Nursing Home Pearls or

Nursing Home Pearls or How to Enjoy Practicing in Skilled Nursing Facilities Lowell C. Dale, MD November 11, 2016 2016 MFMER slide-1

DISCLOSURE Relevant Financial Relationship Medical Director Golden Living Center Rochester East Golden Living Center Rochester West Off Label Usage None 2016 MFMER slide-2

Learning Objectives 1. Provide examples of strategies that can create a more rewarding nursing home practice 2. Discuss concepts in medication management that are particularly relevant to the nursing home practice 3. Describe two resources available to enhance our nursing home practice 2016 MFMER slide-3

February 2014 OIG Report 653 Medicare Beneficiaries discharged from hospitals to SNF s for post-acute care 2008-2012. SNF stays were 35 days or less 22% experienced adverse events 11% more experienced temporary harm events 1.5 % experienced events contributing to their deaths Over 50% were hospitalized because of the event 59% were clearly or likely preventable 2016 MFMER slide-4

February OIG Report (cont) Three Clinical Categories Medications (37%) Ongoing Resident Care (37%) Infections (26%) 2016 MFMER slide-5

February OIG Report (cont) Attributed events of preventable harm Primarily to: Substandard Treatment Inadequate Resident Monitoring Failure or Delay of Necessary Care 2016 MFMER slide-6

U.S. Demographics 14,800 Skilled Nursing Facilities 67% for profit 27% non-profit 6% government run 1.7 million beds Average occupancy 85% 50-66% of revenue comes from Medicaid 2016 MFMER slide-7

A Heterogeneous Population Short Term Stayers (< 6 months) Terminally ill Acute rehabilitation Subacute care Long Term Stayers Cognitively impaired Physically and cognitively impaired Physically impaired 2016 MFMER slide-8

A Multidisciplinary Team Executive Director Director of Nursing RNs LPNs TMAs CNAs Social Worker Activities Director Dietician Pharmacist Education specialist Infectious disease coordinator Housekeepers Custodian MD/DO, NP/PA 2016 MFMER slide-9

Overarching Goal PROMOTE or MAINTAIN the highest practicable physical, functional and psychosocial well being of the people that reside in these facilities 2016 MFMER slide-10

What it takes to make this work Investment in the facility: time and interest Respect for facility staff and what each of them does in caring for the patient Expect professionalism Be a Mentor, not an adversary Flexibility 2016 MFMER slide-11

RESPECT Establish a schedule for visits and be on time Say Hello : To ALL the staff Encourage staff participation on rounds but structure them so it is an efficient use of their time and yours Review labs, Sign orders and other documents in a timely manner 2016 MFMER slide-12

Expect Staff to be Professionals Prepared for your visits: Vitals, clinical information, orders, medication administration record, etc. Prepared when you are called with concerns (e.g. SBAR) Perform at the highest level of their licensure Carry out your orders correctly 2016 MFMER slide-13

INTERACT Interventions to Reduce Acute Care Transfers Quality Improvement Program focusing on management of acute change in long term care residents conditions Clinical tools Education tools Strategies for everyday care Focus on: Early Identification of Change Assessment Documentation Communication 2016 MFMER slide-14

INTERACT http://interact2.net/docs/publications/overview%20of%20i NTERACT%20JAMDA%202014.pdf INTERACT Quality Improvement Project: An overview for medical directors and primary care clinicians in Long Term Care. Ouslander JF, Bonner A, Herndon L, Shutes,J. JAMDA 15(2014): 162-170. 2016 MFMER slide-15

INTERACT 17-24% reduction in all cause hospitalizations over six months [Ouslander JG, et. al. JAMDA 2009;10:644-652] Version 3.0: NIH funded randomized, controlled Quality Improvement Implementation Project involving 250 Nursing Homes in the USA 2016 MFMER slide-16

INTERACT SBAR http://interact2.net/docs/interact%20version%203.0% 20Tools/Communication%20Tools/Communication%20 Within%20the%20Nursing%20Home/INTERACT%20SB AR%20Form%20v8%20Jan%2014%202013.pdf A structured evaluation of the change in condition Prepare the nurse for and structure the communication with the provider (YOU) 2016 MFMER slide-17

Improving Our Patient Care Experience Give yourself time to be with them Pull up a chair--or ask permission to sit beside them on the bed Acknowledge family that may be with them Direct questions to the resident first (family later) Find out who they are the Social History Explore their values and goals 2016 MFMER slide-18

Random Clinical Tips Appreciate Sensory Deficits especially Vision and Hearing Examine their mouths/dentition Check their skin, especially Feet Bottoms 2016 MFMER slide-19

Medication Management Any symptom in an elderly person should be considered a medication side effect until proven otherwise! 2016 MFMER slide-20

Use Medications Only if Helps promote or maintain the highest practicable physical, functional and psychosocial well-being of the person... With risks for adverse effects or negative outcomes due to the medication minimized 2016 MFMER slide-21

Look for Unnecessary Medications Excessive Dose Excessive Duration Without adequate monitoring Without adequate indication for use Without use or consideration of non-pharmacologic interventions In the presence of adverse effects which indicates need to decrease or discontinue 2016 MFMER slide-22

Medication Management: Key Considerations Indications for Use Diagnosis Consistent with goals of care Dosage Duration Monitoring: effectiveness, continued need, side effects, drug/drug interactions Tapering/gradual dose reduction Prevent, identify, respond to adverse effects 2016 MFMER slide-23

Antibiotic Prescribing for Urinary Tract Infections Without Urinary Catheter At least one of the following: acute dysuria or acute pain, swelling, tenderness of male genital organs/prostate Fever or leukocytosis And at least one of the following: Flank tenderness Suprapubic pain Gross hematuria New or marked increase: incontinence, urgency, frequency (If no fever or leukocytosis, then two or more of above) 2016 MFMER slide-24

Antibiotic Prescribing for Urinary Tract Infections Without Urinary Catheter Clean catch voided urine and positive culture with no more than 2 species of bacteria, at least one of which is bacteria of at least 100,000 CFU/ml Specimen collected by in-and-out catheter and positive culture with any bacteria, at least one of which is bacteria of at least 100 CFU/ml http://www.cdc.gov/nhsn/pdfs/ltc/ltcf-uti-protocol-current.pdf 2016 MFMER slide-25

Antibiotic Prescribing for Urinary Tract Infections With Urinary Catheter At least one of the following Fever, rigors, or new onset hypotension Either acute change in mental status or functional decline New-onset suprapubic pain or flank tenderness Purulent discharge from around the catheter or acute pain, swelling, tenderness of male genitalia/prostate And the following Urinary catheter specimen culture with any bacteria, at least one of which is at least 100,000 CFU/ml http://www.cdc.gov/nhsn/pdfs/ltc/ltcf-uti-protocol-current.pdf 2016 MFMER slide-26

Gradual Dose Reduction Psychopharmacological Medications Within the first year of admission or first use, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts, unless clinically contraindicated After the first year, a GDR must be attempted annually, unless clinically contraindicated 2016 MFMER slide-27

Choosing Wisely - AMDA Don t insert Feeding Tubes in individuals with advanced dementia Don t use Sliding Scale Insulin for long-term diabetes management Don t obtain a urine culture unless clear signs and symptoms that localize to urinary tract Don t prescribe antipsychotic medications or behavioral and psychological symptoms of dementia without assessing for underlying cause of the behavior Don t routinely prescribe lipid lowering medications if limited life expectancy 2016 MFMER slide-28

Hospice in the Nursing Home ¼ of older Americans die in nursing homes each year, including nearly 70 percent of individuals with advanced dementia 1/3 of all nursing home decedents now use the Medicare hospice benefit before death Hospice use in NHs is associated with decreased unnecessary therapies, fewer hospitalizations, improved pain and symptom management, and higher family satisfaction with care 2016 MFMER slide-29

AMDA The Society for Post-Acute and Long-Term Care Medicine http://www.paltc.org/ 2016 MFMER slide-30

The Blessings of a Nursing Home Practice Caring for people who truly need our help An opportunity for continuity of care Strengthen our clinical skills working with complex problems physical, cognitive, psychosocial Working with an interdisciplinary team of professionals Emphasis on continual quality improvement 2016 MFMER slide-31

Other Pearls? Questions? 2016 MFMER slide-32

Learning Objectives 1. Provide examples of strategies that can create a more rewarding nursing home practice 2. Discuss concepts in medication management that are particularly relevant to the nursing home practice 3. Describe two resources available to enhance our nursing home practice 2016 MFMER slide-33

Overarching Goal PROMOTE or MAINTAIN the highest practicable physical, functional and psychosocial well being of the people that reside in these facilities 2016 MFMER slide-34