].

According to Dr. Edwards, they ana-lyzed whether speed of processing train-ing, which has been shown to improve everyday function and longitudinally modifi ed functional trajectories, could reduce dementia risk. “Dementia involves cognitive and functional impairment. So if speed training improves function, then it makes sense that it would delay dementia onset,” Dr. Edwards said.

Among initially healthy older adults, Dr. Edwards and colleagues examined three different forms of cognitive training — memory training, reasoning training, and speed training — along with a no-contact control group. The study’s meth-odology used instruction and practice in

strategy use for the memory training that focused on verbal episodic memory, and for reasoning training that focused on problem-solving and serial patterns. The speed training entailed using computer-ized, visual-perceptual exercises intended to increase the quantity and complexity of information that could be quickly processed.

The participants in each training arm underwent ten 60- to 75-minute sessions delivered to small groups during 5- to 6-week intervals. At 11 and 35 months after completion of the initial training, the researchers randomly selected a sub-set of participants who had completed at least 80% of the training sessions to receive booster training (i.e., four 75-minute sessions). The outcomes were assessed immediately after training, and at 1, 2, 3, 5, and 10 years after training.

The demographics, health character-istics, and attrition did not signifi cantly differ among the training groups. The participants had a mean age at baseline of 73.6 years and were predominantly white (73.3%) and female (76.2%). Their pre-served cognitive status was determined by Mini-Mental State Examination.

Of the 2,785 participants in the ana-lytic sample, 702 received memory train-ing, 690 received reasoning training, 698 received speed training, and 695 had no contact. At 10 years, 260 partici-pants developed dementia. Those who developed dementia were more likely to

be older, male, nonwhite, less educated, and nondrinkers. They also had more diabetes or congestive heart failure, and more depressive symptoms.

The 10-year results revealed that, when compared with the control group, speed training lowered dementia risk by 29%, but memory and reasoning training had no statistically signifi cant impact on dementia risk. The partici-pants who completed a greater num-ber of speed training sessions had a more prominent reduction in dementia risk: Each additional speed training ses-sion was associated with a 10% lower hazard for dementia. This association remained after controlling for age, sex, race, depressive symptoms, diabetes, and congestive heart failure. In fact, in the subset of patients who received booster training (639), an additional training session yielded an 11% lower risk for dementia.

“Cognitive training is most likely to be effective prior to cognitive impair-ment,” Dr. Edwards noted. “There is evidence that those with mild cognitive impairment also benefi t, but older adults should work on cognitive training prior to noticeable impairment,” she said. “We should use it before we think we need it.”

For future research, Dr. Edwards said they will look into identifying the most effi cacious training techniques, interven-tion timing, and doses of training. “We would also like to confi rm these fi ndings

in a large-scale primary prevention type trial,” she said.

Brian Ellis is a NJ-based freelance writer and editor.

Cognitive Speed Training May Reduce Dementia Risk Brian Ellis

EDITOR’S NOTE

This is a nifty study because of both the 10-year data and the differentia-tion of the cognitive training inter-ventions. The association between cognitive “exercise” and preservation of brain function has been observed in many types of studies, but it’s inter-esting that straight memory training (the most commonly applied interven-tion) and reasoning training did not demonstrate any signifi cant effect on incident dementia. More interestingly, a few sessions of this speed training seemed to confer a robust protective effect. Hey, where do I sign up? Does playing Boggle With Friends on my smartphone count? Meanwhile, also of interest and covered frequently in Caring, concomitant depression and diabetes also were associated with inci-dent dementia — as was congestive heart failure. This should not come as a surprise to our readers.—Karl Steinberg, MD, CMD, HMDC

Editor in Chief

As long-term care increasingly becomes an extension of acute care, the issues of workload and burnout have the potential to significantly increase as well.

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staff for ADL care for residents in more than 13,500 nursing homes nationwide was converted into seven workload categories, which captured 98% of all residents. The study found that the aver-age nurse aide staffi ng level reported by nursing homes fell below the staffi ng level predicted as necessary to provide consistent ADL care to all residents in need.

DES methodology can be used to determine the nurse aide staffi ng require-ments to provide ADL care and to sim-ulate the management interventions needed to improve care effi ciency and quality. Yet this looks only at one aspect of what a certifi ed nursing assistant does in the course of the day.

The use of electronic health records has increased the amount of time required to do charting for everyone, including licensed nurses, yet I found no research on the impact of electronic charting on nursing workload in the literature. In my own practice I have experienced a substantial increase in the time required to complete electronic health record doc-umentation for all assigned residents. Similarly, Drs. Bodenheimer and Sinsky reported that physicians perceived they were spending 25% to 50% of their time on the computer.

As long-term care increasingly becomes an extension of acute care, the issues of workload and burnout have the potential to signifi cantly increase as well. In long-term care, the added variable is the lack of resources to increase pay and staffi ng levels accordingly.

Person-Centered Care Drs. Bodenheimer and Sinsky described how focusing only on the Triple Aim may not improve outcomes. The barri-ers to achieving the Triple Aim include the decline in population health in a society experiencing obesity and dia-betes epidemics and growing income disparities; the rising cost of health care; and a dispirited and disengaged health care workforce. If the gap continues to widen between society’s expectations for primary care and primary care’s avail-able resources, the feelings of daily stress and betrayal among primary care prac-titioners will grow — and the negative impact on patient-centered care will be deep and long lasting.

On the other hand, an emphasis on the workforce at the expense of patients’ needs could have negative consequences as well. Health care is a relationship between those who provide care and those who seek care, a relationship that can only thrive if it is symbiotic, ben-efi ting both parties. I fi nd this is also evident in long-term care — where the well-being of the care team is rarely addressed.

When Cassandra A. Okechukwu, ScD, MSN, and colleagues from the Harvard School of Public Health exam-ined the association of household-level stressors with depressive symptoms among low-wage nursing employees, they found that household fi nancial

strain, food insuffi ciency, and work–family spillover were pervasive (Am J Public Health 2012;102:126–133). Depression symptoms also were signifi -cantly associated with fi nancial strain and food instability.

Nursing home workers form a grow-ing part of the workforce, and they face higher rates of household food insuffi -ciency, fi nancial strain, and work–family spillover. The importance of our work-force’s well-being must be considered if person-centered care is our goal. Person-centered care must extend to the provid-ers of that care as well — we cannot care for others properly until we care for ourselves.

Where to Start I have several thoughts on the practical steps to begin achieving the fourth aim, as outlined by Drs. Bodenheimer and Sinksy.

1. Self-care seminars. Yearly inservice training should be expanded to in-clude self-care management strat-egies, with a focus on emotional well-being and work–life balance.

2. Basic fi nancial literacy/management classes for workers that includes budgeting, building an emergency fund, and improving credit

3. Time management. The lack of training that nursing home staff receive on how to manage their priorities and their time must be addressed.

4. Research on the use of electronic health records. The impact of the electronic health record on work fl ow and quality, both quantita-tively and qualitatively, needs to be studied in depth.

5. Employee recognition. On a weekly basis, employees should to be rec-ognized for their work, including peer-to-peer recognition, fi nancial bonuses or extra paid time off.

What is happening in the centers where you work to address the care team’s well-being? For my next column, I would like to hear about the success stories from centers that acknowledge the importance of this concept. Please share your experiences with me at fl ana-gan@binghamton.edu.

Dr. Flanagan is an assistant professor of nursing at the Decker School of Nurs-ing, Binghamton University, NY, and has more than 20 years’ experience as a nurse practitioner in a variety of settings, including long-term care and rehabilitation.

In-service training should be expanded to include self-care management strategies, with a focus on emotional well-being and work–life balance.

12 CARING FOR THE AGES JANUARY 2018

people’s efforts to be positive. “I know they mean well and genuinely are root-ing for my recovery,” she said. However, she fi nds misplaced optimism frustrat-ing. For example, she said, “When I’m in the hospital and sick from chemo, I know that I look awful. Telling me that I look great doesn’t help because I know it’s not true. I would prefer that people focus on something else and not make up compliments or words of encourage-ment that are just patently untrue or unrealistic.” She prefers not to pretend that everything is great when it isn’t, and she appreciates the opportunity to talk honestly about her feelings.

From Point A to Point B Tatyana Shteinlukht, MD, a geriatric psychiatrist based in Massachusetts, understands why people tend to be overly positive.

“You cannot all of a sudden spill the whole truth about bad news or a negative diagnosis. You have to be sequential, start slow, and not make any promises or pres-ent a defi nitive prognosis, as it depends on the individual course of illness in a particular patient,” Dr. Shteinlukht said. For those who are in denial, she said, “Start with the picture they want to see and gradually over time walk them to a more realistic view.”

For example, consider the patient who strives to go home from the nurs-ing home after a hip fracture but who is likely too sick and frail for that to happen. During the fi rst meeting, Dr. Shteinlukht suggested, talk about what they enjoy about their home and what could make their stay in the facility more pleasant and comfortable. In the second meeting, talk about where they are in their recovery and where they need to be before they can go home.

“Slowly go into more detail about what they are capable of and what skills and abilities they are likely to recover,” Dr. Shteinlukht said. For instance, if they will be unable to drive, you can help them realize that they need to reside someplace where there is transportation. “You can’t be unrealistically optimistic. However, you do have to be completely realistic all at once. You need to slowly walk them from point A to point B — from the picture they imagine to a more realistic one. You have to explore with your patients the benefi ts of ... adjusting to a new reality.”

Maureen Nash, MD, a geriatric psy-chiatrist and internal medicine physi-cian who serves as medical director of Providence ElderPlace, a Program of All-Inclusive Care for the Elderly in Oregon, agrees that it can be helpful to break down the situation into steps. The prac-titioner has to walk a fi ne line between encouraging false expectations and dash-ing the person’s hopes.

“You can say, ‘This is the plan. We’ll see how you do in therapy; and we’ll

reassess goals based on your progress. We’ll take it a day at a time,” Dr. Nash suggested.

It can be challenging to determine how much “reality” a patient wants or can handle. Tools such as the Physician Orders for Life-Sustaining Treatment (POLST) paradigm can help promote conversations about what the patient wants and encourage family discussion so that everyone can get on the same page. “This gives you an opportunity to sit with someone and really hear what he or she is saying,” said Joshua Schor, MD, CMD, medical director of New Jersey-based Daughters of Israel. He added that legal standards such as the Patient Self-Determination Act “also gives you some legal scaffolding to rest on when families don’t want to give up or refuse to accept mom or dad’s desire to pursue palliative care over aggressive treatments.”

“You don’t want to get too far ahead of where they are in their understanding of illness and the likely future,” Dr. Nash said. She suggested paying attention to verbal and nonverbal cues as you talk to residents and family members. People provide clues with their body language (nervous laughter, crossing arms, or look-ing down) and facial expressions (appear-ing confused, grimacing, or frowning) when the practitioner has perhaps given them a bigger dose of reality than they are ready to digest. Regularly checking in with people to determine their under-standing of the illness helps direct the conversation.

None of this is to say that positiv-ity is never appropriate. According to David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, TX, “The positive message is important, but it needs to be crafted individually for each person so that it isn’t just delivering false hopes.”

Helping Families Function It can be hard for families to accept their loved one’s illnesses and limitations. As a result, they may be unable to face reality

and unable to abandon — or tone down — their need to be cheerleaders. When this happens, said Dr. Shteinlukht, “My job is to fi nd out why they think the way they do, and I have to do some cogni-tive restructuring.” She starts, she said, by trying to determine what experience their feelings are based on.

“They might say, ‘Well, I had a friend in that situation.’ At this point, we can talk about the differences between the situations,” Dr. Shteinlukht said. “I admit that this takes time. It helps if you have a longitudinal relationship with the family.”

Especially with a diagnosis such as dementia, said Beverly Chang, MD, a geriatric psychiatrist in private practice, “It is a progressive terminal illness, and I don’t like to give false hopes about the diagnosis. Instead, I focus on quality of life issues, how to slow the progression,

and how to manage the disease as it advances.” Again, ensuring that these patients have a completed advance directive or POLST paradigm form is a priority.

Particularly for diseases such as can-cer, there are many treatments that are tremendously expensive and may have limited value or may be harmful for frail elders. However, sometimes families or patients want everything possible done. “My approach is always to sit down with them and discuss the risks and bene-fi ts,” said. Dr. Shteinlukht. She admitted that not every practitioner can do this; however, she suggested that other team members, such as social workers or even clergy, can have these conversations.

“In situations where family members refuse to accept comfort measures, I lay out the prognosis and encourage them to focus on palliative efforts and maxi-mize their loved one’s quality of life. I try to absolve them of making diffi cult decisions,” Dr. Chang told Caring. “It always goes back to what the patient wants.”

If family members are being overly optimistic, Dr. Smith said, “I would visit the patient and ask, ‘How do you feel about what you daughter said the other day?’ If the patient says he or she agrees with her, I would talk about other, more practical approaches.” If the patient thinks the daughter is being unrealistic, he said, “I would say that I know your daughter means well, but I also know you want me to shoot straight with you.”

Don’t be surprised if families disap-pear or make themselves scarce after a practitioner has a serious talk with them regarding their attitudes about their loved one’s condition or limita-tions. “Sometimes they will come back after they’ve had time to digest every-thing and say, ‘You were right,’” said

Cheerleadingfrom page 1

HOW TO HELP WITHOUT CHEERLEADING

Mary Lou Dallam considers herself fortunate to have a large network of friends and family to support her as she battles cancer. She also knows what helps and doesn’t help when a person is ill, hurting, and uncertain about what the future will bring. She suggested a few ideas that practitioners can pass along to family and friends.

• Instead of asking how you can help, be specifi c. “I don’t want to put anyone on the spot, and I may not be able think of something quickly or on the spur of the moment,” said Ms. Dallam. “Offer to do or bring something that you are comfortable with. If you cook, offer to bring food. If you have a car, offer rides to the doctor. If you like to shop, offer to get groceries or other items. If you’re a pet lover, offer to help with pet sitting.” This keeps the patient, who already has a full plate, from having to brainstorm about what others can do to help.

• If you don’t know the person’s spiritual beliefs, ask if they would mind if you prayed for him or her.

• Try to arrange visits with other friends and family so that the patient isn’t overwhelmed at some times and left alone at others. If possible, fi nd out when the person prefers company.

• If you visit a patient and he or she clearly is unwell (such as after chemother-apy or a tiring physical therapy session), take the cue. Offer to get the person water or juice, then excuse yourself and offer to return at another time.

• Let the patient take the lead regarding what and how much he or she wants to talk about his or her health, condition, or prognosis.

— Joanne Kaldy

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An elderly individual with a progressive terminal illness needs quality care and disease management, not false hope.

CARINGFORTHEAGES.COM CARING FOR THE AGES 13

Excellence in ResearchValerie Sabol, PhD, ACNP-BC, GNP-BC,

ANEF, FAANP, Duke University

Excellence in Clinical PracticeSuzanne Ransehousen, GNP-BC, ACTS

Signature Community Services

Excellence in Leadership Susan Mullaney, DNP, APRN, GNP-BC, UnitedHealth Group

Cynthia Gerstenlauer, ANP-BC, GNCS-BC, CDE, CCD,Troy Internal Medicine

Excellence in Community ServiceMarva Edwards-Marshall, DNP, ARNP,

ANP-BC, Optum Care

Excellence in EducationBarbara Harrison, PhD, GNP-BC, APN,

FGSA, West Chester University

GAPNA salutes this year's Awards for Excellence winners!

GAPNA salutes this year's Awards for Excellence winners!

Dr. Shteinlukht. “It can be challenging. The majority of people listen to them-selves and their own experiences. They will trust what you say when they believe you are on the same page. You have to have a lot of patience.”

Cheerleading With Caution Of course, there are times when some cheering and encouragement is acceptable and even important, noted Dr. Schor. Physical therapists are a good example. “They focus on minute-by-minute, hour-by-hour functional cheerleading,” he said. They target specifi c tasks, and they encourage and support patients to accomplish these. However, if they start making unre-alistic promises or are overly optimis-tic about a person’s chance of cure or recovery, team leaders need to step in and help them understand that this is not part of their role. In fact, it can do more harm than good.

“We don’t want to be the voice of doom, but if we cheerlead, we are ignoring reality and ultimately doing the patient and family a disservice,” Dr. Schor said.

It may seem harmless to be a cheer-leader for a family member or friend with an illness or other medical issue. However, it can cause a surprising amount of harm.

“It can lead the patient to feel alone and isolated if they want to talk about their illness and what could happen and his or her family insists on cheerleading all the time,” Dr. Shteinlukht explained. Sometimes it is helpful to encourage family members to consider what they would want if they were in their loved one’s shoes. “When you do this, they often become more realistic because their thinking isn’t clouded by their feelings about the patient,” she said.

Delivering false hope, even when it is well intended, can have tremendous repercussions. “If you deliver false hope to patients who desperately want to believe it, they might pursue treatments and tactics that won’t result in positive outcomes and may even increase pain and suffering. This wastes time, energy, and money, takes resources away from potentially benefi cial palliative therapy, and diminishes quality time with loved ones,” Dr. Smith noted. “Delivering false hope in a Pollyanna fashion to someone who is pragmatic tells that person that he or she can’t talk to you honestly about their fears and concerns.”

If the practitioner is overly optimistic and turns a blind eye to cheerleaders surrounding the patient, the result can be destructive as well. “You can lose credibility if they are trusting you with their health and they come to view you as a liar,” Dr. Shteinlukht said.

As the rise of accountable care organi-zations, bundled payments, and value-based medicine continues, practitioners and facilities will increasingly need to be realistic about the risks and benefi ts of various treatments, as well as lengths

of stay and when it might be safe for a patient to leave post-acute care or return to the community. In this new world, there is a place for optimism and encour-agement. However, there is increasingly little or no place for unrealistic expec-tations, unnecessary or excessive treat-ments, and cheerleading that potentially can hurt patients more than it helps them.

Ultimately, Dr. Smith said, even when family and friends are cheerlead-ing in a potentially detrimental way, it

is important to realize that people usu-ally have the patient’s best interests at heart. “By reframing the conversation and bringing it back to what is best for the patient and in line with his or her wishes, loved ones will usually do the right thing," he said.

Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations.

“I lay out the prognosis and encourage [the family] to focus on palliative efforts and maximize their loved one’s quality of life. I try to absolve them of making difficult decisions.”

14 CARING FOR THE AGES JANUARY 2018

Experts Explore VSED as ‘Last Resort’ End-of-Life Option Brian Ellis

An ethics discussion in JAMA Inter-nal Medicine has detailed multiple

facets of voluntarily stopping eating and drinking (VSED) as a “last resort” op-tion for seriously ill patients who wish to hasten their deaths.

“Not infrequently we run into patients who are ready to die, but do not fi t into the usual circumstances where we have adequate strategies,” said Timothy E. Quill, MD, of the University of Rochester Medical Center, NY, a coau-thor of the article. “They are not on life-sustaining therapy that can be stopped, and they do not have severe acute symp-toms that can be managed more aggres-sively,” he told Caring.

Dr. Quill and colleagues sought to bet-ter understand the clinical, ethical, and legal aspects of VSED for this subset of seriously ill patients.

Clinical Aspects Despite their limitations, palliative care and hospice remain the standards of care for the relief of suffering and support of seriously ill patients. “The prolonged debility and dependence that can accom-pany the dying process is intolerable to some patients who would prefer to forgo its late stages,” Dr. Quill and colleagues wrote. “Many patients would like to exert as much control as they can over their deaths.”

According to Dr. Quill and colleagues, unlike other potential last resort options, VSED theoretically does not require direct physician involvement. “In prac-tice, however, clinician participation is critical in terms of both initial assessment and ongoing management,” they wrote. “Key aspects of assessment are to ensure that the patient has decision-making

POLST Quality in Nursing Homes Could Be Improved Randy Dotinga

Since they were fi rst developed in Oregon in the 1990s, Physician

Orders for Life Sustaining Treatment (POLST) Paradigm forms have become common in nursing homes, hospices, and hospitals across the United States. However, even as the use of POLST forms has continued to increase, some critics are questioning whether they actu-ally improve the dying process.

A large new study has contributed evidence of some weaknesses in the nursing home setting: researchers in California found that about one-third of the POLST forms they examined were technically invalid, often because they lacked the required signatures or were outdated — or had no dates on them at all (J Palliat Med 2017;20:538–541).

“This is pretty troubling. We were not able to establish a sense of high quality here,” said Susan Enguidanos, PhD, MPH, the report’s coauthor. “This could lead to care that is not consis-tent with the care the patient wants.” Dr. Enguidanos, an associate professor of gerontology at the University of Southern California Leonard Davis School of Gerontology, spoke about their study’s fi ndings at the 2017 World Congress of Gerontology & Geriatrics, pre-sented by the International Association of Gerontology and Geriatrics in San Francisco.

Advance health care directives are designed to provide direction to medical personnel in the future about a person’s care. As a recent report in the Journal of the American Medical Association noted, POLST forms were created to smooth the way for a patient’s wishes to be imple-mented (JAMA 2016;315:259–260).

“By making physicians’ orders por-table, the original intent of POLST was

to provide legal authority for emergency medical services personnel (i.e., paramed-ics and emergency medical technicians) to not attempt CPR for patients who had requested that CPR be withheld,” wrote the JAMA report’s authors. “In contrast to advance directives, which provide guid-ance for clinicians and family members in the future if a patient were to become ter-minally ill or permanently unconscious, POLST enacts legally valid medical orders for current treatment.”

California, Oregon, and West Virginia are at the forefront of using POLST forms. In those states, they’re now used by more than half of hospitals, nursing

homes, and hospices, according to the National POLST Paradigm (http://polst.org/programs-in-your-state). Overall, 23 states have programs endorsed by the POLST task force, and 23 more states are developing programs. Vermont, Massachusetts, and Maryland have pro-grams that don’t comply with guidelines, and South Dakota and the District of Columbia have no programs at all.

The JAMA report raises questions about the POLST program, noting that the research has suggested that many of the orders in the forms are ignored. “Standing physician orders dictating future treatment decisions are appropriate

only if preferences are stable over time and across foreseeable clinical contexts,” the report added. “Despite recommendations that POLST be revisited with changes in clinical status, there is no mechanism for [ensuring] that this is done, particularly after acute health changes.”

The new study by Dr. Enguidanos’ group, which was based on an analysis of POLST forms at 13 nursing homes in Los Angeles, suggested that the lack of a system to require updates is indeed a problem. Of 938 forms, only 855 (91%) had dates on them. Of the forms with dates, about half were dated at least 6 months before the researchers’ review. Over 17% had been prepared 18 months to 3 years earlier.

About 30% of the forms were invalid, Dr. Enguidanos said, because they lacked a physician’s signature, a signature from the patient or proxy, or both. “One of the things that’s been suggested in the literature is that the forms that lack sig-natures may be a result of poor commu-nication between the caretaker and the proxy,” she said.

“Some reports around nursing homes [have pointed to] … physicians devel-oping POLST forms for the patient before they talk to the patient about it,” Dr. Enguidanos added. “We need more information about this since we don’t know to what extent the POLST repre-sents what the patient or family wants.”

Their study concluded that the qual-ity of POLST forms must be improved. One solution, Dr. Enguidanos said, could be to develop a POLST-related quality metric for nursing homes.

Randy Dotinga is a San Diego-based freelance writer.

EDITOR’S NOTE

This study confi rms what many of us know: POLST Paradigm forms are not always completed in nursing homes with the level of professional attention, and gravity, they warrant. These are life-and-death documents that can be crucial in ensuring that patients get medical treatment that’s concordant with their goals of care and their medical condition. POLST should not be used universally as a code status document for nursing home residents; it’s meant for patients near-ing the end of life. Yet in some facilities, that is the procedure: Every resident is expected to have a POLST completed, even those who are not appropriate for POLST orders. It is not surprising that some of these forms may not be fully completed; a family member or the physician may not have both signed it for a variety of reasons. But, as I have written before, it’s completely unacceptable for a nursing home physician (or any physician or practitioner) to sign a POLST form without having a rich conversation with the patient or the surrogate.

As to whether there’s a mechanism for reassessing POLST status, it should happen no less frequently than quarterly in the nursing home, because it’s part of what’s expected as part of the interdisciplinary team care planning process. And many patients never change their POLST, so the fact that some forms may have been signed a year or even 2 years earlier does not trouble me in the least. The most important factor here is that patients understand what the orders mean, and want to get the treatment the orders specify. Let’s be sure we do our due diligence to ensure our patients make informed decisions — it’s the least we can do!

—Karl Steinberg, MD, CMD, HMDCEditor in Chief

For clinicians who believe suicide is morally wrong, caring for a patient who chooses VSED may be untenable.

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CARINGFORTHEAGES.COM CARING FOR THE AGES 15

ABOUT THE PRACTICE GROUP NETWORK (PGN)

The PGN will advocate for policies that promote PA/LTC practices which serve the nation’s frail, elderly, and disabled population. Specifically, the PGN focuses on the promotion of the practice and the reduction of administrative burdens and penalties that threaten the sustainability of these practices. It will advocate for:

• Development of appropriate quality measures for physician quality reporting programs

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• Interoperability of IT systems between PA/LTC practices and facilities they serve

• Development of a specialty for PA/LTC practices• Appropriate reimbursement for fee-for-service codes in the

resource-based relative value scale system

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complicated and shifting waters of post-acute and long-term care (PA/LTC).

EDITOR’S NOTE

For those who have an interest in VSED, I highly recommend this brief review article that also mentions phy-sician aid-in-dying and euthanasia. Most of us who work in post-acute and long-term care have cared for patients who elect to voluntarily stop eating and drinking (sometimes also referred to as voluntary refusal of food and fl uids [VRFF]). As with patients who involuntarily stop eat-ing and drinking, such as those who have suffered a stroke with severe dys-phagia and who do not wish artifi cial nutrition, dying from hypovolemia seems to be a comfortable process for most — much more comfort-able than many alternative ways to die — and we can make it even more comfortable with appropriate use of benzodiazepines, opioids and oral care for xerostomia while they are still conscious. The AMA’s Council on Ethical and Judicial Affairs does not consider VSED to be unethical, and it appears to be an appropriate way to respect autonomy. With all due respect to Dr. Quill, an emi-nent palliative medicine specialist and bioethicist, I am a little uncomfort-able with placing limits on when it is “permissible” to tell a patient what options are available. If other physi-cians prefer not to mention it for their own ethical reasons, I suppose that is their prerogative — like phy-sicians who won’t tell their patients about abortion, or even birth control. —Karl Steinberg, MD, CMD, HMDC

Editor in Chief

capacity, the decision is not infl uenced by a mental illness, the patient is fully informed of the risks and alternatives, and the choice is voluntary” [JAMA Intern Med, Nov. 6, 2017; doi:10.1001/jamainternmed.2017.6307].

Furthermore, the patient-proxy discussion “should explicitly include the patient’s future wishes about how caregivers should proceed if the patient develops delirium, forgets his or her goals, and then requests food or fluids.”

Ethical Aspects One of the controversies surrounding the use of VSED centers on the question of whether suicide is always morally wrong.

“Although suicide harms a person by causing that person to die, it may be rational if the act is necessary to protect that person from what they perceive to be a greater harm,” the authors said. “In circumstances where a patient with decision-making capacity and without a mental disorder determines that the harm of death is less than the harm of continued existence with physical or existential suffering, then the person’s choice may not be morally wrong.”

Another controversy in this topic is whether clinicians who believe suicide is morally wrong have an obligation to participate in the care of patients who choose VSED, or to inform these patients of the option. Opponents of VSED, Dr. Quill and colleagues wrote, argue that physicians should not men-tion the practice to patients because they may be tempted or infl uenced to choose it; then the physicians would be advising, assisting, or tempting others to engage in wrongdoing.

On the other hand, the authors wrote, “proponents counter that physicians have obligations to inform patients of all potentially relevant treatment options, and that discussion of VSED does not necessarily need to be persuasive, imply an endorsement, or be interpreted as a suggestion that the patient’s life is not worth living.”

Legal Aspects At present, there is a lack of judicial, legislative, or administrative guidance on the practice of VSED, and many clinicians perceive the legal risks to be higher than they actually are, according to the authors.

“VSED is patient controlled almost entirely, and is based on the right to bodily integrity and patient autonomy. There have been a number of very vis-ible cases and no one has brought them

to court, which I believe continues to be the best strategy,” Dr. Quill said. “There is nothing to suggest that the practice violates the law.”

Dr. Quill and colleagues added that the legality of VSED can be deduced from broader principles and patient rights. “The most relevant are the patient’s right to refuse unwanted medical interventions, and the patient’s right to refuse unwanted bodily intrusions,” they wrote.

In Practice For nursing home professionals, Dr. Quill cautioned against routinely broaching the subject of VSED with patients and their families.

“[VSED] is only for patients who are nearing the end of their lives and are ask-ing about means for achieving a peace-ful death sooner rather than later,” he said. “Many are unaware of this option, so if they would potentially qualify, are unaware of the possibility, and are ask-ing about options, I believe it would then be permissible to tell them about VSED.”

Brian Ellis is a NJ-based freelance writer and editor.

According to the study authors, many clinicians perceive the legal risks [of practicing VSED] to be higher than they actually are.

16 CARING FOR THE AGES JANUARY 2018

If you or a loved one is in a nursing home or other post-acute/long-term care facility, it is important to fi nd ways to get out and about, interact with others, and participate in fun and satisfying activities. People who are more social tend to be happier and stay healthier longer, while studies have shown that social isolation can lead to cognitive decline and depression.

Some people may think that the more someone moves or interacts with others, the more likely they are to get hurt or sick, but that’s not necessarily true. Being active keeps muscles stronger, so elders who walk and move regularly are less likely to experience falls and fall-re-lated injuries. And studies suggest that the human im-mune system is negatively affected by social isolation and that elders who socialize actually get fewer colds. There’s also good evidence that both physical and mental exercise help prevent or delay dementia. So-cialization and activity also can help decrease the need for medications, increase appetite, and improve sleep.

Socializing and activities can help elders with depression and anxiety, or those who have experienced the loss of a spouse, realize that others share their experiences, chal-lenges, and frustrations and that they can still enjoy fun and friendship, despite their age and illnesses.

It is important to seek out activities that you or your loved one enjoy. Don’t be discouraged if illnesses or physical problems seem limiting. For example, maybe Mom can no longer dance, but she can still clap, sway, and enjoy moving to music. Perhaps Dad can’t go fi sh-ing, but he can meet with other outdoor enthusiasts to share stories and watch videos.

You might be surprised at how many different kinds of activities, events, and social opportunities there are.

Many nursing settings offer everything from dancing, swimming, and art programs to computer classes, virtual reality experiences, and performances by choral groups, Elvis impersonators, and comics. If there is something you or your loved one want to do that isn’t currently be-ing offered, talk to the activities director or other team member about the possibility of starting a new group.

Especially in winter, it may be tempting for residents to stay in their rooms and watch TV, but they are likely to feel better and be happier if they have time with family, friends, and activities they enjoy. The facility, after all, is a home; and the care team wants residents to enjoy quality of life that includes socialization.

Questions to Ask Your Practitioner• What if my loved one just wants to be alone? • Are there ways to still be involved in things I can no

longer do?• If the facility doesn’t offer an activity my loved one

wants, what can we do?

What You Can Do• Make sure the care team knows what activities your

loved one enjoys.• Let the practitioner know if your loved one loses in-

terest in people or activities.• Be willing to consider trying an activity that you don’t

think you’ll enjoy.• Let the care team know if any physical activity causes

you or your loved one pain or discomfort.

For More Information• Elderly Enrichment: The Importance of Activities for

Seniors: http://bit.ly/2kpwUxV• Seniors Can Benefi t from Physical Activity: http://bit.

ly/1hv6uDJ

Staying Active Is Part of Healthy AgingKarl Steinberg, MD, CMD, Caring for the Ages editor in chief, talks about the importance of staying active and enjoying hobbies and fun for elders, even when they are ill or disabled.

Caring for the Ages is the official newspaper of AMDA – the Society for Post-Acute and Long-Term Care Medicine and provides post-acute and long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care. Content for Caring for the Ages is provided by writers, reporters, columnists, and Editorial Advisory Board members under the editorial direction of Elsevier and AMDA.

The ideas and opinions expressed in Caring for the Ages do not necessarily reflect those of the Society or the Publisher. AMDA – the Society for Post-Acute and Long-Term Care Medicine and Elsevier Inc., will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.

©2018 AMDA – the Society for Post-Acute and Long-Term Care Medicine.

INNOVATIONS IN PA/LTCCari Levy, MD, CMD

Teen Entrepreneur Helps Elderly Understand Technology

Age is no barrier to being a member of the Innovations Platform Advi-

sory Committee (I-PAC), as 15-year-old entrepreneur and committee member Noah Krieder aptly demonstrates. Noah

is the founder of DT Cyber Solutions Tech Lessons. DT Cyber Solutions was established in 2016 with the goal of providing technology lessons to a wide array of individuals and organiza-

tions, but with a focus on helping older adults understand technology. In the time since Noah established the busi-ness, technology education has been provided to parents, executive directors

for corporations, and seniors who are living independently or in assisted liv-ing facilities.

DT Cyber Solutions offers different styles of tech lessons, but the most common form is a one-on-one session with a DT Cyber Solutions associate in the client’s home. When they work one on one with clients, the associates teach lessons using the client’s device. They’ve found that this not only main-tains the client’s comfort level with the technology, but it also allows for better retention of the information. Associates also have found that taking notes on the topics covered during each session and providing copies to their clients afterward promotes retention of infor-mation and allows each step to be refer-enced later. Their second main teaching method is more formal group presenta-tions targeted to companies, events, or residents in assisted living facilities.

At the time of the interview, DT Cyber Solutions had delivered 39 one-on-one sessions and 10 presentations. Based on this work, we invited Noah to join our Innovations Platform Advisory Committee. We also thought his ambi-tion and ability would complement the group, offering unique insights from his stage of life. We asked him about his decision to start this type of company and what might interest others his age in working with older adults, and we share his responses to our questions here.

1. What piqued your interest in working with older adults?

My interest in working with older adults was piqued when I saw there was a severe lack of people or companies that provided services to help them learn how to use technology and stop fearing it. When I looked further into it, I realized that the services that were available were very overpriced, and in my eyes, a scam. I really wanted to combat that, thus DT Cyber Solutions was created.

2. How do your peers respond when they learn about your business?

When my peers learn that I have a business, I often get the same response. The response that I will normally get is similar to “No, what do you really do?” or “That’s not possible, you’re still in high school.” However, most of my peers don’t understand how hard it truly can be sometimes. There’s a common misconception with my age group that business ownership is glamorous, easy, or intense business meetings like you see on TV. They are shocked when I tell them the reality of business ownership, which is grueling hours, high stress, tax-ing expenses, and the hardships of being self-employed.

CARINGFORTHEAGES.COM CARING FOR THE AGES 17

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3. In an ideal world, what will we do to address unsustainable health care costs and the growing senior population over the next decade?

In an ideal world, I would tackle unsus-tainable health care costs and the grow-ing population by implementing more technological solutions. When I think of the emergency room right now as it is, I think of a very busy hospital with a lot of questions that could be answered with just [a visual or remote examination].

There isn’t always a need to see the doctor in person. The mole that may seem suspicious to you, might be just that. Although I’m not a doctor, I can guarantee you that some instances of ER, primary care, or urgent care visits could be handled remotely. If technology could get implemented in health care more for the average visit, then we could eliminate wait times, cost, transportation issues, and reduce a signifi cant amount of con-gestion in our hospitals. I also believe that solutions such as online access por-tals, where someone can message their doctor, can make an astronomical differ-ence if they were utilized better.

4. How can we engage people at your age in the fi eld of caring for older adults?

People my age (high school) could become more engaged to care for older adults if they could see the difference they make. When I fi rst started my com-pany, it was extremely diffi cult, and to

a degree, it still is. However, what kept me going — and keeps me doing what I’m doing — was seeing the difference that I made in people’s lives. Today’s youth want to feel like they’re making a difference. If you were to ask a group of high schoolers what they want to do for their career and why, a majority would respond saying they want to make a difference and help others. If I were to try to engage a group of people to care for older adults, I would show them the difference it would make and why their participation is important to the overall goal.

Common Goals As I read Noah’s last response, I thought it was not so different from any genera-tion. Sometimes I think of “kids these days” as aliens, with their foreign meth-ods of communication that are continu-ously new and leave me continuously out of date and hopelessly confused. However, as Noah points out, they sim-ply want to make a difference — just as we wanted to make a difference when we were their age.

As we think about our appeals to this new generation in our Innovations Platform, we will look to Noah as an advisor and keep our sights on this gen-eration who, as technological natives, can teach us much as we welcome them into our community of post-acute and long-term care. Our hope is that this partnership will introduce Millennials or Generation Z to the bounty of good work that awaits this capable, ambitious generation in PA/LTC, where they can indeed make a difference.

This column is sponsored by AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Innovation and Implementation Workgroup. Dr. Levy is a geriatrician board certifi ed in hospice and palliative medicine, and is associate director of the Denver-Seattle Center for Veteran-Centric and Value-Driven Care. She is president-elect of the Society.

Noah Krieder (l), of DT Cyber Solutions, enjoys seeing the positive impact his technology assistance company is making in elders’ lives.

ERRATUMIn the November issue of Caring, in the article entitled “Direct Oral Anticoagulants in Elderly Complicated, but Safe” it should read: “Although missed DOAC doses may put patients at risk for a thromboembolic problem or clotting, Dr. Garwood advised against placing adherence at the top of the algorithm, noting that patients who are nonad-herent with one DOAC are likely to be nonadherent with another drug, including warfarin.” Caring regrets the error.

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18 CARING FOR THE AGES JANUARY 2018

Editor in Chief Karl Steinberg, MD, CMD, HMDC

Editorial Advisory BoardChair: Karl Steinberg, MD, CMD, HMDC, California

Robin Arnicar, RN, West Virginia

Nicole Brandt, PharmD, CGP, BCPP, FASCP,

Maryland

Ian L. Cordes, MBA, Florida

Jonathan Evans, MD, CMD, Virginia

Phyllis Famularo, DCN, RD, New Jersey

Janet Feldkamp, RN, JD, BSN, Ohio

Nina Flanagan, PhD, GNP-PC, APMH-BC, New York

Robert M. Gibson, PhD, JD, California

Daniel Haimowitz, MD, FACP, CMD, Pennsylvania

Paige Hector, LMSW, Arizona

Jennifer Heffernan, MD, CMD, Texas

Jeanne Manzi, PharmD, CGP, FASCP, New York

Jeffrey Nichols, MD, New York

Dan Osterweil, MD, CMD, California

Barbara Resnick, PhD, CRNP, FAAN, FAANP,

Maryland

Caring for the Ages is the official newspaper of AMDA – the Society for Post-Acute and Long-Term Care Medicine and provides long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care. Content for Caring for the Ages is provided by the Society and by Elsevier Inc.

The ideas and opinions expressed in Caring for the Ages do not necessarily reflect those of the Society or the Publisher. The Society and Elsevier Inc., will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.

©2018 AMDA – the Society for Post-Acute and Long-Term Care Medicine

Caring for the Ages (ISSN 1526-4114) is published monthly by Elsevier, 230 Park Avenue, Suite 800, New York, NY 10169. Business and Editorial Offices: Elsevier, 230 Park Avenue, Suite 800, New York, NY 10169. Accounting and Circulation Offices: Elsevier Health Sciences Division, 3251 Riverport Lane, Maryland Heights, MO 63043. Periodicals postage paid at New York, NY and additional mailing offices.

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JOURNAL HIGHLIGHTS

From the January Issue of JAMDA

Skilled Nursing Home Facilities Skilled nursing facilities that hire more registered nurses and specialize are more likely to achieve positive long-term out-comes with trauma and surgery patients, according to a retrospective study in the United States.

Led by Lucas W. Thornblade, MD, from the University of Washington, researchers studied data from the Centers for Medicare and Medicaid Service for 389,133 benefi ciaries — 83,207 trauma patients and 305,926 surgical patients — admitted to 2,707 skilled nursing facilities in fi ve states. Specifi cally, the researchers looked at 1-year mortality, hospital readmission, and failure to discharge home, as well as the nursing home factors that affected these outcomes.

Evaluating data over a 3-year period, the researchers found that 23% of trauma patients and 36% of surgical patients died within the year. Also, 24% of trauma patients and 27% of surgical patients were readmitted to the hospital. And, failure to discharge home occurred among 48% of the trauma patients and 43% of the surgical patients.

The researchers found that bed-to-nurse ratios and levels of training affected these outcomes. Specifi cally:

• Skilled nursing facilities that had fewer than 4.1 beds per nurse had signifi cantly lower odds of 1-year mortality, hospital readmission, and failure to discharge home than fa-cilities that had more than 6.7 beds per nurse.

• Facilities with fewer than 12 beds per registered nurse had signifi cant-ly lower odds of 1-year mortality, hospital readmission and failure to discharge home than facilities with more than 49 beds per RN.

• Facilities that had fewer than 5.3 beds per licensed practical nurse had lower odds of readmission and failure to discharge home surgical patients than those that had more than 10 beds per LPN. There was no difference among trauma patients. For surgery and trauma patients, there was no difference in mortality among facilities with higher or lower bed-to-practical nurse ratios.

• Facilities that had fewer than 1.6 LPNs, who have less training, per RN had lower odds of mortality, readmission and failure to discharge home than facilities with more than 7.4 LPNs per RN.

“So, the hypothesis behind the notion [is] that nurses with more experience and more training may be more likely to pick up on preventable illnesses earlier

in the course of the hospitalization,” Dr. Thornblade told Caring. “Or, in terms of the care ratio, if they’re caring for fewer patients at any given time, [they] may be more free to either prevent an adverse event like a fall or a medication error, or to arrive at earlier diagnosis or earlier alert to a patient who’s declining in their status.”

The fi ndings also suggest that special-ization matters, whether one fl oor or the entire facility specializes in caring for a certain type of patient. There was no dif-ference in mortality among facilities that had a higher density of trauma patients (more than 4.3% of patients admitted after trauma) than in those with a lower density, but odds of mortality were lower in those facilities with a higher density of surgical patients (more than 14.1%). Overall, the research shows wide vari-ability in outcomes in post-acute care, even after adjusting for such factors as age and level of illness.

“There are a lot of things that we can’t control and a lot of that has to do with patients we care for,” Dr. Thornblade said. “But some things that essentially are quite modifi able are the ratios, the staffi ng ratios that we apply in our facili-ties, and also this notion that nursing facilities and post-acute care facilities can be specialized.”

Source: Thornblade LW, Arbabi S, Flum DR, et al. Facility-level factors and out-comes after skilled nursing facility admis-sion for trauma and surgical patients. J Am Med Dir Assoc. 2017 [doi: 10.1016/j.jamda.2017.08.007].

Frailty Defi nitions and Falls Operational defi nitions of frailty are not able to predict short-term occurrence or falls and deaths among nursing home residents, according to a study in Liège, Belgium.

Fanny Buckinx, PhD, of the University of Liège, and colleagues monitored 584 individuals from the Sample of Elderly Nursing home Individuals: An Observational Research (SENIOR) Cohort, a prospective longitudinal study of Belgian nursing home residents. The researchers diagnosed frailty based on 11 operational defi nitions and monitored falls and deaths over a year.

At least one fall occurred among 211 out of 565 individuals (37.3%) during the follow-up period, but only one defi -nition of frailty, the Groningen indicator, was associated with falls, the research-ers found. Also, 93 of 584 individu-als (15.9%) died during the fi rst year, with only two defi nitions of frailty, the Tilburg Indicator and the Share Frailty Instrument, associated.

There were, however, independent fac-tors associated with falls and mortality. Individuals who fell tended to have a lower calf and arm circumference, were more likely to use a walking support, were at risk of malnutrition, had low energy expenditure, and were more likely to be frail. Individuals who died were more likely to be male, live in nursing homes, have lower arm circumference and lower percent of body fat, and were more likely to have sarcopenia.

Source: Buckinx F, Croisier JL, Reginster JY, et al. Prediction of the incidence of falls and deaths among elderly nursing home residents: The SENIOR study. J Am Med Dir Assoc. 2017 [doi: 10.1016/j.jamda.2017.06.014].

Access to Cannabis Enrollment in a medical cannabis pro-gram, or MCP, may help lead individu-als to use fewer scheduled II-V drugs, according to a pragmatic historical cohort study in Albuquerque, NM.

Sarah S. Stith, PhD, of the University of New Mexico, and colleagues, com-pared schedule II-V drug prescription patterns over a 24-month period for 83 patients enrolled in the New Mexico MCP with 42 individuals who were not enrolled. They assessed scheduled II-V prescription drug patterns through 24 months of prescription monitoring program records.

During the study period, patients used an average zero to 10 prescriptions a month in zero to four classes. Opioids and benzodiazepines were the most fre-quently prescribed groups.

There were signifi cant reductions in scheduled II-V prescription drug activity and use of conventional pharmacies and prescribing providers among patients enrolled in the MCP, the researchers found. Also, 28 patients (34%) enrolled in the MCP stopped using all sched-uled prescription medications by the last 6 months of the observation period vs. one patient (2%) who was not enrolled.

Possible explanations are that can-nabis alone can address conditions for which patients typically take multiple prescription drugs, and that patients may be replacing prescription drugs with cannabis.

Source: Stith SS, Vigil JM, Adams IM, et al. Effects of legal access to cannabis on scheduled II-V drug prescriptions. J Am Med Dir Assoc. 2017 [doi: 10.1016/j.jamda.2017.07.017].

Jeffrey S. Eisenberg, a freelance writer in the Philadelphia area, compiled this report.

CARINGFORTHEAGES.COM CARING FOR THE AGES 19

NEWS FROM THE SOCIETY

January 8, 2018 Core Online Winter Session Early Bird Deadline Contact: Registrar Phone: 410-992-3116 Email: registration@paltc.org Website: https://paltc.org/core

January 9 – April 18, 2018 Core Online Winter Session Contact: Registrar Phone: 410-992-3116 Email: registration@paltc.org Website: https://paltc.org/core

January 17, 2018 Society 2018 Annual Conference Early Bird Deadline Contact: Registrar Phone: 410-992-3116 Email: registration@paltc.org Website: https://paltc.org/annual-conference

January 27, 2018 Alabama Medical Directors Association 2018 Mid-Winter Conference Birmingham, AL Contact: Jennifer Hayes Phone: 334-954-2500 Email: jhayes@alamedical.org Website: www.almda.org/page/upcoming-events-1

March 15, 2018 Core Online Winter Session Deadline Contact: Registrar Phone: 410-992-3116 Email: registration@paltc.org Website: https://paltc.org/core

March 16 – 17, 2018 GAPNA Pharmacology Conference Boston, MA Contact: Jill Brett Phone: 856-256-2333 Website: www.gapna.org/events/annual-conference

March 22 – 25, 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine 2018 Annual Conference Grapevine, TX Contact: Registrar Phone: 410-992-3116 Email: registration@paltc.org Website: https://paltc.org/annual-conference

April 21 – 24, 2018 American College of Health Care Administrators 2018 Convocation & Exposition Orlando, FL Contact: Elizabeth Lollis Email: elollis@achca.org Website: https://achca.memberclicks.net/events

DON’T MISS THESE EVENTS

Post-acute and long-term care medi-cine is an interdisciplinary art,

populated by passionate, creative pro-fessionals, and it is a proving ground for innovation. To recognize and promote innovation, the Society is holding its fi rst Shark Tank Competition during the 2018 Annual Conference in March. Modeled after the popular television show where individuals present their business ideas and models to a panel of successful entrepreneurs, this is a unique opportunity to share your idea with the largest national audience in PA/LTC. You will be recognized as an innovator and visionary, and will have opportunity to work with experienced innovators to advance your idea.

If you have created a system, device, or technology that will revolutionize care in post-acute and long-term care medicine, we urge you to submit your innovation to this cutting-edge compe-tition. Eligible innovators must meet the following criteria:

• Must have a minimum viable prod-uct and completed at least one pilot (or have current customers).

• Must have fundraising, and no more than $3 million in overall funding.

• Must have an initially defi ned target consumer/patient population.

• Must have a working product road map and defi ned intended impact.

• Should be seeking clinical advise-ment, industry expertise, and part-nership opportunities.

• Must be able to attend the annual conference.

Through a competitive review process, the Shark Tank Competition Committee will be selecting 15–20 innovations to be displayed an exhibited in the Innovations Tech Pavilion at the annual confer-ence. Five innovators will be chosen to present and compete in a live Shark Tark Competition at the conference on March 23. Two winners will be chosen, one by the judging panel and one by the audience.

“You will have the ability to present your solutions, your innovations before our panel of judges and an audience of colleagues and others from across the

country. Winners will get the opportu-nity to collaborate with Society innova-tion specialists to help take their ideas to the next level,” said Arif Nazir, MD, CMD, chief medical offi cer for Signature HealthCare, Society vice president, and chair of the Innovation Platform Advisory Committee. Dr. Nazir also will be presenting the closing keynote,

entitled “The Future Is Not What It Used To Be! Innovating for an Unpredictable Tomorrow” at the conference.

“This is an exciting opportunity to take your innovative idea and see it grow into a solution that makes a mean-ingful difference for facilities, practitio-ners, and patients everywhere,” he said. Dr. Nazir hopes to see cutting-edge ideas about collaboration, staff empow-erment, improved communication, and more.

Innovators are a special breed, Dr. Nazir said. “They are dissatisfi ed with the status quo, and they don’t think that ‘acceptable’ or ‘good’ is good enough. They have a thirst of doing things bet-ter and are open to change. They aren’t afraid to put ideas out there. They realize that they might fail, and they are pre-pared to learn from their failures.”

Go to https://paltc.org/shark-tank#timeline to read more and submit your innovation. You could be swim-ming with the sharks!

Attention, Innovators: Society Launches First Shark Tank Competition

Society to Offer ABIM Maintenance of Certifi cation

The Society recently announced its eli-gibility to provide American Board of

Internal Medicine Maintenance of Certi-fi cation (MOC) credits. The Society’s ed-ucational programs that will offer ABIM MOC credits in 2018 include the annual conference, Core Curriculum on Medi-cal Direction in Post-Acute and Long-Term Care Medicine, and select webinars. MOC participation demonstrates that a physician is completing ABIM approved continuing education and professional development activities regularly.

According to the Society’s 2017 mem-bership survey, 53% of the Society’s phy-sician members’ primary board specialty is internal medicine. The Society is cur-rently working through the process to

also provide American Board of Family Medicine MOC for those individuals whose primary board specialty is family medicine.

“We are thrilled to add ABIM main-tenance of certifi cation credits to our list of professional development opportuni-ties,” said Society President Heidi White, MD, MHS, MEd, CMD. “Our goal is to educate our members and others who participate in our educational programs, and assist them in maintaining their cer-tifi cations and enhancing the quality of care they provide.”

For more information on the Society’s accreditations and recognitions, visit https://paltc.org/accreditation-recogni-tions.

Registration is open for the AMDA – the Society for Post-Acute and Long-Term Care Medicine 2018 Annual Conference.

If you are a Society member, you can receive the discounted member registration rate as well as receive all the benefi ts

of Society membership from now through Dec. 31, 2018. If you are not currently a member, visit www.paltc.org/membership for details on benefi ts and dues before registering. The annual conference takes place from March 22–25 at the Gaylord Texan Resort and Convention Center. Visit https://paltc.org/annual-conference/register-now to register for the meeting and book your hotel.

TIME TO REGISTER

Five innovators will be chosen to present and compete in a live Shark Tark Competition at the conference on March 23.