Long Term Care Past, Present, and Future Daniel Swagerty, MD, MPH, CMD AMDA Foundation Chair.
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Long Term CarePast, Present, and Future
Daniel Swagerty, MD, MPH, CMD AMDA Foundation Chair
ThemesHealth Care Delivery is changingNursing Facilities are transforming from
sites of custodial care into sites of high intensity care for sick, complex patients
Expectations are risingMuch more is and will be expected of
facilities, attending physicians, and medical directors
ThemesLong-Term Care Medicine is a legitimate
specialtyMore and more care will be provided by
fewer practitionersAMDA is committed to meeting the needs
of LTC practitioners for information, education, support, advocacy, and recognition
LTC: Past
“Rest Homes” The road to the nursing home is said to be ONE WAY
Custodial care for patients with severe cognitive impairment, functional impairment, or both
Physicians absent or inadequate Skilled care absent or low intensity
LTC: Present Form follows finance: Increased focus on shorter-term
‘skilled care’ = increased revenue/profit for facilities Patients discharged from hospital ‘sicker and quicker’ with
greater and more acute needs Frequent mismatches between patient and family
needs/expectations and available resources– Rapid access to pain medications, availability of
physicians, information from hospitals, provider skills, etc.
– The job of nurses and doctors are different from the job for which they were trained
Increased governmental/payor emphasis on quality measures, especially for issues/areas of high cost (hospital readmission rates, antipsychotic drug use)
Common Care Delivery Problems in SNFHospital Related Issues
Facility not able to provide necessary, appropriate or desired care – Lack of communication/ handoff of care between hospital/LTC
physicians, staff– Inadequate medication reconciliation in hospital = Prescribing
errors– Unprofessional practices in hospital
Lying about patient care needs or omitting important facts in order to get SNF to accept patient
– Failure of hospital to provide medication and treatments on day of transfer resulting in pain and other acute problems upon arrival to SNF
Common Care Delivery Problems in SNF Hospital Related Problems
Inappropriate and/or unnecessary care in hospital - Excessive medication doses, chemical/physical restraints, PPIs, heparin
Inadequate patient communication – Lack of accurate explanation of patient diagnoses,
prognosis, hospital course, goals by hospital staff with unrealistic expectations created
Ignorance of health care delivery, SNF Care, regulatory environment by hospital staff with unrealistic expectations created
Failure to provide specialty physician follow-up
Common Care Delivery Problems in SNFFacility Related Problems
Lack of preparation/planning at facility to begin care– Necessary equipment, narcotic and other medications
not quickly available in SNF– Lack of communication with families
Realistic expectations for care, likely outcomes, timeline, goals, preferences including advance directives, identification of decision maker with contact information
Lack of physician availability at SNF – Assess patient, meet with family, provide orders
Lack of availability of facility staff at peak admit times – Begin care in timely manner and inspire confidence in patients/
families
Overpromising and underdelivering
Common Care Deliver Problems in SNF Ongoing Care Concerns
Gaps in resources, communication, and collaboration of greatest concern
Movement of sick, complex patients into facility has proceeded faster than the movement of resources into facility to provide necessary care
Mismatch between patient needs and available staff /other resources – Ability to accurately assess patients with changing
conditions
Common Care Deliver Problems in SNF Ongoing Care Concerns
Ability to respond quickly to meet changing care needs – IVs, labs, medications– Ability to monitor sick or unstable conditions continuously for an
extended time
Skill set of providers often lacking – Assessment skills, communication skills, geriatric prescribing, and
knowledge of regulations
Inconsistent provision of care due to variable attitudes, knowledge, and skills of staff
Common Care Delivery Problems in SNFOngoing Care Concerns
Poor communication/teamwork between disciplines
Poor communication/teamwork between facility and family
Poor communication/teamwork between physicians
Poor availability of physician services
Common Care Delivery Problems in SNF Attending Physicians
Often unavailable/busy elsewhere– Not part of the team
On-call or covering physicians may be unqualified and/or unwilling to provide orders, see patient, be responsive
May be ignorant of regulatory issues, Medicare coverage/payment issues
Common Care Delivery Problems in SNF Attending Physicians
May be ignorant of health care delivery/LTC processes of care
Failure of facility staff to plan and/or communicate may result in emergencies for physicians (e.g. running out of narcotic pain medication after hours)
Lack of accountability to facility administration and medical director
Common Care Delivery Problems in SNF Medical Directors
Many facilities don’t know what to do with a (good) medical director
Many medical directors don’t know what to do with themselves, other than accept new admissions
Lack of awareness of medical director responsibilities Lack of availability/willingness to fulfill
roles/responsibilities required by regulations
Current Trends Facilities want more complex patients, fewer custodial care patients
– Facilities want to offer more services i.e. cardiac monitoring – More SNFs providing post-acute care only; no long-term care
Need physician services continues to rise as a result– Increased interest in full-time LTC physicians nationwide among
both facilities and physicians Greater scrutiny of quality and cost as overall health care costs rise
– Atypical antipsychotic drug use in dementia will be actively discouraged (> $15 billion /yr vs $4 billion/yr for LTC practitioner compensation)
– Hospital readmission rates scrutinized– Rehabilitation outcome measures being introduced
Reduced access for certain patients (Medicaid patients with dementia)
LTC : Future
Facilities, patients, families, regulators, others will expect more of attending physicians and medical directors
Quality assurance/Process Improvement (QAPI) a CMS requirement of SNFs
Physicians must expect more of themselves Physicians involved in LTC need more from facilities
– Teamwork, support, qualified staff, communication, etc AMDA must meet the needs of physicians and other LTC
professionals in order to fulfill mission of improving quality
LTC : Future
Emergence of LTC specialists (a la Hospitalists)– Fewer physicians overall, providing more care to more
SNF patients– Full-time practitioners in nursing facilities– Increasingly will be employees of NH chain or LTC
physician group– Specific set of competencies required -
Knowledge/skills/attitudes/behaviors– Attractive compensation and lifestyle compared to
hospital and office-based primary care practice
LTC : Future
Greater emphasis on patient outcomes– Reporting of outcomes
Changing payment structures to incentivize quality, preferred outcomes, resource utilization
Greater scrutiny of costs, service utilization (esp. rehabilitation and medications), and quality measures
LTC : Future
Labor shortages (especially for lower wage workers) will create greater challenges for facilities
Greater involvement and scrutiny by family members– Use of internet
Role of hospital diminishing- May be bypassed in future
Less access for custodial care in NH, especially Medicaid patients with dementia
AMDA
Mission is to promote quality LTC AMDA uniquely concerned about meeting
needs of patients, families, and practitioners in LTC – What do patients/families need?– What do LTC practitioners need in order to meet
patient/family needs and improve quality of care ?
What Is AMDA doing for you?
Education– Providing information/education to medical directors,
LTC practitioners to achieve clinical, administrative excellence, thrive in changing environment
– Articulating Core Competencies and developing training materials related to those competencies for attending physicians and NPs
– Clinical Practice Guidelines– Education materials for nurses and other disciplines,
such as “Know it All Before You Call” cards to enhance assessment and communication skills
What Is AMDA doing for you?
Education– Annual Education Symposium : March, 2013
Gaylord Hotel - Suburban Washington DC– Core Curriculum in Medical Direction– Advanced Course on Medical Direction
What is AMDA doing for you?
Development of broader menu of focused educational offerings– On line, self paced– Related to core competencies
Education to support teamworkEducation for interdisciplinary team
members
What is AMDA doing for you?
Internal Reorganization:– New CEO fall 2012– Complete reassessment of organizational effectiveness– Strategic planning 2012/2013 to identify member
needs, develop new products, and services to meet those needs
– Increased support of state chapters– Needs assessment of members– Enhancement of products and services to meet those
needs
What Is AMDA Doing for You ?
Advocacy Public Policy: Monitoring and influencing external
environment (government, consumers) in a strategic way to improve care and careers in LTC
Demonstrate value of CMD to Government, Industry, and public
Demonstrate value of Competence in LTC Medicine to government, industry, and public
Enhance recognition of CMDs and Competencies in LTC Medicine
What Is AMDA Doing for You ?
Advocacy Strong advocacy for payment to LTC practitioners Provide invaluable expertise to CMS and other
others in regulations, standards, quality promotion, and measurement
Position ourselves as advocates for patients in order to improve care and enhance our role
What is AMDA Doing for You:
Mentorship and Career support Increased reimbursement for LTC service codes Develop LTC workforce
– AMDA Futures program– Supportive network of LTC professionals– AMDA Foundation Capital Campaign
Increased recognition for LTC practitioners and CMDs
What is AMDA Doing for You:
Pursue other benefits and opportunities for members
Health information technologies/ EMR/e-prescribing for LTC
Set research agenda for LTC Evaluate effectiveness of CPGs Define quality in LTC population/setting
Summary – General
Health care delivery rapidly changingStatus quo not an optionTremendous opportunities and challenges in
LTCLTC is considered a solution, not a problem
in health care reform
Summary - AMDA
Professional society for LTC practitioners One “Stop Shop” for LTC and Medical
Director educationShape long-term care delivery by
emphasizing quality and advocating for LTC practitioners and consumers
Providing all of the necessary tools for excellence and professional satisfaction
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