March 2019 • VOLUME 20, NO. 2 www.CaringfortheAges.com FREE ONLINE ACCESS

An Official Publication of From Detection to Prevention and Beyond: The Future of Sensor Technology in Senior Living Christine Kilgore IN THIS ISSUE n an innovative senior living commu- Inity in Columbia, MO, called Tiger- Paradise Lost Place, sensor technology that continually Natural disasters that monitors the residents and sends alerts drive seniors out of their when patterns change is helping nurses communities remind us and other providers prevent falls and de- again of glaring gaps in the tect early signs of illnesses and changes in senior care system. 8 health status, allowing them to intervene days or weeks earlier than they otherwise might. The facility — a state-sponsored aging-in-place site that is jointly oper- ated by the University of Missouri (MU) Sinclair School of Nursing and Americare Systems, Inc. — is one of the

@iStockphoto.com/NLshop oldest living laboratories in the coun- try for passive monitoring technology, When the Cookie Jar which aims to slow and prevent func- Fills Up tional and cognitive decline and keep Photo courtesy University of Missouri Good transitions required people out of nursing homes and hospi- Marilyn Rantz, PhD, RN, leads research aiming at measuring function with clear, concise and tailored tals. Today TigerPlace has growing com- sensors to help residents live healthier lives. instructions. 14 pany; experts who are developing and/ or tracking the development of elder said Justin Smith, innovation and tech- [into alerts] that tell the clinician ‘Here’s care technology say that interest in pas- nology manager for Direct Supply, Inc., a trend we’re seeing for this resident . . . Medical Director sive monitoring systems is gaining steam in Milwaukee, WI. “Facilities tradition- maybe you need to check in with them.’” of the Year Finalists both inside and outside academia and ally have had an episodic data-gathering The commercial marketplace for pas- The most innovative and across the care continuum. approach. But now we’re seeing a move sive sensor systems is still in its infancy. committed PALTC leaders “It’s the biggest push that we’re seeing toward more continuous, round-the- compete for the Medical [in technology innovation for seniors],” clock data — data that can be turned See TECHNOLOGY • page 10 Director of the Year title. 15

Medical Cannabis A Person-Centered Approach to Fall Prevention is No Pot A New York nursing home Barbara Resnick, PhD, CRNP leads the way in legal medical cannabis use. 16 all prevention is a major concern slow healing process that requires signifi- strength, gait and balance, cognitive Ffor every community in which older cant nursing time. Falls also can have a function, visual and hearing impair- adults live. Approximately 15% to 50% psychological impact — such as instilling ment, depression, and the use of certain Caregivers in Crisis of older adults living in assisted living a fear of falling with a subsequent decline medications (antidepressants, anxio- Overloaded with communities experience a fall over a 6- in physical activity. The staff may begin lytics, antipsychotics, diuretics, or any responsibility, family to 24-month period, and 4% to 22% to fear a resident’s falling as well and wish medication that can cause orthostatic caregivers increasingly of nursing home residents fall annually. to keep that resident immobilized. hypotension). The environmental factors engage in risky health-related Only a small percentage of falls result in The factors that influence falls are that contribute to falls include tortuosity behaviors to cope with major adverse outcomes such as a fracture many, encompassing issues with both of paths, cluttered areas, slippery areas, stress. 17 or head trauma, but bruising can still individuals and the environment. The cause pain, and skin tears can result in a resident-level factors include age, muscle See FALL PREVENTION • page 18

Join the only medical specialty society representing practitioners working in the various post-acute and long-term care settings. Visit paltc.org/membership to learn more! 2 carING FOR THE AGES March 2019

ON MY MIND Karl Steinberg, MD, CMD, HMDC

Medical Directors Should Help Improve Quality and Reduce Liability

rofessional negligence lawsuits The medical director also should assist Pagainst skilled nursing facilities and whenever other practitioners are not other senior living communities — and making safe, prudent, or evidence-based to a lesser extent, against the physicians orders. This should include assertively and other practitioners who provide care educating clinicians and firmly request- in them — continue to increase in num- ing changes in ordering habits when ber and average value. appropriate. For example, outdated and The increase in lawsuits can prob- potentially harmful practices — such as ably be attributed to multiple factors. using sliding-scale insulin or as-needed One has been the trend toward more antipsychotic treatments, or sending resi- medically frail, complex, and seriously dents to the hospital inappropriately, or ill residents. These residents are likely ordering urine studies for vague symp- to experience “bad outcomes,” such as toms such as confusion or a fall in the death or pressure ulcer development, absence of actual urinary tract symp- that are often unrelated to any negli- toms — should be actively discouraged. gence but rather to progressive illness Nurses can assist in changing these and poor prognosis. behaviors, but often it will require a Some plaintiffs’ attorneys capitalize peer-to-peer conversation — sometimes on family members’ guilt about plac- @iStockphoto.com/SelectStock with transmission of actual data, such as ing their parent or spouse in a nursing Miscommunication or documentation lapses can expose SNFs to liability. the references in the Choosing Wisely home by placing billboards near skilled guidelines (“Ten Things Physicians and nursing facilities (SNFs) or by otherwise are made available to state survey agen- charge nurse and the treatment nurse. Patients Should Question,” http://bit. soliciting new cases. This creates a win- cies represent a perfect invitation for a For example, if the charge nurse checks ly/2DLlf3z) propounded by AMDA — win situation for the potential plaintiffs: plaintiff’s attorney to cherry-pick cases the box for “no skin issues” but the The Society for Post-Acute and Long- They can assuage their own guilt by that show how a facility was already on treatment nurse documents the care of Term Care Medicine. blaming someone else for what may just notice — for example, for a pressure several stage 3 or 4 pressure ulcers, it As Caring’s readers undoubtedly know, be disease progression while potentially ulcer problem. It’s unclear whether these suggests that the charge nurse and the there is a certification process for medical getting significant financial compensa- documents, which will be a matter of nursing staff in general are not inter- directors, and there is evidence that the tion in the process. public record, can be protected under ested in what can be a serious medical Certified Medical Director (CMD) cer- Employees of nursing homes may the rubric of quality improvement. It’s problem. Similarly, sometimes a physi- tificate, available through the American make offhand remarks about perceived probable that they will make their way cal therapist may document that the Board of Post-Acute and Long-Term Care understaffing, sometimes as an excuse into evidence in some jurisdictions. A resident vomited or was incontinent, Medicine (www.abplm.org), is associated for a delay in answering a call light or SNF’s performance on a variety of qual- with a large, malodorous loose bowel with a statistically significant improvement responding to a resident’s request. Such ity measures (and its Five Star rating) movement during therapy — but the in a nursing home’s publicly reported qual- lapses can be turned into allegations of and the results of the surveys, includ- nursing notes may make no mention of ity measures. Some nursing home chains widespread, deliberate understaffing that ing any deficiencies, can also easily be a potential change of condition. These require or encourage their medical direc- places “profits above patient care.” And obtained by family members and plain- types of miscommunication or docu- tors to take the coursework and obtain the despite significant improvement in the tiffs’ attorneys. And this information can mentation lapses can create significant CMD certificate as part of their contract or average competencies of nurses who work be admissible in court in some instances. exposure to liability. More importantly, other explicit expectations, allowing such in U.S. SNFs, there are still substantial Electronic health records (EHR) they may compromise the quality of professional development hours to count turnover issues and a lack of consistent promised improved documentation, but resident care. toward their contracted hours. Other assignment in some areas. Workforce they have not turned out to be a godsend In these times of increasing transpar- companies pay an increased differential shortages, particularly of certified nurs- in actual practice. On a positive note, ency and access to information, it is salary for CMD-certified medical direc- ing assistants, certainly don’t help this their legibility is excellent (compared critically important for nursing homes tors. And some corporations that under- perception, and they are looming larger with the illegible scrawl many physicians to provide and document appropriate stand the importance of well-informed all the time. At the same time, advo- display), but the platforms being used care, and to continue to strive to improve medical directors will underwrite the costs cacy groups are clamoring for higher and in this care setting can create myriad their care processes. Even though no of attending the Society’s annual meeting higher minimum staffing requirements. additional problems when a nursing chart is ever perfect, and consistently or its state chapter meetings. And the lay public serving on juries is home must defend itself from allegations charting every detail of care is impos- It is clear that an engaged, knowledge- unlikely to be sympathetic to nursing of negligence — or, worse yet, accu- sible, it is important for nursing homes able medical director can help improve homes, making them easy targets. sations of fraudulent documentation. to document care appropriately and quality and reduce liability. Medical Copying and pasting, and rote docu- accurately. When residents refuse treat- directors should also regularly perform The Role of Information mentation of meaningless entries (such ments or medications, these episodes chart reviews and ensure that the nurs- Increased access to medical informa- as “call light within reach” for a resi- should be documented every time they ing facility’s policies are up to date and tion — both patient-specific and the dent with advanced dementia), can give occur. Nonadherence should be care clinically and ethically sound, and they more general disease-related subject the appearance of sloppiness. A single planned — and the attending physician should assist when state survey agency matter available on the internet — can skilled Medicare nursing note, created should be made aware of these events. teams are in their buildings. be a double-edged sword. It may create with numerous drop-down menus and The Society has a liability workgroup unrealistic expectations and further serve with carried-over data from the previous The Medical Director’s Role through our Public Policy Committee, to undermine some of the care being shift’s or day’s entry, can run 15 pages The Quality Assurance/Performance and readers with an interest in par- provided in nursing homes. But it also long. Not only are such items tedious Improvement (QAPI) paradigm is a ticipating should get in contact with may improve care and accountability. to work through, they can perpetuate great data-driven tool to improve a vari- Alex Bardakh, our public policy direc- Also, with respect to transparency, the erroneous data as “chart lore.” ety of care-related parameters. The care tor ([email protected]). Our House relatively new mandates requiring global More worrisome still, sometimes there facility’s medical director should be an of Delegates has created Society policy facility assessments — including areas iden- appears to be a disconnect among the active participant in QAPI programs and tified as in need of improvement — that various disciplines, or even between the in the overall care provided in the facility. See ON MY MIND • page 7 carINGFORTHEAGES.COM CARING FOR THE AGES 3

Serendipitous Leadership Lessons Kathleen Rathke, MSN, MBA, AGNP-C, SPHR

ne of the most delightful aspects of vigilance against discrimination, and we and growth. Michelle L. Odlum, BSN, training and development, and mate- Oreading is serendipity — the hap- must work to promote diversity, inclu- MPH, EdD, would agree: “A diverse, rial resources. py discovery of insights in unexpected sion, and cultural competency. places. After a long workday, sometimes In yet another instance of serendipity, “In PALTC, different I’d rather curl up with a good book than I happened also to be reading an article functions, perspectives, a professional journal, but important on “The Secrets of Great Teamwork” lessons can be found everywhere, even by Martine Haas, PhD, and Mark and organizations all work when we’re reading for pleasure. Mortensen, PhD, who describe the Patenting the Sun: Polio and the Salk conditions conducive to the success of under one roof. Well- Vaccine (1990) by Jane S. Smith, PhD, 4-D teams (dispersed, digital, diverse, is a fascinating account of the effort to and dynamic), which share similarities designed processes, clear conquer the dreaded disease once known with work groups in PALTC (Harv Bus principles, and good as infantile paralysis. Dr. Jonas Salk Rev 2016;6:70–76). In both 4-D and clearly made an enormous contribution PALTC teams, people who have differ- communication are even to world health, but he did not do that ing functions, backgrounds, and roles alone. The eventual number, breadth, collaborate across work sites/shifts, use more necessary to foster a and devotion of the contributors to the technology in their work, and experi- collaborative environment polio vaccine were impressive, including ence hectic environments with frequent Salk’s laboratory colleagues, the other staffing changes. And the conditions and deter negative researchers, and the National Foundation that enable their success are compelling for Infantile Paralysis (NFIP). direction, strong structure, supportive behaviors.” What leadership lessons or remind- context, and a shared mindset. ers for post-acute and long-term care Given all these similarities, I won- culturally competent healthcare work- PALTC is an admittedly challenging (PALTC) might lie within this gripping dered if more connections might be force is essential to health equity,” and it environment whose foundation costs story? For me, the importance of engage- made between the polio eradication can potentially overcome health dispari- must be managed carefully. Drs. Haas ment and collaboration, driven by a clear effort described in Patenting the Sun ties and improve health outcomes (“How and Mortenson noted that rewards can vision and audience-specific communi- and PALTC teams, using Drs. Haas and to Advance Minority Health?” Apr. 29, be extrinsic (such as compensation and cation, jumped off the pages. For them- Mortensen’s framework. 2014; https://rwjf.ws/2HvZOaU). recognition) but also can be intrinsic selves the researchers expected scientific Leaders play a critical role in attract- (pride and a feeling of purpose). One papers, but the lay public responded Compelling Direction ing, developing, and retaining diverse individual may leap at the chance to best to emotional appeals — how they One might imagine no more noble cause talent across all levels and roles and lead a polypharmacy project while could personally contribute to defeating than fighting the scourge of polio, and ensuring a welcoming, inclusive envi- another may prefer to be assigned a polio. The NFIP campaigns, which built in fact it attracted recruits far and wide. ronment. Formal cultural competency mentee. Both assignments reward and strong engagement and trust, produced However, as Dr. Smith points out, some training is important, and self-study recognize the value of the individual. large donations for research and patient individuals “had not joined the polio resources are available as well. For For the virus researchers, as Dr. Smith care. And parents willingly — and often crusade because it gripped their hearts instance, the Society’s excellent AMDA wrote, “A grand gesture was to bring a eagerly — enrolled their children in the above all others. They were profession- On-the-Go podcast, hosted by Wayne flask of whiskey when you went to meet vaccine trials. als . . . who peddled polio the same way Saltsman, MD, PhD, includes a dis- a colleague at the airport . . . glamour they could have sold cars or corsets or cussion with Tim Johnston, PhD, from was being sent on an urgent assign- annuities.” Yet, significantly, many of SAGE, Services and Advocacy for GLBT ment to an epidemic area.” To ensure these people would also become pas- Elders (http://bit.ly/2TeBnjp). the foundation in your own workplace, sionate about the work and spend years PALTC roles certainly represent a know your team members and provide supporting the battle against polio. mix of skills, of which certified nurs- the rewards and recognition that align In a similar fashion, although some ing assistants, housekeeping staff, nurses, with their preferences — though per- individuals may have limited interest in pharmacists, providers, and therapists are haps it’s best to leave the whiskey at PALTC initially, leaders can engage them just a few. There are different functions, home. through a powerful vision, ambitious perspectives, and even organizations goals, and a reward system, just as Drs. (e.g., direct staff, hospice, geropsych) all Shared Mindset Haas and Mortensen suggest. How many working under one nursing home roof. Drs. Haas and Mortensen noted that of us stumbled into PALTC accidently Thus, as Drs. Haas and Mortensen point the leader has a vital role in creating only to become hooked thanks to strong out in their article, well-designed pro- a shared mindset through information mentors who modeled a vision of posi- cesses, clear principles, and good com- sharing, common experiences, and other tive social impact, quality, innovation, munication are even more necessary to techniques. The 1954 field trial for the and fascinating work? foster a collaborative environment and Salk vaccine involved nearly 2 million

S A Scandinavian irlines [Public domain], via Wikimedia C ommons So strategic outreach, mentoring, and deter negative behaviors. The rivalries schoolchildren and at least 150,000 vol- development programs are important. and misunderstandings may make for unteers. Dr. Smith wrote that leaders Jonas Salk A great example of this is the Futures exciting reading in Patenting the Sun, but in that endeavor worked tirelessly to Program of AMDA — The Society these are more painful than thrilling for create and distribute procedure manuals As Patenting the Sun also reminds for Post-Acute and Long-Term Care leaders in real life — and they require a and bulletins across 44 states and small us, diversity enriches our lives and Medicine. proactive approach. parts of Canada and Finland. Imagine brings enormous benefits to individu- the manual effort required! Despite the als, patients, teams, and organizations. Strong Structure Supportive Context challenges presented by electronic medi- The book recounts appalling examples of A strong structure involves both people Foundational resources are another cal records, we do have more options for anti-Semitism and racism. Yet Salk, who and processes. Drs. Haas and Mortensen responsibility of leaders, reminiscent of sharing information and helping cre- was Jewish, the African American par- point out that a team that is diverse and Abraham Maslow’s hierarchy of needs. ate a shared mindset, such as mobile ents and their children in Montgomery has a mix of skills can provide broad If your basic needs haven’t been met, apps, web-based training, and other in the 1954 field trial, and countless oth- perspectives, minimize groupthink, and it’s going to be difficult to arrive at technologies. ers worked through prejudice and barri- increase innovation. According to Vivian self-actualization. As Drs. Haas and During polio eradication, the NFIP ers to contribute to the vaccine’s success, Hunt, DBE, and her coworkers, research Mortensen explain, in a professional leveraged common experiences to engage inspiring us today with their courage and has shown that a diverse workforce setting those basic needs include a per- people in their fundraising efforts: commitment. It’s a strong reminder to favorably impacts organizational health, formance-based rewards system, access us as leaders that we must continue our including its financial performance to necessary data, opportunities for See LEADERSHIP • page 8 4 carING FOR THE AGES March 2019

DEAR DR JEFF Jeffrey Nichols, MD, CMD

Professional or Patsy?

Dear Dr. Jeff: of care as defined by the patient. The More of my time is being spent with fami- job of the health care professional is lies of residents distressed because of my to advise patients on the best means to refusal to order tests, medications, consul- achieve those goals. Primum no nocere tations, emergency room visits, and even (first, to do no harm) is embedded in hospitalizations, which they insist should the Hippocratic Oath and the ethical be done. Although occasionally these are principle of non-maleficence to remind reasoned discussions regarding optimal us that we have a professional obligation care, frequently they are angry confronta- to protect our patients from injury. tions accompanied by threats of lawsuits. The corner drug pusher sells what I understand and support the rights of the consumer wants and can pay for. patients or their proxies to make choices A physician or nurse practitioner is not among alternate treatment regimens or to a prescription-dispensing machine, a refuse unwanted care or lifestyle limita- glorified Pez dispenser in a white coat tions. Is there a corresponding right to who produces a pill whenever desired. If access any treatment they choose as well? patients had a right to any medication or study, the whole notion of prescription Dr. Jeff responds: medications or a requirement for prac- The changing structures of medical care, titioners’ orders to perform laboratory the ready availability of internet searches and radiology procedures would make with plentiful information and misinfor- no sense. @iStockphoto.com/Stígur Már Karlsson/ H eimsmyndir mation, the dramatic overselling of the There are days when it feels as though A physician or nurse practitioner is not a Pez dispenser in a white coat potential of modern medicine to treat we are the last ones at the barricades who produces a pill whenever desired. If patients had a right to any end-stage disease, and the movement while the ignorant hordes — sadly, medication, the whole notion of prescription medications would make no from a doctor–patient relationship to the sometimes led by medical subspecialists sense. paradigm of a health care consumer and with extremely limited knowledge of the a “provider” are all driving encounters care needs of frail seniors — struggle community — or, worse, refer to the Infect Dis2002;35:1205–1210). The such as those you describe. The practitio- to overwhelm our residents with use- federal policy to reduce hospitalizations concerns raised by Morton C. Creditor, ner at the bedside is often caught among less tests, with ineffective, unnecessary, — we may sound to the patients and MD, in “Hazards of Hospitalization of competing pressures from demanding or frankly toxic medications, and with families as though we’re placing the the Elderly” remain as relevant now as families and insurance plans and health unnecessary hospitalizations that can interests of our institution — and its when he wrote it 25 years ago (Ann care systems to improve consumer satis- return the resident to the facility in desire to keep beds full and maximize Intern Med 1993;118:219–223). That faction scores (sometimes increased by worse overall condition than before they insurance reimbursements — over the same year Sharon K. Inouye, MD, pay-for performance measures that treat left. However, the professional response interests of our residents. MPH, and colleagues of Yale University these scores as metrics of performance). to all these pressures should not be a Even worse can be the reaction of resi- demonstrated a 50% risk of functional Pressure also may come from antibiotic policy of “Just Say No.” We should rec- dents and families to the suggestion that decline in the elderly, of which a quarter stewardship programs, which discour- ognize that most families are advocating a proposed treatment or test is a waste of occurred after hospital admission (J Gen age treating viral syndromes and “foul- for what they genuinely believe are the money. Although practitioners do have Intern Med 1993;8:665–672); the risk smelling urine” inappropriately with best interests of their loved ones, and some responsibility to the medical sys- was 2.8 times greater for those admitted antibiotics, and from agencies that fol- often they want treatments that their tem to minimize waste and fight against from nursing homes. Nursing assistants low the published metrics of emergency relatives have experienced in the past. insurance fraud, our opposition to an who have a relationship with the family department (ED) referrals and 30-day Our response should be based on our expensive, unnecessary test or medica- can confirm from their own experience rehospitalization rates — which may by knowledge of best practices in the care of tion should be based on the exposure of that residents typically return from hos- inappropriately used as proxies for qual- frail seniors, their differential responses the patient to risk or discomfort with- pitalizations weaker, less able to partici- ity care. Practitioners can be pressured to medications, and whenever possible out any compensating benefits, not the pate in care, more confused, and with by their own judgment and conscience the medical literature. expense per se. skin breakdowns. as well. For example, many older patients with Practitioners and medical directors Many of the bitter struggles between The various demands can escalate severe venous insufficiency experience should be familiar with a number of families and practitioners center on to appeals to the medical director or stasis dermatitis. Some undergo multiple classic articles related to overused or patients with dementia, particularly administrator to intervene — and the hospitalizations where — despite their unnecessary, even risky medications and those in their last months of life. Unlike stressed practitioners themselves are fre- lack of fever or elevated white blood procedures. Start with the Choosing cognitively intact residents who can quently happy to punt these decisions cell counts — the condition is treated Wisely materials from AMDA — The participate in their care decisions, cog- to administration. In addition to the as “bilateral cellulitis” with bedrest and Society for Post-Acute and Long-Term nitively frail individuals are inevitably patients’ families, ombudsmen and risk intravenous antibiotics. These patients Medicine and the American Geriatrics subject to care decisions made by prox- managers may encourage appeals to the typically improve with such care, not Society. The words “Black Box Warning” ies. As many articles in Caring and other medical director as well. Sometimes the because of the antibiotics but despite should come tripping off your tongue publications have discussed, these legally unit staff, including the floor nurses and them: the bedrest with leg elevation can whenever the use of antipsychotics is authorized decision-makers experience social workers, may refer a family’s issues relieve the elevated venous pressure that proposed for the behaviors of dementia. conflicting emotions because they have to a mediator or higher authority, if only had, in turn, produced the skin changes. The article by David Dosa, MD, and limited ability to predict what their loved to reassure them that their concerns are In this type of situation, the nursing the review by Thomas Yoshikawa, MD, one or friend would wish under these being heard and addressed. home practitioner’s reluctance to follow and Joseph Mylotte, MD, reinforce that circumstances. Medical practitioners have an absolute a previously “successful” antibiotic treat- hemodynamically stable nursing home What is known is these residents have obligation to provide the best possible ment may seem misguided, obstinate, or residents with nursing home pneumo- an increased risk of behavioral distur- care to their patients. Of course, “best even ageist. nia have as good or better survival rates bances, agitation, confusion, depression possible care” is determined, in part, by If we make vague references to our when managed in the nursing home (J — and a consequent increased risk of the values of the patient and the goals ability to treat a problem in our care Am Med Dir Assoc 2005;6:327–333; Clin feeding tube placement and sedative carINGFORTHEAGES.COM CARING FOR THE AGES 5

use — when they are subjected to the nursing home — contrasted with the depletion are present). It might be better given the courtesy of the practitioner’s stress of transfers away from a familiar time required to arrange an ED transfer not to do a requested urinalysis and cul- time to explain the decision process — in environment and known care staff. This followed by the likely wait time in your ture, but it might be wise to do a meta- most situations hostile encounters can be is especially true when they are shuttled local hospital for a low-priority ED visit. bolic profile to assess hydration status. defused.  from site to site — to the hospital, obser- The lethargic resident with cloudy, We should not expect families to have vation unit, ED, outside consultant’s foul-smelling urine and no other symp- a sophisticated understanding of the office, imaging center, or ambulatory toms does not require an antibiotic best available care for frail seniors — Dr. Nichols is past president` of surgery suite — during their extended (which is likely to decrease the resident’s and doing the right thing should not be the New York Medical Directors dying process. This phenomenon is oral intake and potentially risk diarrhea expressed as doing nothing. Once again, Association and a member of the known variously as relocation crisis, and antibiotic resistance). The resident communication is of the essence here. If Caring for the Ages Editorial Advisory transfer trauma, or dislocation delirium, does need increased fluids (preferably families in stressful circumstances under- Board. Read this and other columns and it contributes to their accelerated orally, but possibly intravenously when stand that their needs and concerns are at www.caringfortheages.com under decline and shortened life expectancy, in the signs and symptoms of intravascular being heard and respected — if they are “Columns.” addition to its obvious immediate nega- tive effect on their quality of life. Calmly asserting that we know what is best for our residents and that we are providing evidence-based medicine — superior to a Google search or to the hospital house staff who told them that 15 white blood cells in a urinalysis “proved” that their relative had a urinary ® tract infection — is not a winning strat- egy. The answer is not a return to the paternalism of the past, even if “father does indeed know best.” Just because we makes all the difference have the power of our licenses does not mean that the wishes of the residents and families can simply be ignored. We do need to partner with our resi- dents and their families to create care plans that meet our residents’ needs and also alleviate their families’ worries and concerns. This partnership should

Calmly asserting that we know what is best for our residents is not a winning strategy. We need to partner with our residents and their families to create care plans that meet our residents’ needs and also alleviate their families’ worries and concerns. emphasize what we can do, the interven- tions we intend to implement, and the close monitoring of resident comfort we With CancerCare, can provide. the difference comes from: Patients and families should be informed of the limited efficacy and sig- • Professional oncology social workers • Free counseling nificant possible side effects of many • Education and practical help commonly used medications and treat- • Up-to-date information Help and Hope ments, particularly anticoagulants, • CancerCare for Kids® antiepileptic medications in patients with no recent history of repeated sei- For needs that go beyond medical care, refer your zures, statins, cholinesterase inhibitors, patients and their loved ones to CancerCare. antihistamines, or prolonged or mini- CancerCare’s free services help people cope with mally indicated courses of antibiotics. the emotional and practical concerns arising from a cancer diagnosis and are integral to the standard 1-800-813-HOPE (4673) The patient with fever and cough will of care for all cancer patients, as recommended not benefit from an ambulance ride to by the Institute of Medicine. www.cancercare.org the ED — but certainly does need a physical examination and may require a chest X-ray, a complete blood count, possibly a blood culture, and perhaps the early initiation of antibiotics if indicated by the examination. Most of this care can occur more quickly in the 6 carING FOR THE AGES March 2019

PTSD and Trauma-Informed Care ANNUAL CONFERENCE in the Long-Term Care Setting RECORDINGS 2019 Whitney Fishburn

rauma-informed care figures promi- symptoms, the dementia, or a combina- Tnently in Phase 3 of the revised tion of the two was unclear, she wrote. federal Requirements of Participation Although the exact nature of the reci- that goes into effect in November of procity between dementia and PTSD is this year, which stipulates that long-term still unknown, studies have consistently care facilities must provide behavioral shown a significant association between health services for residents with a his- the two. For this reason — and because tory of trauma or a post-traumatic stress antipsychotics carry a boxed warning for disorder (PTSD) diagnosis. all-cause mortality in the elderly with Treatment of PTSD typically entails dementia — Dr. Jakel urged careful con- a combination of medication and sideration before deciding to use antipsy- psychotherapy. But in the elderly, in chotics for PTSD in the elderly. whom PTSD is less understood than Benzodiazepines also are thought to in other patient populations, special have limited utility in this patient popu- attention must be paid to age-related lation, according to Dr. Jakel. “They comorbidities and changes in drug can worsen dissociation, reduce ability metabolism, according to Rebekah J. to engage in psychotherapy, and worsen Jakel, MD, PhD, an assistant profes- mood and substance use,” she wrote, ATLANTA sor of psychiatry and behavioral sciences adding that they also confer “signifi- at Duke University School of Medicine cant risks of falls, delirium, dependence, GEORGIA 2019 in Durham, NC. “Certain medications increased confusion, and respiratory may confer increased risk in the elderly depression, and [they] may prolong and should be avoided or used with PTSD symptoms.” ANNUAL CONFERENCE caution,” wrote Dr. Jakel in her review Although cognitive behavioral thera- article on what is currently known about pies might be less feasible in this pop- PTSD in the elderly (Psychiatr Clin N ulation because of cognitive concerns AMDA – The Society for Post-Acute Am 2018;41:165–175; https://bit. or lack of access, these therapies have and Long-Term Care Medicine ly/2WmXPZK). been shown effective in younger cohorts, PTSD is defined in the 5th edition Dr. Jakel said, so they should be made March 7 – 10, 2019 of the Diagnostic and Statistical Manual available to the elderly when indicated, Hyatt Regency Atlanta of Mental Disorders (DSM-5), as recur- in accordance with the revised federal rent, distressing memories, nightmares, rule. In an email, Timothy Gieseke, flashbacks, avoidance of trauma-asso- MD, a general internist and associate ciated reminders, negative cognitions, clinical professor at the University of and moods associated with the traumatic California–San Francisco’s Department event, and hyperarousal symptoms that of Family and Community Medicine, persist beyond 1 month and have no noted that “Clinical psychology ser- other known cause. Antidepressants such vices have become more available in my as selective serotonin reuptake inhibitors community.” (SSRIs) and serotonin-norepinephrine Dr. Gieseke, who has served as a medi- reuptake inhibitor (SNRIs) are the most cal director to five skilled nursing facili- commonly used medications for treating ties and two subacute care units in his trauma-based symptoms such as those career, recounted how when three of his Post Conference Pricing in PTSD. facilities experienced rapid evacuations In lower doses — with slower titra- due to wildfires, many of his patients tion and possible dose adjustments for suffered trauma, which led to new diag- Conference Recordings Digital format concurrent hepatic or renal impair- noses of PTSD. In some cases, he said, ment — antidepressants are generally these conditions had “likely been quies- or USB format fine for treating PTSD in the elderly, cent,” and access to clinical psychologists (CME Credit available for Digital format, No CME Credit for USB) Dr. Jakel wrote. However, older anti- was a great help in identifying and treat- depressants such as the tricyclics, which ing these patients. are anticholinergic, should be avoided PTSD in the elderly who require hos- because of their potential for adverse pitalization is cause for special attention, cardiac events. Prazosin, an alpha-agonist according to Dr. Jakel. Medical con- $675 that crosses the blood-brain barrier, has ditions that alter oxygenation, such as shown efficacy in targeting nightmares; chronic obstructive pulmonary disease, however, Dr. Jakel warned that although may be associated with psychological dis- the drug is sometimes prescribed for tress. Beta-agonists and atrial fibrillation hypertension, when it is used at typical also can be associated with autonomic Conference Special doses to target nightmares it is often changes that can approximate anxiety, (Combo of both Digital and USB formats) poorly tolerated by patients because of according to Dr. Jakel. Although there the potential for hypotension, especially are few data on interactions between postural hypotension. delirium and PTSD in the intensive care The data reviewed by Dr. Jakel indi- unit, according to anecdotal accounts $725 cate that older patients with PTSD and combat veterans with PTSD have tended dementia have more than twice the to incorporate flashbacks into their delir- odds of being prescribed second-gen- ium, which manifested as paranoia and Order at: paltc.digitellinc.com eration antipsychotics compared with agitation. patients who have PTSD alone. Whether According to Dr. Gieseke, having or by calling 1-800-679-3646 the therapeutic target was the PTSD access to cognitive behavioral therapies carINGFORTHEAGES.COM CARING FOR THE AGES 7

when determining which symptoms are unclear. In the case of suicide, screen- medical and which are PTSD-related can ing for depressive symptoms could help be useful in such situations. “They have lower the risk — one study reviewed been of great help identifying psycho- by Dr. Jakel showed that suicidal ide- pathology that I have missed, and have ation and PTSD were associated with helped me be more precise in my medi- depression. cal interventions based on more precise Other studies reviewed by Dr. Jakel diagnoses,” he said. indicated PTSD was correlated with The DSM-5 sets the lifetime PTSD an elevated risk of cardiovascular dis- prevalence rate by age 75 at 8.7%, but ease in a male veteran population. data on the disorder are derived largely Studies also have found positive asso- from studies of cohorts in early adult- ciations between PTSD and type 2 hood who were mostly white, male diabetes mellitus and gastrointestinal combat veterans or Holocaust victims. disease. PTSD was also associated with Meanwhile, the exact nature of acute reduced physical performance, accord- trauma’s impact on the elderly, much ing to self-reports by older male vet- UPDATE of which occurs outside the realm of erans in a study that was controlled combat, remains a mystery, according for demographics and other psychiatric to Dr. Jakel. “It is unclear whether age disorders. confers a vulnerability or protective fac- Dr. Jakel’s review offers a reminder tor for trauma sustained in the elderly.” to clinicians to look deeper into the And it may be impossible to ever know possible causes of impaired cognition, GUIDE TO POST ACUTE definitively due to the inherent chal- according to Dr. Gieseke. “[Physicians] lenges of designing studies that can assess commonly miss cognitive impairment pretraumatic baseline functioning and due to serious mental illness, and AND LONG TERM CODING, trauma severity as well as effectively con- likely miss it in those with PTSD,” trol for the multitudinous conditions he said. “In the latter case, recogni- REIMBURSEMENT, AND and processes that correlate with age, tion and appropriate management including cumulative trauma, according may improve cognition and problem to Dr. Jakel. behaviors associated with PTSD.” Dr. DOCUMENTATION Although the effects of trauma can Gieseke said this is especially impor- persist across the life span, their exact tant in skilled nursing facilities where trajectory is hard to predict. For some “there is a tendency to view agitation individuals, age may be associated with in a generic way and miss antecedent resilience and less vulnerability to devel- life events that may be contributing to oping PTSD. But for others, accord- the agitation.” The Society has updated its Guide to ing to Dr. Jakel, “It is theorized that Both Dr. Jakel and Dr. Gieseke believe Post-Acute and Long-Term Care Coding, trauma-based symptoms may emerge or more research into the causes, trajec- worsen in the context of aging-related tory, and cumulative effects of trauma Reimbursement, and Documentation. This challenges. Some of these stressors could across the life span could improve care include changes in roles, retirement, loss for this patient population. “It would popular publication contains documentation of family members and friends, loss of be valuable to better define the impact autonomy, and physical and cognitive of PTSD in seniors on life expectancy requirements and Society-developed coding decline.” and quality of life,” said Dr. Gieseke. Beyond the symptomology of PTSD, “Confirming a quantifiable serious vignettes for each of the nursing home the disorder has been associated with adverse effect could free up funding for a higher risk of suicide, dementia, and intervention studies.” family of codes as well as Chronic Care other changes in health and functional performance, although PTSD’s exact Management (CCM), Advance Care mechanism is still unknown and the Whitney Fishburn is a Washington, DC- causal links for these associations are area freelance health sciences writer. Planning (ACP), and Behavioral Health Integrated (BHI) services. It also features frequently asked questions on a variety of

these causes of action. But paying close related topics and an exclusive link to On My MInd attention to the care processes, commu- from page 2 nication, and oversight of medical care documentation examples. in your nursing facility — in addition supporting tort reform, particularly caps to creating realistic expectations among on noneconomic damages. Also, because residents and family — can go a long For more information or to most lawsuits require medical expert way toward mitigating that risk.  testimony to help the jury or judge order your copy, please visit determine the standard of care and any damages from negligence, our readers Dr. Steinberg is chief medical officer paltc.org. who are experienced clinicians and medi- for Mariner Health Central in Califor- cal directors should consider offering nia and a longtime nursing home and their services as expert witnesses. Many hospice medical director. He is editor of the so-called experts who testify in in chief of Caring and chairs the Public nursing home cases do not even cur- Policy Committee for the Society. The rently work in nursing homes, so there views he expresses are his own and is always a need for qualified, truthful not necessarily those of the Society or experts. any other entity. He may be reached at There is clearly no way to avoid all [email protected] and he can be lawsuits, and SNFs are an easy target for followed on Twitter @karlsteinberg. 8 carING FOR THE AGES March 2019

MEDITATIONS ON GERIATRIC MEDICINE Jerald Winakur, MD, MACP

Paradise Lost

hey have been driven out now, the We have been warned again and again. Tones who managed to survive Para- We are waiting for a savior who will not dise. The inferno burned them from come. Our destiny, it seems — in the their tiny homes, their trailers, their RVs, richest democracy in the history of the their tranquil plots along the ridges and world — is in our own frail and trem- valleys among the pines. bling hands.  It was there in a forested place where the long-married, the widow, or the widower could afford to live, meagerly, Dr. Winakur is a grandfather and a and at least semiautonomously with geriatrician. His latest book is Human their canes and walkers and wheelchairs, Voices Wake Us (Kent State University leaning into each other when needed, Press, 2017). always ready with a neighborly hand. A village of elders, the greatest generation, many in assisted living, or care homes, or rehabilitation facilities. Their chil- Leadership dren and grandchildren dispersed, they from page 3 were struggling in their own lives. In Paradise, CA, where 25% of the population was over 65, while hell bore “Everyone knew someone whose child @iStockphoto.com/Pedarilhos down, a garbageman scooped a nonage- had been stricken.” The children in narian off her porch and, with the help Camp Fire, the wildfire that destroyed Paradise, CA, gave residents no the 1954 field trial were called Polio of others, hauled her up into the cab of time to escape. Pioneers, and they retained that lifetime his truck. There are so many stories like identity from “a moment of personal this, and let’s face it: when the fires roar died at more than twice the rate as the mobile, and 50% have some degree of glory achieved by being part of a crowd.” down the canyons, the floodwaters rage under-65 population of the area. When dementia, recognized or not. The safety In PALTC there are great examples of through the river valleys, the hurricanes Hurricane Irma knocked out the power nets woven in the last century to cush- creating a similar shared mindset through batter the shores, all we will have is each of a rehabilitation center in Florida in ion our inevitable fall, back when life common experiences — from interdis- other, if we are lucky. September 2017, no evacuations took expectancy was 60, are woefully inad- ciplinary rounds to shared metrics for According to the New York Times, place, even though a fully functioning equate now that we hang on through key result areas. Professional member- “many of the thousands of structures in hospital was just across the street. Twelve eight decades. ships also can resonate with our inter- Paradise and surrounding parts of Butte elderly residents died of heat stroke. The One in three Americans has no sav- ests and values to provide a common County that were lost in the fire were home’s license was suspended, but as ings at all — fixed pensions are gone. identity. The first time I attended the nursing homes, assisted living facilities, of January 2019 no charges have been Where are the families, you ask? They annual conferences of the Society and other geriatric care centers or mobile filed. are scattered and struggling. Our the Gerontological Advanced Practice home parks catering to retirees. Roughly Our elderly — our patients — are daughters are scrambling: 40% are try- Nurses Association (GAPNA), I imme- 2,300 residents of the fire zone had relied the detritus, the human fuel accumulat- ing to raise their own children alone. diately felt a strong sense of kinship and on in-home health aides, according to ing in all the forgotten corners of our And our sons, albeit with exceptions, belonging. Shelby Boston, the county director of nation, waiting for the next spectacular tend to exempt themselves from care- Ensuring the enabling conditions — employment and social services” (“After conflagration to bring their plight onto giving. Yet grandma and grandpa still compelling direction, strong structure, a Wildfire, Rebuilding Life Can Be our screens. For a moment we hear their help when they can: in 2014, they were supportive context, and shared mind- Hardest for the Oldest,” Nov. 25, 1918; stories, then they are lost in the smoke of raising close to 3 million of our nation’s set — while exciting, may also seem https://nyti.ms/2FJ0A2o). other concerns, the next terrorist bomb- grandchildren. daunting, especially for a new leader. The secular gods have decreed this to be ing or school massacre. Professional development plans are our New Normal: disasters building over Americans rouse themselves and But demography is destiny. vital so that leaders can build on exist- a long period of time due to global envi- march in the streets to ban guns, but Eventually we will all need care. And ing capabilities, acquire new skills, and ronmental forces “out of our control,” who is marching in defense of our unless we are very poor or very wealthy, engage their teams and other stakehold- exurbanization and limited affordable aging population? As Time magazine that care is unaffordable and thus unob- ers effectively and with confidence. As housing, too much fuel on the ground, points out, “from senior living centers tainable. You, with some resources, think Maya Angelou said, “People will forget inadequate funding priorities, poor prepa- to hospice, the country is struggling you will float above the fray? Try to what you said, people will forget what ration, and overly stretched first respond- to adapt a rickety system to handle find — today, right now — a qualified you did, but people will never forget ers. “Who could have known? Who could the demographic wave that is crash- geriatrician, an honest advocate, a 24/7 how you made them feel”. The goal is have predicted this?” they say. ing over it. At stake are the health, live-in caregiver, a “good” long-term care a positive culture where individuals feel Haven’t we been paying attention? It wealth and dignity of a generation” facility. It is a difficult task at present, respected, challenged, and central to the is always our most vulnerable who suffer, (“Dignity, Death and America’s Crisis and it will be much harder in 10 to 20 success of the vision.  who are left behind in the flames. They lie in Elder Care,” Nov. 16, 1917; http:// years. Our nation does not reward those submerged in their bedrooms. They are bit.ly/2SaBIGy). who do this work. swept from their front stoops. They drown Driven out of Paradise, our elderly — Ms. Rathke is principal at KMR in their long-term care facilities. They are Are we marching yet? living in shelters or tents, or in cars Consulting and specializes in talent too cold or too hot, dying of hypothermia Most of us are just waiting, aging in or vans, perhaps even with relatives or management and organizational or heat stroke in derelict apartments. They place, quietly suffering loneliness and empathic strangers — are on full display. effectiveness solutions. She is an adult/ are, as they have been: our old-old and loss, gathering frailty and waning facul- They are now the “new abnormal.” As gerontological nurse practitioner with oldest-old. ties. In our increasing irrelevance, by the fires still rage, pandemonium reigns, senior leadership experience in global In the Paradise fire, at least 46 of the 2050 there will be 80 million of us. and too many have been turned to ash. human resources. Ms. Rathke is active 88 dead were our geriatric patients, who Of octogenarians, only 20% are fully America is not innocent in this disaster. in both AMDA and IMDA (Indiana). carINGFORTHEAGES.COM CARING FOR THE AGES 9

Our Foundation’s Unique Annual Fund By Matthew Wayne, MD, CMD

o the best of my knowledge, just PALTC profession. Our Foundation is contributing at the level you can afford what we can together uniquely call Our Tabout every college and university the only nonprofit dedicated to workforce to our annual fund. All you need to do Foundation. alumni association has an annual fund development, quality care, and recogni- is go online at www.paltcfoundation. Thank you.  campaign to raise money for scholar- tion of caregiving excellence. Your con- org and find “Donate” or write a check ships, facilities, and other higher educa- tribution to Our Foundation makes an to the Foundation for Post-Acute and tion purposes. At some schools, classes important difference. Long-Term Care Medicine. We won’t Dr. Wayne is chair of the Foundation’s compete to determine which is giving I am asking you as a reader of Caring hound you with phone calls, so it is Annual Appeal Campaign and a past the most funds. for the Ages or an AMDA member to important that you act now and make president of AMDA – The Society for The Foundation for Post-Acute and please join me and many others in what is a very important contribution to PALTC Medicine. Long-Term Medicine (PALTC), which we refer to as “Our Foundation,” also has an annual fund and I accepted the invitation to take on the role of campaign chair. I agreed because I strongly believe that AMDA – The Society for Post-Acute and Long-Term Care Medicine needs Matthew Wayne, a robust foun- MD, CMD dation, a body dedicated to rais- ing money for special programs and pur- poses not covered by our membership dues. It is like a college that raises money for programs not covered by tuition. Our Foundation focuses on three key areas: workforce development, PALTC quality measures, and recognition of excellence and innovation. Each year, the Foundation board reviews and evaluates the programs it is funding and the board continues to see great success in our Futures program, our efforts to develop and fund quality measures, and the excellence recognition awards we pres- ent at the annual conference each year. Yet, there is at least one significant difference between a college annual fund and our own annual campaign. The difference is largely math. For an undergraduate college, there is close to a 100% turnover in students every four years. Over time, this creates a very large pool of alumni. But within our Society, many people are members for as long as they are in practice—one, two, three, or more decades. While some give to the Foundation even after they are no longer members, most are donors at the same time they are members. So, the pool of funders for Our Foundation is much smaller. To me, that means we must accom- plish a much higher percentage of contributions in order to fund Our Foundation. But there is a way that math can work in our favor. I may be setting the bar very low—or very high—but if AMDA members contributed an average of $100 each, Our Foundation would be able to fund programs with roughly $500,000—and that would mostly be new money. When I say “an average of $100 each,” I know I’m not speaking of a pittance. But I do want to point out that Our Foundation is unique. It is the only charity created by and that works for the purposes of our 10 carING FOR THE AGES March 2019

to prove the [clinical value and efficacy] has been collaborating with researchers device originally designed for gaming Technology of these new ways of providing care and at Stanford University’s artificial visual consoles, each resident can be accurately from page 1 services,” said Ms. Jensen. intelligence laboratory on piloting the differentiated from other residents, fam- Passive monitoring technology is not use of depth and thermal sensors that ily, and caregivers. Even so, some independent assisted liv- “ready for prime time . . . but the tech- monitor daily activity patterns and pro- From the start, “we set out to find ing facilities and full-spectrum corpora- nology is moving in the right direction,” duce corresponding analytics that cli- new ways to detect changes in function tions are investing and signing on as said geriatrician Jay Luxenberg, MD, a nicians can use to identity potentially because we thought that, as health care early adopters, said Mr. Smith and Liz clinical professor at the University of troubling patterns of activity. providers, if we could measure func- Jensen, RN, MSN, RN-BC, the compa- California at San Francisco and medical “We tell [the researchers] at Stanford, tion better, we could help people stay ny’s clinical director. Technology compa- director of On Lok, Inc., which oper- this person got dehydrated, this person healthier longer,” said Marilyn Rantz, nies, in the meantime, seem more willing ates a PACE program (Programs of All- fell, this person needed to be hospital- PhD, RN, curators’ professor emeritus to invest in the research “that’s necessary Inclusive Care for the Elderly). On Lok ized with a [urinary tract infection],” in the MU Sinclair School of Nursing Dr. Luxenberg said. Over time, the sys- and executive director of the Aging In “We [clinicians] tell [the tem learns which changes can precipitate Place project and Sinclair Home Care. — and predict — a significant change Iterations of the sensor systems were technology developers], in function and health. “This,” he told installed in the apartments of consenting this person got Caring, “is the future.” residents starting in 2005. Over time, longitudinal collection of sensor data dehydrated, this person Inside TigerPlace and analysis of significant health events TigerPlace was built as a state-of-the-art enabled the researchers to develop and fell, this person needed to independent living facility in which resi- test various health alert algorithms. “We be hospitalized. Over time, dents could live through the end of life went through a lot of sensors over the with the support of both care coordina- years, and we also experimented with the system learns which tion led by registered nurses (RNs) and various clinical parameters so that we got new technologies to help them improve a handle on what [sensors and data] give changes can precipitate — and maintain their physical and cogni- us the most bang for your buck — the and predict — a significant tive functions. It was built to nursing most clinically relevant information,” home standards but was licensed as an said Marjorie Skubic, PhD, professor change in function and intermediate-care facility with waivers of electrical engineering and computer to operate as an aging-in-place facility. science and director of CERT. health. This is the future.” Essentially, the 54-apartment facility is For instance, “over the years we’ve — Jay Luxenberg, MD run as independent housing, with the learned how to map their average in- facility and service operations managed home walking speed to a standardized by Americare and the care component fall risk assessment instrument, the TUG managed by a federally certified home [Timed Up & Go] score,” she noted. “So health agency created as a department we can tell from our data analysis system within the MU Sinclair School of whether someone has a low fall risk or a Nursing. high fall risk.” One of the most recently The wireless sensor system, developed published studies on falls showed that a at the MU College of Engineering’s decline in walking speed of 5.1 centime- Center for Eldercare and Rehabilitation ters per second over a week is associated CHICAGO Technology (CERT) in consulta- with an 86% probability of falling. The tion with nursing staff and with input CERT clinical teams continue to work ILLINOIS 2020 from resident focus groups, has several on streamlining their intervention pro- main components. Hydraulic bed sen- cess for fall prevention, Dr. Skubic said. ANNUAL CONFERENCE • APRIL 2-5 sors measure pulse, respiration, and The sensor technology has also alerted restlessness. Depth sensors produce providers to early signs of urinary tract three-dimensional silhouettes and col- infections, pneumonia, upper respiratory lect information on movement and gait infections, pain, delirium, hypoglycemia, (such as stride length, gait symmetry, and other problems, Dr. Rantz said. She and speed). And simple passive infra- and her colleagues have described the red motion sensors produce data that health alerts and what they call a new are processed to convey activity levels paradigm of technology-enabled “vital and patterns (known at TigerPlace as signs” in several published articles. “motion density” patterns). With the use In an interview with Caring, Dr. Rantz of Microsoft Kinect, a motion-sensing vividly recalled the first time, early in

KEY TECHNOLOGY TRENDS SAVE THE • The commercial marketplace for passive sensor systems is still in its infancy. • Continuous, around-the-clock data that can translate into alerts or pre- dict changes in health is the biggest trend in technology innovation for seniors. • The use of monitoring technology — both biometric remote patient DATE monitoring (as in chronic disease management) and activity monitoring — is on the rise. Abstract Submission Opens • User interface and modes of delivery of usable information to residents April 29, 2019 and families are becoming increasingly important. • Most facilities willing to invest in technology are drawn to its fall preven- tion capability while considering its illness-predicting capability too far fetched. • Technology that helps skilled nursing facility (SNF) providers follow patients home after discharge will emerge in the future. • As the use of sensors increases, issues related to data security and resident privacy will demand more attention. carINGFORTHEAGES.COM CARING FOR THE AGES 11

Not all residents at TigerPlace have And under another 4-year grant from and Skubic are involved in Foresite as lived with sensor technology. On aver- the National Institutes of Health, Dr. advisors and researchers.) Thus far, Dr. age, about half of the facility’s apart- Skubic and her team are developing Chronis said, the main draw for facili- ments have had active systems and half prototype systems for communicating ties has been the “fall detection and haven’t — a breakdown that has enabled sensor data to seniors who are younger prevention feature of the system.” For the researchers to tease apart the effects than the population at TigerPlace and many clients, early illness detection still of automated alerts versus the effects of to their family members. “Right now often “sounds like magic,” he said, even RN coordination, the latter of which we’re asking, What’s the best platform? though ultimately it has much greater is the standard at the facility. A study How should the information be orga- value. of length of stay over a span of almost nized so they and their families can use Majd Alwan, PhD, senior vice presi- 5 years found that residents using the it? What will they use the information dent of technology and executive direc- sensor technology lived at TigerPlace for? Could family members get text tor of the LeadingAge Center for Aging for 1.7 years longer than those without messages?” she said. Dr. Skubic noted Services Technology (CAST), has been the sensors (Nurs Outlook 2015;63:650- that focus group sessions with seniors tracking technology adoption and devel- 655). (RN coordination alone added an and their families have helped shape the oping toolkits for technology selection. average of 0.8 years to length of stay prototypes. Later this year, the sensor He said there has been a recent jump in compared with the national median of systems will be deployed in two set- using monitoring technology — both 1.8 years in residential senior housing.) tings — an upscale senior living com- biometric remote patient monitoring CERT’s current research on sensor munity and a government-subsidized (as in chronic disease management) and technology aims to further improve the senior housing community — to test activity monitoring (passive or active). Shoshana H erndon alert algorithms and “back-end pro- them out. Approximately 17% of 200 large, Marylin Rantz talks to a TigerPlace cessing,” but increasingly it focuses on nonprofit, multisite senior living orga- resident. the user interface — on how best to Outside TigerPlace nizations that participated in an annual deliver information to the clinicians A more robust, commercialized version survey conducted by LeadingAge and the research process, that sensor data who are caring for patients in assisted of the sensor system used at TigerPlace Ziegler, an underwriter of financing prompted a valuable intervention. “I was living or other senior living communi- has been installed in hundreds of rooms in this sector, had adopted technology looking over [nighttime bed sensor] data ties. At TigerPlace, for instance, a clini- in multiple assisted living communities for activity monitoring by the end of and graphs during a routine morning cian might now receive an alert of an and memory care units in Missouri and 2016. Dr. Alwan said, “Within that meeting and knew right away what was “increase in bed restlessness” or “greater other states by Foresite Healthcare, a 17%, almost all of them include some going on — that the patient’s [conges- use of the bathroom,” with a link to company formed in 2013 by former level of [passive] monitoring of activi- tive heart failure] was accelerating. We graphs and other data for their interpre- MU doctoral student George Chronis, ties . . . and some are incorporating caught it early, and we prevented an tation. But the goal is to capture even which partnered in 2017 with Stanley [intensive care unit] stay,” she said. “This more in words. With funding from the Healthcare as a distributor. (Drs. Rantz Continued to next page was the first case of a pattern recognition National Library of Medicine, CERT is for us . . . before we’d even gotten to the trying to achieve “linguistic summariza- point of sending out automated alerts” tions” of clinically relevant trends and to clinicians. changes.

WHAT ABOUT WEARABLES? Introducing the Society’s Podcast: Researchers at the University of Missouri (UM) made a deliberate decision not to use wearable devices — and to focus solely on passive sensor monitoring — when they developed their technology for TigerPlace in the early 2000s. “As AMDA-On-The-Go nurses with experience in long-term care and older adults, we knew they would not wear stuff when they’re not feeling well,” said Marilyn Rantz, PhD, RN, Hosted by: Dr. Wayne Saltsman curators’ professor emeritus in the MU Sinclair School of Nursing and executive director of the Aging in Place project and Sinclair Home Care. “It’s just when they need it most that they wouldn’t have it on.” By now, TigerPlace and other communities have proven that valuable clinical information can be gleaned from the environment without requiring the elderly to wear anything or handle any buttons or plugs. Still, wearable devices are one of the three main categories of technology — along with passive monitoring and interactive technology — that have a role in addressing and preventing functional decline, experts say. Certainly, “any technology that can track individuals and encourage them to engage in physical activity (including physical therapy) is the best preventive use AMDA of technology,” noted Majd Alwan, PhD, senior vice president of technology and executive director of the LeadingAge Center for Aging Services Technology On-The-Go (CAST). Today’s wearables aim to do more than track step counts and pulse, however. Some are being marketed for the collection of data on behavior, activity, and movement in seniors with the goal of predicting illnesses early. The challenge, said Marjorie Skubic, PhD, the director of MU’s Center for Eldercare and Rehabilitation Technology, is that “many aren’t carefully validated against clini- cal outcomes.” And the question remains of whether these devices can be used reliably in the Explore the eld of post-acute and long-term care, geriatric population. Dr. Skubic is planning to integrate wearable devices into with expert interviews, journal article reviews, her upcoming studies of senior living communities outside of TigerPlace. In innovations news, and more. addition to tracking levels of activity outside the home (where passive monitor- ing will not be possible), one of the things she wants to know is whether seniors will use them consistently. Visit paltc.org/podcast or search for Research will tell, but tomorrow’s seniors will be much more comfortable with devices overall. “It makes sense for whomever is looking at solutions for [the “AMDA On The Go” on: aging] to think comprehensively about solutions that support today’s residents with passive technologies as well as tomorrow’s residents who will be moving in with their Fitbits and Apple watches,” Dr. Alwan said. 12 carING FOR THE AGES March 2019

Continued from previous page in two communities, compared with an “SNF providers are now technologies can support their costs unmonitored cohort in a third, similar related to infrastructure, hardware, more comprehensive and advanced community in the same region (Telemed following the resident software, and staff training, Dr. Alwan functionalities.” J E Health 2007;13:279–285). noted. Thus far, most of the use of activity The technology won’t deliver, how- home after discharge with As monitoring technology evolves monitoring has been in retirement and ever, unless staff have the training and the hope of avoiding their and is adopted by more facilities and assisted living/senior housing communi- resources to understand the predic- systems, Ms. Jensen said, it is impor- ties “where the provider is making the tive data and to “turn it into preven- return to the hospital. I tant that caregivers and clinicians con- investment and folding it into the rent tive action that improves function,” Dr. tinue to appreciate their roles. Sensor of the unit or the overall [price] being Alwan said. And at the most basic level, think we’ll see more SNFs technology “is not replacing who they charged,” Dr. Alwan said. “The value the current payment models and a lack invest in technology that are — it’s giving them more informa- proposition is keeping people as inde- of reimbursement streams are hamper- tion to make a good decision. Their pendent as possible for as long as possi- ing its adoption, Dr. Alwan and other supports this process, but role is still to be a good critical thinker,” ble . . . delaying a transition into assisted sources said. There are competing pri- she pointed out. “But it’s also to be an living, for instance, or when they’re in orities, moreover; some facilities are still who will ultimately pay for advocate for the resident. The applica- assisted living, delaying a transition to trying to achieve basic Wi-Fi capability, it remains the question.” tion of these sensors will create new skilled nursing.” and others are investing in electronic issues related to privacy and data secu- Dr. Alwan said his belief in the power health record systems. — Liz Jensen rity . . . and clinicians will probably find of passive health status monitoring was Mr. Smith of Direct Supply said he themselves being asked by a daughter, bolstered years ago when he and his expects the passive monitoring market the evolving market. “SNF providers for instance, ‘Is this camera or sensor then-colleagues at the University of to quickly evolve, given the current are now following the resident after a good idea to put in place for my Virginia’s Medical Automation Research attention to fine-tuning the software discharge to home with the hope of mom?’” Clinicians will “need to be Center conducted a controlled study and decreasing the cost of the systems. avoiding their return to the hospital, able to understand what the technology of their passive monitoring system in “The hardware is ready to go,” he said. but many of their processes are staff can give [their patients],” Ms. Jensen assisted living, the same technology “And in the long term, costs may be intensive, like follow-up phone calls said. They must know “what they can that would serve as a basis for the first- lower in the scheme of things because or visits,” she said. “I think we’ll see expect to get out of it,” and they need generation system used at TigerPlace. the system doesn’t necessarily change more SNFs invest in technology that to listen to and respect their patient’s Over a 3-month period, they dem- with the turnover of a room [or living supports this process, but questions of concerns.  onstrated a 75% reduction in billable space].” who will pay for it remain.” LeadingAge interventions — including hospitaliza- Ms. Jensen, in the meantime, pre- has been advocating that the Centers for tions, physician visits, and antibiotic dicted that skilled nursing facilities Medicare & Medicaid Services ensure Christine Kilgore is a freelance writer in prescriptions — in a monitored cohort will increasingly see the potential of that the SNFs using remote monitoring Falls Church, VA.

Performers Put Practitioner Communication in the Footlights Joanne Kaldy

ommunication. It’s something ev- the situation and feel with the person. Ceryone does every day. But some- They will learn what it’s like to be that times what is said and what is heard are person and to have that particular illness. two different things. “Clinicians get frus- This gives them a safe place to reflect.” trated because they think they’re commu- She also encourages practitioners to nicating well, but people don’t seem to read literature that addresses aging and understand what they trying to say,” said illness. She said, “Literature teaches us Bob Arnold, MD, one of the founders eternal truths in entertaining ways and of VitalTalk. Practitioners, he said, often reminds us that there is always more talk to each in “shorthand and words we than one way to interpret any human have a common understanding of, but experience.” She added, “Literature patients don’t share this understanding.” shows us again and again that different He added, “It’s hard to shift gears from people have a different experience and talking to colleagues to talking to patients perspective of the same event.” Reading, and families.” One solution is to help she offered, helps us understand and practitioners develop and use different even internalize some of these different skill sets — such as acting and improvi- views.

sation — to be better communicators. Shoshana H erndon From Improv to Info Practice Makes Perfect Megan Cole helps practitioners find balance between engagement and Actor Alan Alda came to a realization Some programs give practitioners an detachment in communicating with patients. several years ago that improvisation opportunity to tap into their inner could help researchers and other practi- actor to be better communicators. For she said, the course is about ways of If I were this person, how would I feel? tioners effectively communicate techni- instance, Megan Cole, a stage and screen looking beyond a patient’s condition to How would I behave?” This isn’t so dif- cal scientific information to lay people. actor, offers workshops and courses for see the person inside. It is about finding ferent from what practitioners need to do As a result, he developed the Alan Alda practitioners on “Balancing Engagement a balance that allows the practitioner to to communicate effectively with patients Center for Communicating Science and Objectivity” and “Literature and engage with the patient without becom- and family members, she suggested. as part of the Stony Brook University Medicine.” In her programs, Ms. Cole ing personally lost. This balance is essen- Ms. Cole encourages practitioners to School of Journalism. “Real listening is shares some of her acting skills with tial, she noted, explaining, “We have watch movies and plays where actors the willingness to let the other person participants, such as being aware of to learn to trust ourselves and how to portray someone struggling with a seri- change you,” Mr. Alda said. The Alda the context and subtext of what people balance engagement and detachment.” ous illness or with aging. She said, “If the Method taught in his programs uses are saying and doing. She helps people Acting is about behaving “as if,” said performer is doing his or her work right the improvisational theater techniques understand how to break events into Ms. Cole. “It’s another way of imagining and well, [viewers] will get the experi- goals, actions, and obstacles. Ultimately, yourself in the shoes of your character. ence by proxy. They will be drawn into See PERFORMERS • page 20

14 carING FOR THE AGES March 2019

CARING TRANSITIONS James E. Lett, II, MD, CMD, with Wayne Saltsman, MD, PhD, CMD

Too Many Cookies

id your mother ever equate learn- make errors and poor choices, followed no English received instructions in I believe the answer is to assess our Ding to your brain being a cookie by frustration, as the brain emotion English. patients to determine their level of ability jar, with each new bit of information regions, previously held in check by the • A patient whose history and physi- to understand and implement discharge we learned like a cookie being stored in dorsolateral PFC, cut loose. Ultimately, cal stated “Patient is blind” was instructions, as proposed by Jackie that jar? My wife, Cheryl, used that anal- the participants just stopped making any given written instructions. Vance, RNC, BSN, my friend, colleague, ogy to her son as a positive incentive to decisions at all. Nor did the instructions generally and former staffer with AMDA — The learning, and it worked until the study This brings us to care transitions and make any reference to the patients’ Society for Post-Acute and Long-Term cramming session when Aaron declared, how the information fatigue phenom- socioeconomic conditions — such as Care Medicine. Doing so allows the dis- “Mom, my cookie jar is full! I can’t enon affects our patients. We now have whether they were infirm, blind, or cog- charging entity to determine the best learn anything else new unless I throw a neurophysiologic explanation for why nitively impaired, whether they needed avenue to effectively craft a discharge out some old cookies that are in there a patient might not carry out the instruc- to obtain the medications themselves plan that is not only appropriate but can now.” Sometimes the wisdom of children tions on changing medications, follow- or were being cared for at home, or actually be implemented by the patient. trumps even the wisdom of mothers — ing up with a physician, or obtaining a whether they could drive or even afford What would such an evaluation look but as mothers always do, Cheryl had follow-up computed tomography scan the medications. for? Here are some thoughts: captured the essence of truth with the or other discharge items we may feel are • Is any sensory impairment present cookie jar analogy. both critical and obvious. I submit my Clinicians provide too (inability to hear, see, speak, etc.)? That perspective is being proven by theory: we are overwhelming our tran- • Can the patient read? research on how people process informa- sitioning patients with so much regula- much information to • What is the patient’s health literacy tion to make decisions, what improves tory and legalistic required information, level? the decision-making process, and what much of it having little relevance to that transitioning patients. • Does the patient use English as a degrades those choices. A key feature, of particular patient, that the key informa- Overwhelming dump of second language? course, is the amount and presentation tion is lost. • Does the patient have cognition, of the information. Data input affects I can support my thinking with some discharge instructions memory, or judgment issues? (This our choices in a bell curve fashion: some anecdotal personal experience. I had the would include such problems as de- information is good, and more informa- pleasure of being part of a project that lowers our decision-making menting disease, delirium, mental tion is better for correct decisions — but implemented an inter-rater reliability capacity, causing patients health issues, and substance abuse.) only up to a point. Beyond this optimal method to ensure accuracy and con- • Can the patient provide self-care? If amount of information, the more input sistency in the Beneficiary and Family to do nothing at all. not, how is care to be provided? we receive, the worse our choices become. Centered-Care Quality Improvement • Does the patient have the financial Take a restaurant menu: the more Organization’s (BFCC-QIO) case review Other data overload problems are in resources to purchase medications appetizers, entrees, salads, and desserts I process. After reviewing randomly selected play with discharge instructions. First, as and medical equipment or meet see, the more likely I am to give up and charts, I noted a number of patterns: decision science advocates have noted, other discharge medical needs? order the last thing I looked at when 1. The charts were never less than in a data overload situation people • In any transitioning patient with the server demands my dinner selection. 100 to 200 pages, and frequently will tend to recall the most recent data the type of concerns listed here, will Invariably, I will hate my dinner selec- they were over 400 pages. (These received, irrespective of its source. Thus, family or a caregiver be present at tion — and all this is just as decision were for a hospital stays that were, after the typical lineup of clinicians have the time the instructions are pro- science would have predicted. In fact, by definition, less than 48 hours.) presented their hospital discharge infor- vided? decision science has become a legitimate 2. The discharge instructions were mation (the hospitalist, pulmonologist, • Can the discharge instructions be subject not only for university courses regularly in excess of 40 pages. cardiologist, dietician, discharge plan- provided by a single person, sum- but also for college majors and even 3. All the instructions were in ner, and others), the memory a patient mating all instructions? established institutes. English. will internalize will be the last person’s Part of the discharge/transition pro- Our information overload world of 4. Even with a medical degree, I often instructions — regardless of licensure, cess should always include an assessment Twitter, Facebook, Snapchat, YouTube, found the instructions dense and professional discipline or specialty, con- of the patient’s (or surrogate’s) under- and other electronic media blasts along difficult to follow. tent, or relative importance for out- standing of the instructions. Preferably with 24-hour newscasts resulted in 5. The instructions were definitely comes. Second, the more information this assessment should include a teach- the term “information fatigue” being not patient-centered to the indi- showered upon us, the poorer our deci- back or similar aspect to ensure that the added to the Oxford English Dictionary viduals being transitioned. sions become. Third, overwhelming patient or surrogate can articulate the in 2009. The physiology of this con- Among the boilerplate sets of discharge data dumps do not cause us to do the critical elements of the instructions. dition is being researched by Angelika instructions in the charts I reviewed, I wrong thing — rather, they prompt us Informed, engaged patients and fami- Dimoka, PhD, the director of the Center found these gems: to do nothing at all. lies are at the heart of good transitions. for Neural Decision Making at Temple • A patient was given a set of simi- At the beginning of my involvement in So let us consider not only the number University. Dr. Dimoka has studied vol- lar — only slightly different — in- care transitions, I believed clinicians were and type of cookies we provide to our unteers who were exposed to increasingly structions to those already provided providing too little information to transi- transitioning patients but also the size complex sets of information then asked less than a week before when the tioning patients and their families. Now and characteristics of the cookie jar we to make theoretical choices while their same patient was discharged from I contend we provide too much informa- use as our discharge instructions.  brain activity was measured by func- the same hospital. tion — by too many members of the clin- tional magnetic resonance imaging. The • A 92-year-old man was given in- ical care team, in an uncoordinated and result was that activity in the dorsolat- structions to not take his discharge rapid-fire way, without tailoring it to the Dr. Lett is a Society past president, past eral prefrontal cortex (PFC), an area of medications with birth control pills. needs of the transitioning patients. After chair of the Society’s Transitions of Care the brain responsible for decision mak- • Patients who had already received we have asked our patients to attempt to Committee, and previous editor of this ing and emotion control, became more flu and pneumonia vaccines were drink from a firehose of information, we column. Dr. Saltsman (pictured above) is and more active — until abruptly it fell given information about obtaining provide them with a 40-page set of dis- the section chief of geriatrics and transi- off, when the information burden (the both. charge directions to ensure compliance, tional care for Lahey Health, Burlington, cookie overload) became overwhelming. • A patient whose admission history with no regard to their language, reading MA. He is the chair of the Society’s At that point, the participants began to and physical indicated he spoke or visual ability, or health literacy. Transitions of Care Committee. carINGFORTHEAGES.COM CARING FOR THE AGES 15

Medical Director of the Year Nominees, 2019 Joanne Kaldy

he role of the post-acute and long- and local-level bipartisan candidates. He Tterm care (PALTC) medical director chairs and co-chairs ethics committees, has evolved over the years. However, and he provides numerous in-service talk to any member of AMDA — The programs and informal consultations Society for Post-Acute and Long-Term on best practices or emerging thoughts Care Medicine who fills this role and through articles and presentations on you will hear passion, commitment, and topics ranging from falls to antibiotic energy. You will hear a love for their pa- stewardship. He is a proud practitioner tients and their work, and loyalty to their serving rural communities and often teams. Yet the role of a facility’s medical travels hundreds of miles each week to director is often a better kept secret than see patients and work with facilities in Superman’s identity. If you were to ask remote areas. He frequently presents on a resident or family member to name topics related to rural medicine at the the medical director, you often would Society’s annual conference. Dr. Feinsod get a blank stare. In 2006 the Society also plays in the Grand Army of the established the Medical Director of the Republic Band, using a mountain dul- Year (MDOY) Award to help showcase cimer he made himself. the medical director as the facility’s clini- cal leader and to recognize outstanding Tsewang Ngodup, MD, CMD physicians who are innovative, visionary, Minneapolis, MN and set high standards for quality care. Dr. Ngodup is passionate about edu- As always, this year’s MDOY nomi- cation and has led countless programs nees are among the most innovative, on topics ranging from substance use inspiring practitioners in the field. disorders and immunizations to hearing Photo by Mark Upchurch loss in older adults and residents’ right to Eric Hasemeier, DO, CMD, is receiving the 2018 Medical Director of the Charles A. Crecelius, MD, PhD, refuse care. Dr. Ngodup implemented an Year award from Barbara Resnick, PhD, CRNP. This year’s award ceremony CMD antibiotic stewardship program that led will be held on Friday, March 8, during the opening session. St. Louis, MO to a decrease in urine tests and improved Dr. Crecelius is everyone’s go-to for edu- documentation regarding urinary tract program in an article in the January issue throughout his state and beyond. He is cation, information, advice, guidance, infections and other infection-related of JAMDA. He is a frequent speaker a wound-care certified physician who insight, and more. He is committed issues, which has contributed to quality at the Society’s annual conference and uses his skills to help others. He also has to promoting PALTC, and as a clini- care and outcomes. He targeted poly- other regional and national programs. been a leading advocate for palliative cal instructor of medicine and geriat- pharmacy, and his efforts have led to care programs. Dr. Rider developed an rics at Washington University School of decreased antipsychotic prescribing, Jennifer Riedinger, MD, CMD innovative pediatric palliative care pro- Medicine, he exposes fellows to the man- lower rates of narcotics use, and bet- Catonsville, MD gram and was instrumental in creating a agement of common geriatric medical ter medication reconciliation. He has Dr. Riedinger is a team leader in the tru- wound-care coalition that involves quar- problems and related issues. In conjunc- served as president and board member est sense possible. She created a robust terly meetings with local wound-care tion with the Sinclair School of Nursing, of the Tibetan American Foundation and meaningful training program for nurses to mentor and educate others. he initiated and helped coordinate a of Minnesota and has been active in advanced practice providers, and she He has provided wound-care education Healthcare Decisions Day at Delmar the Asian Pacific Endowment and the has mentored several physicians, all of to hospice and nursing home staff, and Gardens, where he has been the medical Council on Asian-Pacific Minnesotans. whom have gone on to pursue their he offers monthly staff in-service train- director for 20 years. He recently helped He has volunteered as a physician for Certified Medical Director designation. ing on a wide variety of topics. He also establish the PAC/LTC Consortium, a community events in the United States She works with staff on establishing worked to set up the McGeer criteria in collaborative effort among post-acute and abroad in India and elsewhere. best practices, educates them on a wide his facilities to help prevent unnecessary care representatives from local hospitals array of topics, and shares her expert- treatment of asymptomatic bacteriuria. and accountable care organizations, rep- Zachary J. Palace, MD, FACP, level knowledge on the Merit-Based Dr. Rider is an expert resource for sur- resentatives from local skilled nursing CMD Incentive Payment System (MIPS) and veyors, and he is always happy to share and rehabilitation facilities, and other Bronx, NY other regulatory issues. Dr. Riedinger his insights and knowledge with medical, stakeholders. The consortium pro- Dr. Palace embraces change and meets established a forum for medical direc- advanced practice nursing, and other vides a forum for professionals across both challenges and opportunities head tors to offer support and discuss best students. In addition to his commitment the care continuum to share views and on. He aided in the development of practices. Additionally, she created a to his work and his patients, he is a com- develop universal clinical care pathways. a groundbreaking Domestic Violence urinary tract infection protocol and munity leader who is active in the Rotary Dr. Crecelius is a past president of the Prevention and Assistance Program other clinical learning tools to stan- Club and his local church. Society and the Missouri state chapter. that educated staff and senior manage- dardize care, and she developed a He has chaired and served on numerous ment across the care continuum in his clinical documentation tool to review Loveleen Sidhu, MD, CMD committees, and he is a frequent and region about the signs, symptoms, and readmissions and contributing factors Bethlehem, PA/Phillipsburg, NJ highly knowledgeable speaker on legisla- prevention of domestic violence. He to rehospitalization and monitor anti- Dr. Sidhu is a strong communicator who tive and regulatory issues (and other top- won the Society Foundation’s Quality biotic stewardship. She led an inte- holds monthly residential council meet- ics) at the Society’s annual conference. Improvement Award for his innovative grated medicine program connecting ings with veterans and their families, project, “Development of an Outpatient hospitalist and post-acute care teams provides an introduction to hospice and Fred Feinsod, MD, CMD Transfusion Program to Reduce to enhance continuity of care. To maxi- palliative care to all facility employees, Colorado Springs, CO Avoidable Hospitalizations,” which not mize quality and the patient experience, and conducts in-service training on a Dr. Feinsod, in addition to being a only kept patients out of the hospital but Dr. Riedinger created and implemented variety of issues, including sleep hygiene strong team leader, has been a passion- also had a positive impact on quality of an effective patient satisfaction survey. and noise control, nonpharmacologic ate advocate for his patients. He initi- life and costs. Most recently, he and his pain management, and new devices for ated conversations in Colorado about team established an innovative program James Rider, DO, CMD respiratory rehabilitation. Dr. Sidhu’s distributive justice, concerning the lack regarding medical cannabis in his facil- Valley Falls, KS commitment to patients is exemplary. of available specialist support for resi- ity. This program not only enables the Dr. Rider is a natural educator whose She provides an annual remembrance dents with complex medical needs. He use of this therapy to improve pain and presentations on Clostridium difficile, ceremony for all bereaved families, and chaired a forum in Colorado Springs symptom management (as well as quality antipsychotic use, and opioids have she holds an annual fall festival and a that involved several long-term care of life), it also ensures compliance with informed and empowered practitio- communities’ councils and federal, state, federal and state laws. He described the ners, caregivers, and other stakeholders See MEDICAL DIRECTOR • page 16 16 carING FOR THE AGES March 2019

What to Expect When Cannabis Comes to Your State Joanne Kaldy

upport for legalization of medical The nurses know which residents are benefits of this treatment for nursing in activities such as painting. Her com- Scannabis is gaining speed in Missis- registered in the cannabis program, but home and other PALTC patients. “The plaining has diminished. sippi. Supporters have collected nearly no nurse, other practitioner, or staff favorable side effect profile makes it a There are many more stories like these. 40,000 signatures to get the issue on the member can administer the cannabis or viable option for this patient popula- For instance, the New York Times pub- state’s 2020 ballot; they just need an- handle it in any capacity. tion. We haven’t seen any adverse side lished an article about Dr. Palace’s facil- other 45,000 by September. To date, 33 effects,” said Dr. Palace. “We haven’t ity featuring a 98-year-old resident in the states and the District of Columbia have Mining the Myths, Focusing on seen patients become dependent, lethar- medical cannabis program (Feb. 2, 2017; approved the use of medical cannabis Facts gic, or constipated the way they some- https://nyti.ms/2UuPhy8). She is now for various conditions, and the number As medical cannabis in nursing homes times do with opioids.” 100, he said, and she is still participating. is expected to grow. As more states are is still fairly uncharted territory, nurses “A major game changer will be when legalizing medical cannabis, more prac- and other staff are likely to have some the FDA recognizes that medical can- Jump In, or Dip a Toe titioners have to consider how this will questions and concerns. Dr. Palace said, nabis shouldn’t remain as a Schedule I If medical cannabis is in your facility impact their patients, their facilities, and “Occasionally a nurse would ask, ‘Is the substance,” Dr. Palace added. While it’s or in your future, said Dr. Palace, “The their work moving forward. patient going to get high? What effects difficult to speculate if and when such most important thing is to become edu- Medical director Zachary Palace, will it have?’” Educating them can ease a change will happen, he suggested, “I cated. There are lots of resources and MD, FACP, CMD, and his team at the some of their worries. “We aren’t giv- would hope that as more studies come numerous articles in the literature. The Hebrew Home at Riverdale in Bronx, ing any patients formulations with a out demonstrating the therapeutic ben- actual cannabinoid pathways in the brain NY, developed an innovative program significant amount of THC [tetrahydro- efits of medical cannabis, the FDA will have been thoroughly articulated. Learn that affords residents the ability to par- cannabinol], which is responsible for the reconsider.” about it, and understand how canna- ticipate in a state-approved medical can- feelings of euphoria and other effects of bis is used for medical purposes.” He nabis program while complying with recreational marijuana use. Sharing the “I Never Smoked Pot!” added, “Treat it as an alternative therapy, federal laws. His experiences offer a use- facts and research with staff helped ease Educating residents and families was a complementary approach to pain and ful path for post-acute and long-term their concerns.” another top priority for Dr. Palace and symptom relief.” care practitioners and their care commu- It also is helpful to share some of his team. They kicked off the program As with any medication, start low nities who are preparing for legal medical the background on medical cannabis with a town hall meeting for residents. and go slow, said Dr. Palace. “See if cannabis use in their states. with staff. The U.S. Food and Drug They also distributed fact sheets to fam- there is a response, then increase the Administration has approved three can- ily members and held meetings for them dose gradually as appropriate. Watch Buy-In From the Top and Beyond nabinoids as medications: Epidiolex as well. “People were concerned about for side effects, and assess and man- Buy-in from the top is essential, and Dr. (cannabidiol or CBD), an oral solution the stigma of medical cannabis,” said age risks for problems such as falls. As Palace noted that he was fortunate to for treating seizures associated with epi- Dr. Palace, adding, “Many people — with any medication, there is always a have this in abundance. “Our president lepsy; and dronabinol and nabilone to residents and family members alike — risk–benefit analysis the practitioner and CEO, Daniel Reingold, saw the treat nausea and vomiting associated didn’t realize that medical cannabis isn’t has to do.” benefits of it with his own father. He with cancer chemotherapy. Dronabinol like smoking recreational marijuana and To learn more about the program, read was very excited. He came to me, and is also approved to treat loss of appetite getting ‘high.’ In truth, it’s nothing like an article authored by Dr. Palace and Mr. I had been thinking about it already.” and weight loss in people with acquired that. This program is very clean and Reingold in the January issue of JAMDA The more he researched and learned immunodeficiency syndrome (AIDS). structured. We know exactly what peo- (https://bit.ly/2SDXUdh).  about medical cannabis, the more Dr. Dronabinol contains synthetic delta-9- ple are getting, what the standardized Palace was struck by the indications for THC, and nabilone involves a similar dose is, and the exact concentration its use. “The diagnoses were so germane chemical structure. The FDA approved of active ingredients.” Dr. Palace fur- to the issues we see in our patient popu- a liquid form of dronabinol in 2016. ther observed, “It’s a highly regulated lation — most specifically, neuropathy, Various professional societies have program, and we have a high degree of Medical Director Parkinson’s disease, and pain.” weighed in on the use of medical can- confidence in it.” from page 15 That medical cannabis has potential nabis. For instance, the American Dr. Palace noted, “I’ve had patients benefit for some of his patients was with- Academy of Neurology (AAN) issued who are absolutely resistant to it. They out question. However, ensuring compli- a formal position statement that states, say, ‘I’ve never tried marijuana in my ance with state and federal laws took a in part: “The AAN acknowledges inter- life, and I’m certainly not going to try it spring dinner for veterans. Always con- little more thought and planning. “No est in medical marijuana from patients now.’” Sometimes, he said, family mem- cerned about quality of life, she started one wants to be in violation of federal and physicians and notes that several bers — such as adult children — are a “happy hour” for nursing home or state laws or do anything to jeopar- states have moved to legalize medical instrumental in convincing their parents residents. She serves as a liaison with dize Medicare or Medicaid funding,” marijuana in some form. The AAN also to consider medical cannabis. They are community hospice programs under a said Dr. Palace. “The two main issues recognizes that medical marijuana may often more open to alternative thera- hospice–veteran partnership, and she were administration and storage, and be useful in treating neurologic disor- pies and can influence their older family implemented a No Veteran Dies Alone we devised a plan to address each.” This ders.” Elsewhere, the American Medical members, Dr. Palace suggested. program via hospice. started with a policy and procedure that Association’s current policy states, “Our An interdisciplinary panel will assess detailed issues such as who is eligible for AMA urges that marijuana’s status as a The Success Stories the nominees on their contributions the medical cannabis program, how the federal schedule I controlled substance Ultimately, the patients and their out- and accomplishments in long-term cannabis is obtained and stored, how it be reviewed with the goal of facilitat- comes tell the story. “We had one resi- care medicine — specifically, their is administered and by whom, where the ing the conduct of clinical research and dent who had pain and was withdrawn clinical expertise, contributions to product can be consumed, and so on. development of cannabinoid-based med- and isolated. Since he started using staff education, leadership, and com- The staff were educated on these new icines, and alternate delivery methods. medical cannabis, his pain has lessened, munity involvement. This year’s award policies and procedures. This should not be viewed as an endorse- he comes out of his room more, and his recipient will be announced during Each resident registered in the medi- ment of state-based medical cannabis, quality of life has improved,” said Dr. the Opening General Session at the cal cannabis program at Hebrew Home the legalization of marijuana, or that Palace. “Another resident on opioids for Society’s annual conference on Friday, must purchase his or her own cannabis scientific evidence on the therapeutic use pain complained consistently. She had March 8. An interview with the winner products directly from a state-certified of cannabis meets the current standards been active and creative at one time, will appear in the April issue of Caring dispensary. The cannabis must be stored for a prescription drug product.” and we encouraged her to get out and for the Ages.  by the resident securely. Each registered AMDA — The Society for Post-Acute participate in activity programs. Instead, individual has his or her own lockbox and Long-Term Care Medicine doesn’t she stayed in her room and obsessed for this purpose, and only that resident currently have a formal policy about the about when she would get her next dose Senior contributing writer Joanne Kaldy can access it. The cannabis can only be use of medical cannabis, but JAMDA of pain medication.” After the move to is a freelance writer in Harrisburg, PA, self-administered or given to the resident has published numerous articles dis- medical cannabis, the resident started to and a communications consultant for by his or her designated caregiver. cussing the documented and potential come out of her room and get involved the Society and other organizations. carINGFORTHEAGES.COM CARING FOR THE AGES 17

CAREGIVER’S PERSPECTIVE MaryAnne Sterling and Geri Lynn Baumblatt The Hidden Health Crisis: What Family Caregivers Want You to Know

MaryAnne’s Story urgent pleas for caregivers to “take care health since they became caregivers. The to many and financially strapped. My I looked at the diagnostic specialist and of yourselves.” Sadly, this conflicts with responses were grim. They told stories of health was in shambles — uncontrolled burst into tears. She had seen other reality for many of us, who find it next to being healthy before they began caregiv- blood sugars, high blood pressure and women like me and knew what was impossible to reduce the stress of provid- ing, only to develop multiple chronic cholesterol, chronic depression, anxiety, wrong with my shoulder. Finally, after ing care and interface with our complex conditions, depression, sleep depri- arthritis.” 14 months of being tossed between phy- health care system — which takes a tre- vation, even complicated conditions “I am the most optimistic person on sicians, specialists, and physical thera- mendous amount of time, energy, and requiring surgery due to the relentless the planet, but due to providing demen- pists and many misdiagnoses, I had an financial resources, actually compounding stress of caregiving. tia care, I am on Prozac.” answer: frozen shoulder. It explained the the stress. We simply don’t have enough Here are their own words: extreme pain in my shoulder along with support. “I stayed too late at the hospital and The Hidden Health Crisis the stiffness and inability to move the So where does this stress come from? drove home tired. I totaled the car and Unfortunately, many studies on caregiver shoulder joint. This condition takes 1 to If you have not been a caregiver for an didn’t tell my kids for 2 weeks for fear health have been done on small groups, 3 years to resolve, and there is little that aging parent or grandparent, you may be they wouldn’t let me stay late to watch and some impacts are still not well stud- can be done to relieve the pain or force surprised. Caregiving responsibilities can over my husband in the long-term acute ied. The effects of caregiving frequently the shoulder to move. It mainly affects begin long before you are actually caring care facility.” sneak up on people. Initially, caregiv- people ages 40 to 60, and women more for someone in your home and continue “In the last year of [mom’s] life and ers may be healthy, but over time they often than men. long after they transition to a long-term for a few years after my mom’s death, often don’t notice how they’ve neglected Ironically, the demographic I just men- care facility (for those who do). The the physical, emotional, and spiritual their own health and well-being. When tioned also matches the demographic physical burdens of caregiving are often strength I once was able to muster a health problem occurs for them, they of the majority of family caregivers in eclipsed by the emotional roller coaster through caregiving devolved into full- don’t seek help because they’re so busy the United States. Coincidence? I don’t that ends in guilt. blown panic attacks, clumsiness result- with caregiving responsibilities. For think so. During my journey with this For many of us, the guilt of having to ing in multiple physical injuries, and an example, a 2015 study found nearly one- condition, one question has popped up place a parent in a nursing home is over- inability to engage effectively in simple third of dementia caregivers “frequently over and over: “Are you under a lot of whelming. We know the quality of their social situations.” or occasionally” missed medication doses stress?” “No more than usual,” I would care will not be the same, and it won’t “Between caring for my dad, husband, and nearly half did not keep their own respond, thinking back on multiple be provided with the same loving com- and adult sister, I had to start working health care appointments (West J Nurs decades and three of the four parents I passion. We feel guilty when we learn a night shift. I gained weight, lost sleep, Res 2015;37:1548–1562). shared with my husband experiencing in the phone calls that inevitably come and developed atrial fibrillation.” Health risk behaviors also go up: 40% dementia. at 3 a.m. that our parent has fallen and “[Mom] woke-up throughout the night of Alzheimer’s caregivers reported smok- But as those 14 months had dragged broken an arm or ribs, and we wonder if to go to the bathroom, 30 to 40 times a ing, and 25% reported a recent increase on, I often thought about my mom. we could have prevented it had they just night. I had to stay awake or she could in smoking. Thirty-four percent of spou- She was my dad’s primary caregiver been in our care. fall or walk out of the house. A few days sal Alzheimer’s caregivers said they used for 14 years before his death in 2001. But we’ve had to make these tough later, I was so exhausted I gave her an alcohol as a coping mechanism. After that point her health had quickly decisions. We can’t stay home to care for Ambien, hoping she would sleep through Good sleep, the single most important gone downhill, and she developed new our parents because we have to work to the night. I fell asleep for a few hours but resource for our health and well-being, chronic conditions and old ones wors- feed our families and avoid bankruptcy. was woken-up by a loud noise — my often becomes a memory. Most caregiv- ened. I’ve always considered caregiving The stress soon becomes a tidal wave. mother had fallen in the bathroom.” ers report poor sleep. To understand how the culprit. “I am sure stress has taken years off little sleep caregivers often get, one study Stories From the Front Lines my life.” of brain tumor caregivers found they The Caregiving Journey We reached out to several current and “Five years later she passed away . . . I averaged less than 6 hours each night, If you’re wondering, a 14-year caregiv- former caregivers for a litmus test of their was now single, unemployed, estranged were awakened 8.3 times per night and ing journey is not unusual: 12% to 15% were awake 15% of the time (Oncol Nurs of the time, caregiving lasts 10 years or CAREGIVER RESOURCES Forum 2013;40:171–179). longer, and the median duration is 5 Family caregivers often need to move years. The truth is, my frozen shoulder The reality of caregiving often prohibits caregivers from taking care of themselves, or transfer people and do other physical began after many years of stressful care- but available resources may be able to alleviate some of the burden by providing tasks but usually get little or no training. giving for my mom, which ended when information and other support. Even though we know this puts them she died in 2016. It didn’t take a rocket at risk for injuries, there are very few scientist to make the connection that I • CareGiving.com, https://www.caregiving.com data on injury rates or how this may had been under long-term duress and • Caregiver Action Network, https://caregiveraction.org contribute to chronic pain. In a small it had taken a toll on me beyond just • Family Caregiver Alliance, https://www.caregiver.org study done in 2014, researchers found “chronic stress.” • VA Caregiver Support, https://www.caregiver.va.gov that for caregivers who spend more than And it’s not just women in their 50s. • National Alliance on Caregiving, https://www.caregiving.org/resources/gener- 21 hours a week helping their loved one Consider that 10% of caregivers are aged al-caregiving/ with activities of daily living, 76% report 75 and older, about one in four are • AARP, “Resources Caregivers Should Know About,” AARG.org, Mar. 22, low back pain, and 43% report knee, millennials, and at least 1.3 million are 2017, https://bit.ly/2OLa1Pt shoulder, or wrist pain (J Appl Gerontol young caregivers aged 8 to 18. In fact, • John M. Bridgeland, John J. Dilulio Jr., and Karen Burke Morison, The Silent 2015;34:734–760). the Gates Foundation reported that 22% Epidemic: Perspectives of High School Dropouts (Washington, DC: Civic While caregiver depression and anxi- of high school dropouts say they left Enterprises, 2006), https://bit.ly/2SeMThI ety are common, caregivers are also at to care for a family member. Across all • Brendan Flinn, Millennials: The Emerging Generation of Family Caregivers, risk for post-traumatic stress disorder. these groups, 15% care for more than AARP Public Policy Institute, Mar. 22, 2018, https://bit.ly/2sdul2j Research conducted on family caregivers one person. • National Academies of Sciences, Engineering, and Medicine, Families Caring of patients in intensive care units found In fact, when somber advocates and for an Aging America (Washington, DC: National Academies Press, 2016), high rates of PTSD symptoms that can journalists talk about the negative health https://bit.ly/2sP0cXL impacts of caregiving, they often make See HEALTH CRISIS • page 18 18 carING FOR THE AGES March 2019

Health Crisis stroke. One study found this association risks. We must make this hidden health four parents with the disease. She is from page 17 was stronger in men, especially African crisis a national priority. Over 43.5 EVP, Caregiver Experience, at Livpact. American men with high caregiving million family caregivers are counting Follow her on Twitter @SterlingHIT. Ms. strain (Stroke 2010;41:331). on it. Baumblatt is a patient engagement and persist for 3 months after the intensive The inescapable conclusion is that health communication expert. She is care experience. Researchers have found caregiving is creating a whole new the principal at Articulations Consulting that many people still had significantrisk health care crisis that looms in the Ms. Sterling was a caregiver and health and cofounded the Difference Collab- for PTSD and borderline anxiety and shadows and is not getting the atten- care advocate for her parents for over orative to help organizations support depression at 3 months. tion it deserves. Caregivers are becom- 20 years. She is a renowned speaker their caregiving employees. She blogs The high stress of caregiving has also ing the patients. We must find ways to and educator on Alzheimer’s/dementia, about patient engagement and is on been associated with a higher risk for minimize and prevent caregiver health as she and her husband have three of Twitter @GeriLynn

Fall Prevention are needed to decrease both the risk and minutes a week of moderate-intensity FALL PREVENTION TOOLS number of falls. Physical activity — par- or 75 minutes to 150 minutes a week of from page 1 ticularly physical activity that is focused vigorous-intensity aerobic physical activ- Listed below are just a few examples on improving strength and balance — ity and muscle-strengthening activities of many tools and resources on fall uneven flooring or sidewalks, poor light- can decrease the risk of falls and their on 2 or more days a week (Scientific prevention currently available. ing or glare, lack of handrails, and prob- incidence. Although no single exercise Report, http://bit.ly/2VLq1VN). Older lems with assistive devices. The majority program or activity is currently consid- adults in long-term care settings gener- • AMDA Falls Clinical Practice of falls occur in the resident’s room and ered the gold standard for fall preven- ally participate in less than a minute of Guide, https://paltc.org/product- are generally associated with physical tion, a number of studies have focused moderate-level physical activity; meeting store/falls-and-fall-risk-cpg transfers and using the toilet. There is on resistance and balance exercises and the guidelines may not be realistic, so a • Supakanya Wongrakpanich, et al. no evidence to confirm that the number others on moderate-intensity aerobic personalized approach to physical activ- STOP-FALLING: A Simple Check- or type of nurses on duty influences falls. activity. ity is recommended. list Tool for Fall Prevention in a The current guidelines from the 2018 The physical activity goals for resi- Nursing Facility (Published online Intervening to Decrease Falls Physical Activity Guidelines Advisory dents should focus on each individual’s December 11, 2018, JAMDA), Because many factors are associated with Committee recommend that older underlying capability and optimizing https://bit.ly/2TNEU8M falling, multicomponent interventions adults engage in at least 150 to 300 what each resident can do. For example, • Ganz DA, Huang C, Saliba D, et al. if a resident can come to a stand inde- Preventing falls in hospitals: a pendently, doing 10 sets of sit-to-stand toolkit for improving quality of three times a day could strengthen her care (Rockville, MD: Agency for ability to transfer and stand without Healthcare Research and Quality, falling. If a resident can walk with or 2013), https://bit.ly/2BHjzoQ Together We Can Make a Difference without an assistive device, then three • Lainie Van Voast Moncada and 10-minute walks a day scheduled around L. Glen Mire, Preventing Falls meals or a 30-minute walk daily on an in Older Persons (Am Fam age-appropriate treadmill setting might Physician 2017;96(4):240-247), be a good goal option. https://bit.ly/2RXZlOG Additional interventions to help pre- vent falls should include evaluating and Management of medications for fall managing medical problems such as prevention requires an individualized degenerative joint disease to optimize approach to determine the potential gait and decrease pain. Experiencing pain risks and benefits. A resident who is so when walking or transferring can alter anxious that he walks to the point of an individual’s balance and potentially fatigue or climbs on tables or chairs may lead to a fall. Monitoring for orthostatic benefit from an anxiolytic, which may hypotension and adjusting medications consequently prevent a potential fall. accordingly can avoid the type of falls Likewise, prophylaxis with drugs such that occur after a drop in blood pressure as beta blockers should be reconsidered We with subsequent dizziness. if they decrease perfusion and thus con- Need There is presently no consensus on tribute to falls from hypotension. Most the impact of psychotropic medica- important is whether a drug is being Your tion on falls. For instance, one study used appropriately. found antidepressants were associated Environmental modifications such as Support! with falls but benzodiazepines were removing clutter and optimizing chair protective of falls (BMC Fam Pract and bed heights are also effective ways 2018;19:73). In other studies, poten- to decrease the risk of falls. Environment tially inappropriate psychotropic medi- adjustments should also be personalized Your donation combined with the generosity of others cations were associated with falls (Age and match the needs of the individual. will ensure that the vulnerable elderly will always have Ageing 2018;47:68–74) as was opioid For example, the optimal chair or bed high-quality, skilled and compassionate care. use (Drugs Aging 2018;35:925–936; height to facilitate safe transfers allows Int Psychogeriatr 2018;30:941–946; individuals to sit on the edge of the Can Med Assoc J 2018;190:E500–506). bed or chair with their feet flat on the The inconsistencies among the studies ground. Better lighting and reduction of may be related to whether individu- glare can also be individualized. als were naïve to a drug, or an opioid Finally, personalized cognitive modi- was combined with other psychoactive fications may be needed. Individuals medications, or other risk factors for who cannot make safe decisions related Make a donation today! falls were involved such as orthostatic to physical activity should not left alone hypotension, vision problems, pain, or www.paltcfoundation.org altered balance. Continued to next page carINGFORTHEAGES.COM CARING FOR THE AGES 19

Continued from previous page Creating Motivation Motivating residents to engage in phys- JAMDA Article on Falls if they will try to walk alone or lean ical activity is the second major chal- over to reach items on the floor and lenge. Walking can seem hard when Wins National Award potentially slide out of beds or chairs. you feel fatigued, in pain, or afraid Alternatively, the environment can be of falling. These unpleasant sensations adjusted to facilitate safety: using low need to be addressed and alleviated, if study of falls, published in the Feb- with an average age of 83 participated beds or chairs can prevent unsafe trans- possible. Sometimes just acknowledg- Aruary 2018 issue of JAMDA, won in the study. The authors found that fers or falls. ing that the resident is in pain or seems the 2018 Mather LifeWays Innovative walking — the most common activity to be fearful of falling can be sufficient. Research on Aging Gold Award (2018; associated with a fall — was more likely Use of localized pain treatments, oral 19:130–135, https://bit.ly/2TmfqyX). to occur in women (40.3%) than men medications, ice, heat, or positioning The award is given to the article that (29.2%). They recommended offering can help with the pain. Reassurance is felt to have the greatest potential customized, gender-specific exercise can help the fear, as can breaking down to improve aging services. A runner- programs based on these results. a task into smaller components: stand up article, “Use of a Robotic Seal as “The fact that JAMDA won this award by the bed the first day, march in place a Therapeutic Tool to Improve De- — which recognizes applied research the next day, and take one step the mentia Symptoms: A Cluster-Ran- with important implications for the third day. Making a physical activity domized Controlled Trial,” was from care of older adults — underscores that fun and ensuring it has a recognized the September 2017 issue of JAMDA the work published in JAMDA is of benefit or outcome — such as an eas- (2017;18:766–773). the highest quality and of relevance ier transfer to the toilet after a few The winning article, “Sex Differences to post-acute and long-term care, weeks of sit-to-stand exercises — are in the Circumstances Leading to Falls: and gaining the attention of provider essential motivational tactics as well. Evidence From Real-Life Falls Captured organizations,” said co-editors-in-chief Dance, physical activity bingo, or walk- on Video in Long-Term Care,” by Philip Sloane, MD, MPH, and Sheryl to-dine programs are all fun ways to get Yijian Yang, MD, PhD, and colleagues Zimmerman, PhD. more physical activity into the lives of examined factors associated with falls in Congratulations to the editorial team residents. two long-term care communities over a of JAMDA and the authors for receiv- Motivating staff is equally important. 9-year period. More than 500 residents ing this prestigious award.  Everyone needs to believe in the benefit of engaging residents in physical activ- ity to make it happen. Show the staff the benefits by continuing to highlight successful examples. Provide positive @iStockphoto.com/ fstop123 reinforcement to the staff members The physical activity goals for resi- who walk residents to the dining room. dents should focus on what each Arrange ongoing education and new resident can do. and fun ways to integrate physical activity into the daily lives of residents. Challenging Inaccurate Beliefs The Function Focused Care webpage ANNOUNCING: Despite the evidence that these person- (www.functionfocusedcare.org) has alized interventions can decrease fall over 100 tidbits to help staff increase risks, they are not easily put into practice physical activity among residents. TEACHING SLIDES because of the pervasive belief among nurses, patients, and families that physi- Working Together cal activity increases the risk of residents So why can’t we just decrease the inci- falling. The physiological fact is that as dence of falls? There is no magic pill, The Society is pleased to release a new muscles become weak with disuse, bal- no single intervention, no best exercise product – Teaching Slides. The PowerPoint ance declines. The weaker the muscles program. Residents and caregivers need presentations are an educational and teaching become, the more likely it is that the to work together to develop person- smallest alteration in balance will result centered approaches to fall prevention. resource on common issues in PA/LTC. in a fall. To motivate caregivers, staff, Individually tailored interventions are They include up-to-date information for the and residents to provide the appropriate the best way to manage the multiple interdisciplinary team including practitioners, care behaviors to prevent falls requires factors that influence fall risks and inci- addressing their inaccurate ideas and dences among residents. The next time nurses, and other healthcare members. strengthening their belief in the benefits you see a resident trying to get up from of physical activity. his or her chair, I encourage nurses and Presentations are available on: So another necessary intervention others in long-term care to stop yourself involves challenging the misconcep- from saying, “Don’t get up! You might • Diabetes Management in the Post-Acute tions, and I’ve found that the best way fall!” Instead help the resident take a to help convince staff, residents, and walk, or put on some music and encour- and Long-Term Care Setting families of the benefits of exercise is age a few minutes of sit-to-stand exer- • Heart Failure Management in the by example. I worked with a resident cises or dancing. Not only will this help Post-Acute and Long-Term Care Setting with prior history of multiple falls who decrease that resident’s risk of falling but could not ambulate independently due it will also bring a few moments of fun • Pressure Ulcers in the Post-Acute and to balance changes resulting from multi- to both your lives. And after the activity, Long-Term Care Setting infarct dementia. Her physical activity once the resident is fatigued and happy program included walking daily for a to sit and rest, you’ll both feel more at few hours in a Merry Walker. One day peace.  For more information or to order, visit she got up from her bed, walked across the room (approximately 20 feet) by https://paltc.org/product-store/teaching-slides herself, grabbed the door, and called Dr. Resnick is the Sonya Ziporkin out for help. Afterward, everyone was Gershowitz Chair in Gerontology at the confident that her Merry Walker activ- University of Maryland School of Nurs- ity, which had strengthened her sig- ing in Baltimore. She is also a member nificantly, prevented this incident from of the Caring for the Ages Editorial resulting in another fall. Advisory Board. 20 carING FOR THE AGES March 2019

their listeners and spontaneously adjust sometimes required in their professional and take on even greater communication Performers to those needs. environment. They learn to relate to oth- challenges.” Susmita Pati, MD, MPH, from page 12 Laura Lindenfeld, PhD, executive direc- ers by listening, observing, and being division chief at Stony Brook Children’s tor of the Alan Alda Center, explained that willing to make spontaneous adjust- Hospital, added, “Going through impro- pioneered by acting coach Viola Spolin the Alda Method encourages profession- ments. This, she said, helps physicians visational exercises helps physicians tap and her son Paul Sills to train scientists als to emerge from the narrowly defined to rediscover their passion for their work into their feelings. They learn to pay to pay dynamic attention to the needs of traditional roles and boundaries that are and inspires them to “share that energy attention to nonverbal cues and respond to them in the moment.” The program also has a curriculum focusing on teamwork because commu- nicating across settings and disciplines is so much a part of health care in today’s world of value-based medicine. “The meaning in work is closely tied to the team you work with. We can help people connect with their teams to reengineer Partner With Providers to Reduce Opioid Risk processes and share burdens so that we can maximize physician face-time,” said Editor-in-Chief of Caring for the Ages, Karl Steinberg, MD, CMD, HMDC, sorts out the facts and myths Dr. Lindenfeld. Being able to connect about the dangers of opioids. with your team is key, as Arif Nazir, MD, CMD, the chief medical officer of You can’t turn on the TV or open a newspaper without Never take more medication than prescribed or mix it with Signature HealthCare and the president- hearing about the “opioid epidemic.” If you or a loved other painkillers or sedatives, including aspirin, sleeping elect of AMDA – The Society for Post- one is in a post-acute or long-term care facility and has pills or other over-the-counter products, except on the Acute and Long-Term Care Medicine, pain, knowing the facts about opioids — as well as oth- advice of your practitioner or pharmacist. Never give your learned early in his career. He said, “My er treatment options — will help ensure that you and opioid medication to someone else for their use. director of nursing made me realize that your practitioner make safe, effective decisions. unless I deliberately disrupt the hierarchy If you or your loved one is in an assisted living facility or between myself as the medical director of Your practitioner will work with you to assess your or other setting where you manage your own medications, a facility and the front-line staff, my title your loved one’s pain, determine what is causing it, and store your opioid medications in a safe, secure place. and my white coat will always be in the consider how it might best be addressed. Sometimes Keep track of the number of pills or capsules, and alert way of a friendly and relaxed relationship. opioids (also called narcotics or opiates) — strong pre- your practitioner immediately if you notice any missing. If staff don’t feel comfortable with you, scription medications used to manage severe pain — they may hold back key information.” may be considered as a treatment option. It’s impor- The opioid medication will only be used for as long as is Dr. Nazir observed, “One simple means tant to understand that no pain medication gets rid of necessary. The practitioner also will look for non-drug treat- I found to connect with patients, family, all pain, and there are a lot of options to reduce pain ments — such as massage therapy, exercise, aromathera- and staff is to share your family photos, and help people live with it. py, meditation, acupuncture, cognitive behavioral therapy, particularly the ones where you appear to or breathing exercises — that might help manage pain. be not a physician but just another human Although opioids have been proven effective for se- being. I remember once I took on the role vere pain management, they have risks. Perhaps the Questions to Ask Your Practitioner of a Pakistani bride in a community play most serious are addiction and overdose. If you have a • How much pain is too much pain? How do I know if my and shared my pictures from the play with personal or family history of drug or alcohol abuse or or my loved one’s pain is bad enough to merit opioids? several patients for weeks. I can’t say that addiction or you take medications for a mental health • Are there other drugs besides opioids to manage pain? I’ve found a better strategy to quickly con- problem, you need to tell your practitioner up front • What about alternative treatments such as medical nect with my patients and their families!” so that he or she can choose an alternative therapy. If cannabis? Few practitioners understand the value opioids are the best option, your practitioner will work • What are the signs of opioid dependence? of improvisation and humor more than to monitor your dosage and response carefully for any • Do non-drug treatments really have any value? Dr. Nazir, who has said that he would problems or signs of dependence. It is important to un- be a comedian if he weren’t a physician. derstand the difference between physical dependence What You Can Do His comedic instincts, for the most part, and addiction. Dependence means when you stop us- • Make sure you or your loved one takes all medica- have served him well in his current pro- ing the opioid suddenly, you will feel sick or bad be- tions as directed. fession. He said, “During medical school cause of a physical habit that is normal for people who • Talk to your practitioner before taking less or more in Pakistan and also in my residency, I got take these medications regularly. Addiction means you medication. Don’t “self-treat” with over-the-counter in trouble for ‘not being serious enough’ are obsessed with getting and taking the drug, and it is products — again, talk to your practitioner. during rounds. Very early in my resi- causing problems for you. • Be honest with your practitioner about pain. Don’t try dency, I once put a funny but very benign to be brave. Don’t ignore it. comment in the medical note which was When opioids are prescribed, it is important to take • Tell your practitioner if you have family members or not appreciated. Of course, I quickly them as directed. Never take more or less than your friends with substance use problems. learned that I was going too far, but it did prescription says, and don’t crush tablets or capsules not take away my drive to make sure that unless your prescriber or pharmacist tells you to. Don’t For More Information I always inserted opportunities for light stop taking your medications suddenly. If you experi- • Steven A. King, “Opioid Analgesics: The Myths—and humor during my time as a faculty mem- ence uncomfortable side effects (such as constipation, the Facts,” Psychiatric Times, Jan. 27, 2017, http:// ber. I always found that learners woke up nausea, or dizziness) or your pain gets better, talk to bit.ly/2RWUke0 after such an interaction and paid more your practitioner. He or she will take you off the medi- • Adriane Fugh-Berman, Anna Lembke, and Christina attention to the content. I always believe cation slowly and safely and find other treatment choic- Prather, “Myths and Facts about Opioids,” PowerPoint that less content delivered with tact and es. Side effects from opioids are more common and Presentation (Department of Health, Government of humor is better than sharing too much severe in older patients. the District of Columbia, 2016), http://bit.ly/2DIt0Y6 content with utmost seriousness.”

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 Back to the Basics commentary about clinical developments and about the impact of health care policy on long-term care. Content Dr. Arnold and his team at VitalTalk offer for Caring for the Ages is provided by writers, reporters, columnists, and Editorial Advisory Board members under the editorial direction of Elsevier and AMDA. interactive, evidence-based clinician and The ideas and opinions expressed in Caring for the Ages do not necessarily reflect those of the Society or the faculty development courses to improve Publisher. AMDA – The Society for Post-Acute and Long-Term Care Medicine and Elsevier Inc., will not assume these skills on both the individual and 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. institutional levels. Their instructors are ©2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Continued to next page carINGFORTHEAGES.COM CARING FOR THE AGES 21

Continued from previous page clinicians who practice what they teach, Download the New App to Make the Most of Your using verbal tools to empower clinicians Conference Experience to communicate about serious illnesses empathetically and effectively. They also seek to enable practitioners to feel less ew this year, the Society’s annual app in the Apple App Store or Google The app lets you browse the entire con- stressed and burned out in the process. Nconference will offer a mobile app! Play Store. Install and open the app, ference schedule, check out the exhibitor The key to effective communication, Downloading the conference app to then select the event: 2019 AMDA An- list and the exhibit hall floor plan, access Dr. Arnold said, is “to ask before you your smartphone or tablet will provide nual Conference. Click on the icon to and download handouts, review the lists of tell.” He observed, “Make sure you the most up-to-date meeting informa- launch your app, then select “Create speakers and attendees, and much more. understand what people know and tion at your fingertips. Getting the app Account” and type in your name and It truly is the best way to make the most build on that information. Realize that is easy: Search for the free eventScribe email address. of your conference experience.  patients and families get information from many sources. Explore how open they are to new information.”

Learning to relate to others by listening, observing, and being willing to make spontaneous adjustments helps physicians to rediscover their passion for their work and inspires Congratulations to them to share that energy and take on even greater Our newest Rising Stars! communication challenges. GAPNA is proud to salute our newest Rising Stars! It's with great pleasure that we recognize outstanding members who are up and coming in their specialty and in It takes extra time to counter wrong leadership. Rising Stars are the future of our organization. Thank you for your excellent information, Dr. Arnold said. He sug- gested asking questions to determine work and commitment to the care of older adults! why someone is attached to misinfor- mation, misunderstandings, or myths. For instance, he observed, “sometimes a patient is insistent that he or she needs antibiotics when the practitioner knows that this is not the right treat- ment choice.” By asking some carefully worded questions, Dr. Arnold suggested, the clinician may determine that the patient just doesn’t want to be sick.” In this case, the practitioner can direct the conversation away from the how (antibi- otics) to the what (feeling better). From improv to acting, talking to lis- Helen Burns Melissa Kramps tening, studying to practicing, every day DNP, GNP-BC, NP-C presents an opportunity to be a better MSN, ANP-BC, AGN-BC, AOCNP communicator. “If you want to get better at communication, it requires intentional practice,” Dr. Arnold said. “This means thinking about it, watching others, and practicing every chance you get.” And as clinicians practice communicating, they get better and more confident at it. Megan Cole will present the Anne-Marie Filkin Lecture at the Society’s 2019 annual conference in Atlanta, GA, on Sunday, March 10. In her presentation, “Elder Voices: How Literature Can Help Us Understand Aging,” she will read from select works of literature that vividly describe what it’s like to age and be elderly, and she will talk about how these help us understand aging.  Kanah May Lewallen Patti Parker DNP, AGPCNP-BC, GNP-BC PhD, APRN, CNS, AGNP, BC, GS-C

Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations. 22 carING FOR THE AGES March 2019

JOURNAL HIGHLIGHTS

Journal Highlights From the March Issue of JAMDA

Opioid Use After Fractures injury,” he said. “Finally, the significant Sixteen (6.3%) reported lack of Editor in Chief Karl Steinberg, MD, CMD, HMDC Older individuals who did not regularly state-level variation in opioid use indi- respect, such as insensitivity by health Editorial Advisory Board use opioids before sustaining fragility cates the potential for quality-improve- care staff, privacy violations and non- Chair: Karl Steinberg, MD, CMD, HMDC, California fractures are more likely to remain on ment projects to reduce any unwarranted compliance with agreements about care Robin Arnicar, RN, West Virginia the medications one year after the frac- variation in opioid consumption among and treatment. Nicole Brandt, PharmD, CGP, BCPP, FASCP, ture occurs, especially those who undergo this demographic at a national level.” Slightly more than half the family Maryland Ian L. Cordes, MBA, Florida surgery, according to a population-based Although this study did not compare members believed their relative died Jonathan Evans, MD, CMD, Virginia cohort study from Dartmouth-Hitchcock the rate of opioid addiction in the elderly peacefully. Phyllis Famularo, DCN, RD, New Jersey Medical Center in Lebanon, NH. population vs. the general population, Families that reported unpleasant expe- Janet Feldkamp, RN, JD, BSN, Ohio Led by Michael T. Torchia, MD, the elderly population has a higher risk riences were more likely to believe that Nina Flanagan, PhD, GNP-PC, APMH-BC, New York researchers sought to characterize the of side effects from opioids. “For exam- their relative did not die peacefully, the Robert M. Gibson, PhD, JD, California patterns and duration of opioid use, ple, even a relatively ‘benign’ side-effect researchers said. Daniel Haimowitz, MD, FACP, CMD, Pennsylvania including regional variations, in patients of opioid medications, such as consti- Source: Bolt SR, et al. Families’ experi- Paige Hector, LMSW, Arizona Jeanne Manzi, PharmD, CGP, FASCP, New York who experienced fragility fractures in the pation, can result in profound disabil- ences with end-of-life care in nursing homes Jeffrey Nichols, MD, New York hip and arm. ity in geriatric patients who may have and associations with dying peacefully Dan Osterweil, MD, CMD, California “Our group had recently published underlying autonomic dysfunction,” with dementia [published online ahead Barbara Resnick, PhD, CRNP, FAAN, FAANP, work that analyzed prescription drug use Dr. Torchia said. “More relevant to the of print February 1, 2019]. J Am Med Maryland in the elderly both before and after fragil- manuscript, opioid medications can Dir Assoc. doi: https://doi.org/10.1016/j. Caring for the Ages is the official newspaper of ity fractures of the hip, distal radius and precipitate delirium among hospitalized jamda.2018.12.001 AMDA – The Society for Post-Acute and Long- Term Care Medicine and provides long-term care proximal humerus,” Dr. Torchia said in geriatric patients, leading to worse out- professionals with timely and relevant news and an email. “We did look at opioid use in comes. Finally, opioid pain medications Antipsychotics and Mortality commentary about clinical developments and about the impact of health care policy on long- that study, but it wasn’t the primary focus. can predispose elderly patients to falls, Use of atypical and typical antipsychotic term care. Content for Caring for the Ages is Given the ongoing conversation in health potentially leading to fragility fractures.” drugs increased the risk of death in indi- provided by the Society and by Elsevier Inc. care about opioids, we thought examin- The good news is that there are many viduals who have dementia, according to The ideas and opinions expressed in Caring for ing opioid use in the year following these options for pain relief after fracture and/ a registry-based cohort study conducted the Ages do not necessarily reflect those of the Society or the Publisher. The Society and Elsevier three common fractures in the geriatric or fracture surgery that don’t involve in Sweden. Inc., will not assume responsibility for damages, population would be particularly timely, opioid use. “Regional and spinal anes- Led by Emilia Anna Schwertner, of the loss, or claims of any kind arising from or related to the information contained in this publication, relevant, and clinically actionable.” thesia are effective non-pharmacologic Karolinska Institutet, researchers studied including any claims related to the products, drugs, For this study, the researchers used methods to manage pain,” Dr. Torchia 58,037patients diagnosed with dementia or services mentioned herein. pharmacy data for Medicare beneficiaries said. “Additionally, intraoperative local and registered in SveDem, the Swedish ©2019 AMDA – The Society for Post-Acute and who had sustained a fracture of the hip, anesthesia injections around the surgical Dementia Registry, which was established Long-Term Care Medicine proximal humerus or distal radius; had site can help alleviate acute postopera- in 2007 to improve the quality of care of Caring for the Ages (ISSN 1526-4114) is published no opioid prescription fills in the four tive pain and the need for opioid pain patients with dementia. 8 times year in January/February, March, April, May, June/July, August/September, October and months prior to fracture; and underwent management.” Individuals who used antipsychotic November/December by Elsevier by Elsevier 230 surgery. Source: Torchia MT, et al. Patterns drugs at the time they were diagnosed with Park Avenue, Suite 800, New York, NY 10169 USA. Periodicals postage paid at New York, NY and at Of 91,749 patients, 61.1% were of Opioid Use In the 12 Months dementia had a 40% greater risk of dying, additional mailing offices. treated surgically. The researchers Following Geriatric Fragility Fractures: the researchers found. Stratification by the POSTMASTER: Send Address changes to Caring for reported three major findings: A Population-Based Cohort Study. J Am type of dementia confirmed increased risks the Ages, Elsevier Customer Services Department, Individuals who sustained hip frac- Med Dir Assoc. Manuscript number: among people with Alzheimer’s disease as 1799 Highway 50 East, Linn, MO 65051. Subscription price is $255 a year (individual). tures (6.4%) had the highest rate of JAMDA-D-18-00338R2 well as dementia of the mixed, unspecified, Editorial Offices 1600 JFK Blvd., Suite 1800, opioid use 12 months later, followed by and vascular types. Philadelphia, PA 19103; (215) 239-3900, fax (215) 239- individuals who sustained fractures of Perceptions of Death Individuals with Alzheimer’s disease 3990. Letters to the Editor: [email protected] the proximal humerus (5.7%) and the Satisfaction with care and decision- who used typical antipsychotic drugs had Society headquarters is located at 10500 Little distal radius (3.7%). making may determine whether family a lower risk of death than those who used Patuxent Parkway, Suite 210, Columbia, MD 21044. Surgical treatment of distal radius and members of individuals with dementia atypical antipsychotics. Editorial Staff proximal humerus fractures resulted in perceive them as having a peaceful death, “It should be emphasized that this is Managing Editor Anna Boyum a statistically significant increase in the according to a study in The Netherlands. an observation study using registry data,” Journal Manager Robert D. Watson III proportion of patients using opioids Sascha Rianne Bolt, of Maastricht the researchers said. “Therefore, we can- Senior Contributing Writer Joanne Kaldy Display Sales Manager Denny Wang in the first six months compared with University, and colleagues performed a not assume causal relationship between 917-816-5960, [email protected] patients managed without surgery. secondary data analysis using data from antipsychotic drugs and mortality or Classified Advertising Adam Moorad There was variation by state in prescrip- the Dutch End of Life in Dementia obtain a conclusive and unambiguous 212-633-3122, [email protected] tion opioid use, ranging from 7.5% to (DEOLD) study, which looked at fami- result. Designs of this type, however, Customer Service Orders, claims, online, change of address: Elsevier Periodicals Customer 18.2%. States with the highest use were lies’ and physicians’ perceptions of the may lead to generation of new hypotheses Service, 3251 Riverport Lane, Maryland Heights, in the Southeast and Northwest regions. quality of dying experienced by nursing and give solid fundaments for further MO 63043; telephone (800) 654‑2452 (United States and Canada), (314) 447‑8871 (outside Dr. Torchia considers this study to home residents with dementia from 34 studies.” United States and Canada); fax: (800) 225‑4030 be a “stepping stone for further inves- facilities. Source: Schwertner EA, et al. Antipsychotic (United States and Canada), (314) 447‑8029 (outside United States and Canada); e-mail: tigation,” as there are not many stud- Of 252 families of nursing home treatment associated with increased mor- [email protected] (for ies of opioid use in the 65-and-older residents with dementia who died, the tality risk in patients with dementia. A print support); JournalsOnlineSupport-usa@ elsevier.com (for online support). Address changes demographic. “On a broader level, our researchers found: registry-based observational cohort study. J must be submitted four weeks in advance. results demonstrate that a proportion of Forty-two (17.0%) reported one or Am Med Dir Assoc. Manuscript number: opioid-naive geriatric patients will be more unpleasant experiences with care JAMDA-D-18-00472R3  consuming opioids one year after three during the last week of their relative’s life. of the most common fractures sustained Thirty-four (13.5%) reported neglect, in this age group, a significant finding namely negligence in providing tailored Jeffrey S. Eisenberg, a freelance writer considering that this group of patients care for their relative and providing in the Philadelphia area, compiled this was not taking any opioids prior to their information about their relative’s disease. report. carINGFORTHEAGES.COM CARING FOR THE AGES 23

NEWS FROM THE SOCIETY

Practice Management Sessions Take the Challenge: Connect in Atlanta

Offer Map for Navigating Challenges ichele Bellantoni, MD, CMD, information they can use to follow up.” Mchair of the Annual Conference In addition to coffee and meal breaks, he practice management sessions Standards and Experts: Telemedicine in Program Planning Subcommittee, chal- the program offers many opportunities Tat the Society’s 2019 annual con- PALTC; and Operationalizing Frailty: lenges conference attendees to engage, to socialize and engage, including con- ference are like “a map,” said Tom The Next Frontier in PALTC. connect, and interact during their time venient exhibit hours (with food and Haithcoat, chief operating officer for These specialized sessions will help in Atlanta, both in and out of the meet- beverages often available in the hall), a CareConnectMD and incoming chair practice managers and others prepare ing rooms. She said, “I’d like everyone welcome reception, state chapter meet- of the Practice Group Network (PGN). their organizations to tackle value-based to commit to leaving with a new friend, ings and events, and the Saturday night This map will help participants navigate medicine programs such as the Medicare a colleague in the field, and have contact President’s Dessert Reception.  challenges, opportunities, new develop- Access and CHIP Reauthorization Act ments, and other issues so they can keep (MACRA) and the Merit-based Incentive up and enjoy success in the constantly Payment System (MIPS). Participants evolving value-based medicine environ- also will learn how to develop and use ment. tools, including health information tech- “The bridge from volume- to value- nology, to improve and stabilize work- DON’T MISS THESE EVENTS driven care is complex and not easy to flow and optimize revenue from patient navigate alone,” said Mr. Haithcoat. visits. Additionally, the program will March 12, 2019 Website: https://paltc.org/core “We’ve worked closely with our Practice provide exclusive opportunities for idea Registration Deadline for Online Contact: Registrar Group Network members to develop exchanges and networking with peers. Core Winter Session Phone: 410-992-3116 a comprehensive program covering the Participants may come to these pro- Website: https://paltc.org/core- Email: [email protected] financial and regulatory challenges post- grams with questions and confusion. curriculum-medical-direction-post- acute practices face while on the volume- However, Mr. Haithcoat noted, “They acute-and-long-term-care August 6–November 17, 2019 to-value bridge.” will quickly see a clearer path to change. Contact: Registrar Online Core Fall Session There are a number of practice manage- They will be able to choose a way for- Phone: 410-992-3116 Website: https://paltc.org/core- ment sessions at the conference. Topics ward and feel confident when facing Email: [email protected] curriculum-medical-direction-post- include: On-Call Strategies and Provider practice challenges. Our measuring stick acute-and-long-term-care Burnout; Impact of MIPS, MCRA, for the success of the conference pro- April 4–6, 2019 Contact: Registrar APMs, VBP, and PDPM on PALTC grams will be that participants go home California Association of Long-Term Phone: 410-992-3116 Physicians; Engaging Clinicians and with resources they need and a network Care Medicine Annual Meeting Email: [email protected] Healthcare Team Members for Higher of colleagues that they didn’t have com- Los Angeles, CA Performance in Value-Based Systems; ing in.” Website: http://www.caltcm.org September 21, 2019 Contact: Barbara Hulz Greater New England Society for Email: [email protected] Post-Acute and Long-Term Care Worcester, MA JAMDA Wants You: Hone Research April 10, 2019 Contact: Nathan Strunk North Central Society for PALTC Phone: 781-434-7329 Analysis Skills at Special Workshop Medicine Annual Seminar Email: [email protected] Sioux Falls, SD special JAMDA workshop at the an- read, and review scientific literature. Website: http://www.sdhca.org/index. October 11–12, 2019 Anual conference is a must for practi- Participants will work in small groups php/medical-directors Michigan Society for PALTC tioners interested in writing or reviewing facilitated by JAMDA editors and edi- Phone: 605-339-2071 Medicine Annual Conference for the journal, as well as anyone who torial board members, discussing and Traverse City, MI wants to effectively analyze and translate critiquing a paper that was recently April 27, 2019 Phone: 517-449-7384 research into practice. “How to Read and submitted to the journal. You should Greater New England Society for Email: [email protected] Review Research Papers” is set for Friday, download the paper from the annual Post-Acute and Long-Term Care March 8, at 1:30 PM. JAMDA co-edi- conference website (https://paltc.org/ Waltham, MA October 11–12, 2019 tors-in-chief Sheryl Zimmerman, PhD, annual-conference) and read it before- Contact: Nathan Strunk Wisconsin Society for Post-Acute and Philip Sloane, MD, MPH, along hand. This is a great interactive learn- Phone: 781-434-7329 and Long-Term Care Medicine Fall with Foundation past-chair Paul Katz, ing experience. You don’t have to be a Email: [email protected] Conference MD, CMD, will provide a hands-on op- researcher or expert going in, but you Madison, WI portunity to learn how to critically write, will be much closer afterwards.  May 7–July 16, 2019 Website: http://www.wamd.org Online Core Spring Session Website: https://paltc.org/core- November 15–17, 2019 Make a Difference in a Minute curriculum-medical-direction-post- Core Synthesis Weekend acute-and-long-term-care San Antonio, TX nformation, opportunities, and a • Participate in an on-site auction Contact: Registrar Website: https://paltc.org/core Ichance to give back await you at the for items that will make your work Phone: 410-992-3116 Contact: Registrar Society’s Foundation booth during the and/or life easier and better. Email: [email protected] Phone: 410-992-3116 annual conference in Atlanta. Stop by • Contribute to the Foundation’s many Email: [email protected] the booth to: initiatives by purchasing 50/50 raffle July 25–28, 2019 • Donate to the Wall of Caring, tickets—have a little fun that also con- Alabama Medical Directors April 2–5, 2020 where every dollar goes to support tributes to the future of quality post- Association Annual Meeting AMDA Annual Conference 2020 a competent, compassionate, in- acute and long-term care medicine. Website: https://almda.org/page/ Chicago, IL formed workforce. (All donations Elsewhere, don’t forget the Founda­ upcoming-events-1 Contact: Registrar received at the Wall will support tion’s session, Quality Improvement: Phone: 800-876-2632 the Futures Program.) You also can How to Achieve Better Outcomes in July 19–21, 2019 Email: [email protected] write and post a tribute to some- Your Facility (Foundation’s QI Awards Core Synthesis Weekend one who has inspired you in your and Expert Panel Discussion), Saturday, St. Louis, MO career. March 9, at 11:00 AM.  It’s our turn to pick up where you’ve left off. Your care plan. Our CAREGivers.

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Home Instead Senior Care offers a variety of free CEU webinars designed especially for professionals in the senior care industry. These webinars are developed and presented by Lakelyn Hogan, Home Instead’s professional on-staff Gerontologist. Lakelyn serves as an expert source for aging-related issues. “Working as a Gerontologist allows me to educate professionals and communities about the issues facing older adults,” Lakelyn said. “It also allows me to gather valuable insights that help Home Instead enhance its services to better serve the aging population.” If you would like to learn more about Home Instead Senior Care’s CEU programs, visit www.caregiverstress.com/professionaleducation.