May 2015 • vol. 16, No. 5 www.Caringfortheages.com

for the Agesfor the Ages A Monthly Newspaper for Long-Term Care Practitioners

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In This Issue

Caring aN offiCial PubliCatioN of aMDa – the SoCiety for PoSt-aCute aND loNg-terM Care MeDiCiNe

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Avi Farin’s room at Lott Residence, an assisted living facility in New

York City, reveals immediately that he is a working artist. A table – lined with boxes of paints, pencils, brushes, plus other tools of the trade, and covered with

drawings and paintings in vari-ous stages of completion – is the centerpiece of the tiny apart-ment. Often, he can be found drawing or painting or at his computer, despite the fact that he suffered a stroke and is par-tially paralyzed on his left side.

To many post-acute and long-term care facility residents, art

brings them joy, keeps them active and engaged, gives them self-esteem, and – for some – provides a reason for living. Just ask Mr. Farin, who is right-handed and glad the stroke only affected his left side. “If I couldn’t draw, I’d be dead. My art gave me an incentive to live after the stroke.”

Alec Pruchnicki, MD, a physi-cian at Lott Residence, under-stands the importance of art to many of his residents. “They are very proud of their artistic works and accomplishments. For some, it is their whole life and keeps them active. It gives them something to do and a sense of purpose.”

Controlling the Pencil The key to art is “controlling the pencil,” said Mr. Farin, a skill he has clearly mastered. Throughout his career, he par-ticipated in numerous art shows, and his work hangs in three pres-tigious museums. He was also

LOUISVILLE, KY – Errors and adverse events in the long-term care setting often result from what Steven Levenson, MD, CMD, calls Asiana 214 Syndrome.

The 2013 crash of Asiana Airlines flight 214 on its final approach from Seoul to the San Francisco International Airport killed three teenagers and injured 181 other pas-sengers – 12 of them critically. The National Transportation Safety Board (NTSB) con-cluded that pilot error was to blame.

The NTSB said the pilots mismanaged their approach and failed to adequately monitor airspeed, and noted that over-reliance on automation and lack of sys-tems understanding by the pilots were major contributing factors.

The pilots, Dr. Levenson said during a pre-conference intensive session at the AMDA 2015 Annual Conference, had an instrument with the potential to do good and also to do harm, and they didn’t fully understand what they were doing. They proceeded anyway.

Furthermore, they failed to anticipate the situation, and when they realized something was wrong they didn’t know how to correct it. They failed to assess the facts first, they acted in a panic, and people were harmed.

“So what are the lessons of this for health care? Well, just about every-thing,” said Dr. Levenson, an internist in Baltimore and past AMDA president.

Multi-Symptom SyndromeThe “syndrome” is common in post-acute and long-term care, and is characterized

by a lack of complete understanding of and familiarity with the task at hand, a lack of technical knowledge and skill to perform the task at hand, a failure to know what it is that isn’t known, and an unwillingness to admit to not knowing, he explained.

As it turned out, the culture of the airline was one in which people were hesitant to admit when they didn’t know something – and they didn’t ask. Rather, they acted as if they knew it.

Doing things by rote without care-ful assessment, failing to anticipate risks

and complications, guessing (and plow-ing ahead based on guesses), and rushing to a conclusion and then to action based on that conclusion (an act first, ask later approach) are other characteristics of the potentially deadly syndrome, he said.

It’s a scenario he has encountered time and again in nursing homes. People don’t really understand what they’re doing but they do it anyway. They don’t ask, aren’t encouraged to ask, or are afraid to ask, he said, noting that this leads to guessing,

Asking Questions Key to Patient SafetyBy Sharon WorceSter

By Joanne Kaldy

Painting Adds Color to Residents’ Quality of Life

According to Steven Levenson, MD, CMD, the key to patient safety is recognizing opportunities to halt the process that leads from a potential risk to a bad conclusion.

Goodbye, SGRThe sustainable growth rate has finally been repealed after many tumultuous years. ..................5

Dear Dr. JeffTo err is human, but to really foul things up requires a computer and EHRs. Healthy skepticism of every word in transferred charts is absolutely necessary. .......... 7

Meeting PreviewAn early peek at some of the presentations and posters from the AMDA Annual Conference. .... 8

Next Generation ACOsPA/LTC physicians must understand how accountable care organizations can maximize their value and optimize patient care. ........................ 18

See Quality of Life • page 16

See Patient Safety • page 12

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2 • CARing foR THE AgES MAy 2015

All physicians and hospitals would need to be meet stage 3 meaning-ful use beginning in 2018, accord-

ing to a recent proposal by the Centers for Medicare & Medicaid Services.

In the agency’s stage 3 proposed rule, there would be no transition period from earlier stages for those just starting or those who were in an earlier stage. CMS said that this is “expected to be the final stage” and will incorporate elements of the previous two stages.

That change comes along with the proposal beginning in 2017 to perma-nently make the attestation period a full year, with a few exceptions. A full-year attestation period was supposed to go

into effect for 2015 with stage 2, but CMS announced that it would reduce attestation to a 90-day period because of low participation.

The American College of Cardiology said in a statement that it is “concerned” by the proposal that even new physi-cians and practices will have to jump immediately to stage 3 in 2018 without a transition period.

“Implementing an [electronic health record] system ... is not as simple as

flipping a switch; it takes time, financial investment, careful consideration and planning, as well as education for all staff. The program must take this learn-ing curve into consideration,” Kim Allan Williams Sr., MD, ACC president, said in a statement.

The final year in which participants in the EHR Incentive Programs can receive bonus payments for meeting meaningful use criteria is 2017; penalties for failing to meet criteria have already begun.

Everybody on Board Stage 3 Meaningful Use in 2018By GreGory tWachtMan

PA/LTC Perspective

“CMS published a pair of companion documents in late March that foretell the health care systems’ future. They are the draft stage 3 meaningful use program and the 2015 edition Health Information Technology (Health IT) Certification Course.

“Combined, these documents define a global health IT infrastructure; post-acute and long-term care, behavioral health, and pediatric care are now ‘baked-in’ the equation,” according to Rod Baird, president of Geriatric Practice Management, Asheville, NC. “There are specific requests for com-ments on PA/LTC certification, and work-flow definitions that support pro-viders. Whether these provisions actu-ally result in PA/LTC medical groups having the capability to realistically achieve meaningful use (e.g., avoid Medicare penalties and earn Medicaid meaningful use dollars when possible) will depend on the final rule(s).

“After surveying these rules, and reading the analyses of some very astute commenters, my overall sum-mation is: go big or go home.

“Frankly, there is no possible way that small practices, or ‘me too’ IT vendors, can survive under the draft rules as written. The requirements on the practices are too immense to satisfy without a dedicated team and bespoke software. The equivalent 560 complete ambulatory electronic health record versions that exist are going to be winnowed down. The estimated development costs are large, and legacy software is often too complex to modify. Adding to that – there are no meaningful use dollars left in out-patient care. Where are the providers going to go to find money to support all of this new software development?

“For PA/LTC practices, the outlook is less dire. We still have the potential to earn Medicaid meaningful use money. The 2015 regulations speak to certifying facility and home care EHR software (not for meaningful use but for interoperability). If PA/LTC facil-ity vendors have to follow standards, the capability of shared care (e.g., electronic order sets and care plans) draws nearer. That is the gateway to both meaningful use and care man-agement payments.

“The PA/LTC industry has a very short window to analyze these new regulations and identify any road-blocks to achieving the dual goals – enabling meaningful use and shared care in LTC settings. Start reading!”

Select Safety Information for Humalog, continued• Hypoglycemia is the most common adverse eff ect

of Humalog therapy. The risk of hypoglycemiaincreases with tighter glycemic control. Severe hypoglycemia may be life threatening and can cause seizures or death.

• Humalog should be given within 15 minutes before or immediately after a meal.

Please see Important Safety Information and Brief Summary of Prescribing Information on following pages.

Indication for Humalog• Humalog is an insulin analog indicated to

improve glycemic control in adults and children with diabetes mellitus.

Select Safety Information for Humalog• Humalog is contraindicated during episodes

of hypoglycemia and in patients who are hypersensitive to Humalog or any of its excipients.

• Closely monitor blood glucose in all patients treated with insulin. Change insulin regimens cautiously.

Small vials*—available only from Lilly—offer versatility in your patient management.

Humalog® comes in small vials, sized for individual use and designed to be more versatile than other delivery options. Just one more way the makers of Humalog show we understand the challenges of administering mealtime insulin to each patient during the course of their stay.

For more information on training, educationalresources, and the many other ways Lilly can help,talk to your Lilly Diabetes representative or visitinsidehumalog.com.

*Smaller vials contain 3 mL of insulin in a 5 mL vial.

Small vials are one of the many ways Lilly supports your diabetes care of post-acute rehab patients.

CARingfoRTHEAgES.CoM CARing foR THE AgES • 3

The proposed rule also contains a number of more stringent requirements. On the patient engagement front, the proposed rule calls for 25% of patients to access their data, although it also allows for third-party providers to access a patient’s account as a means of satisfy-ing the requirement.

Patient-generated data also are high-lighted, with a proposed requirement that physicians collect information via mobile devices or apps from 15% of their patients.

Under the proposed stage 3 of mean-ingful use, physicians and eligible hospi-tals must meet two of three criteria: that

more than 50% of referrals or transi-tions of care involve the passing of infor-mation by the referring provider; that more than 40% of transitions or referrals received by a provider seeing a patient for the first time include information imported into that new provider’s EHR; or that for more than 80% of those new patients seen in transition or by referral for the first time, a clinical reconciliation be done on the information received during the health information exchange, including a review of current medica-tions, medication allergies, and current and active diagnoses.

“This stage 3 proposed rule does three things: it helps simplify the meaningful use program, advances the use of health IT toward our vision for improving health delivery, and further aligns the program with other quality and value programs,” Patrick Conway, MD, MSc, CMS acting principal deputy administrator and chief medical officer, stated in a press release. Comments on the proposed rule will be accepted at www.regulations.gov until May 29. CfA

Gregory Twachtman is a reporter with Frontline Medical News.

network Supports Value-Based Medicine

By WhItney McKnIGht

The federal government has launched the Health Care Pay-ment Learning and Action Net-

work as a way to help physicians and other players in the health care system transition to value-based medical care. The network was announced recently at a White House event.

“Health reform is really hard,” President Obama said at the event. “Everyone in the trenches knows that.”

Sylvia M. Burwell, secretary of the Department of Health & Human Services, recently announced what the administration portrays as the next step in health reform. Building on the cost-saving efforts of the health reform law’s accountable care organi-zations, HHS plans to shift at least a third of all Medicare payments away from fee-for-service to value-based payment models by 2016. By 2018, half of all Medicare payments are to be value-based.

The Health Care Payment Learning and Action Network is intended to sup-port those goals and give everyone a say in the process’s success, Secretary Burwell said at the briefing.

Specifically, the network will facili-tate new care delivery models and the collection, analysis, and leverage of data from them; break down obstacles to care; create evidence-based quality metrics that do not create record-keep-ing burdens; and foster transparency in the health care system, according to the Centers for Medicare & Medicaid Services.

Over 2,800 partners have registered with the network, including physician organizations, insurers, accountable care organizations, hospitals and health systems, and patient advocacy groups, according to CMS.

At the briefing, Bruce Broussard, CEO of network partner Humana, said that the ACA’s focus on quality has “wrapped the focus around the journey of some-one’s health. It’s really changing the sys-tem from a treatment-oriented one to a health-oriented one.”

Robert M. Wah, MD, president of the American Medical Association, said that his organization joined the net-work because of the access to decision makers that participation is expected to give.

“It is critical that physicians take a proactive role in defining the details of new payment models, and this network will help facilitate that,” Dr. Wah said in an interview. CfA

Whitney McKnight is a reporter with Frontline Medical News.

Select Safety Information for Humalog, continued• Hypoglycemia is the most common adverse eff ect

of Humalog therapy. The risk of hypoglycemiaincreases with tighter glycemic control. Severe hypoglycemia may be life threatening and can cause seizures or death.

• Humalog should be given within 15 minutes before or immediately after a meal.

Please see Important Safety Information and Brief Summary of Prescribing Information on following pages.

4 • CARing foR THE AgES MAy 2015

Using epinephrine during resusci-tation for out-of-hospital cardiac arrest may lower neurologically

intact survival, according to an obser-vational study published in the Journal of the American College of Cardiology.

This negative effect was dose related and unaffected by postresuscitation inter-ventions such as percutaneous coronary intervention or therapeutic hypothermia

in a single-center observational cohort study, said Florence Dumas, MD, PhD, of the Parisian Cardiovascular Research Center, Paris Descartes University, and her associates.

In this study, as in some previous stud-ies, epinephrine was associated with an improved rate of return of spon-taneous circulation. But that benefit didn’t translate into higher long-term survival, possibly because of an as-yet unidentified harmful effect during the

postresuscitation phase of treatment, the investigators noted.

International resuscitation guidelines recommend giving epinephrine every 3 to 5 minutes during cardiac arrest resus-citation efforts, regardless of the ini-tial cardiac rhythm. This approach has been shown to enhance the return of spontaneous circulation. However, it is unclear how the treatment affects long-term survival, with some studies report-ing no effect or even deleterious effects

on that outcome. To examine the issue, Dr.  Dumas and her associates assessed outcomes for 1,556 patients who had non-traumatic out-of-hospital cardiac arrest, achieved return of spontaneous circula-tion, and were admitted to a specialized medical center during a 12-year period.

The average patient age was 60 years, and 71% were men. Nearly 75% of the participants received epinephrine dur-ing resuscitation. As expected, those who were given epinephrine had less

Epinephrine Tied to Lower neurologically intact SurvivalBy Mary ann Moon

CMS Proposes Mental Health Parity for Medicaid

By GreGory tWachtMan

Low-income patients who receive health care coverage from Med-icaid would get greater coverage

for mental health and substance abuse services under a federal proposed rule issued April 6.

The proposed rule extends to certain aspects of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which requires private health insurance to cover mental health and substance abuse treatments as they do medical and surgical services. The 2008 law originally applied to group health plans and group insurance cover-age; the Affordable Care Act extended it to individual health insurance policies as well. According to the proposed rule, Medicaid managed care organizations will be required to offer the same men-tal health and substance abuse services, subject to the same financial and treat-ment limitations consistent with regula-tions applicable to private insurers in that state. The rule does not apply to fee-for-service Medicaid.

The proposed rule also applies to states that offer Medicaid alternative benefit plans. States delivering services through a non-Medicaid managed care organization “must comply with the same requirements that would be nec-essary if such services were delivered through a managed care organization,” officials from the Centers for Medicare & Medicaid Services said in a fact sheet about the proposed rule.

Approximately 21.6 million Medicaid beneficiaries would benefit from action, based on estimates from 2012 Medicaid enrollment, according to the proposed rule. Among adults aged 18 to 64 years with Medicaid coverage, about 10% have a serious mental ill-ness, 31% have any mental illness, and 12% have a substance abuse disorder, according to CMS. CfA

Gregory Twachtman is a reporter with Frontline Medical News.

Indication for Humalog• Humalog is an insulin analog indicated to improve glycemic

control in adults and children with diabetes mellitus. Important Safety Information for HumalogContraindications• Humalog is contraindicated during episodes of

hypoglycemia and in patients who are hypersensitive to Humalog or any of its excipients.

Warnings and Precautions• Dose Adjustment and Monitoring: Closely monitor blood

glucose in all patients treated with insulin. Change insulin regimens cautiously. Concomitant oral antidiabetic treatment may need to be adjusted.

The time course of action for Humalog may vary in diff erent individuals or at diff erent times in the same individual and is dependent on many conditions, including delivery site, local blood supply, or local temperature. Patients who change their level of physical activity or meal plan may require insulin dose adjustment.

• Hypoglycemia: Hypoglycemia is the most common adverse eff ect of Humalog. The risk of hypoglycemia increases with tighter glycemic control. Educate patients to recognize and manage hypoglycemia. Hypoglycemia can happen suddenly and symptoms may vary for each person and may change over time. Early warning symptoms of hypoglycemia may be diff erent or less pronounced under conditions such as long-standing diabetes, diabetic nerve disease, use of medications such as beta-blockers, or intensifi ed diabetes control. These situations may result in severe hypoglycemia and possibly loss of consciousness prior to the patient’s awareness of hypoglycemia. Severe hypoglycemia may be life threatening and can cause seizures or death.

Use caution in patients with hypoglycemia unawareness and who may be predisposed to hypoglycemia. The patient’s ability to concentrate and react may be impaired as a result of hypoglycemia. Rapid changes in serum glucose levels may induce symptoms similar to hypoglycemia in persons with diabetes, regardless of the glucose value.

Timing of hypoglycemia usually refl ects the time-action profi le of administered insulins. Other factors such as changes in food intake, injection site, exercise, and concomitant medications may alter the risk of hypoglycemia.

• Allergic Reactions: Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with Humalog.

• Hypokalemia: Humalog can cause hypokalemia, which, if untreated, may result in respiratory paralysis, ventricular arrhythmia, and death. Use caution in patients who may be at risk for hypokalemia (eg, patients using potassium-lowering medications or medications sensitive to serum potassium concentrations).

• Renal or Hepatic Impairment: Frequent glucose monitoring and insulin dose reduction may be required in patients withrenal or hepatic impairment.

Important Safety Information for Humalog, continuedWarnings and Precautions, continued• Mixing of Insulins: Humalog for subcutaneous injection

should not be mixed with insulins other than NPH insulin. If Humalog is mixed with NPH insulin, Humalog should be drawn into the syringe fi rst. Injection should occur immediately after mixing.

• Subcutaneous Insulin Infusion Pump: Humalog should not be diluted or mixed when used in an external insulin pump. Change Humalog in the reservoir at least every 7 days. Change the infusion set and insertion site at least every 3 days.

Malfunction of the insulin pump or infusion set or insulin degradation can rapidly lead to hyperglycemia and ketosis. Prompt correction of the cause of hyperglycemia or ketosis is necessary. Interim subcutaneous injections with Humalog may be required. Train patients using an insulin pump to administer insulin by injection and to have alternate insulin therapy available in case of pump failure.

• Drug Interactions: Some medications may alter glucose metabolism, insulin requirements, and the risk for hypoglycemia or hyperglycemia. Signs of hypoglycemia may be reduced or absent in patients taking anti-adrenergic drugs. Particularly close monitoring may be required.

• Fluid Retention and Heart Failure with Concomitant Use of PPAR-gamma Agonists: Thiazolidinediones (TZDs), which are PPAR-gamma agonists, can cause dose-related fl uid retention, particularly when used in combination with insulin, including Humalog. This may lead to or exacerbate heart failure. Observe patients for signs and symptoms of heart failure and consider discontinuation or dose reduction of the PPAR-gamma agonist.

Adverse Reactions• Adverse reactions associated with Humalog include

hypoglycemia, hypokalemia, allergic reactions, injection-site reactions, lipodystrophy, pruritus, rash, weight gain, and peripheral edema.

Use in Specifi c Populations• Pediatrics: Humalog has not been studied in children

with type 1 diabetes less than 3 years of age or in children with type 2 diabetes.

Dosage and Administration• Humalog should be given within 15 minutes before or

immediately after a meal. Please see Brief Summary of Prescribing Information on adjacent pages.HI HCP ISI 29MAR2013Humalog® is a registered trademark of Eli Lilly and Company and is available by prescription only.

Humalog small vials sizedfor individual patient care.

HI90913 07/2014 PRINTED IN USA ©Lilly USA, LLC 2014. All rights reserved.

CARingfoRTHEAgES.CoM CARing foR THE AgES • 5

favorable prognostic characteristics than patients who were not given the drug: they were older, less likely to have had a witnessed cardiac arrest, less likely to have had a shockable rhythm when paramedics arrived, and they had longer durations of resuscitation.

A total of 449 patients (29%) survived to hospital discharge with a good neu-rologic status, defined as a Cerebral Performance Category of 1 or 2. Patients who received epinephrine during resus-citation were markedly less likely to do so (17%) than patients who didn’t receive epinephrine (60%).

The investigators performed several adjusted analyses of the data, includ-ing propensity scoring, cross matching, and numerous sensitivity analyses. The negative effect associated with epineph-rine “was robust to a variety of different methodological approaches designed to limit confounding,” Dr. Dumas and her associates said ( J Am Coll Cardiol 2014;64:2360-7).

There was a stepwise association between increasing dose of epinephrine and decreasing odds of surviving neu-rologically intact, with an odds ratio of 0.48 for 1 mg epinephrine, 0.30 for 2 to

5 mg, and 0.23 for more than 5 mg. The timing of administration also showed a linear association with survival odds. Patients who received epinephrine within 9 minutes of cardiac arrest had an odds ratio of neurologically intact sur-vival of 0.54, those who received it at 10 to 15 minutes had an OR of 0.33, those who received it at 16 to 22 minutes had an OR of 0.23, and those who received it after 22 minutes had an OR of 0.17.

“Before incriminating the drug itself, our findings probably should provoke further discussion on the most appro-priate scheme of treatment and its

interaction regarding the resuscitation phases,” the researchers said, referring to the electrical phase within the first few minutes after cardiac arrest, when epinephrine isn’t required; the subse-quent circulatory phase, when both epinephrine and chest compressions enhance reperfusion; and the later meta-bolic phase, when epinephrine might be detrimental.

“It is highly probable that patients receiving late or repeated doses of epi-nephrine have little or no chance of sur-vival. Altogether, the scheme and timing of administration may be crucial to pro-vide the appropriate effect of epineph-rine,” they said. CfA

Mary Ann Moon is a Frontline Medical News freelance reporter based in Clarksburg, MD.

Bipartisan Effort Leads

to SGR RepealOn April 14, the Senate voted 92 to 8 to repeal the sustainable growth rate (SGR) formula for physician reim-bursement under Medicare.

The bill, known as the Medicare Access and CHIP Reauthorization Act of 2015, includes a measure to replace the SGR with a 0.5% increase in Medicare physician reimburse-ment beginning in July 2015 through December 2015, followed by yearly 0.5% increases through 2019. The Senate voted on H.R. 2, which passed the House in March.

President Obama signed the bill into law on April 16.

“The SGR fix is an extremely wel-come solution to a long-standing fiscal dilemma,” said Charles Crecelius, MD, PhD, CMD, assistant clinical profes-sor of internal medicine and geriatrics at Washington University School of Medicine, and past chair of AMDA’s Public Policy Committee. “As a bonus it also assists in addressing some of the concerns about the implementation of value-based models.”

A new merit-based incentive pay-ment system applied to payments starting Jan. 1, 2019 will replace physicians’ mandatory participation in the value-based payment program under Medicare.

The legislation focuses on four key areas: quality, resource use, meaning-ful use of electronic health records, and clinical practice improvement (including care coordination).

“Many of us thought we would never see this day, even when there was much less partisanship in the leg-islative branch,” said Karl Steinberg, MD, CMD, who is on AMDA’s Board of Representatives, State Presidents Council, and is editor in chief of Caring for the Ages. “Let’s hope this SGR fix ushers in a new day of sensible and collaborative changes for the better.”

Watch for more about the ramifi-cations of the SGR repeal in the June issue of Caring for the Ages.

Humalog® (insulin lispro injection, USP [rDNA origin]) ) HI HCP BS 31JAN2014 Humalog® (insulin lispro injection, USP [rDNA origin]) ) HI HCP BS 31JAN2014

Humalog®

(insulin lispro injection, USP [rDNA origin]) Brief Summary: Consult the package insert for complete prescribing information.

INDICATIONS AND USAGE Humalog is an insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus.

ADMINISTRATIONHumalog has a rapid onset of action and should be given within 15 minutes before a meal or immediately after a meal.

CONTRAINDICATIONSHumalog is contraindicated:

• During episodes of hypoglycemia.• In patients who are hypersensitive to Humalog or to any of its excipients.

WARNINGS AND PRECAUTIONSDose Adjustment and Monitoring — Glucose monitoring is essential for patients receiving insulin therapy. Changes to an insulin regimen should be made cautiously and only under medical supervision. Changes in insulin strength, manufacturer, type, or method of administration may result in the need for a change in insulin dose. Concomitant oral antidiabetic treatment may need to be adjusted.

As with all insulin preparations, the time course of action for Humalog may vary in different individuals or at different times in the same individual and is dependent on many conditions, including the site of injection, local blood supply, or local temperature. Patients who change their level of physical activity or meal plan may require adjustment of insulin dosages.

Hypoglycemia—Hypoglycemia is the most common adverse effect associated with insulins, including Humalog. The risk of hypoglycemia increases with tighter glycemic control. Patients must be educated to recognize and manage hypoglycemia. Hypoglycemia can happen suddenly and symptoms may be different for each person and may change from time to time. Severe hypoglycemia can cause seizures and may be life threatening or cause death.

The timing of hypoglycemia usually reflects the time-action profile of the administered insulin formulations. Other factors such as changes in food intake (eg, amount of food or timing of meals), injection site, exercise, and concomitant medications may also alter the risk of hypoglycemia) (see Drug Interactions).

As with all insulins, use caution in patients with hypoglycemia unawareness and in patients who may be predisposed to hypoglycemia (eg, the pediatric population and patients who fast or have erratic food intake). The patient’s ability to concentrate and react may be impaired as a result of hypoglycemia. This may present a risk in situations where these abilities are especially important, such as driving or operating other machinery.

Rapid changes in serum glucose levels may induce symptoms similar to hypoglycemia in persons with diabetes, regardless of the glucose value. Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as longstanding diabetes, diabetic nerve disease, use of medications such as beta-blockers (see Drug Interactions), or intensified diabetes control. These situations may result in severe hypoglycemia (and, possibly, loss of consciousness) prior to the patient’s awareness of hypoglycemia.

Hypersensitivity and Allergic Reactions—Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with insulin products, including Humalog (see Adverse Reactions).

Hypokalemia—All insulin products, including Humalog, cause a shift in potassium from the extracellular to intracellular space, possibly leading to hypokalemia. Untreated hypokalemia may cause respiratory paralysis, ventricular arrhythmia, and death. Use caution in patients who may be at risk for hypokalemia (eg, patients using potassium-lowering medications, patients taking medications sensitive to serum potassium concentrations).

Renal or Hepatic Impairment—Frequent glucose monitoring and insulin dose reduction may be required in patients with renal or hepatic impairment.

Mixing of Insulins—Humalog for subcutaneous injection should not be mixed with insulin preparations other than NPH insulin. If Humalog is mixed with NPH insulin, Humalog should be drawn into the syringe first. Injection should occur immediately after mixing.

Do not mix Humalog with other insulins for use in an external subcutaneous infusion pump.

Subcutaneous Insulin Infusion Pumps—When used in an external insulin pump for subcutaneous infusion, Humalog should not be diluted or mixed with any other insulin. Change the Humalog in the reservoir at least every 7 days; change the infusion sets and the infusion set insertion site at least every 3 days. Humalog should not be exposed to temperatures greater than 98.6°F (37°C).

Malfunction of the insulin pump or infusion set or insulin degradation can rapidly lead to hyperglycemia and ketosis. Prompt identification and correction of the cause of hyperglycemia or ketosis is necessary. Interim subcutaneous injections with Humalog may be required. Patients using continuous subcutaneous insulin infusion pump therapy must be trained to administer insulin by injection and have alternate insulin therapy available in case of pump failure (see Dosage and Administration and How Supplied/Storage and Handling).

Drug Interactions—Some medications may alter insulin requirements and the risk for hypoglycemia and hyperglycemia. Some medications may mask the signs of hypoglycemia in some patients. Therefore, insulin dose adjustments and close monitoring may be required.

Fluid Retention and Heart Failure with Concomitant Use of PPAR-gamma Agonists—Thiazolidinediones (TZDs), which are PPAR-gamma agonists, can cause dose-related fluid retention, particularly when used in combination with insulin, including Humalog. Fluid retention may lead to or exacerbate heart failure. Observe patients for signs and symptoms of heart failure and consider discontinuation or dose reduction of the PPAR-gamma agonist.

ADVERSE REACTIONS Hypoglycemia and hypokalemia are discussed in Warnings and Precautions.

Clinical Trial Experience—Because clinical trials are conducted under widely varying designs, the adverse reaction rates reported in one clinical trial may not be easily compared with those rates reported in another clinical trial, and may not reflect the rates actually observed in clinical practice.

The frequencies of treatment-emergent adverse events during Humalog clinical trials in patients with type 1 diabetes mellitus and type 2 diabetes mellitus are listed in the tables below.

Table 1: Treatment-Emergent Adverse Events in Patients with Type 1 Diabetes Mellitus

(adverse events with frequency ≥5%)

Events, n (%) Lispro (n=81)

Regular human insulin (n=86)

Flu syndrome 28 (34.6) 28 (32.6)Pharyngitis 27 (33.3) 29 (33.7)Rhinitis 20 (24.7) 25 (29.1)Headache 24 (29.6) 19 (22.1)Pain 16 (19.8) 14 (16.3)Cough increased 14 (17.3) 15 (17.4)Infection 11 (13.6) 18 (20.9)Nausea 5 (6.2) 13 (15.1)Accidental injury 7 (8.6) 10 (11.6)Surgical procedure 5 (6.2) 12 (14.0)Fever 5 (6.2) 10 (11.6)Abdominal pain 6 (7.4) 7 (8.1)Asthenia 6 (7.4) 7 (8.1)Bronchitis 6 (7.4) 6 (7.0)Diarrhea 7 (8.6) 5 (5.8)Dysmenorrhea 5 (6.2) 6 (7.0)Myalgia 6 (7.4) 5 (5.8)Urinary tract infection 5 (6.2) 4 (4.7)

Table 2: Treatment-Emergent Adverse Events in Patients with Type 2 Diabetes Mellitus

(adverse events with frequency ≥5%) Events, n (%) Lispro

(n=714)Regular human insulin (n=709)

Headache 63 (11.6) 66 (9.3)Pain 77 (10.8) 71 (10.0)Infection 72 (10.1) 54 (7.6)Pharyngitis 47 (6.6) 58 (8.2)Rhinitis 58 (8.1) 47 (6.6)Flu syndrome 44 (6.2) 58 (8.2)Surgical procedure 53 (7.4) 48 (6.8)

Insulin Initiation and Intensification of Glucose Control Intensification or rapid improvement in glucose control has been associated with a transitory,

reversible ophthalmologic refraction disorder, worsening of diabetic retinopathy, and acute painful peripheral neuropathy. However, long-term glycemic control decreases the risk of diabetic retinopathy and neuropathy.

Lipodystrophy Long-term use of insulin, including Humalog, can cause lipodystrophy at the site of repeated

insulin injections or infusion. Lipodystrophy includes lipohypertrophy (thickening of adipose tissue) and lipoatrophy (thinning of adipose tissue), and may affect insulin absorption. Rotate insulin injection or infusion sites within the same region to reduce the risk of lipodystrophy (see Dosage and Administration).

Weight Gain Weight gain can occur with insulin therapy, including Humalog, and has been attributed to the

anabolic effects of insulin and the decrease in glucosuria. Peripheral Edema Insulin, including Humalog, may cause sodium retention and edema, particularly if previously

poor metabolic control is improved by intensified insulin therapy. Adverse Reactions with Continuous Subcutaneous Insulin Infusion (CSII) In a 12-week, randomized, crossover study in adult patients with type 1 diabetes comparing

Humalog (n=38) to regular human insulin (n=39), the rates of catheter occlusions per month (0.9 vs. 0.10, respectively) and infusion site reactions (2.6% vs. 2.6%, respectively) were similar.

In a randomized, 16-week, open-label, parallel design study of children and adolescents with type 1 diabetes, adverse event reports related to infusion-site reactions were similar for insulin lispro and insulin aspart (21% of 100 patients versus 17% of 198 patients, respectively). In both groups, the most frequently reported infusion site adverse events were infusion site erythema and infusion site reaction.

6 • CARing foR THE AgES MAy 2015

A substantial number of nursing home residents undergo lower-extremity revascularization each

year, but very few of them gain any func-tion and approximately half die within the year, according to a report published online in JAMA Internal Medicine.

In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Lawrence Oresanya, MD, of the depart-ment of surgery, University of California, San Francisco, and his associates.

Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is war-ranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arte-rial disease, and higher rates of mortal-ity after most invasive procedures,” the investigators said.

Dr. Oresanya and his colleagues identi-fied 10,784 nursing home residents across the country who underwent lower-extrem-ity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder; the endovascular approach was more closely associated with clinical success than was open surgery.

The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impair-ment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.

The investigators assumed that most patients in this setting had critical limb ischemia. They did not have information about the severity of the lower-extrem-ity ischemia or about the prevalence or duration of nonhealing wounds.

One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained

or improved their presurgical func-tional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote ( JAMA Intern Med 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).

The researchers were unable to deter-mine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physi-ologic reserve.”

Although they focused on functional outcomes of lower-extremity revascular-ization, namely ambulation and mortal-ity, the researchers suggested that some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation. CfA

Mary Ann Moon is a Frontline Medical News freelance reporter based in Clarksburg, MD.

Residents Have Poor outcomes After RevascularizationBy Mary ann Moon

Editor’s NoteMany frail elderly patients who undergo attempted limb salvage by revascularization don’t do well; however, these interventions can be palliative in a number of respects, even if not curative in the sense of restoring ambulation. Early interven-tion for poorly perfused skin ulcers (pressure-related and arterial) confers definite advantages with respect to wound healing and reduction of risk of amputation. Losing a limb, even for a non-ambulator, can have devastating consequences. And these days, non-invasive revascularization techniques pose less risk of surgical complications and related problems. So, despite the findings of this study, we should not discount the potential benefits of these procedures in the frail population.

—Karl Steinberg, MD, CMD Editor in Chief Humalog® (insulin lispro injection, USP [rDNA origin]) ) HI HCP BS 31JAN2014

Allergic Reactions Local Allergy—As with any insulin therapy, patients taking Humalog may experience redness,

swelling, or itching at the site of the injection. These minor reactions usually resolve in a few days to a few weeks, but in some occasions, may require discontinuation of Humalog. In some instances, these reactions may be related to factors other than insulin, such as irritants in a skin cleansing agent or poor injection technique.

Systemic Allergy—Severe, life-threatening, generalized allergy, including anaphylaxis, may occur with any insulin, including Humalog. Generalized allergy to insulin may cause whole body rash (including pruritus), dyspnea, wheezing, hypotension, tachycardia, or diaphoresis.

In controlled clinical trials, pruritus (with or without rash) was seen in 17 patients receiving regular human insulin (n=2969) and 30 patients receiving Humalog (n=2944).

Localized reactions and generalized myalgias have been reported with injected metacresol, which is an excipient in Humalog (see Contraindications).

Antibody Production In large clinical trials with patients with type 1 (n=509) and type 2 (n=262) diabetes mellitus,

anti-insulin antibody (insulin lispro-specific antibodies, insulin-specific antibodies, cross-reactive antibodies) formation was evaluated in patients receiving both regular human insulin and Humalog (including patients previously treated with human insulin and naive patients). As expected, the largest increase in the antibody levels occurred in patients new to insulin therapy. The antibody levels peaked by 12 months and declined over the remaining years of the study. These antibodies do not appear to cause deterioration in glycemic control or necessitate an increase in insulin dose. There was no statistically significant relationship between the change in the total daily insulin dose and the change in percent antibody binding for any of the antibody types.

USE IN SPECIFIC POPULATIONSPregnancy—Pregnancy Category B. All pregnancies have a background risk of birth defects, loss, or other adverse outcome regardless of drug exposure. This background risk is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes or history of gestational diabetes to maintain good metabolic control before conception and throughout pregnancy. In patients with diabetes or gestational diabetes insulin requirements may decrease during the first trimester, generally increase during the second and third trimesters, and rapidly decline after delivery. Careful monitoring of glucose control is essential in these patients. Therefore, female patients should be advised to tell their physicians if they intend to become, or if they become pregnant while taking Humalog.

Although there are limited clinical studies of the use of Humalog in pregnancy, published studies with human insulins suggest that optimizing overall glycemic control, including postprandial control, before conception and during pregnancy improves fetal outcome.

Nursing Mothers—It is unknown whether insulin lispro is excreted in human milk. Use of Humalog is compatible with breastfeeding, but women with diabetes who are lactating may require adjustments of their insulin doses.

Pediatric Use—Humalog is approved for use in children for subcutaneous daily injections and for subcutaneous continuous infusion by external insulin pump. Humalog has not been studied in pediatric patients younger than 3 years of age. Humalog has not been studied in pediatric patients with type 2 diabetes.

Geriatric Use—Of the total number of subjects (n=2834) in eight clinical studies of Humalog, twelve percent (n=338) were 65 years of age or over. The majority of these had type 2 diabetes. HbA1c values and hypoglycemia rates did not differ by age. Pharmacokinetic/pharmacodynamic studies to assess the effect of age on the onset of Humalog action have not been performed.

OVERDOSAGE Excess insulin administration may cause hypoglycemia and hypokalemia. Mild episodes of

hypoglycemia usually can be treated with oral glucose. Adjustments in drug dosage, meal patterns, or exercise may be needed. More severe episodes with coma, seizure, or neurologic impairment may be treated with glucagon or concentrated intravenous glucose. Sustained carbohydrate intake and observation may be necessary because hypoglycemia may recur after apparent clinical recovery. Hypokalemia must be corrected appropriately.

STORAGEDo not use after the expiration date.Unopened Humalog should be stored in a refrigerator (36° to 46°F [2° to 8°C]), but not in the

freezer. Do not use Humalog if it has been frozen. In-use Humalog vials, cartridges, pens, and Humalog KwikPen® should be stored at room temperature, below 86°F (30°C), and must be used within 28 days or be discarded, even if they still contain Humalog. Protect from direct heat and light.

PATIENT COUNSELING INFORMATION: See FDA-approved patient labeling and Patient Counseling Information section of the Full Prescribing Information.

Humalog® and Humalog® KwikPen® are registered trademarks of Eli Lilly and Company.

Marketed by: Lilly USA, LLC, Indianapolis, IN 46285, USA

Copyright © 1996, 2011, Eli Lilly and Company. All rights reserved.Additional information can be found at www.humalog.com.

HI HCP BS 31JAN2014

CARingfoRTHEAgES.CoM CARing foR THE AgES • 7

Dear Dr. Jeff:We used to complain endlessly about the failures of local hospitals to send adequate, or sometimes any, transfer information when sending patients to our facility. But now that they have switched to electronic health records, they send hundreds of pages, always repetitious and usually filled with medical errors and misinformation. Do you have any suggestions?

Dr. Jeff responds:“To err is human; to really foul things up requires a computer.” The anonymous author of this common observation was simply reflecting the near-universal frustration with the failures of comput-erization to improve human communi-cation. Although computerized medical records may have simplified billing and coding and facilitated data collection for medical research, there is little evidence that they have improved clinical care. Billions of dollars invested in such sys-tems and millions of hours of valuable time from virtually every category of health worker allocated to training and use have not produced the promised dividends. The frustration of clinicians transformed into poorly trained ward clerks with limited typing skills contin-ues to escalate.

Understanding the causes for these frustrating outcomes might help to cor-rect some of the problems, whereas oth-ers may be beyond help. Among the underlying issues are the failure of those at the highest level who funded these systems to mandate a single, universal system and to address the ease with which errors can enter the system with multiple replications; the virtual inabil-ity to correct mistakes once they enter the medical record; and ongoing poor communication between hospitals and the long-term care system. Although skilled nursing facilities have made prog-ress in communicating significant health information to hospitals, particularly when the INTERACT tools are used, information transfer in the reverse direc-tion remains problematic.

Of course, 20th century paper records allowed multiple opportunities for errors due to imprecise or illegible handwriting. Hurried professionals with notoriously poor handwriting often produced notes that only they could read, and sometimes notes they couldn’t. Discharge summa-ries and transfer documents completed by hand were time-consuming, so they were postponed, omitted, or completed in a highly abbreviated form. But they are also, obviously, the product of human effort and therefore subject to the usual skepticism and review.

Electronic health records (EHRs) appear, however, with the apparent authority of the printed word. Due to the cut and paste function, an error can be endlessly repeated in ways that clinicians would never have done if actually writing the words. When every hospitalist note and multiple consultation notes contain histories and physical examinations that are word-for-word identical, it is clear that only one was actually done. Repetition appears to carry authority, no matter how bizarre the error, while the actual source of the information is obscured. Healthy skepticism of every single word in trans-ferred charts is absolutely necessary to prevent e-iatrogenic errors.

Chart LoreFor example, an 80-year-old patient transferred from a major medical cen-ter to our facility after an episode of pneumonitis. Two-hundred pages of printed records accompanied her. Every note after the initial admission history contained the “information” that she had total right hip replacement at age 19 – including notes from consulting pulmonary and cardiology specialists, a physiatrist consultation with daily ther-apy notes, and daily progress notes from three different hospitalists. None had questioned why an otherwise healthy young woman would have needed her hip replaced (much less why it might have been done when still an experimen-tal procedure) or had been concerned that her long-healed right thigh scar was not compatible with a joint replacement.

A single question revealed that she had been struck by a car while crossing the street, necessitating a pinning of her right hip. The morphing from “pinning” to “replacement” started as an error in her chart two admissions previously. Although this error was trivial in her overall management, a thorough clini-cian might have otherwise wondered about the underlying condition that had necessitated the joint replacement, and a systemic illness might require altered management of her recovery from her pneumonia. Instead, this fictitious joint replacement became “chart lore.” Because all records are time-dated and usually forbid retroactive changes (late entries) without significant effort, there will never be an opportunity to correct all those errors.

Although surgical protocols now require multiple checks to prevent wrong-side surgery, no such measures are used in progress notes, and right-sided problems frequently migrate to the left (or vice versa) in notes or radi-ology reports. Several hundred pages

of transfer information will not nec-essarily assist the receiving physician’s admission process; the time required to review so much data would be excessive if actually done. Buried within those pages might be a DNR order, recom-mendations regarding a follow-up x-ray, a transfusion that resolved a postopera-tive anemia, but clearly there are times when less is more.

Failures in ConnectivityAs SNFs and home care agencies adopt EHRs, there is little hope that the abil-ity to share data directly with hospitals will improve anytime in the foresee-able future. Many major hospital sys-tems, including most hospitals that have achieved the stage 7 completely paper-less status, are using Epic, which lacks an LTC component. Software systems that thrive in long-term care, although effective in the completion of required documentation, such as Minimum Data Set and the Outcome Assessment and Information Set, are not compatible with any popular hospital EHR systems.

Even wonderful new technologies are not necessarily implemented in the most efficient fashion. Years, even centuries, may be required to resolve connectiv-ity issues. Some systems will need to be scrapped or totally rebuilt. Others will require patches. Late adopters of EHRs may benefit from the connectivity improvements that will come. But the forces of change may not allow most facilities to wait that long. Regional Health Information Organizations were mandated with the intent to over-come these issues, but they have largely been unsuccessful due to a long list of obstacles, some technical, some involv-ing governance, some related to HIPAA restrictions and security concerns. A few countries with national health insurance programs have apparently been able to overcome the technical issues. Not so in the United States.

Potential SolutionsFortunately, there are some potential solutions. Hospitals have incentives to improve this process as rehospitaliza-tion penalties increase in the coming years. Most hospitals still have very little understanding of the needs or processes of LTC facilities, but many will be open to meetings to discuss how the transfer procedures could be changed to improve overall communication. Computers can be programmed not to “Print All” but rather “Print SNF” or some similar instruction. Operative notes are virtually always accurate, and surgical descrip-tions of what was performed may be

very helpful. A dictated discharge or transfer summary is also invaluable.

Information for one patient may not be relevant or useful for another. For example, a single chest x-ray report may be very helpful information for one patient, whereas 24 reports from portable x-rays done on a patient in the intensive care unit confirming tube loca-tions would not.

Some facilities have opted for solu-tions that appear more time consuming but are more useful. First is the “warm handoff [or handover],” jargon for one human being personally speaking to another. The warm handoff, which is standard for transfers within the hos-pital, ensures that valuable patient care information can be rapidly exchanged and provides an opportunity to ask ques-tions. Management of tubes, dressings, special patient needs, and psychosocial or family dynamics can be identified early, and patient care can be improved. Unfortunately, person-to-person com-munication among physicians is gener-ally more difficult to arrange, particularly when the post-acute admitting physician is not on-site at the time of transfer, and the referring physician is already off shift by time the resident has arrived and is being evaluated.

Another potential solution is to install the same portals to the EHR on post-acute units that are used for affiliated physician offices or outpatient clinics. Only minimal data would then be necessary at the time of transfer. Although this may require some staff training in the EHR systems that major referral hospitals use, it allows multiple luxuries. The records can be queried if, after admission, new issues arise. For example, although it is important to know what dose of steroids a resident was receiving at the time of transfer, it is also important to know whether that dosage represented a tapering process and whether the resident had been on steroids before hospital admis-sion. “Read-only” access and a secure connection might be the maximum required.

Computerization holds great promise, but we are living in the age before that promise is realized. Our patients deserve better. In this period of transition, we still need to find ways to provide it for them. CfA

Dr. Nichols is president of the New York Medical Directors Association and a member of the Caring for the Ages Editorial Advisory Board. Comment on this and other columns at www.caringfortheages.com under “Views.”

garbage in, garbage out

By Jeffrey Nichols, MDDear Dr. Jeff

8 • CARing foR THE AgES MAy 2015

LOUISVILLE, KY – An innovative training program designed to provide nursing staff with hands-on skills to prevent or man-age challenging behavioral symptoms in patients with dementia was well received by participants, well-supported by admin-istrators, and effective for increasing com-petency among participants.

The Interprofessional Dementia Training program, which is part of an ongoing Center for Medicare & Medicaid Innovation (CMMI) clinical demonstration project known as OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care) involved six consecutive weekly half-day sessions during which par-ticipants viewed video vignettes and partici-pated in small group discussion and role play scenarios. Post-test results for the 42 partici-pants demonstrated improved competency in managing a number of behaviors, such as physically or verbally aggressive or non-aggressive behaviors, Monica Tegeler, MD, CMD, of Indiana University, Indianapolis and her colleagues reported in a poster at the AMDA 2015 Annual Conference.

For example, 12 participants (28%) reported being uncomfortable man-aging physically aggressive behaviors among residents at baseline; only one reported being uncomfortable following training, and the number who reported being comfortable managing physically aggressive behaviors increased from 18 to 24 (43%-57%), according to Dr. Tegeler, whose poster received the 2015 Howard Guterman Best Poster Award.

Similar results were seen for manage-ment of physically nonaggressive, verbally aggressive and verbally nonaggressive behaviors, and for use of the “Positive Approach” and root cause analysis. The number of participants who reported being uncomfortable with each of these ranged from three to seven at baseline, but none of the participants reporting being uncomfortable with them after the intervention, while the number of partici-pants reporting being very comfortable increased across the board.

All Hands On DeckParticipants included 24 registered nurses and nurse practitioners and 17 “demen-tia care champions” from nursing homes

participating in the OPTIMISTIC proj-ect, including clergy members, nurses, social workers, and activity directors.

Training ses-sions included one session with instruction on the “Positive Approach” developed by Teepa Snow  – a compre-hensive approach to dementia care; two to five sessions on managing physically and verbally aggres-sive and nonaggres-sive behaviors; and six sessions on strat-egies to disseminate the skills to other nursing staff in each facility. Participants were filmed during interactions, and structured feedback was provided.

A survey following participation showed that all of the participants strongly agreed or agreed that the

training increased their knowledge about dementia (80% and 20%, respectively) and about dementia behavior manage-ment (77% and 23%, respectively).

“The hands-on, interactive approach provided participants with numerous opportunities to increase their compe-tency in managing challenging behav-iors. I was surprised by the overwhelming majority of participants who found the program practical. The role playing and standardized patients – the interac-tive method – really made the differ-ence between our training and standard dementia training,” Dr. Tegeler said.

This training program is part of the OPTIMISTIC project, developed by CMS to reduce rehospitalizations among long-stay residents in the nursing home setting.

Avoiding Rehospitalizations“Rehospitalization related to behav-iors associated with dementia is in the top five reasons for rehospitalization in our project. Also, with the National Partnership to Improve Dementia, there has been increased scrutiny on the use of antipsychotics in patients with dementia, and many facilities are actively trying to decrease their use of antipsychotics,” Dr. Tegeler said, adding that the timing is perfect with the recent change in the star rating system to reflect antipsychotic use.

“Based on these results of the first phase of the Interprofessional Dementia Training program, the approach will be incorporated into regional collab-orative trainings with the Indiana State Department of Health in 2016 with a goal of reducing antipsychotic use and rehos-pitalization of patients with dementia for behavior symptoms by increasing pro-vider competency in managing behaviors.

“We have already started phase 2, which is looking at each of the individ-ual facilities and tailoring the approach based on the facility’s needs. We are also dividing the training into mini-segments that can be taught by facility staff to new staff without taking them off site for training,” she said. CfA

Sharon Worcester is a freelance writer based in Birmingham, AL.

Hands-on Training Helps Manage Dementia BehaviorsBy Sharon WorceSter

Monica Tegeler, MD, CMD, accepts the 2015 Howard Guterman Best Poster Award from David Nace, MD, MPH, CMD.

LOUISVILLE, KY - In geriatric care prac-tices and nursing homes, non-physician practitioners (NPPs), including nurse prac-titioners (NPs) and physician assistants (PAs), are successfully taking on many of the duties traditionally carried out by phy-sicians, according to Elaine Shirar, MD, founder and medical director of Rocky Mountain Senior Care in Denver, CO.

“I don’t think our practice could be financially successful without NPPs,” she said during her presentation at the AMDA 2015 Annual Conference. “They help with the workflow, they do the heavy lifting. They dramatically increase the quality of care for our patients.” As it becomes more difficult to recruit physi-cians into practice, the growing volume of NPPs fills practice gaps, she said. “We use them for more frequent patient visits and transition of care management.”

Tuck-In Notes Dr. Shirar’s practice uses NPPs to create the “tuck-in” note if a physician is not imme-diately on-site for the first patient visit. “Instead of the initial visit, we ask the NPPs to go in and see patients for a tuck-in note for acute visits. We don’t bill a new patient code; we bill an established patient code… but they can get eyes on the patient right away.” In Colorado, she said, physicians only have 72 hours to see new skilled nurs-ing or long-term care patients. Until then, the NPPs get the note started, “allowing the doctor to get deeper into the treatment plan when they first see the patient. The tuck-in note helps with physician efficiency and time management, and really improves our physicians’ quality of life,” she said.

The NPPs will also work on week-ends to create the tuck-in note, so the physicians can get a jump on their busy Monday visits. “Consider using those weekend warriors; that frees up so much time,” she told the audience.

She added that NPs and PAs can also be used for signing some certifications, freeing up physicians to focus on patient care, rather than paperwork.

NPPs Add Quality of Care NPPs offer quality of care comparable to physicians, according to Steven Atkinson, PA-C, MS, a co-presenter who works with Dr. Shirar. Patient satisfaction scores between NPPs and MDs are similar across the board, and seniors do not seem to differentiate the NPP from the physician, he said. NPs can practice independently in some states, but that’s rarely the case, he added. PAs, although they can prac-tice autonomously, require a collaborat-ing physician, who often trains them in a practice style similar to their own.

“They teach us very well in school, where your level of comfort is,” Mr.  Atkinson said. “I have a lot of autonomy in my clini-cal decision making, but there are times when I feel that autonomy goes beyond my scope of practice, and that’s when I reach out to my supervising physician.”

Mr. Atkinson said providers need to be clear about their expectations of the NPP, and how independent they want the NPP to be. Understanding the state regulations is important when develop-ing the NPP’s scope of duties. And he suggested being mindful of using the correct title for the NPP.

Questions for providers seeking to bring on an NPP:

▶▶ Will the NPP will have on-call duties?▶▶ Will the NPP have their own panel of

patients (where permitted by law) or will they be shared with the physician?

▶▶ Will the NPP handle only urgent care, chronic disease management, or both?

▶▶ Will the NPP provide services that are separately billable, or services that allow physicians to see more patients and increase collections?

▶▶ What level of supervision or collabo-ration does a physician feel comfortable with, and what is required by law?

Like many working relationships, the most important thing to consider when bringing in an NPP, Mr. Atkinson said, is connection. “You have to have personalities and styles that connect,” he said. CfA

Carey Cowles is the managing editor of Caring for the Ages.

By carey coWleS

Many Benefits to Collaborating With nPPs

Steven Atkinson, PA-C, MS, said setting clear expectations of the NPP is vital.

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LOUISVILLE, KY – A novel concept in nursing home-level care – medical foster care – is providing a viable alternative for veterans who meet the requirements for nursing home care but who prefer to live in a more home-like setting.

“Medical foster care provides an alter-native site of care to meet the increasing demand for long-term care services,” according to June Leland, MD, medical director of the Department of Veterans Affairs Home Based Primary Care (HBPC) Program in Tampa, FL, which provides oversight of the foster care pro-gram. The program also provides longi-tudinal medical care to veterans enrolled in the program.

Dr. Leland described the program in a poster presented at the AMDA 2015 Annual Conference.

Vets Prefer Home-Based Care Medical foster homes offer a commu-nity-based living arrangement for veter-ans in need of room and board, but who require round-the-clock supervision for safety and personal care due to physical or mental impairments or disabilities, she explained in an interview.

The VA serves many such veterans who prefer home-based care to nursing home care, she said.

VA HBPC teams coordinate the place-ments in private homes with specially trained caregivers. Care is taken to ensure that placements are well-matched, taking into consideration the veteran’s health care needs and the caregiver’s skills and training.

Caregivers provide a range of services, including ventilator support, mental health care for the seriously mentally ill, care for those with spinal cord injuries, and care for the frail elderly. Care may include end-of-life care and preventative care, and it can be personalized and cus-tomized for those in need who might oth-erwise live alone with inadequate support, Dr. Leland said. He noted that caregivers often are individuals who have previously cared for a spouse or family member and who have developed the unique skills necessary for providing quality care.

The relationships between the caregiv-ers and residents range from skilled nurse to surrogate family member, depending on the resident’s needs and desires, she said.

Cost Effective Medical foster care also is cost-effective. The program has been shown to reduce hospitalizations and emergency room

visits, and it is self-sustaining through avoidance of the high costs associated with care in LTC facilities, which total about $100 per day to taxpayers for the care of veterans, she said.

In Tampa, the average fee paid by medical foster home residents is $2,292 per month – $214 per day lower than the average cost of nursing home care – resulting in a savings of $78,110 annually.

Additional savings are seen due to the earlier hospital discharges, shorter

lengths of stay, and decreased admis-sions, Dr. Leland said.

Since its inception in 2000, the medi-cal foster care program has grown from a single site to more than 45 sites across the country with a total of 561 caregivers. The average length of stay in foster care is 315 days, and the total cost savings in fiscal year 2013 was $31 million over projected costs of nursing home care, assuming all foster care residents were eligible for VA payment of nursing home care, she said.

The medical foster care program is proving extremely successful and rewarding for both residents and care-givers, she said, and it continues to grow.

“These are really good and kind peo-ple,” she said of the caregivers, who she said seem to find great purpose in caring for these veterans in need. CfA

Sharon Worcester is a freelance writer based in Birmingham, AL.

By Sharon WorceSter

Veterans Have new Place to Call Home

Posters at the AMDA meeting came from as far away as Japan and China.

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10 • CARing foR THE AgES MAy 2015

More than ever, practitioners need to know what is happen-ing in their state legislatures,

and they need to be ready to act. Failure to do so can have a tremendous impact on reimbursement and their facilities’ ability to thrive or even survive. For ex-ample, when Pennsylvania policymakers announced their intent to establish non-payment policies for long-term serious adverse events, practitioners had to be proactive.

“Whether you like it or not, you’ll likely have to deal with this at some point,” said J. Kenneth Brubaker, MD, CMD, medical director at Masonic Village in Elizabethtown, PA. He shared his state’s experiences at an AMDA Annual Conference session, “Serious Adverse Events: Pennsylvania’s Approach for Reducing Events and Prohibiting Payments.”

According to Dr. Brubaker, the hand-writing has been on the wall since last year’s Office of Inspector General Report, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries,” showed that 22% of patients experience adverse events, 59% of which were determined to be “clearly preventable.” Additionally, according to the report, 37% of adverse events were attributable to medica-tions, 37% to resident care, and 26% to infections.

Understandably, this document caused a stir, and the government quickly focused on solutions. For example, the 2015 OIG work plan proposed to determine the extent to which skilled nursing facility residents are hospital-ized due to a “manageable or prevent-able” condition, and whether states can withhold Medicaid payment for health care-acquired conditions and provider-preventable conditions.

Medicaid rules mandate that states identify other provider-preventable con-ditions for which payments won’t be made. These conditions must be deter-mined to be “reasonably preventable”

through the application of procedures supported by evidence-based guidelines, and have a negative consequence for beneficiaries. Every state list of prevent-able conditions must include wrong surgical or other invasive procedures, procedures performed on the wrong body part, and those performed on the wrong patient. States can reasonably iso-late for nonpayment the portion of the reimbursement directly related to treat-ment for or related to the preventable condition or event.

Pennsylvania Clarifies Rules Pennsylvania was one of the first states to enact its own legislation on this issue, the Preventable Serious Adverse Events (PSAE) Act. Among its key points:

▶▶ A health care provider may not know-ingly seek payment from a payer or patient for a PSAE or any service required to correct or treat the problem created by a preventable event.

▶▶ If a provider discovers that payment has unknowingly been sought for a PSAE or services required to correct the

problem, it must immediately notify the payer or patient and refund payment within 30 days of discovery or receipt of payment, whichever is later.

▶▶ A PSAE is defined as an event that occurs in the skilled nursing facility, is on the PA Department of Human Services list of PSAEs, and meets four condi-tions: it is preventable (could have been anticipated and prepared for), serious (subsequently results in death, lost body part, disfigurement, disability, or loss of bodily function lasting more than 7 days), within the facility’s control, and the result of an error or other system failure within the nursing facility.

Facilities are expected to self-report PSAEs. However, the DHS will look for adverse events via data mining of Medicaid nursing home resident hos-pitalizations, review of Minimum Data Set information, and referrals from Medicaid state survey evaluations or from adult protective services.

Once an event has been self-reported or identified by DHS, the department will send written notice that it has initi-ated a review. DHS also may request documentation regarding the event or the facility’s policies and procedures.

If, after review, DHS confirms that a PSAE has occurred, there will be no pay-ment for the day of the event or for bed-hold days or durable medical equipment required to address the problem. If the facility has already billed for any of these services or items, DHS will notify the payer, and the facility will be expected to refund payments within 30 days of discovery or payment receipt.

How PA Providers Helped Although the legislation regarding PSAEs isn’t perfect, physicians and oth-ers in Pennsylvania got involved early in its development to ensure that their insights and experiences were considered and that their patients were protected. Dr. Brubaker advised his colleagues to learn from his state’s experience when PSAE comes home for them.

“If you’re in a state looking at imple-menting a PSAE law, you want to get involved now and be an advocate for your patients and your teams,” he said. He offered some key tips:

▶▶ Sometimes, procedures or treatments sneak into best practices that aren’t evi-dence-based; physicians should watch for these in state laws as they develop.

▶▶ Work with the state to clarify how reporting will be done. What is the pro-cess for self-reporting? What sources of data/information will the state use to mine for PSAEs? Help policymakers understand how the facility conducts quality improvement and identifies prob-lems. This can help them understand what data is most reliable and likely to identify an actual PSAE.

▶▶ Advocate for a law that enables pro-viders to demonstrate that a situation was not necessarily preventable. Provide policymakers with data about unavoid-able problems that often are mistakenly identified as preventable. For example, just because a pressure ulcer goes from stage 3 to stage 4 under a facility team’s care doesn’t mean that the deterioration-could have been prevented.

▶▶ Work with your facilities and teams to ensure that they have effective PSAE tracking and reporting systems in place. Make sure that these are non-punitive, so that nurses and others are more likely to report PSAEs promptly, ferret out root causes, and put preventive solutions in place.

Dr. Brubaker noted that states may expect big things from PSAE laws, but many facilities already have measures to prevent avoidable adverse events. “My sense is that the bureaucrats thought that there was a lot of money to be gained,” he said. “But the jury is still out on whether or not that actually is the case.” CfA

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

By Joanne Kaldy

one State’s Solution for Preventable Serious Adverse Events

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Co-presenters Paula G. Sanders, JD, and J. Kenneth Brubaker, MD, CMD, encouraged getting involved in state efforts to address serious adverse events.

Dr. Brubaker said that although states may expect big things from legislation that seeks to rein in serious adverse events, many facilities already have such safeguards in place.

CARingfoRTHEAgES.CoM CARing foR THE AgES • 11

LOUISVILLE, KY – How can a facil-ity send anemic patients out for blood transfusions without having them admitted to the hospital? This was the challenge Hebrew Home at Riverdale in Bronx, NY, faced, and medical director Zachary Palace, MD, CMD, discovered that some simple changes could have a big impact.

In a session at AMDA’s 2015 Annual Conference, Dr. Palace described his solu-tion, which was the focus of his AMDA Foundation Quality Improvement award-winning project, “Development of an Outpatient Transfusion Program to Reduce Avoidable Hospitalizations.”

The problem was “distressing,” Dr.  Palace said. His facility would send anemic residents requiring trans-fusions to the emergency department, and the physicians there would admit them to the hospital based on the diag-nosis of anemia and need for a transfu-sion. “Our residents would come back to us with decubiti and all sorts of infections that they didn’t have when we sent them out.”

Needless Hospital Stay These residents had a 5.3-day mean length of stay in the hospital with a mean cost to Medicare of $10,339. “It was appalling. There had to be a way to get them transfusions without all the complications and exposure to risks,” Dr. Palace said.

Dr. Palace realized that hematologists in the area were sending their commu-nity-based patients to a blood center for transfusions. He and his team ultimately determined that they could use this model provided the hospital physician knew what was happening and could take responsibility for the patient if he or she required special care during the

transfusion, or needed to be hospital-ized afterward. To address these issues, Dr. Palace and his team implemented a

transfusion transfer form that is com-pleted by the nursing facility physician or nurse practitioner and faxed to the hospital-based geriatrician. “We hoped that this would facilitate getting patients out and back as efficiently as possible.”

The form contains relevant patient demographic and clinical data, including diagnoses, medications, allergies, recent lab values, and previous transfusion his-tory, Dr. Palace said. Using this document, the hospital-based physician coordinates with the blood center for an outpatient transfusion the day after the information is received. Instead of going to the ED and then being admitted to the hospital, the patient is transported to the blood center for the transfusion and returned to the nursing home later that same day.

“This is a relatively simple fix, but it requires developing relationships with the hospital,” Dr. Palace said. “You can’t do this by yourself. You need an interested party at the other end.” As hospitals have an incentive to reduce readmissions, they are more likely to buy into ideas and work to sustain the new processes, he noted.

Simple Solution, Big Savings“We got significant impact from a simple intervention,” Dr. Palace said. From July 2009 through December 2014, there was a 74% reduction in patients transferred to the hospital for a diagnosis of ane-mia. The cost savings to Medicare per patient was a whopping $9,772. During 2014 alone, 71 patients were able to get outpatient transfusions, at a total saving of nearly $700,000.

The results have gone beyond posi-tive outcomes and reduced costs. “Not only have we reduced avoidable hospi-talizations of the elderly, but we have improved relationships with the local hospital,” said Dr. Palace. And it all started with a simple change. CfA

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

Shot in the Arm for Transfusion ProceduresBy Joanne Kaldy

AMDA Quality Award Winners Dr. Palace’s project was the recipi-ent of the 2015 AMDA Foundation Quality Improvement and Health Outcomes (QIHO) Award. Introduced in 2012, the QIHO awards are designed to recognize programs implemented by medical directors and care teams that have demonstrated quality improvement and enhanced quality of life for their post-acute care/long-term care facility residents. For the first time, this year’s award came with a $1,000 prize.

“Improving the quality of care to the elderly is a fundamental corner-stone of the practice of geriatric medi-cine. An important aspect of quality improvement involves rethinking current practices and seeking ways to bring about changes,” Dr. Palace said.

AMDA also presented two Quality Improvement (QI) Awards at the AMDA conference. Designed to

encourage the development of inno-vative projects that improve PA/LTC quality, these awards support initia-tives that focus on staff education, QI programs, research on interventions and treatment, and health literacy to directly enhance the quality of care provided to patients in this set-ting. Each awardee receives $3,000. Recipients of the 2015 QI Awards are:

▶▶ Phyllis Gaspar, PhD, RN, national director of research and develop-ment for The Goodman Group in Chaska, MN, for “Implementation of the Prevention of Avoidable Hospitalizations for Assisted Living Facilities: A Pilot Study.” The project will implement the Prevention of Avoidable Hospitalizations for ALF residents’ protocols for residents with an at-risk probability of repeated admission score. The team will inte-grate the use of the protocol, which

incorporates an adaptation of the INTERACT care transitions tool, with evidence-based programs that focus on wellness and self-management involving both the resident and family. The researchers will implement the protocol at one ALF as a pilot. If hos-pitalization rates decrease, they may expand the protocol’s use to other facilities.

▶▶ Arif Nazir, MD, CMD, associate professor, Indiana University School of Medicine and Medical Director for Westpark Rehab and Nursing Facility, Evansville, IN; and Gina Couch, administrator, Westpark Rehab and Nursing Facility, for “POISe-Care (Patient-Oriented Interdisciplinary Sub-acute Care): A Unique Model for Rehabilitation Patients.”This care model utilizes biweekly, bedside team rounds; encourages the patient to be the “CEO” of his or her health; provides continuous performance feedback to the team; and requires monthly team training sessions, said Dr. Nazir. “We expect that the model’s unique phi-losophy will result in patient/care-giver engagement in care and yield higher satisfaction. Moreover, based on our previous work in skilled nurs-ing facility QI, we expect that the model will enhance job satisfaction among staff.”

—Joanne Kaldy

A simple plan to avoid hospital stays for blood transfusions was this year’s AMDA Foundation Quality Improvement award winner from Zachary Palace, MD, CMD.

Quality Improvement Award winners Arif Nazir, MD, CMD, and Phyllis Gaspar, PhD, RN, with Paul Katz, MD, CMD, who presented their awards.

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‘Not only have we reduced avoidable hospitalizations of the elderly, but we have improved relationships with the local hospital.’

‘This care model ... encourages the patient to be the “CEO” of his or her health.’

12 • CARing foR THE AgES MAy 2015

Pervasive computing technology can radically change the way clinical research is conducted,

“leading to major advances in detect-ing prodromal change, in managing manifest dementia disease, and in transforming the effectiveness of clini-cal trials,” according to Jeffrey Kaye, MD, Layton Professor of neurology and biomedical engineering at Oregon Health and Science University, Port-land, and director of the Oregon Cen-ter for Aging and Technology. Data obtained using pervasive computer monitoring and passive sensing may allow practitioners to accurately pre-dict when cognitively-impaired elderly individuals will require transition to a more intense level of care.

Dr. Kaye spoke at the Alzheimer’s Disease Research Summit 2015: Path to Treatment and Prevention, sponsored by the National Institute on Aging, in Bethesda, MD.

A fundamental limitation of current dementia research is detecting mean-ingful change, he said. “The cardinal features of dementia make it chal-lenging to detect change. The changes are slow and imperceptible. Those features are slow decline punctuated with acute, unpredictable events, all challenging to assess with current tools and methods.”

Acknowledging the difficulty in dementia assessment and detecting change, Dr. Kaye described a project in which a pervasive computing platform is being used to assess elderly individuals in their homes in an ongoing commu-nity-wide “life lab” in Portland, OR.

The program uses passive iris sen-sors that provide data about activity, sleep, gait speed, room transitions, mobility time, and location. Additional sensors track door openings and clos-ings. Telemedicine provides physi-ologic measures and information on balance, body composition, heart rate, room environment, temperature, and

air quality. A medication tracker (an instrumented pill box) registers the day and time medication is accessed. Phone use is tracked, and a computer acts as a sensor to track psychomotor activity (keyboarding, mousing) and also deliv-ers a questionnaire that asks about self-reported behavior that would be harder to discover by passive sensing (mood, pain, etc.).

In developing a community track-ing program, “the approach needs to be technology agnostic, so it’s not about a fitness band or a wearable, or competition about who has the best technology,” Dr. Kaye said. “It’s about what works the best. So we tend to use passive sensing whenever possible, but we’re happy to use wearables or car-ryables as well.

“This platform works best when it’s scaled out into the community,” he said. This particular project is in place in sev-eral hundred homes in the Portland area. Residents are instructed to go about their normal daily activities, and

up to 100 volunteers monitor the data, allowing the system to function 24/7.

Scatterplot data gleaned from the home sensors reveal patterns of rest and activity during typical busy peri-ods, for instance, at night when resi-dents get up to use the bathroom, and during regular daylight hours. As time progresses, however, in residents who develop mild cognitive impairment, the patterns shown in the scatterplots change, Dr. Kaye said.

He cited “passively obtained” results from previous studies on individu-als with mild cognitive impairment (MCI) that support measurement data within the “smart home” community program. For example, in one study, residents with MCI showed higher vari-ance in total activity and walking when compared with age-matched controls. In another, trajectories of walking speed over time (fast, medium, slow) showed elderly individuals with MCI were nine times more likely to be in the slow group. In another study in which sleep activities were monitored and compared with controls, individuals with MCI showed clear differences after 26 weeks in wake-after-sleep onset, and times up at night.

Taking medication is a cognitive task, Dr. Kaye said, and passive sensors can measure it. “Taking medication is a functional task that has cognition embedded in it,” he said. He described another study with elderly individuals, mostly women, in which medication adherence was used as a measure of cog-nitive function. Adherence was assessed continuously for 5 weeks with a medica-tion tracker device, as participants took medications twice daily. The group was split into high and low cognition groups.

“The lower cognition group was sig-nificantly worse in their adherence to their medication regimen,” Dr. Kaye said. “These individuals were out of the range of people who might be consid-ered passing for a clinical trial, the 80% adherence rate.”

He said combining all the avenues of data (weekly self-reporting on mood, falls, emergency department visits, visi-tors); behavioral activity data (computer use, time out of home, etc.); contextual data (weather, consumer cost index, liv-ing in a retirement community); annual clinical assessment; demographics; and controlled data can predict the likeli-hood of care transitions.

In Dr. Kaye’s study of 108 individu-als, involving more than 63 million observations using pervasive comput-ing technology, “you can predict with high accuracy those will transition [to a higher level of care or nursing home from a normal state] within the next 6 months,” he said.

He concluded that data attained from pervasive computing also can be used in clinical trials to speed the trajectory of new products in the pipeline.

Dr. Kaye reported no disclosures. CfA

Carey Cowles is the managing editor of Caring for the Ages.

Electronic Tracking May Predict Cognitive DeclineBy carey coWleS

which is one of the greatest threats to patient safety, yet is commonplace.

A 2014 report from the Office of Inspector General, which studied adverse events in skilled nursing facili-ties from 2008 to 2014, determined that a third of Medicare beneficiaries expe-rienced some form of harm during their SNF stay, and 22% experienced adverse events. An additional 11% experienced temporary harm during their SNF stay.

The OIG determined that about 60% of adverse events and temporary harm events were clearly or likely preventable. The findings highlighted both the need and opportunity for significantly reduc-ing the incidence of “harm events.”

“Patient safety is primarily about pro-cess,” Dr. Levenson said.

Stopping the Dominoes Dr. Levenson said it is helpful to think about the cascade of events leading to an adverse outcome as a series of fall-ing dominoes.

“Every adverse outcome has a certain number of dominoes from the begin-ning to the end, and at any point along the way someone could have stepped in, put their hand out, and stopped the rest of the dominoes from falling, but nobody did,” he explained, noting that the key is recognizing the opportuni-ties to stem the tide that leads from a risk and a precipitating factor to a bad conclusion.

“The primary route to adverse event reduction and prevention is to do a more thorough job with the whole care pro-cess and to build in communications, coordination, collaboration, challeng-ing, questioning, careful thinking, and rethinking of what we’re doing,” he

added. “This must be done in real time to stop the falling of the dominoes.”

Trigger-based chart reviews are a valid approach for accomplishing this, he said. Trigger tools – simple checklists of crite-ria used as a screen for possible adverse events – can serve as an early warn-ing system of problems – the hand that reaches out and stops the domino effect.

One example of a trigger for a medi-cal records review is hypoglycemia in an individual who is taking a drug that might cause hypoglycemia. Other triggers include elevated international normalized ratios in a patient taking warfarin, and hyperkalemia in a patient taking a drug known to cause or worsen hyperkalemia.

Chart Reviews Add Up Smart use of case reviews can also help to improve processes and outcomes.

Dr. Levenson recommended using key information from a chart to address multiple issues simultaneously, includ-ing monitoring of care, identification of clinical issues and complications, assessing the quality of documenta-tion, and identifying the rationale for interventions.

Reports that can be helpful in the review process include resident rosters,

resident diagnoses, the patient dash-board, care plans, progress notes, weight and vital signs, and patient summaries.

Each of these can provide clues to possible issues. For example, admis-sions and readmissions could serve as red flags regarding appropriate patient management and could serve as a trigger for further review for possible adverse events, diagnostic quality issues, advance directive issues, and patient decision-making capacity. Recent vital signs could signal possible nutritional or hydration issues, diagnostic issues, and prescribing issues.

Case reviews provide a wealth of information but require that many ques-tions be asked and many conclusions be challenged. Performing numerous case reviews at a single facility can be a highly effective and efficient means for identifying problematic system pro-cesses and revamping them as neces-sary, Dr. Levenson said. In fact, the OIG report notes that “retrospective medical record review is often considered the most definitive method for detecting adverse events.”

“It’s 5,648 miles from Seoul to San Francisco. Of those 5,648 miles, [Asiana flight 214] was perfect, except for the last quarter mile. So statistically speaking, 99.996% of this flight was impeccable,” Dr. Levenson said, adding that if this information was brought to a [quality assurance/performance improvement] meeting, it would be buried in the statistics.

“We have to stop just looking at the numbers and having campaigns and meetings. Instead we have to dig and find what’s going on in and across facili-ties,” he said.

Dr. Levenson reported having no financial disclosures. CfA

Sharon Worcester is a freelance writer based in Birmingham, AL.

Patient Safetyfrom page 1

14 • CARing foR THE AgES MAy 2015

A nursing facility must ensure that its resident environment remains as free of accident hazards as pos-

sible, and that each resident receives ade-quate supervision and assistance devices to prevent accidents. These Medicare/Medicaid certification requirements, found at F323 of the State Operations Manual, are frequently cited by the State Agencies for a variety of “unavoidable” resident accidents.

One frequent resident accident/safety citation relates to resident elopement, which is often cited at the immediate jeopardy level. Many elopements occur and are cited across the country each year, and some result in significant injury or death. Prevention of accidents related to wandering and exit seeking is vital to implement on a consistent basis to avoid the regulatory and litigation risks that are a result of a resident elopement.

An unsafe elopement occurs when a resident leaves the premises without authorization and supervision. Residents with confusion or dementia are among those who are not safe being out of the facility without authorization.

Data Tag F323 requires facilities to proactively undertake numerous actions relating to a safe environment and acci-dent prevention for each facility resident. The required processes include:

▶▶ Identifying hazards and risks.▶▶ Evaluating and analyzing the identi-

fied hazards and risks.▶▶ Implementing interventions to reduce

hazards and risks.▶▶ Monitoring for effectiveness and mod-

ifying interventions as necessary (SOM, Appendix PP, F323).

Accident prevention and risk reduc-tion include many areas of concern for facilities, such as the risk of elopement for residents at an increased risk of wan-dering and exit seeking.

Case RulingA recent Health and Human Services Departmental Appeals Board (DAB) case highlights the importance of ensuring that appropriate safety measures are in place and are being effectively monitored to prevent elopements. The DAB hears the formal appeals of certified facilities when they challenge survey citations and the resulting sanctions imposed related to the survey process. The August 2014 DAB decision in the case filed by Methodist Health and Rehabilitation Center against the Centers for Medicare & Medicaid Services upheld noncompliance deficien-cies issued at F323 citing multiple resident elopements over several months in 2013.

The administrative law judge (ALJ) determined that the facility failed to:

1) comprehensively investigate the causes of the elopements, 2) determine the actual causation allowing the residents to exit the facility undetected, and 3) fol-low its internal anti-elopement policies and procedures resulting in gaps in the facility’s safety measures.

If residents are successfully exit-seeking, the facility’s interventions will likely be determined to be ineffective in a survey by the state agency.

These alleged gaps allowed a 94-year-old resident with dementia to elope on two separate occasions within a month. The facility was cited for failing to thor-oughly investigate the cause of the resident’s exit. The resident was able to leave in both instances undetected, which placed her at risk of harm when unsupervised outdoors. The resident had been deemed an increased risk for elope-ment, and was wearing an electronic bracelet designed to alarm when exiting through a door equipped with a sensor. However, on both occasions, the alarm failed to sound when the resident silently exited the building alone and without staff knowledge. Fortunately, the resi-dent did not have any significant injuries as a result of the two elopements.

Unfortunately, within 3 months, an-other resident eloped from the building. An 87-year-old resident with dementia eloped from the premises when the resi-dent similarly exited without triggering an alarm. The facility took action by placing tape over the door until the maintenance supervisor could arrive the next day and reactivate the alarm. During the investiga-tion, a door sensor indicated that the door had been opened, but no audible alarm had sounded.

The ALJ cited a failure to thoroughly investigate the cause of the elopements when the facility assumed that a con-tractor had disabled the alarm, and so determined that the facility failed to take reasonable measures to protect the resi-dents at risk of elopement. The ALJ’s decision stated that something caused the alarm system to be defeated and, whether it was human error or a fail-ure of the equipment, it did not matter because the facility did not fully investi-gate. Additionally, the ALJ stated that the facility failed to make effective systemic changes to correct the alarm system after

each of the three elopements. The imme-diate jeopardy citation and the imposed civil money penalty of $3,150/day for 29 days and $150/day for another 15 days were upheld.

This case highlights the importance of a facility’s ongoing culture of safety that includes consistent and effective measures to prevent elopement that are consistently implemented by all facil-ity staff members. Some considerations when reviewing safety measures to pre-vent elopements include:

▶▶ The DAB and regulators have an unstated presumption that all elope-ments are preventable, as a facility knows there are wandering residents and some of those residents will have exit-seeking behaviors. In other words, elopement is a known risk that must be prevented. If residents are wandering and successfully exit-seeking, the facil-ity’s interventions that are in place will likely be determined to be ineffective in a survey by the state agency.

▶▶ Assessing a resident at admission for a risk of elopement, coupled with periodic reassessments, can reduce the risk.

▶▶ Increased monitoring for new resi-dents is a good practice, as the environ-ment is new to the resident and the staff is unaware of the resident’s daily patterns of activity and capabilities.

▶▶ A comprehensive elopement preven-tion program with ongoing education for all facility staff should be implemented.

▶▶ Periodically conduct elopement drills to ensure that the staff is knowledge-able about the elopement policies and procedures.

▶▶ Door alarms and other equipment-based systems must be routinely

monitored and documented for proper function. If systems are damaged or inop-erable, other interventions must be under-taken to maintain the residents’ safety until the systems are effectively repaired.

▶▶ Elopements consistently are cited at the immediate jeopardy level across the country, and incur significant civil money penalties.

▶▶ Actual harm or injury to a resident is not necessary for an immediate jeopardy citation to be issued or upheld.

▶▶ The duty to protect residents includes protection from foreseeable risks out-side of the building. A known dementia resident will be unsafe outside of the building without supervision.

▶▶ Care planning alone is not an effective action plan. The planned interventions must be consistently implemented.

▶▶ Supervision must be “adequate” to meet the residents’ needs. Each resident may need different types and amounts of supervision based on the identified needs, goals, plan of care, and current standards of practice.

▶▶ Reasonable interventions must be implemented to prevent elopement, as this is a foreseeable risk.

Monitoring Is VitalElopement prevention is an important component of a facility’s overall safety program. Nursing facilities work on a daily basis to maintain a safe environ-ment for their residents through imple-mentation of numerous safety and accident prevention measures. These measures include people-based inter-ventions, such as diligent observation of residents at increased risk of acci-dents, and equipment-based interven-tions, such as electronic door alarms and delayed egress systems. Daily moni-toring of the staff interventions and the equipment-based systems are vital to maintain a safe and secure environment. An ineffective or incomplete elopement prevention program places residents at significant risk of injury or death, and also places facilities at risk of immediate jeopardy citations and civil negligence lawsuits. CfA

This column is not to be substituted for legal advice. The writer, Janet K. Feldkamp, practices in various aspects of health care, including long-term care survey and certification, certificate of need, health care acquisitions, physician and nurse practice, managed care and nursing related issues, and fraud and abuse. She is affiliated with Benesch Friedlander Coplan & Aronoff LLP of Columbus, OH. You can comment on this and other columns at www.caringfortheages.com, under “Views.”

Legal Issues By Janet K. Feldkamp, RN, BSN, LNHA, JD

implement Safety Measures to Avoid Resident Elopements

Get the Annual Conference

Online Take resources, tools, and informa-tion from AMDA’s 2015 Annual Conference home with you to use throughout the year. Order the AMDA online library and get access to audio, synced PowerPoint slide sets, and CME for most educational sessions offered at the meeting.

“There is so little solid informa-tion and data on the post-acute and long-term care environment, and it is wonderful to have this library of infor-mation and materials from experts who also are working in the trenches,” said AMDA Past President Karyn Leible, RN, MD, CMD. To order, go to www.prolibraries.com/amda/.

CARingfoRTHEAgES.CoM CARing foR THE AgES • 15

Smoking causes death from many diseases that until now have not been linked officially to tobacco

use, including digestive disorders, liver cirrhosis, infections, renal failure, and breast and prostate cancers, according to a report published in the New England Journal of Medicine.

“Our results suggest that the number of persons in the United States who die each year as a result of smoking cigarettes may be substantially greater than currently estimated,” said Brian D. Carter, MPH, of the epidemiology research program, American Cancer Society, Atlanta, and his associates.

The 2014 Surgeon General’s report estimated that smoking causes more than 480,000 deaths every year in the United States, based on mortality figures from 21 diseases that have been formally established as caused by smoking: 12 types of cancer, six types of cardiovas-cular disease, diabetes, chronic obstruc-tive pulmonary disease, and pneumonia. Mr. Carter and his associates pooled data from five large cohort studies to exam-ine possible associations between smok-ing and an additional 31 cause-of-death categories. They now estimate that an additional 60,000 to 120,000 deaths each year can be attributed to smoking.

For their study, the investigators assessed 421,378 men and 532,651 women aged 55 years and older at base-line whose smoking status was carefully recorded and who were followed from 2000 to 2011 in the Cancer Prevention Study II Nutrition Cohort, the Nurses’ Health Study I, the Health Professionals Follow-up Study, the Women’s Health Initiative, and the National Institutes of Health-AARP Diet and Health Study.

As expected, smokers had a twofold to threefold higher mortality from any cause, compared with nonsmokers. Smokers also had a markedly higher risk

of death than nonsmokers from all 21 causes already established as attributable to tobacco use, such as lung cancer, oral cancer, ischemic heart disease, athero-sclerosis, and stroke. But approximately 17% of smokers’ excess mortality was accounted for by several diseases that previously have not been attributable to tobacco use.

For example, the risk of death due to intestinal ischemia was approximately six times higher among smokers than among nonsmokers, a remarkably strong association that was also reported in the Million Women Study. “Smoking acutely reduces blood flow to the intes-tines, and evidence suggests that smok-ing causes risk factors that can often lead to intestinal ischemia, including ath-erosclerosis, platelet aggregation, and congestive heart failure,” Mr. Carter and his associates said (N Engl J Med 2015; 372:631-40). In this study, smoking also more than doubled the risk of dying from other digestive diseases. Previous studies have suggested a link between smoking and digestive disorders such as Crohn’s disease, peptic ulcers, acute pan-creatitis, paralytic ileus, bowel obstruc-tion, cholelithiasis, diverticulitis, and gastrointestinal hemorrhage. “Although these diseases are not common causes of death, they account for millions of hospitalizations each year,” the investi-gators noted.

The mortality risk from liver cirrhosis, after the data were adjusted to account for alcohol consumption, was more than three times higher in smokers than in nonsmokers. Even smokers who did not drink alcohol were at significantly increased risk of cirrhosis, compared with nonsmokers.

The risk of death due to infection was 2.3 times higher in smokers than in nonsmokers. This strong association was dose-dependent, as infection-related mortality rose with increasing smoking intensity. And among study participants

who had quit smoking, infection-related mortality declined as the number of years since cessation increased.

The rate of death due to renal failure was twice as high among smokers as among nonsmokers. And the rate of death due to hypertensive heart disease, the only category of heart disease not already established as smoking related, was 2.4 times higher in smokers. The latter association “is relevant for assess-ing the public health burden of smoking, since a considerable number of deaths in the United States are attributable to hypertensive heart disease,” according to Mr. Carter and his associates.

Smoking also was strongly associated with “multiple diseases too uncommon to examine individually.” This included all rare cancers combined, rare digestive diseases, and respiratory diseases other than those already known to stem from smoking.

In women, smoking raised breast can-cer mortality, with a relative risk of 1.3. This association was strongly dose depen-dent. In men, smoking raised prostate cancer mortality, with a relative risk of 1.4.

This study was limited in that most of the participants were white and better educated than the general population, which may affect the applicability of the results to other populations. CfA

Mary Ann Moon is a Frontline Medical News freelance reporter based in Clarksburg, MD.

Smoking Linked to Many More Causes of DeathBy Mary ann Moon

PA/LTC Perspective“Smoking in long-term care affects the residents and their individual health. Many are requiring LTC services because of complications related to poor lifestyle choices, including smoking,” said Rebecca Ferrini, MD, CMD, medical director, County of San Diego.

“These studies confirm what clinicians have suspected, that smoking is the single most hazardous activity a person can undertake, far overtaking other risk factors for disease and disability. Quitting smoking enhances health and well-being – both of the residents and those around them. Permitting smoking within a long-term care facility impacts not only the smokers, but all of those around them exposed to secondhand smoke, including nurses who are given the unenviable task of assisting or supervising smoking times, and other resi-dents exposed to the smoke,” Dr. Ferrini said.

“The findings reported by Carter et al. substantiate that until now, estimates of premature deaths due to smoking have markedly underestimated the bur-den of tobacco use on U.S. society. Attributing 60,000 to 120,000 additional deaths each year to smoking would have an important public health impact, since it is comparable to the number of annual deaths attributed to excess alcohol intake. Many people see the war against smoking as one that we have already won, given that rates have declined so much since the 1960s. But these findings show that although we have had some major victories, the war on smoking is far from over,” according to Graham A. Colditz, MD, Washington University, St. Louis. Dr. Colditz made these remarks in an an editorial accom-panying Mr. Carter’s report (N Engl J Med 2015;372:665-6). He reported having no financial disclosures.

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Smoking also was strongly associated with ‘multiple diseases too uncommon to examine individually.’

Smoking was found to contribute to deaths due to hypertensive heart disease, the only category of heart disease not previously related to smoking.

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16 • CARing foR THE AgES MAy 2015

the official artist for the United Nations’ Tolerance Day.

“Art is 1% talent, and 99% hard work,” he told Caring for the Ages. “Creating comes from the gut.” Although he said that he paints for himself, he is happy to share his talents with others. For exam-ple, he has a student – a fellow Lott resident. “I’ve given him several lessons, and he’s made a huge improvement,” Mr. Farin said of his protégé.

Mr. Farin is grateful that he can still draw because he can no longer partici-pate in his other passion – drumming. In his younger days, he worked as a drum-mer for jazz great Dizzy Gillespie and later for The Manhattan Transfer. “As limited as I am, I’m happy if I can express myself,” he said. Although he can’t do oil paintings because he can’t stand at an easel, he is content to do drawings and watercolor pieces at his table.

After 3 years at Lott, Mr. Farin contin-ues to work on his recovery, and he cred-its his art with much of the progress he’s made to date. “If I hadn’t been able to draw or paint, it would have affected my recovery big time. The ability to express myself and create was therapy,” he said.

Art Means Everything Colorful paintings line the wall of Marie Tuazon’s apartment at Lott Residence. She started painting 5 years ago and is proud of her work. “Painting means everything. It’s a way to really express myself. I’ve really discovered myself since I started painting.”

Ms. Tuazon shared the stories behind some of her favorite paintings. “I love to paint people from different nationali-ties and create a sense of spirituality in my work,” she said. “Painting keeps my mind active.”

Safe Place To Create It is important to give creative residents a way to express themselves. “Art is a non-verbal way of expression. It gives resi-dents a chance for freedom, to let go and create something judgment-free,” said Whitney Bryant-Glandon, director of resident programs at Hallmark Battery Park Senior Residence-Brookdale in New York. For people who identify as artists, “it is essential to their existence to be able to create, express, and discover new things about themselves,” she said.

Art can create a sense of community for some residents. “Classes or groups give them a safe place to create. They’re able to talk about their work with others if they want,” Ms. Bryant-Glandon said. “Art also has an amazing way of taking away your problems. You forget about your aches and pains.”

“Some residents have developed dis-abilities, so they feel a little discouraged. They don’t want to paint because they can’t do it the way they used to. We try to support them and encourage them to focus on the art and not their disability. We try to help them see themselves as artists again,” said Sherita Sparrow, ADC, CDP, founder and chief executive officer of Delaware-based The Feather’s Touch, LLC. Others, she said, need no encouragement. “These are the ones

who still find joy in their love of art and painting. Art is their way of staying con-nected. They make things for friends and family, and they feel like they are giving back and making a contribution.”

Art Has a Message for Staff Art can create a bond between residents and the staff. “It’s a nice way to create a dialogue. By stopping to admire their art and ask questions, the staff can learn so much,” said Ms. Bryant-Glandon. “It gives residents a chance to become nar-rators of their own story and share what is significant to them.”

What a resident paints or draws can also tell the staff what the person is feel-ing. For example, Ms. Bryant-Glandon said, “We had one resident who was an accomplished artist for 60 years. She was always drawing flowers and using vivid colors. Then she got sick and went to the hospital. When she came back, her can-vases were much darker, and her work completely changed.” When staff talked with her, they discovered that she wasn’t feeling well, and she was expressing this in the way she was most comfortable. “If someone stops coming to class, we

will call and ask how they are doing. If someone’s art starts going in a different direction, we will start a dialogue and prompt them to talk about what they’re feeling,” said Ms. Bryant-Glandon.

Ms. Sparrow agreed that residents’ work can tell a story about their health. “I had worked with one artist in her 90s. She was in great health and always came to art classes stylishly dressed and cheer-ful. She worked with a palette of bright colors.” Then Ms. Sparrow was away for a month; and when she returned, the older woman’s art had changed. “She was now painting with browns, grays, and blacks – the opposite of her previous works. I asked staff later what happened, and I found out that she had experienced a fall and felt a little unstable. She was expressing this through her paintings.”

“Whether their art gives me a greater understanding of my residents, I don’t know,” Dr. Pruchnicki said. “Sometimes it can reflect their mental status, but mostly it gives me a chance to relate to them and encourage them.” He is more excited about the opportunity to share his residents’ art with others. “I suggested we hang their works around the facility. We have so many residents who are artists, we could fill our walls with their art.”

The paintings and drawings that grace the lobby, offices, and other spaces do more than add to the facility’s décor. “When people come to visit, we like to show it off. It demonstrates that we keep people active and engaged once they come here,” Dr. Pruchnicki said. “It reminds them that our residents are still vibrant, active people with interests and abilities.” CfA

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

one physician knows from expe-rience how important art can be. “I can’t see my life without

art. I have always tried to make a space for myself where I can create,” said author, photographer, and artist Jeffrey Levine, MD.

Dr. Levine, who is assistant professor of medicine and geriatrics at the Icahn School of Medicine at Mount Sinai and faculty physician in the Center for Advanced Wound Care at Mount Sinai Beth Israel Medical Center, believes that his observa-tions as an artist and right-brained thinking abilities have made him a better clinician. “Wound care and geriatrics are visual, tac-tile fields, and you need to integrate a broad field of information. The right side of the brain powers you to do this,” he said. “Medical decision making in geriat-rics is complicated. To digest information and devise a care plan takes skills, brain power, intuition, and creativity.”

Dr. Levine helps his students use the right side of their brains and sharpen

their observational skills. “I use observa-tional games all the time in my teaching. These help to focus students’ attention and see things they missed before,” he told Caring for the Ages.

Dr. Levine lamented the split between the arts and sciences in our culture. “This struck me strongly when I was asked to precept medical students on a trip to a famous art museum in New York City. I was considering how to best guide them through the galleries, and a colleague said, ‘Don’t worry. None of these students has ever been to an art museum.’ I couldn’t imagine that was true, but when I asked the students who had ever visited an art museum, no one raised their hand,” Dr. Levine said. “There has to be a greater effort to integrate the arts and sciences.”

Practitioners should feed their cre-ative impulses, said Dr. Levine, “even if they’re not the best.” He added, “It’s difficult to be alone in a solitary pursuit. You need people to help you.” Thanks to social networking groups such as Facebook, Twitter, and Meetup, it’s

easy to connect with people who share creative interests. “I found a huge sup-port system for my watercolor painting through social media. I never had social media experience before, but when I started posting online, it opened a whole new world to me in terms of feedback and networking,” he said.

Dr. Levine said for those clinicians who say they don’t have the time for creative pursuits, it is worthwhile to make the time. He finds that art is stimulating even though it is hard work. “I sometimes think I’ll be too tired, but when I get started, it actually is energizing,” he said.

His own artistic interests and pursuits have helped Dr. Levine connect with his patients. “I worked at a facility in the West Village [in New York City], and we cared for many elderly artists there. I went to their shows and retrospectives. I became friends with many of them. It was a wonderful experience.” He added, “It was amazing to see people making art in their old age and how they adapt their art to their aging bodies.” CfA

—Joanne Kaldy

Physician Urges Arts-Science ConnectionBy Joanne Kaldy

Quality of Lifefrom page 1

Marie Tuazon’s love of painting is apparent in the array of colorful canvases that fill her apartment.

Avi Farin paints or draws daily, despite a stroke that left him partially paralyzed.

Marie Tuazon started painting 5 years ago and hasn’t stopped since.

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CARingfoRTHEAgES.CoM CARing foR THE AgES • 17

Alternating-air and low-air-loss mattresses and overlays have lit-tle data to support their use for

preventing or treating pressure ulcers, the Clinical Guidelines Committee of the American College of Physicians has concluded.

Many U.S. acute care hospitals, home caregivers, and long-term nursing facili-ties use alternating-air and low-air-loss mattresses and overlays, even though the evidence in favor of using these surfaces is sparse and of poor quality, the guide-line writers said.

The devices have not been show to actually reduce pressure ulcers. The harms have been poorly reported, but could be significant. “Using these sup-port systems is expensive and adds unnecessary burden on the health care system. Based on a review of the cur-rent evidence, lower-cost support sur-faces should be the preferred approach to care,” said Amir Qaseem, MD, direc-tor of the department of clinical policy at the ACP, Philadelphia, and his associ-ates wrote.

The committee performed an exten-sive literature review on pressure ulcers and compiled two Clinical Practice Guidelines – one concerning prevention (Ann Intern Med 2015;162:359-69) and the other concerning treatment (Ann Intern Med 2015;162:370-9) – in part because “a growing industry” has devel-oped in recent years and aggressively pitches a wide array of products for this patient population. The guidelines present the available evidence on the comparative effectiveness of tools and strategies but state repeatedly that evi-dence regarding pressure ulcers is sparse and of poor quality.

The prevention guideline strongly rec-ommends that clinicians choose advanced static mattresses or advanced static over-lays rather than standard hospital mat-tresses for at-risk patients. These products are among the few actually shown to reduce the incidence of pressure ulcers. They are also preferable to alternating-air mattresses and overlays, and to low-air-loss mattresses and overlays.

Evidence is similarly poor or lacking concerning the use of other support surfaces such as heel supports or boots and a variety of wheelchair cushions. Also lacking evidence are other preven-tive interventions that extend beyond “usual care,” such as different types of repositioning schemes, a variety of leg elevations, various nutritional supple-ments, and a wide variety of skin care strategies and topical treatments.

The prevention guideline advises patient assessments to identify those at risk of developing pressure ulcers. However, there is not enough evidence to demonstrate that any one of the many risk assessment tools for this pur-pose is superior to the others, or that any of these tools is superior to simple clinical judgment.

The treatment guideline for patients who already have pressure ulcers

similarly notes that the lack of evidence for advanced support surfaces such as alternating-air and low-air-loss mat-tresses and overlays. It similarly recom-mends advanced static mattresses or overlays for these patients.

The treatment guideline recommends protein or amino acid supplements as well as hydrocolloid or foam dressings to reduce wound size, and electrical stimu-lation to accelerate wound healing. The

evidence for these recommendations is “weak” and of low- to moderate-quality, Dr. Qaseem and his associates said. The evidence for the safety and efficacy of hyperbaric oxygen therapy, even though it is often used to treat pressure ulcers in hospitals, is similarly inconclusive. Also lacking good-quality evidence are the use of alternating-air chair cushions, three-dimensional polyester overlays, zinc supplements, L-carnosine supplements,

wound dressings other than the ones already discussed, debriding enzymes, topical phenytoin, maggot therapy, bio-logical agents other than platelet-derived growth factor, or hydrotherapy in which wounds are cleaned using a whirlpool or pulsed lavage. CfA

Mary Ann Moon is a Frontline Medical News freelance reporter based in Clarksburg, MD.

ACP guidelines for Preventing, Treating Pressure UlcersBy Mary ann Moon

PA/LTC Perspective“ACP promulgated three recommen-dations for risk assessment and preven-tion of pressure ulcers and three for the treatment of pressure ulcers. The committee based their recommen-dations on the strength of evidence for each item,” said Gabriel (Gary) Brandeis, MD, CMD, associate profes-sor of medicine at Boston University School of Medicine, Boston.

“Since there are many scales that can be used in different settings, no studies were found to be high quality and they even went so far as to cite a Cochrane review that clinical judg-ment might be as good as the tools/scales available. Although this may be true, scales are needed to act as a guide along with clinical acumen. Clinicians should use the items in the scales (not just a summary number), knowing they are not perfect and add judgment from the bedside to give a complete picture of the patient, and then develop a treatment plan to attempt to minimize the risk of devel-oping an ulcer.

“ACP recommended static-type mattresses over alternating-air mat-tresses. One needs to consider face validity when looking at mattresses or even pressure reducing/relieving boots. Since pressure is necessary for a

pressure ulcer to occur, any device that eliminates or reduces pressure should eliminate or decrease the risk of pres-sure ulcer occurrence. (Pressure is necessary but needs other factors [such as skin frailty and/or poor circulation] for an ulcer to occur). Clinicians find themselves in a conundrum. Pressure ulcers are being called preventable, avoidable and institutions are being not reimbursed when they occur. Providers are being sued when ulcers occur. Currently, many of the more advanced mattresses are not reimbursed as pre-ventative measures. So, when pressure ulcers occur, is it because the mat-tress/boot was not in place because now insurance companies and the government claims evidence is lacking? Are the ACP recommendations just a cry for better studies vs. not using the technology we have?

“The second guidelines give three recommendations regarding treat-ment. The first references protein or amino acid supplementation in order to heal an ulcer. Over the years, vita-mins and different supplements have been tried, but none to show great benefit. The probable best treatment for the presence of a pressure ulcer is a good diet and adequate calories. Often, however, this is not possible

because many people may have co- or multi-morbidity and intake of ade-quate calories is difficult.

“The second recommendation con-cerns the use of hydrocolloid or foam dressings. These have their place in the treatment armamentarium. They should be used for what they have been designed, such as decreasing exudate.

“Recommendation three for treat-ment involves electrical stimulation as a weak recommendation but with moderate-quality evidence. This modality is not widely available, but this recommendation may merit a push to increase its usage.

“Overall, the ACP guidelines for risk assessment, prevention and treat-ment point out the lack of high qual-ity evidence in these areas. Insurers, government, and lawyers are all calling pressure ulcers as never events, yet clinicians know this is not true, but, to date, we do not have robust evidence available regarding the factors that the ACP guidelines studied. If studies can be performed to address the issues that do not provide robust recommenda-tions, they should be. In the meantime, expert opinion and clinical acumen regarding the assessment, prevention and treatment need to guide practice.”

The AMDA Foundation Futures Class of 2015 thanks the generous individuals and organizations who made

this program possible.

We gratefully acknowledge the support of our AMDA members, AMDA state chapters, residency and fellowship programs,

LTC private practices, nursing home partners and industry foundations.

For a complete list of donors, please go to amdafoundation.org.

We will begin taking online applications for the Futures Class of 2016 beginning in July 2015.

Thank YouThank You

www.amdafoundation.org

18 • CARing foR THE AgES MAy 2015

Public Policy

Accountable care organizations have been promoted by the Centers for Medicare & Medicaid as a key al-

ternative practice model to the current value-based model that all physicians will soon face. ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctors’ offices, hos-pitals, and long-term care facilities. The ACO is financially rewarded for providing efficient care and meeting performance standards while controlling costs. There are two basic types of ACOs – the Pioneer and the Medicare Shared Savings Program (MSSP). The success of the Pioneer model has been equivocal, with only a minority of original programs still functioning or being fiscally sound. The jury is still out on the MSSP model, but the interest is certainly there. There are currently about 14 million lives covered in 47 different states in all ACO models.

There are many issues with the MSSP that have slowed its uptake or success. First, the program is tiered. Simply put, the higher the tier, the more risk the organization takes if spending exceeds target goals. To compensate for this risk, the higher tiers have more poten-tial reward through shared savings, in which savings beyond a benchmark, usu-ally historical spending, are split between Medicare and the ACO. These ACO sav-ings are then shared among the hospital and various providers. As important as the fiscal reward, higher tiers offer more liberal CMS consideration of bending historical hindrances to efficient medical care, such as the 3-day qualifying stay rule for skilled care in a skilled nursing facility under Medicare Part A.

A second obstacle to ACO uptake is the fact that shared savings are based on historical spending of the organization, rather than whether they are already efficient. An ACO that starts out his-torically saving 20% of usual Medicare spending per patient will have a harder time being more efficient and providing more savings than an ACO that was at the historical benchmark. The net effect of this is that ACOs that started as effi-cient organizations do not have as much ability to be rewarded for better cost-effective care, whereas ACOs whose past performance has been poor are essen-tially rewarded because their incremen-tal improvement will be greater.

Current MSSP ACOs are still ham-pered by traditional Medicare rules that may limit efficient care, such as restrictions on telehealth, extent of post-discharge home services, and the 3-day rule for SNF services. Even higher tier ACOs have some of these restrictions,

which CMS is considering waiving fur-ther. In the interim, such restrictions do not encourage participation in higher risk sharing ACO models.

Another difficulty in current ACO structure is the fact that they may not know for certain what patients the ACO is responsible for, given difficulties with attribution. Attribution is the process by which patients are ultimately assigned to an ACO. The basic rule is that the pro-vider (and the ACO they belong to) who makes the most visits at the end of the year “owns” the patient, his or her care quality, and expense, regardless of what provider or ACO the patient started with. With all these considerations, the current fiscal reward – given the current struc-tural issues noted – has not been great enough to encourage most MSSP ACOs to move to higher tiers of risk sharing.

Next Generation, Next Answer Due to the aforementioned structural problems, CMS announced in March the formation of a new ACO model called the Next Generation ACO. This model has been viewed favorably by ACO experts, who believe it improves the basic ACO model, allows for better care of the patient, and offers greater success for the physician. Patrick Conway, MD, MSc, chief medical officer at CMS, said the Next Generation ACO is a response to physicians’ feedback and requests. This new and improved ACO is more evidence that CMS is committed to shifting at least half of all Medicare physician payments away from fee-for-service payments toward alternative payment models by the end of 2018.

The Next Generation ACO model gives providers greater opportunities to coordinate care, and ensures more appropriate and consistent fiscal targets. This new ACO will also make it easier to attain the highest standards of patient care. There will be greater financial risks for doctors and hospitals in exchange for greater shared savings when high perfor-mance is achieved. The increased risk sharing will be offset by a more stable, predictable benchmark and flexible pay-ment options that support investments in care improvement infrastructure that provide high-quality care to patients.

Cost Efficiency RewardedThe fiscal issues surrounding shared sav-ings of Pioneer and MSSP ACOs have been mitigated to a good extent in this new model. The Next Generation ACO model will use historical expenditures to develop baseline and benchmark data for performance years 1 through 3, which will be risk-adjusted and trended before

a discount is applied, just as for previous ACOs. However, the discount incorpo-rates regional and national efficiency. The net result is that ACOs that have already attained cost efficiency com-pared with their regions will have a more favorable discount and a greater reward. With this approach, ACOs achieve sav-ings through year-to-year improvement over historic expenditures (improve-ment), but the magnitude by which they must improve will vary based on rela-tive efficiency (attainment). In years 4 and 5, attainment becomes the primary payment consideration, de-emphasizing improvement goals. This method recog-nizes past achievements of efficient Next Generation ACOs, unlike past models, and encourages currently efficient orga-nizations to become ACOs.

Issues of alignment and attribution are better addressed with this new model, which supplements current claims-based alignment with voluntary alignment. Under voluntary alignment, beneficiaries are offered the option to confirm or deny their care relationships with specific Next Generation providers and suppliers. This beneficiary input will be reflected in align-ment for the subsequent year, and con-firmations of care relationships through voluntary alignment supersede claims-based attributions. This should take care of the current quandary for the PA/LTC physician who can become responsible for the patient’s entire cost and care simply because they saw the patient more often in the SNF in 1 year than did the primary care doctor. Such voluntary alignment continuity should allow the primary care physician and ACO to more accurately follow the care and cost of their patients across performance years. It is impossible to improve patient health while decreas-ing cost of care without the primary care physician/ACO being able to con-sistently follow the patient.

CMS will work with Next Generation ACOs to improve communication with beneficiaries about the characteristics and potential benefits of ACOs in relation to their care. Beneficiaries who seek high levels of coordinated care through their aligned ACO can receive waived or reduced copays and a $50 coordinated care reward per year from CMS. Expanded use of SNF services without a qualifying hospital stay, increased use of telehealth, and enhanced postdischarge home health care services should also encourage patients to use Next Generation ACO services.

Building on Past Models Many have stated that this ACO model is a marriage of past ACO models and Medicare Advantage (MA) plans. There

are distinct differences between the two, however. Patients who are aligned to Next Generation ACOs maintain origi-nal Medicare benefits. Beneficiaries have freedom of choice of their provider in the ACO, as opposed to the defined provider network of an MA plan. Patients are not required to receive services from an ACO, and there is no additional premium paid by the beneficiary for being in an ACO, as there is for most MA plans. Patients may receive a reward for receiving most of their care from ACO providers but are not penalized in any way for seeing non-ACO providers. The Next Generation ACO model does not require beneficiary enroll-ment. Beneficiaries are aligned to ACOs through claims, which voluntary align-ment supplements by allowing beneficia-ries to confirm a care relationship with an ACO provider. The Next Generation ACO may eventually be viewed as an improve-ment on both past ACOs and MA plans.

This new ACO model, however, does require a large and well-established organization in order to control the inherent risks and manage populations. This Center for Medicare & Medicaid Innovation-sponsored ACO model will be limited to larger groups, with a total number of 15 to 20 organizations anti-cipated to qualify. Applications are being accepted in two rounds with deadlines of June 1, 2015 and June 1, 2016. Quality metrics, including patient experience rat-ings, will be posted on the CMS website.

There is little doubt that the princi-ples – if not the exact model – embodied in the Next Generation ACO is the direc-tion that CMS and value-based model will be headed. Efficient use of resources, coordination of care, communication among providers, and patient invest-ment in their care are principles that AMDA has promoted for years. Newer models of value-based care, including ACOs, are beginning to acknowledge the value of the competent PA/LTC physician. It is equally important that competent PA/LTC physicians under-stand how these newer models of care operate in order to maximize their value and optimize patient care. CfA

Dr. Crecelius is a private practitioner, multifacility medical director for Delmar Gardens Nursing Homes in St. Louis, and assistant clinical professor of internal medicine and geriatrics at Washington University School of Medicine. Currently chair of AMDA’s Public Policy Committee and alternate advisor to the AMA RVS Update Committee, he is a past president of the association. You can comment on this and other columns at www.caringfortheages.com, under “Views.”

next generation ACos: CMS increases Risks, Rewards

By Charles Crecelius MD, PhD, FACP, CMD

CARingfoRTHEAgES.CoM CARing foR THE AgES • 19

Tai Chi and Fall PreventionSun style tai chi, although known to improve muscle strength, flexibility, and mobility, does not prevent falls among preclinically disabled older peo-ple, according to a multisite, parallel group, randomized controlled trial in Melbourne, Australia.

Led by Lesley Day, PhD, of Monash University, researchers randomized community-dwelling residents aged 70 years and older and identified as pre-clinically disabled into two groups. The intervention group (n=204) participated in 1-hour sessions of Sun style tai chi twice a week for 48 weeks, whereas the control group (n=205) participated in a seated, group-based flexibility exercise program. Participants self-reported their falls during the study.

“At the time we started this study, there was growing research evidence to support the effectiveness of tai chi to reduce falls among older people and to achieve a number of other physical benefits [including improved balance, muscle strength, mobility] as well as some psychological benefits,” fellow researcher Keith Hill, PhD, of Curtin University, Perth, Australia, told Caring for the Ages.

Several key issues led them to under-take this study. “Different types of exercise can be beneficial for different groups of people; it is not one-size-fits-all,” Dr. Hill said. “Also, older people defined as preclinically disabled – that is, they continued to live independently but were starting to have some difficulties with some activities – are an important group to target for exercise approaches, namely because they still remain rea-sonably active and have not developed the multiple secondary problems that develop as frailty progresses, such as greater problems with mobility, reduced activity levels, and loss of confidence in mobility.”

Researchers found no evidence that a modified Sun style tai chi program reduced fall risk. Specifically, 53 out of 204 individuals (26%) who performed tai chi reported falls during the first 24 weeks vs. 58 out of 205 individu-als (28%) in the control group. At 48 weeks, 99 of the 204 individuals in the intervention group (49%) reported falls vs. 112 of 205 control subjects (55%). A slightly lower proportion of falls – 4.7% at 24 weeks and 5.2% at 48 weeks – resulted in injury to individuals in the tai chi group.

These results differ from previous studies that associated tai chi with fall reduction. “This form of tai chi may not have been sufficiently challenging for the sample we used [preclinical dis-ability], even though this form of tai chi has been shown to achieve some positive outcomes with samples with increased health problems, such as arthritis,” Dr. Hill said.

Two messages emerged from this study. “There is a need to ensure an

exercise program [tai chi or other pro-grams] is targeted at a suitable level for the target population of older people,” Dr. Hill said. ‘If it is too easy it will not be effective, even if it may be effective in a different population.”

Also, adherence to the tai chi pro-gram in this study was fairly low, possi-bly because the program did not provide sufficient challenge for the individuals. “However, for tai-chi and other forms of exercise in any setting, there is a need for strategies to support older people start-ing these programs in the first instance, and then maintaining participation lon-ger term,” Dr. Hill said.

▶▶ Source: Impact of Tai-Chi on Falls Among Preclinically Disabled Older People. A Randomized Controlled Trial – Day L, et al.

Therapist Motivators Physiotherapists noted several key motivators for organizing physical activity for residents of long-term care facilities, according to a mixed qualita-tive and quantitative study in Brussels, Belgium.

Led by Veerle Baert, MSc, Vrije Universiteit Brussel, Laarbeeklaan, researchers surveyed 24 physiothera-pists using semi-structured interviews, followed by an online survey of 254 physiotherapists.

During the interviews, the physiother-apists identified 41 different motivators and 35 barriers to organizing physical activity in LTC facilities.

Some of the strongest motivators cited by respondents to the online survey included maintaining the independence of the residents, cited by 98% of those surveyed; reducing the risk of falling, 98%; improving residents’ physical and psychological well-being, 93% and 90%, respectively; promoting social interac-tion among residents, 91%; reducing the burden of care for their colleagues, 89%; and receiving appreciation from residents, 85%.

Respondents also noted several barri-ers to organizing physical activity among residents. Physiotherapists said they did not want to force residents to perform physical activity if they didn’t want to or if activity was contraindicated in certain residents. They also cited the difficulty in organizing activity for residents with dementia.

In another finding, none of the phys-iotherapists interviewed were familiar with physical activity guidelines from the World Health Organization; in fact, 84% of those who responded to the online survey were not familiar with these guidelines.

▶▶ Source: Physiotherapists’ Perceived Motivators and Barriers for Organizing Physical Activity for Older Long-Term Care Facility Residents – Baert V, et al.

Frailty Screening The FRAIL scale may be used by non-health care professionals as a community

screening tool for frailty and the first part of a step-care approach to elderly individuals, according to a two-phase study in Hong Kong.

Led by Jean Woo, MD, of the Chinese University of Hong Kong, researchers screened 816 individuals aged 65 years and older using the FRAIL scale. The scale looks at five components: fatigue, resistance, ambulation, illness, and weight loss. Of these individuals, 529 (65%) had a frailty score of 1 or greater, meaning they were prefrail or frail.

The prevalence for frailty ranged from 5.1% for those aged 65 to 69 years to 16.8% for those aged 75 years and older, and prevalence was higher in women than in men (13.9% vs. 4.2%). Of the 529 individuals identified as pre-frail or frail, 42.5% had sarcopenia, and 60.7% had mild cognitive impair-ment. Among the 102 classified as frail, 12.8% had sarcopenia, 14.7% had mild cognitive impairment, and 63.7% had both sarcopenia and mild cognitive impairment.

Of 255 individuals (48.2%) who returned for the second phase of inter-views, those who were frail vs. prefrail were less physically active; had higher number of chronic diseases; were tak-ing more medications; reported more falls; rated their health as poor; and had higher prevalence of depressive symp-toms, mild cognitive impairment, sar-copenia, and disability in performing activities of daily living.

▶▶ Source: Frailty Screening in the Community Using the FRAIL Scale – Woo J, et al. CfA

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

From the May Issue of JAMDAJournal Highlights

‘For tai-chi and other forms of exercise in any setting, there is a need for strategies to support older people starting these programs ... and then maintaining participation longer term.’

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CongratulationsCongratulations

20 • CARing foR THE AgES MAy 2015

Antipsychotics such as haloperidol and risperidone are associated with a dose-related increase in

mortality in elderly patients with demen-tia, compared with antidepressants or nonuse, according to a retrospective case-control study involving 90,786 patients.

Patients taking haloperidol had a 3.8% increase in mortality, and those taking risperidone had a 3.7% increase

relative to nonusers, while olanzapine and quetiapine also were associated with significant increases in mortality risk, according to a study published online in JAMA Psychiatry.

When compared with individuals on antidepressants, haloperidol was associ-ated with a 12.3% increase in mortality, representing a number-needed-to-harm of 8, whereas antidepressants alone were associated with a small but statistically significant increase in mortality risk.

“Antidepressant use was associated with a small, but statistically significant, increase in mortality. This finding is of note in light of the recent [randomized controlled trial, by Porsteinsson et al.] suggesting that citalopram significantly reduced agitation but may also carry adverse cognitive and cardiac effects. Our findings suggest that, during a 180-day period, starting haloperidol therapy for a patient with dementia may be associated with 1 additional

death for every 26 patients receiving treatment,” wrote Donovan T. Maust, MD, of the department of psychia-try at the University of Michigan, Ann Arbor, and his coauthors ( JAMA Psychiatry 2015 March 18 [doi:10.1001/jamapsychiatry.2014.3018])

“Prescribing a medication that increases mortality risk seems contrary to the tenet ‘first, do no harm,’ yet for patients who pose a danger to them-selves and others and are in profound distress, use of such medications may still be appropriate. These new data can help physicians minimize the poten-tial harm associated with antipsychotic treatment,” they wrote.

The study was supported by the National Institute of Mental Health, the National Institute on Aging, the American Federation for Aging Research, the John A. Hartford Foundation, and the Atlantic Philanthropies. CfA

Bianca Nogrady is a Frontline Medical News freelance reporter based in New South Wales, Australia.

Changes in vision as we age are normal. We may eventually need reading glasses, or it may become increasingly difficult to see well in low light or in the dark. However, although such changes are common, vision loss is not a normal part of aging.

Vision loss can be devastating for elders. It con-tributes to depression, isolation, delirium, and lost independence. It may cause older adults to give up their homes and enter a nursing home. Working with the physician, you can prevent some eye problems and diagnose and treat others early to limit vision loss as much as possible.

By the age of 65, about one in three people have some form of vision-reducing eye disease. The most common causes of vision loss in elders include age-related macular degeneration, glau-coma, cataracts, and diabetic retinopathy. Other health problems such as diabetes, hypertension, and hyperlipidemia also can contribute to eye problems. Some medications – such as amio-darone and phosphodiesterase inhibitors – may have vision-related effects. Adults older than 65 should receive vision screenings every 1 or 2 years, with special attention to the conditions mentioned here.

When people can’t see well, they are more likely to become withdrawn and less active. Vision loss sometimes may contribute to visual hallucina-tions. Adults with vision problems are at risk of making mistakes in taking their medications, which can contribute to falls and hospitalizations.

Some lifestyle changes can improve eye health. These include stopping smoking, monitoring blood pressure, getting regular exercise, limiting expo-sure to ultraviolet light, and wearing UV-protective sunglasses in bright sunlight. Talk to your doc-tor or other practitioner about what vitamins or

supplements might be useful for eye health. Antioxidants and zinc have been shown to have some value in preserving vision in people with macular degeneration.

In cases where vision loss is unavoidable, your doctor or other practitioner can help identify ways for your or your loved one to stay as independent and active as possible, access appropriate aids (e.g., magnifiers or guide dogs), and monitor for and treat depression or anxiety.

▶▶ Questions To Ask Your Practitioner • What vision problems or diseases am I or my loved one at risk for?• How often should I schedule eye exams? • What credentials or qualifications should I look for in an eye doctor?• What lifestyle changes should my loved one or I consider?

▶▶ What You Can Do • Alert your doctor or other practitioner imme-diately if you or your loved one has any vision changes or eye pain or discomfort.• Maintain a healthy diet and stop smoking. Limit exposure to UV light.• Make sure eyeglasses fit well and that the pre-scription is current.• Make sure rooms and halls in your loved one’s or your home are brightly lit.

Caring for consumers

A Clear View of Eye Health in Elders

Lindsey Neal, MD, CMD, a Virginia-based physician, discusses vision loss in elders and how to keep aging eyes healthy and deal with vision loss when it occurs.

™

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 in part by Frontline Medical News and 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 Association 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.

©2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine.

▶▶ For More Information • Adult Vision – Over 60 Years of Age: http://bit.ly/1OHJxJd • Tips for Coping With Vision Loss: http://www.allaboutvision.com/over60/ living-challenges.htm• Age-Related Eye Diseases: https://www.nei.nih.gov/healthyeyes/aging_eye

Dose-Related Mortality increased With AntipsychoticsBy BIanca noGrady

PA/LTC Perspective

“[This is] another study confirming higher mortality rates in users than non-users of this class of medication. This further supports our need to explore nonpharmacologic interven-tions for patients with dementia that can be effective vs. medication that does carry a risk and not insignificant cost,” said Susan M. Levy, MD, CMD, AGSF, AMDA president-elect.

“Our view of the risk: benefit ratio of this class of medications has shifted and so our practice must shift. As with all patients, treatment needs to be aligned with goals of therapy. There are indications for the use of these medications as Dr. Maust points out, but they must be used judi-ciously, monitored closely, and only used in the lowest effective dose for the shortest period of time. This is all in keeping with standards of good medication management. At every visit and change in condition we need to evaluate the need for the ongoing use of all medications and always question if medication is still needed, if the patient is still benefiting, and if an effort to taper is warranted.

“We also need to be able to help staff describe behaviors better and truly target therapy to those behaviors that might respond to medications and not just simply sedate our patients. As medical directors and as practitioners in this setting, we need to advocate for best practices for our patients and work collaboratively with the team to best approach and manage patients with this devastating condition. We need to educate our patients’ families about this illness so they also under-stand when medications may benefit and when they may cause harm.”

CARingfoRTHEAgES.CoM CARing foR THE AgES • 21

This is the third in a series of col-umns that examines long-term care provider organizations that

serve people in both facility-based set-tings and home- and community-based settings, as seen through the eyes of the chief medical officer (CMO). Previous articles have covered the Good Samaritan Society and Golden Living. This column spotlights HCR ManorCare and its chief medical officer, Mark J. Gloth, DO, MBA.

With more than 55,000 employees, HCR ManorCare, headquartered in Toledo, OH, is a network of more than 500 skilled nursing and rehabilitation centers, assisted living facilities, outpa-tient rehabilitation clinics, and hospice and home health care agencies providing services in 34 states. A subsidiary corpo-ration, Heartland Care Partners, is a pro-fessional medical practice that employs and manages medical directors, physi-cians, and nurse practitioners in 32 states.

Focus on Care Transitions The organization’s current business strat-egies have been greatly affected by the focus on transitions of care, resulting in the geographical consolidation of post-hospital providers and service lines. Since 2014, HCR ManorCare has been working with Optum on a Center for Medicare & Medicaid Innovation (CMMI) initia-tive, BPCI (Bundled Payments for Care Improvement) Model 3 in the Detroit, Chicago, and Philadelphia markets. This bundled payments initiative links the pay-ments for multiple services that beneficia-ries receive during an episode of care. In Model 3, the episode of care is triggered by an acute care hospital stay and begins at the initiation of post-acute care services with a participating skilled nursing facility, long-term care hospital, inpatient reha-bilitation facility, or home health agency.

Home and community-based services (HCBS) – through home health and hos-pice – are a part of HCR ManorCare’s business strategy. The company has also made a significant investment in developing a case management model that positions the registered nurse as a “transitions of care” coach.

From Practice to Corporate Entity Dr. Gloth is also vice president for HCR ManorCare and has served in that capacity since 2005. His responsibilities include executive and operational over-sight of medical services for the organi-zation’s 500 sites of care, as well as for the company’s subsidiary corporation, Heartland Care Partners. Dr. Gloth is board certified with training in internal medicine, geriatrics, and physical medi-cine and rehabilitation.

Dr. Gloth explained some of the joys and challenges of his role as CMO, par-ticularly the move from direct clinical practice to the “virtual reality” of life in the corporate office and structure  – the well-recognized shift from patient contact to interactions more broadly within the field, and the ability to influ-ence quality of care and quality of life through education, systems design, and program development.

The challenges are different, too, or at least they are on a different scale. Working systematically with 750 con-tracted physicians and 2,000 attend-ing physicians across the organization, Dr. Gloth continually addresses issues related to consistency of medical care and the standard of care. Although it is universally acknowledged that the level of medical care is increasing dramati-cally, that consistency is getting bet-ter “as the paradigm of care changes,” Dr. Gloth told Caring for the Ages.

The paradigm shift begins with another universally recognized trend: patients are leaving the hospital quicker and sicker. The PA/SNF settings of today look like the medical/surgery units of yesterday. What was formerly hospital-based care is shifting to the PA/SNF and HCBS settings. The pressures and requirements for the clinical systems of those respective systems are different and unique.

Tool Boxes of Care To Dr. Gloth and HCR ManorCare, that paradigm shift and focus on transi-tions of care require systems that miti-gate patients bouncing back and forth between settings of care. For example, Dr. Gloth pointed out “tool boxes of care” that target disease states (e.g., chronic obstructive pulmonary disease, congestive heart failure). In one of these tool boxes in the PA/LTC setting, the physician or nurse practitioner focuses on the first 72 hours, the 3 to 7 day window, and the 30-day window, targeting inter-ventions to the particular disease state, in which “if you do nothing else, you must maintain the evidence-based standard of care,” Dr. Gloth said.

In the home health or hospice set-ting, “tool boxes” become “disease

management guidelines,” with an empha-sis necessarily shifting to nursing: what to watch for, what information to report, and when. It’s important to have guidelines that are specific to the care environment.

Given that there are differences in care delivery systems between facility-based and home-based care, are physicians who are effective in one naturally good in the other? “I used to think that ‘a good doc is a good doc,’ but there are vari-ances,” Dr. Gloth said. “In both settings, you have to have an appreciation for and confidence in the clinical capabilities of the care setting. In both, you need effec-tive relationships with the care team.”

Important things that physicians prac-ticing in home-based care settings need to know and embrace include an ability to work with less information or frequency of information; different resources than institutional PA/LTC settings; the need for time to ask questions  – of patients and of staff; the areas of risk and liability and strategies to mitigate them; and the regulatory environment in which pro-gram managers operate.

Staying Connected to Physicians HCR ManorCare has a deliberate pro-cess for screening and developing its con-tracted physicians and medical directors across the continuum. Each is interviewed personally by the CMO. Each is educated on the clinical and operational tool box, and within the first 6 months, attends a medical director training seminar with essentially an SNF or Home Health and Hospice 101 curriculum. Monthly con-tinuing education webinars are offered to physicians and medical directors, while contracted attending physicians and nurse practitioners receive training on topics covering electronic health records and legal, regulatory, and pharmacy issues. Both didactic and case study for-mats are used, but all focus on evidence-based medicine. After 2 years or more of service, attendance at a national confer-ence – AMDA or American Geriatrics Society – is supported.

Dr. Gloth looks for physicians who are familiar with PA, SNF, hospice, or home health care settings, and the continuum of care. They need not be geriatricians, but it is important for them to be board certified.

“It’s not about ‘how many patients can you send me?’ but ‘why do you do this?’ ” Dr. Gloth said, adding that he stays per-sonally connected to the physicians. He said he talks to a physician somewhere virtually every day.

What does Dr. Gloth see on the hori-zon from his vantage point as CMO?

Because of the higher acuity that is cas-cading down through the continuum, he pointed to several increasing trends:

▶▶ More medical and clinical investment in SNF settings; decreasing investment in long-term acute care settings.

▶▶ Case mix/rehabilitation focus.▶▶ More “money follows the patient”

models, including coverage for assisted living.

▶▶ Home health on the cusp of another boom.

▶▶ More opportunities for growth in telehealth.

▶▶ Expanded role of nurse practitioners as part of care delivery.

▶▶ Increased use of hospice and focus on palliative care.

▶▶ Increased focus on chronic disease processes, advance care planning, deci-sions about life-sustaining treatment, and empowering people with health care decision making.

Exciting and challenging times are ahead in health care, Dr. Gloth said. There is a distinct need for good physi-cians, particularly in the PA environment, and there are clinical practice opportuni-ties for those who are able to recognize, adapt, and respond to them. Dr. Gloth is a passionate, articulate, and focused voice in this environment, and certainly one worth paying attention to. CfA

Mr. Kubat is director of mission integration for the Evangelical Lutheran Good Samaritan Society. He is an editorial adviser for Caring for the Ages and coordinates the work of various authors for this column. You can comment on this and other columns at www.caringfortheages.com, under “Views.”

Community LTC, HCR ManorCare, and Mark gloth

By Bill Kubat, LNHACommunity LTC

Mark Gloth, DO, MBA

There are clinical practice opportunities in PA/LTC for those who are able to recognize, adapt, and respond to them.

22 • CARing foR THE AgES MAy 2015

Caring for the Ages ™

Editor in Chief Karl Steinberg, MD, CMD

editorial advisory Board

Chair: Karl Steinberg, MD, CMD, California

Robin Arnicar, RN, West Virginia

Nicole Brandt, PharmD, CGP, BCPP, FASCP, Maryland

Ian L. Cordes, MBA, Florida

Jonathan Evans, MD, CMD, Virginia

Janet Feldkamp, RN, JD, BSN, Ohio

Robert M. Gibson, PhD, JD, California

Daniel Haimowitz, MD, FACP, CMD, Pennsylvania

Linda Handy, MS, RD, California

Jennifer Heffernan, MD, CMD, Texas

Bill Kubat, MS, LNHA, South Dakota

Jeffrey Nichols, MD, New York

Dan Osterweil, MD, CMD, California

Barbara Resnick, PhD, CRNP, FAAN, FAANP, Maryland

Dennis L. Stone, MD, CMD, Kentucky

AMDA headquarters is located at 11000 Broken Land Parkway, Suite 400, Columbia, MD 21044.

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 AMDA and by Elsevier Inc.

The ideas and opinions expressed in Caring for the ages do not necessarily reflect those of the Association or the Publisher. AMDA 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.

©2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine.

Caring for the ages (ISSN 1526-4114) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010. Business and Editorial Offices: Elsevier Inc., 360 Park Avenue South, New York, NY 10010. 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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LTC Pharmacy

The use of antipsychotic medications has been an ongoing target for scru-tiny due to concerns about appro-

priateness and safety in older adults with dementia. Recently, the U.S. Government Accountability Office released a report (www.gao.gov/products/GAO-15-211) documenting antipsychotic medications that are frequently prescribed to older adults with dementia. Pharmacists can assist in increasing outreach and edu-cational efforts aimed at reducing anti-psychotic drug use in this population.

Three Steps to Better Care As a pharmacist practitioner within a continuing care retirement community, as well as a member on an interpro-fessional dementia care team, it is my perspective that pharmacists could be employed more effectively through the following examples:1. Inclusion on behavioral health teams. Pharmacists can be instrumental in assisting with the following:

▶▶ Obtaining details about the patient and his or her symptoms and risks.

▶▶ Determining appropriateness of pro-posed treatment by matching patient-specific details to the known indications and the potential complications of a treatment.

▶▶ Considering medications after ruling out potentially remediable causes of symptoms (e.g., pain, adverse effects of medications) and trying to limit use to individuals whose symptoms are severe enough to adversely affect function and quality of life.

▶▶ Monitoring often enough to identify benefits and complications in a timely way.

▶▶ Trying to use the lowest effective dose for the shortest possible duration, based on findings in the specific patient.

▶▶ Trying to taper the medication when symptoms have been stable at least for several months or adjusting doses to obtain benefits with lowest possible risk.

▶▶ Monitoring closely for adverse con-sequences that can be attributed to the medications (e.g., falls, worsening confusion) and reduce or stop doses if adverse consequences are identified.

Examples of documentation to support this care process include: Multidisplinary Medication Management Committee Antipsychotic Use in Dementia Assessment (http://bit.ly/19MLhS0) and the Alliant GMCF Patient at Risk Form (PAR) for Antipsychotic Medication Reduction (http://bit.ly/1DrFZZF).

Furthermore, pharmacists can assist with providing quality assurance (QA) reports that can help facilities and practitioners understand how they are meeting the needs of the patients they serve. These can then be compared with Nursing Home Compare data, but caution needs to be employed when interpreting how the public data are pre-sented (http://go.cms.gov/1FmfHWi). 2. Educational initiatives/training. Pharmacists can provide ongoing edu-cational programs targeting prescribers, staff, and family or caregivers. Examples of initiatives that have been successful include academic detailing to prescrib-ers, in-services to care staff, and edu-cation to caregiver support groups. Examples of handouts that may be useful for these various target audi-ences are the Antipsychotic Medication

Reference (http://www.mdqio.org/docs/Antipsychotic_Tool.pdf) and the American Health Care Association and National Center for Assisted Living Quality Initiative Fast Facts: What You Need to Know About Antipsychotic Drugs for Persons Living with Dementia (http://bit.ly/1BRXdIJ). 3. Care planning discussions. During an individualized care plan meeting, a resident’s conditions, abilities, needs, routines, and goals are discussed and folded into a plan of care. It has been noted in an Office of Inspector General report (http://oig.hhs.gov/oei/reports/oei-07-08-00151.pdf) that high-risk medi-cations such as antipsychotics are not adequately addressed in the care plan. Pharmacists can assist in this effort and national clinical service initiatives, such as medication therapy management (MTM) may be able to meet this clinical need. MTM is a patient-centric and com-prehensive approach to improve medi-cation use, reduce the risk of adverse events, and improve medication adher-ence. MTM programs include interven-tions such as comprehensive medication reviews to engage the patient, caregiver, and their prescribers. This was discussed at AMDA’s 2015 Annual Conference and the handout is available at: www.proli-braries.com/amda.

Ongoing monitoring and changes to care plans are critical because many side effects emerge early on in the treatment course that could lead to negative out-comes, such as falls or a decrease in day-to-day function. Outside of nursing homes, family members and caregivers may not understand why antipsychotics are being

used, let alone how to identify if their loved one is benefiting from the medica-tion. These types of issues can be targeted and addressed during an MTM encounter, as well as in the community.

CMS Initiatives The Centers for Medicare & Medicaid Services has established reduction goals of 25% by the end of 2015, and 30% by the end of 2016, in the use of anti-psychotic medications in long-stay nurs-ing home residents. A recently launched portal at cms.gov, National Partnership to Improve Dementia Care in Nursing Homes (http://go.cms.gov/1BUzyZ3), provides numerous resources that can support the aforementioned approaches. Furthermore, CMS has included the use of antipsychotics in calculating the Five Star ratings on the Nursing Home Compare website (http://go.cms.gov/1CfAA0L).

It is critical that we work together to improve awareness across all settings of care to ensure appropriate use of all medications including, but not limited to, antipsychotics. This column in the future will detail how pharmacists can help address these concerns. CfA

Dr. Brandt is a professor of geriatric pharmacotherapy, pharmacy practice and science at the University of Maryland School of Pharmacy, and director of clinical and educational programs of the Peter Lamy Center for Drug Therapy and Aging, Baltimore. She is the president-elect of the American Society of Consultant Pharmacists (ASCP). She seeks to optimize the care of older adults through educational, clinical, and health care policy.

Teamwork needed To improve Medication Safety in PA/LTCBy Nicole J. Brandt,

PharmD, MBA, CGP, BCPP, FASCP

N e w s F r o m t h e s o c i e t y ™

CARingfoRTHEAgES.CoM CARing foR THE AgES • 23

May 5-6, 2015 NYMDA Spring 2015 Meeting Albany, NY Website: nymda.org/educational- meetings/spring-2015-meeting/

May 14-17, 2015 SHEA Spring 2015: Science Guiding PreventionOrlando, FL Website: http://shea2015.org/

May 15-17, 2015AGS 2015 Annual Scientific MeetingNational Harbor, MDWebsite: www.ameri-cangeriatrics.org/annual_meeting/

June 6-10, 2015 NADONA 28th Annual Conference Atlanta, GA Website: www.nadona.org

June 16, 2015 AMDA Live Webinar: The Pitfalls of EMRs Contact: AMDA Registrar Phone: 410-992-3116Email: registration@amda.com Website: www.amda.com/cmedirect/#web

June 22-23, 2015Geriatric/Elder Trauma Management ConferenceVancouver, British Columbia, Canada

Contact: Tracy AhearnPhone: 813-658-2563Email: Tracy.ahearn@ghpnetwork.com

July 18-24, 2015 AMDA Core Curriculum on Medical Direction in Long- Term CareBaltimore, MD Contact: AMDA RegistrarPhone: 410-992-3116 Email: registration@amda.com

September 30-October 3, 2015GAPNA: Annual ConferenceSan Antonio, TXContact: Jill BrettPhone: 866-355-1392Email: gapna@ajj.com Website: www.gapna.org

October 22-25, 2015FAMDA Best Care Practices in the Geriatrics ContinuumLake Buena Vista, FL Website: www.bestcarepractices.org/index3.html

March 17-20, 2016AMDA – The Society for Post-Acute and Long-Term Care Medicine 2016 Annual Conference Kissimmee, FLContact: AMDA Registrar Phone: 410-992-3116Email: registration@amda.comWebsite: www.paltcmedicine.org

ImportantDates

As part of AMDA’s participation in the American Board of Inter-

nal Medicine (ABIM) Foundation’s Choosing Wisely campaign, the So-ciety recently released five additions to its list of medical tests and proce-dures common in PA/LTC that may be unnecessary or even cause harm. AMDA published its first set in 2013.

Choosing Wisely is an initiative led by the ABIM Foundation to support and engage physicians as better stewards of finite health care resources. Participating societies such as AMDA have developed lists relevant to their specific care set-tings and patient populations to encour-age discussions that help patients make wise care choices. Consumer Reports is also a partner of the initiative working with participating organizations, includ-ing AMDA, to develop consumer tools based on recommendations.

AMDA’s recommendations (6-10 are newly released):1. Don’t place an indwelling uri-nary catheter to manage urinary incontinence.

2. Don’t recommend screening for breast, colorectal, or prostate cancer if life expectancy is estimated to be less than 10 years.3. Don’t obtain a Clostridium difficile toxin test to confirm “cure” if symp-toms have resolved.4. Don’t recommend aggressive or hospital-level care for a frail elder without a clear understanding of the individual’s goals of care and the possible benefits and burdens.5. Don’t initiate anti-hypertensive treat-ment in individuals aged 60 years and older for systolic BP less than 150 mm Hg or diastolic BP less than 90 mm Hg.

The directives released in 2013:1. Don’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings.2. Don’t use sliding scale insulin for long-term diabetes management for

individuals residing in the nursing home.3. Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.4. Don’t prescribe antipsychotic medi-cations for behavioral psychological symptoms of dementia in individuals with dementia, without an assess-

ment for an under-lying cause of the behavior.5. Don’t routinely prescribe lipid-lowering medica-tions in individuals with a limited life

expectancy. AMDA Clinical Practice Committee

Chair Gwendolen T. Buhr, MD, MEd, CMD, who oversaw the develop-ment of the new items, uses the list to influence relationships between providers and patients. “AMDA is committed to improving the qual-ity of post-acute and long-term care. We believe the discussions between

patients and providers that will be stimulated from the items on this list will bring great progress toward our goal of always delivering the highest quality care.”

Daniel B. Wolfson, ABIM Foundation vice president and chief operating officer, lauded AMDA’s efforts. “More than 70 specialty soci-eties have joined Choosing Wisely, and many, like AMDA, are expanding on their original lists of overused tests, treatments, and procedures clinicians and patients should talk about. The more than 350 collec-tive recommendations from our Choosing Wisely partners illustrates the pervasiveness of unnecessary care in our health care system, and it’s through the leadership of organi-zations like AMDA that we are mak-ing real progress to reduce waste and improve care for patients across the country.”

For more information, go to www.amda.com/tools/choosingwisely.cfm. CfA

AMDA Adds to Choosing Wisely List

AMDA has announced its 2015-2016 board of directors, and Naushira

Pandya, MD, CMD, is the new presi-dent. An AMDA member for 15 years, she has served in numerous leader-ship positions including as chair of the AMDA Clinical Practice Guideline Steering Committee and the Clinical Practice Committee. She has been instrumental in the development of sev-eral AMDA Clinical Practice Guidelines. She also is active in her state chapter, the Florida Medical Directors Association.

Dr. Pandya is the chair of the Department of Geriatrics and a pro-fessor at Nova Southeastern College of Osteopathic Medicine. She is board certified in internal medicine, geriat-rics, and endocrinology.

“We are very fortunate to have such an excellent group of experienced, passionate and visionary leaders to move our organization forward in an evolving health care landscape,” said AMDA Executive Director Christopher Laxton, CAE.

Other members of the 2015-2016 AMDA Board of Directors:

▶▶ President-Elect: Susan M. Levy, MD, CMD, AGSF, Bethany Beach, DE

▶▶ Vice President: Heidi K. White, MD, MHS, MEd, CMD, Durham, NC

▶▶ Immediate Past President: Leonard Gelman, MD, CMD, Ballston Spa, NY

▶▶ Chair, House of Delegates: Milta O. Little, DO, CMD, St. Louis, MO

▶▶ Secretary: Daniel Haimowitz, MD, CMD, Levittown, PA

▶▶ Treasurer: Arif Nazir, MD, CMD, of Indianapolis, IN

▶▶ State Presidents Council Representatives to the Board: Thomas Lehner, MD, CMD, Cleveland, OH; Karl Steinberg, MD, CMD, Oceanside, CA; Meenakshi Patel, MD, CMD, FACP, MMM, CMD, Centerville, OH

▶▶ Board Representatives – House of Delegates: Michele Bellantoni, MD, CMD, Baltimore, MD; Kevin W. O’Neil, MD, CMD, Sarasota, FL; Sabine von Preyss-Friedman, MD, CMD, Seattle, WA CfA

AMDA Announces 2015-2016 Board of Directors

Don’t Miss These Events

in action

Outgoing President Leonard Gelman, MD, CMD, and President Naushira Pandya, MD, FACP, CMD, seemed to be everywhere during the AMDA meeting.

Coming in JuneCouldn’t make the meeting? We’ve got you covered. Look for more exclusive coverage from the AMDA Annual Conference in the June issue.

T I M E L I N EA P R I L 1 6 , 2 0 1 5Abstract Submission Site Opens

J U LY 1 6 , 2 0 1 5Deadline for Oral Presentation Submissions

S E P T E M B E R 3 0 , 2 0 1 5Deadline for Model Programs and Polices Swap Submissions

O C T O B E R 2 8 , 2 0 1 5Deadline for Poster Abstract Submissions

The Annual Conference Program Planning Committee

invites you to submit abstract proposals for AMDA – The

Society for Post-Acute and Long-Term Care Medicine

Annual Conference 2016.

™

AMDA’S ANNUAL CONFERENCE 2016 THE SOCIETY FOR POST-ACUTE AND LONG-TERM CARE MEDICINE

Submit online at https://amda2016.abstractcentral.com.

M A RC H 1 7-20 , 20 1 6 • O R L A N D O, F L Gaylord Palms Resort & Convention Center

Call for Abstracts

T A R G E T A U D I E N C EThe program is designed for medical directors, attending physicians, physician assistants, nurse practitioners, nurses, administrators, consultant pharmacists and other professionals practicing in the post-acute/long-term care continuum. Medical students, interns, residents and fellows planning a career in geriatrics are also encouraged to attend.

S U G G E S T E D T O P I C SAMDA welcomes submissions on all topics pertinent to post-acute/long-term care medicine and medical direction. Emerging clinical information, best practices in management and medical direction, research, innovations in non-pharmaceutical modification of challenging behaviors, and updates on approaches to regulatory compliance, are areas of interest. AMDA also seeks proposals that emphasize strategies for successful cooperation with consultant pharmacists and administrators as well as the entire interdisciplinary team.

Attendees expect clinical topics to be evidence-based with cited references and management topics to be relevant to their setting and grounded in best practices. For their learning experience, attendees seek opportunities to network with colleagues and engage in interactive presentations through various formats such as point-counter point, case-based discussion (Q&A), small group and/or role play, and practical information for valuable take home tools such as handouts, key points, guides or quick tips.

H O W T O S U B M I TTo submit an oral proposal or abstract for the 2016 conference or for more information, please go to https://amda2016.abstractcentral.com. All abstracts must be submitted via the abstract submission site.

Q U E S T I O N S ?Contact AMDA at llang@amda.com or call 410-992-3129.