THE TEAM TO IMPROVE CARE

THE TEAM TO IMPROVE CARE For SNFs, meeting the challenges posed by accountable outcomes requires the effective collaboration of a comprehensive, multi-disciplinary team. Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD and Corey L. Cusack, PhD 18 The Director Special 2016 Conference Issue

EDITOR S NOTE: This article is meant to open a dialogue on what a comprehensive LTC team should include. As such this is not an all encompassing list, but rather we would appreciate your thoughts on additional roles and responsibilities that you consider critical to your facility s LTC team. Email your feedback and input to: hudson.garrett@nadona.org The nursing home team has changed drastically over the past few years. The challenges of today s accountable outcomes for SNFs, which include measurable results such as hospitalization and psychotropic utilization rates, can only be met through the effective collaboration of a comprehensive team of professionals from many different disciplines. Instead of just a few health providers working in silos, healthcare providers in nursing homes need to combine their diverse experiences, knowledge, and skills to consciously work together to achieve better quality care. 1 Teamwork is critical to reaching key goals in LTC 2,3 yet there is no comprehensive approach to care coordination for many individuals and caregivers. 1 Good teamwork in nursing facilities creates a positive environment, encourages healthy relationships among coworkers, and lightens the burden on all members of a team. 1 Effective teams also provide more consistent, higher quality care to patients. 1 If a staff believes in a vision of quality care and can effectively communicate that vision, then everyone will always be working towards the same goal even if some team members leave and newcomers join. 1 Capitalizing on the passion that many LTC workers have for caring for older adults will also help create a strong team. 1 Specific practices have been shown to promote teamwork in long-term care. First, demonstrating commitment to training and development is key. SNFs should invest in training that Special 2016 Conference Issue The Director 19

goes beyond the minimum mandated regulations and tailor training to individual needs; this practice also involves utilizing mentors to support new workers, model appropriate behaviors, and demonstrate positive attitudes that facilitate effective communication and collaboration between team members. 2,3 Another important team-building practice involves flexible and team-oriented management. Managers should consider the unique characteristics and circumstances of their facilities when deciding to implement certain changes in addition to seeking out input from workers before making any changes. 2,3 Also, SNFs should have a mechanism in place to provide regular feedback to workers and acknowledge their positive contributions to the facility. Rather than limiting feedback opportunities to disciplinary situations, directors and managers should provide consistent, constructive feedback to foster positive working relationships and support career growth. 2,3 Managers should consider the unique characteristics and circumstances of their facilities when deciding to implement certain changes in addition to seeking out input from workers before making any changes. There is likely a symbiotic relationship between teamwork and management in LTC; good teamwork is associated with training, management style, and feedback, yet teamwork may strongly and directly influence these specific practices. 3 Thus, from a director s perspective, providing thoughtful leadership and implementing team-oriented policies are practices that will likely improve the SNF environment and ultimately contribute to more positive patient, worker, and facility outcomes. THE INTERDISCIPLINARY TEAM SNFs employ an interdisciplinary team of healthcare professionals who assess, coordinate, and manage each resident s comprehensive health care, including his or her medical, psychological, social, and functional needs. 4 This practice is mandated in SNFs, and the roles and descriptions of diverse specialists are detailed in the tables below and pages 21-23. 4,5 TEAMWORK The Interdisciplinary Team (IDT) approach to caring for patients includes many professionals performing a variety of specialized functions designed to meet the physical, emotional, and psychological needs of the patient. The collaborative efforts of the members are focused on delivering patientcentered coordinated care. A number of experts have said that IDT collaboration improves safety and quality of care (Robert Wood Johnson Foundation, 2010). This approach can be used to optimize individual resident management assuring appropriate use of antipsychotic medications, which should result in the CMS goal of a 15% reduction. The goals for this team are as follows: Prevent initiation of inappropriate use of psychotropic medications to residents. Taper and discontinue inappropriate psychotropic medications, to ensure that use of the medications is appropriate and that monitoring and documentation are properly conducted. Improve disruptive behaviors while limiting/diminishing the use of psychotropic medications, by educating and encouraging prescribers and nursing facility staff to adopt a more structured and broader approach to management of behavioral symptoms. The team approach to management of older adults with disruptive behaviors should emphasize certain key principles: Individuals who exhibit disruptive symptoms should be thoroughly assessed by a qualified health professional. The assessment should seek to identify possible underlying causes that may contribute to disruptive symptoms, so that treatment can target the underlying cause. Disruptive symptoms should be objectively and quantitatively monitored by caregivers or facility staff and documented on an ongoing basis. If the behaviors do not present an immediate and serious threat to the patient or others, the initial approach to management should focus on environmental modifications, behavioral interventions, psychotherapy, or other nonpharmacologic interventions. ADMINISTRATIVE 6 Nursing Home Administrator Medical Director As the managing officer of the facility, it is the administrator s responsibility to plan, organize, direct, and control the day-to-day functions of a facility and to maintain the facility's compliance with applicable laws, rules, and regulations. The administrator shall be vested with adequate authority to comply with the laws, rules, and regulations relating to the management of the facility. Roles and responsibilities of the medical director in the nursing home can be divided into four areas: physician leadership, patient care-clinical leadership, quality of care, and education. Nursing facilities are required to have a medical director as outlined in OBRA 87. Typically a certificate program of about 120 hours is required before sitting for a licensing examination. Most are required to have completed a bachelor degree program as well as preceptor training as a NHA. Currently Maryland is the only State that requires Medical Directors to be a Certified Medical Director (CMD) in Long Term Care or have similar training. CMD was established by the American Medical Directors Association to professionalize the field of medical direction. 20 The Director Special 2016 Conference Issue

When medications are indicated, an appropriate agent should be selected only after consideration of the underlying diagnosis or condition, effectiveness of the medication, and risk of side effects. While developed for antipsychotic medications, these practices should be applied to all classes of medications when managing pharmacotherapy in older adults. 8 SNFs are highly regulated, interdisciplinary environments with a steadily growing need for healthcare provider specialization due to increasing patient acuity. 7 People are living longer with conditions, though oncefatal, still cause substantial health problems and result in greater long-term healthcare resource utilization by older Americans. 2 Hospital stays are becoming briefer as higher numbers of patients transition to SNFs for post-acute care; this change means that SNFs are providing a more critical service in the continuum of patient care. 2 The unique roles and responsibilities provided by members of the SNF teams will help prevent hospital readmissions and enhance the overall quality of care, but this can only occur if each member functions as a part of a collaborative and effective team. References 1. Teamwork in long-term care: A winning strategy for caregivers. Nursing Assistant Monthly. June 2009;14(6):1-4. 2. Larson R. Teamwork: Why It Matters, What Makes It Thrive. PHI National Website. http://phinational.org/blogs/teamwork-why-it-matters-what-makes-it-thrive. July 27, 2011. Accessed February 29, 2016. 3. Tyler, Denise A., Parker, Victoria A. (2010) Staff teamwork in long-term care facilities: the influence of management style, training and feedback. Research in Gerontological Nursing. 2010;4(2):135-146. 4. Stefanacci R, Brown G, Reich S. Behind the Scenes at Nursing Facilities. In: Fenstemacher PA, Winn P, eds. Post-Acute and Long-Term Medicine. 2nd ed. Springer International Publishing; 2016:51-72. 5. Lax JR, Gossett D. Physicians and Long Term Care: Current and New Models of Integration, the Regulatory Framework, and Reimbursement Part I. https://www. healthlawyers.org/events/programs/materials/documents/ltc12/papers/h_lax.pdf. January 30, 2012. Accessed February 7, 2016. 6. Stefanacci R, Cusack CL. (2016) The LTC Team of the Future. Annals of Long-Term Care. 7. Zigmond J. SNFists at work: nursing home docs patterned after hospitalists. Modern Healthcare. 2012;42(13):32-33. 8. Stefanacci RG. Pharmacotherapy Principles in Older Adults. Chapter in Pharmacotherapeutics for Advanced Practice Andrew Peterson Editor. 2015. In press PRIMARY CARE PROVIDERS 6 Attending Primary Care Physician Physician Assistant (PA) Nurse Practitioner Responsibility for initial patient care and support discharges and transfers. Also make periodic, pertinent on-site visits to patients and insure adequate ongoing coverage. PAs communicate closely with the primary care physician, patients, and their families to coordinate treatment and guide patient management. PAs have become increasingly incorporated into the LTC team, performing follow-up, acute, and regular care visits. Their generalist training and emphasis on patient relationships make them qualified for essential patient care responsibilities and help them bolster patient and family morale. Advanced practice nurses who provide high-quality healthcare services similar to those of a doctor. NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education and counseling. In addition to 4 years of medical school most nursing home attending physicians complete a primary residency, which is typically 1 3 years. Some go on to complete a geriatric fellowship as well. Following undergraduate coursework in science, PAs complete a 2-3 year master s degree in an accredited PA program. PAs need to pass the Physician Assistant National Certifying Exam (PANCE) and obtain a state license before they can practice. PAs can also specialize in specific fields by obtaining additional board certification. The entry-level training for NPs is a graduate degree. At this time, NPs complete a master s or doctoral degree program. This means that NPs earn a bachelor s degree in nursing (4 years of education), then their graduate NP degree (2-4 years of education). SOCIAL WORKER 6 Attending Primary Care Physician Social workers assist people by helping them cope with issues in their everyday lives, deal with their relationships, and solve personal and family problems. All States and the District of Columbia have licensing, certification, or registration requirements regarding social work practice and the use of professional titles. Although standards for licensing vary by State, a growing number of States are placing greater emphasis on communications skills, professional ethics, and sensitivity to cultural diversity issues. Most States require 2 years (3,000 hours) of supervised clinical experience for licensure of clinical social workers. Special 2016 Conference Issue The Director 21

SPECIALTY CONSULTANTS 6 Consultant Pharmacist Podiatrist Psychologist Wound Care Specialist Dietitian Focuses on reviewing and managing the medication regimens of patients, particularly those in institutional settings such as nursing homes. Consultant pharmacists ensure their patients medications are appropriate, effective, as safe as possible and used correctly; and identify, resolve, and prevent medication-related problems that may interfere with the goals of therapy. Podiatrists diagnose and treat disorders of the foot, ankle, and related structures of the leg. Podiatrists perform patient evaluations and design treatment plans. Proper care of foot and ankle problems can significantly improve the quality of life for patients who already face reduced mobility due to age and other health conditions. A growing number of clinical/counseling psychologists, geropyschologists, rehabilitation psychologists, and neuropsychologists address behavioral needs of patients in LTC. Psychologists from different specialties support the care of patients struggling with depression, anxiety, dementia, and other mental health conditions. Different healthcare providers are trained in the care and treatment of various types of acute and chronic wounds. The most commonly treated wounds are those sustained from an injury, surgical wounds, diabetic wounds, and sores, as well as wounds that will not heal. Nurses provide an initial assessment and plan of care, often cleaning, treating, and dressing wounds in addition to educating patients and families about continuing wound care at home. Physicians are instrumental in coordinating communication and therapy among wound care specialists, and physical therapists specialize in treatment modalities such as ultrasound and compression therapy, among others. Plan food and nutrition programs, supervise meal preparation, and oversee the serving of meals. They prevent and treat illnesses by promoting healthy eating habits and recommending dietary modifications. They perform nutrition screenings for their clients and offer advice on diet-related concerns such as weight loss and cholesterol reduction. The Doctorate of Pharmacy (Pharm.D.) is the only professional Pharmacy degree, and the five-year Bachelors of Science in Pharmacy is being phased out as a professional degree. Since this program traditionally follows two years of Pre-Pharmacy education, students typically take six years of post-secondary education to obtain their Pharm.D. Doctors of podiatric medicine (DPMs) complete 4 years of training in a podiatric medical school and 3 years of hospital residency. Podiatrists can specialize in areas such as surgery, sports medicine, wound care, or diabetic care. Typically a bachelor s degree in psychology or clinical psychology is required, followed by a master s and/or doctoral degree in clinical psychology. A wound care specialist must accrue at least 3 years of experience in wound care and pass a written exam to prove their specialized knowledge and competence. Wound care specialization status requires continuing education credits and periodic re-certification testing. At least a bachelor s degree. Licensure, certification, or registration requirements vary by State. NURSING 6 Certified Nurses Aid (CNA) Licensed Practical Nurse CNAs work under the supervision of a nurse and provide assistance to patients with daily living tasks. Licenses practical nurses provide the patient care on a very personal level. They usually report directly to physicians and RNs, and are usually responsible for taking vitals and monitoring in-and-out volumes, treating common conditions like bedsores, and preparing or performing several procedures such as dressing wounds, bathing and dressing, and giving enemas. In some, but not all, states LPNs and LVNs may administer prescribed medicines or start IV fluids. In addition to a high school diploma or GED, completion of a 6-to-12 week CNA certificate program at a community college or medical facility. Required to pass a licensing examination, known as the NCLEX-PN, after completing a State-approved practical nursing program. A high school diploma or its equivalent usually is required for entry. 22 The Director Special 2016 Conference Issue

NURSING (cont.) 6 Registered Nurse Registered Nurse Assessment Coordinator (RNAC) Director of Nursing (DON) Infection Prevention and Control Officer (IPCO) Physical Therapist Occupational Therapist Recreational Therapist Registered nurses work directly with patients and their families. They are the primary point of contact between the patient and the world of health care, both at the bedside and in outpatient settings. RNs perform frequent patient evaluations, including monitoring and tracking vital signs, performing procedures such as IV placement, phlebotomy, and administering medications. Because the RN has much more regular contact with patients than physicians, the RN is usually first to notice problems or raise concerns about patient progress. The Registered Nurse Assessment Coordinator (RNAC) will assist the Director of Nursing (DON) with ensuring that documentation in the center meets Federal State and Certification guidelines. The RNAC will coordinate RAI process assuring the accuracy timeliness and completeness of the MDS RAPS and Interdisciplinary Care Plan. The Registered Nurse Assessment Coordinator (RNAC) conducts the nursing process Assessment Planning Implementation and Evaluation under the state s Nurse Practice Act for Registered Nurse Licensure. The Director of Nursing has the responsibility of overseeing the standards of nursing practices for the organization s nursing services. The DON participates with other members of Nursing Services and Administration in the development of patient care programs, policies and procedures to meet all requirements including ethical and legal concerns. The IPCO is responsible for incorporating practices that achieve three core goals identified by the Centers for Disease Control and Prevention: preventing infections and the spread of those infections, tracking and monitoring infections, and improving antibiotic prescribing and stewardship. The IPCO oversees proper vaccination procedures and antibiotic use protocols. Each facility is required to review and update its Infection Prevention and Control Program, analyze the performance of their LTC resident population and facility, establish proper procedures, and properly train all staff. Physical therapists provide a variety of medical services to help individuals who have been injured or physically affected by illness to recover or improve function. A physical therapist must be able to evaluate a patient s condition and devise a customized physical rehabilitation and treatment plan to enhance strength, flexibility, range of motion, motor control, and reduce any pain, discomfort and swelling the patient is experiencing. Occupational therapists help patients improve their ability to perform tasks in living and working environments. They work with individuals who suffer from a mentally, physically, developmentally, or emotionally disabling condition. Occupational therapists use treatments to develop, recover, or maintain the daily living and work skills of their patients. The therapist helps clients not only to improve their basic motor functions and reasoning abilities, but also to compensate for permanent loss of function. The goal is to help clients have independent, productive, and satisfying lives. Recreational therapists devise programs in art, music, dance, sports, games, and crafts for individuals with disabilities or illnesses. These activities help to prevent or to alleviate physical, mental, and social problems. The three major educational paths to registered nursing are a bachelor s degree, an associate degree, and a diploma from an approved nursing program. Nurses most commonly enter the occupation by completing an associate degree or bachelor s degree program. Individuals then must complete a national licensing examination in order to obtain a nursing license. In addition to a post-secondary degree, a healthcare professional must have at least 2 years experience in infection prevention and control before passing an exam given by the Certification Board of Infection Control and Epidemiology (CBIC).Recertification is required every 5 years. Graduate from a physical therapist educational program with a master's or doctoral degree. A master s degree or higher in occupational therapy is the minimum requirement for entry into the field. Bachelor's degree with some additional training is usually required for this field. Special 2016 Conference Issue The Director 23