INSIDE: Starts on Page 4 Hospitals April 2020 • VOLUME 21, NO. 3 www.CaringfortheAges.com FREE ONLINE ACCESS

An Official Publication of The Evolution and Devolution of Hospital Care By Jerald Winakur, MD, MACP, CMD

entered medical school in 1969. IN THIS ISSUE IThrough a quirk of fate, I found my- self part of an experimental program in medical education, the “Clinical Pro- gram,” as it was called. It was an off- the-wall endeavor, but I was forged by it. From my first day of medical school — before I had taken classes in anatomy or physiology, pathology or pharmacol- ogy — I was placed into clinical clerk- ships that traditional students do not enter until their third year of training. And since I knew nothing of the culture of medicine, its doctors or hospitals, my sole identification was with my patients. That first day I duly reported for my as- signed clerkship: general surgery at the Looking Ahead, Philadelphia General Hospital (PGH). with Confidence PGH, a city-financed facility for the The immediate past president underserved, had evolved from “Old and the executive director Blockley,” established in 1732 as an of AMDA – The Society almshouse for the poor, the sick, the The author caring for a long-time patient during one of her many hospital for Post-Acute and Long- elderly, and the insane. William Osler, stays. Term Care Medicine sum up the Father of Internal Medicine, during recent accomplishments and his time at Penn (1884–1888) regularly dim, gray light. Hand-cranked hospi- hub of nursing activity. Nurses, aids, and initiatives in progress and made rounds there. Historians consider tal beds lined two long opposing walls, trainees worked 24/7 in the ward with share plans for the future. 3 Old Blockley to be the first hospital in with a painted metal nightstand by each the patients. what would become the United States. one. Folding partitions would be placed I remember that the patients, if they PDPM and Hospitals The surgery ward at PGH was a around a bed when necessary, such as were well enough, would socialize with Vital partners of post-acute huge open space with large windows during examinations, therapeutic min- each other, assist each other, and often and long-term care facilities, all around, though by 1969 they were istrations, or a patient’s death. At each hospitals are affected by the covered in deep grime and only let in end of the ward was a large table, the See EVOLUTION • page 8 patient driven payment model in many ways. 7

Nursing Home Abuse How to “ACHIEVE” Better Transitions Abuse in nursing homes can By James E. Lett, II, MD, CMDR take many forms and have many causes, but it always requires a response. 14 his is the epoch of Value Based Pay- These measures purport to determine are created, approved, shaped, defined, Tments (VBP). Some in the medical the adequacy or quality of our clinical and prioritized from sources such as community consider them wonderful, care. Further, just how well we clini- the Centers for Medicare & Medicaid Medical Director and while others may feel they are evil. Re- cians perform on these measurements Services, the Joint Commission, the the Survey Process gardless of our feelings, they are here to determines whether we are paid and how National Association for Healthcare Medical directors play a vital stay for the foreseeable future. Within much. All this is now ingrained into our Quality (NAHQ), the National Quality role before, during, and after that VBP framework, the true financial practice lives. Forum (NQF), and many others. the survey. 16 determinants and the components of our Quality measures, including those “report card” are reportable measures. judging “success” in care transitions, See TRANSITIONS • page 9

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 April 2020

CARING COLLABORATIVE By Elizabeth Galik, PHD, CRNP, and Richard Stefanacci, DO, MGH, MBA, AGSF, CMD

Caring Collaborative for Friendly Institutions and Communities

ypically our patients come out of methods of delivering skilled profes- consulting service comprising nurses, The cornerstone of the Age-Friendly Ta hospitalization worse than when sional services. It is designed from the geriatricians, pharmacists, case manag- Health System (https://www.johnahart- they went in, whether that be with de- ground up to look and feel like a real ers, and physical therapists to improve ford.org/age-friendly-health-systems- lirium, a decline in function, nosocomial home. Food is cooked on the prem- the comprehensive assessment and initiative) includes the 4Ms: addressing infections, polypharmacy, or medical er- ises, and medical equipment is often plan of care for older adults in ED what matters (choice and goals of care), rors. Despite efforts to treat older adults tucked away in wall closets. Skilled nurs- observation units (Acad Emerg Med mentation, mobility, and medications in place and avoid hospitalization, 35% ing assistants manage the residents’ care 2018;25:76–82). (Healthc [Amst] 2018;6[1]:4–6). A pilot to 40% of all hospital admissions include with support from nurses and therapists Comprehensive guidelines for geri- test of the Age-Friendly Health System individuals who are 65 years of age and but without the extra supervisory and atric EDs have been developed by model of care is underway in five hos- older. administrative layers — a reversal of the the American College of Emergency pital systems across the country, and Over the past decade, the focus of traditional nursing home model. Physicians (ACEP) in collaboration additional cohorts are planned. More policy makers and providers has shifted Of course, efforts can be made by with the American Geriatrics Society, information can be found at the IHI site across a multitude of initiatives that all LTC facilities to transform institu- Emergency Nurses Association, and (http://www.ihi.org/Engage/Initiatives/ have impacted the care of older adults as tional settings to be more home-like the Society for Academic Emergency Age-Friendly-Health-Systems/). they move through complicated health and friendly for older adults without Medicine (Ann Emerg Med 2014;63:e7– Addressing the 4Ms is certainly not systems. Some of these initiatives have undergoing a full Green House trans- 25). Consumers will recognize the envi- new to PALTC collaborative teams. included improving care transitions, formation. John E. Morely, MB, BCh, ronmental and equipment modifications This gives us an opportunity to serve preventing 30-day hospital readmis- of the Saint Louis University School in geriatric EDs, such as pressure-reliev- as experts, educators, and mentors for sion, increasing the use of emergency of Medicine in Missouri detailed this ing mattresses, no-skid flooring, and hospital systems. department (ED) observational stays, transformation in his discussion on the chairs with armrests. The guidelines also and responding to value-based payment design of nursing homes of the future (J emphasize the importance of geriatric Dementia-Friendly America models. The response of some hospital Am Med Dir Assoc 2013;14:227–229). interdisciplinary teams, adequate staffing Even as changes are transforming our systems to these initiatives has been to And while SNFs have been undergo- ratios and education, and policies and LTC institutions, EDs, and health sys- create preferred networks of skilled nurs- ing these transitions for several decades, protocols that address the assessment tems, similar changes are occurring in ing facilities. The need for faster, better, our other settings are just getting up to and management of geriatric syndromes. our communities. Dementia-Friendly and cheaper has tested relationships and speed. Quality improvement initiatives, geriat- America (DFA) is a national network of collaboration among hospitals and post- ric prescribing principles, targeted care communities, organizations, and indi- acute and long-term care settings, as each Geriatric Emergency Departments of falls, delirium, and dementia, and viduals who are seeking to ensure that group works to care for more medically Older adults comprise 25% to 50% of palliative care are key components of communities across the United States are complex older adults. all individuals admitted to the ED. They the geriatric ED — it sounds a lot like equipped to support people living with Although it is easy to blame recent have longer ED stays and use 50% more PALTC. dementia and their caregivers. Dementia- policy changes and hospital providers, laboratory and imaging services than With support from the John A. friendly communities encourage people we wanted to step out of our PALTC their younger counterparts (Ann Emerg Hartford Foundation and West Health, living with dementia to remain in their silo to recognize how hospitals and other Med 2014;63:e7–25). And despite their the ACEP offers a geriatric ED accredi- communities, supporting their ability to settings outside of LTC have adapted to high use of services, many older adults tation program. Since 2018, over 130 engage and thrive in day-to-day living. the new environment. They have been and their families are dissatisfied with the hospital EDs have completed the accred- The DFA movement, which began in promoting geriatric care principles and ED experience. itation process. We encourage you to September 2015 after the White House using collaborative teams to better meet While the use of specialized geriatric explore the guidelines, resources, and Conference on Aging, is based on ACT the needs of their older patients. EDs isn’t new, we are seeing more of accreditation process at https://www. on Alzheimer’s, Minnesota’s successful them, with more research to support acep.org/geda/. If your local hospital is statewide initiative. DFA launched in Friendly LTC their use. A recent pragmatic trial of a not listed, consider sharing this resource 2015 with pilot communities in Denver, No surprise that LTC settings are friendly geriatric ED intervention led by a col- with your colleagues in the ED. CO; Prince George’s County, MD; Santa for older adults, although that has not laborative team of nurses and physicians Clara County, CA; Tempe, AZ; and the always been the case. In the past SNFs resulted in decreased lengths of stay in Age-Friendly Health Systems state of West Virginia. A dementia- were much more hospital like — institu- the ED and hospital, reduced costs of Addressing the unique needs of older friendly community is a village, town, tional looking and feeling. Today, thanks care, and no risk of increased mortality adults in the ED and PALTC is to be city, or county that is informed, safe, to Green House and other efforts, these or same-cause readmission for their older commended, but it is imperative to and respectful of individuals with the settings are becoming more home like. patients (BMC Geriatr 2018;18:297). improve the care of older adults across disease, their families, and caregivers and The Green House Project (https:// More importantly, there was evidence of entire health systems through improved provides supportive options that foster www.thegreenhouseproject.org) began the intervention’s sustainability: positive continuity of care and more choices quality of life. almost 20 years ago when Dr. Bill outcomes were maintained, even after when it comes to PALTC. The John So whether it’s making your LTC Thomas (actually a pediatrician, not a the initial implementation team changed A. Hartford Foundation, which previ- facility more friendly for older adults geriatrician) visited the Robert Wood their roles. ously funded the preparation of leaders by adding plants or the smell of freshly Johnson Foundation to discuss a concept Another geriatric ED study used a in geriatric clinical care and research as baked cookies, or working with your designed to abandon the cold, institu- pharmacist and geriatrician collaborative well as the development of evidence- health system or ED to launch commu- tional feel of nursing homes. In sub- team to reduce polypharmacy among based geriatric resources and models of nity-based efforts to support dementia sequent years, with support from the older adults. This resulted in sustained care, is now partnering with the Institute care, so much can be done to make our Foundation, the concept evolved into medication reductions and additional for Healthcare Improvement (IHI) to environments friendly for those who are the Green House Project: small homes deprescribing by the outpatient clini- develop age-friendly health systems most at risk — our older adults.  that return control, dignity, and a sense cians 30 days after discharge from the that promote healthy aging principles, of well-being to elders while providing ED (J Clin Med 2020;9:348). prevent avoidable adverse events, sup- high-quality, personalized care. While many of us can describe care port family caregivers, improve the care Dr. Galik and Dr. Stefanacci are the co- A Green House home differs from a delivery challenges for older adults when of older adults with acute and chronic editors in chief of Caring for the Ages. traditional nursing home in terms of they are admitted to ED observation illness, and provide palliative options The views they express are their own facility size, interior design, organiza- units, some health care providers in geri- at the end of life (J Am Geriatr Soc and not necessarily those of the Society tional structure, staffing patterns, and atric EDs are using a multidisciplinary 2018;66:22–24). or any other entity. CARINGFORTHEAGES.COM CARING FOR THE AGES 3

The Search for PALTC Utopia: Annual Report From AMDA By Arif Nazir, MD, FACP, AGSF, CMD, and Christopher E. Laxton, CAE

magine a world where all patients, Society for Post-Acute and Long-Term represented misplaced expectations and a consulting platforms. The table provides Iresidents, and families in post-acute Care Medicine may ask, Why should the flawed system in need of a serious redesign. an overview of key strategic initiatives and long-term care (PALTC) settings Society’s members care? We should care Now, back to the utopia. As the imme- that can help the Society exert significant receive seamless care and service, per- for many reasons. diate past president and the executive influence on PALTC redesign. fectly responsive to their needs and goals. The Society’s vision for PALTC is a director of the Society, we believe that Only the Society has the experience, A world where physicians and advance world in which all patients and residents the current health care environment, leadership, and talent to produce the practice clinicians work side by side with receive the highest quality, compassion- with all its inadequacies, inefficiencies, exciting interdisciplinary solutions that all the other disciplines. A world where ate care for optimum health, function, and constraints, has never been more fer- will be required to counter the iner- nursing assistants are front and center and quality of life. Achieving this vision tile ground for new solutions and better tia created by decades of failed policies in care meetings. A world where mean- will not be possible unless everyone is fir- outcomes. Add to that an explosion in in PALTC. Most importantly, only the ingful care outcomes are rewarded. A ing on all interdisciplinary cylinders and new technologies and possibilities, and Society can help deliver the promise of world where unavoidable, unfavorable can demonstrate the value of providing we could be on the verge of revolution- the vision that we, our patients, and their outcomes don’t bring finger-pointing the necessary funding and resources. All ary change. If PALTC were the RMS families have been waiting for. and shame, but are seen as opportuni- care team members — including patients Titanic — huge, hard to maneuver, and It has been a busy and exciting year — ties for learning and improvement. and families — will need to support each headed for an iceberg — the door to the let’s continue to build on the momen- A dream? You may call us dreamers, other and be empowered in forming control room has just cracked open for tum. We look forward to connecting but if we make the right choices this uto- care plans. Members of the Society, as us. The question is, Are we ready to stick with you in the coming year and to see- pian vision can actually become a reality! key leaders, have a colossal role to play our foot in? ing you at the 2021 Annual Conference, In many ways, both positive and neg- in keeping the team enthusiastic and Over the last several months, the where we will measure our progress!  ative, 2019 was historic. For the first engaged during the most fragmented Society’s board has given the nod to time since nursing homes were measured and chaotic period of the PALTC setting. move full throttle to lead and collaborate nationally, more than half the skilled This chaos in PALTC is not a sudden, on initiatives to reimagine the Society’s Dr. Nazir is chief medical officer for Sig- nursing facilities in the United States ran random event. It is the product of years influence and role in PALTC quality. nature HealthCARE and president for a deficit. Yes, a setting that is the most of ineffective and often counterproduc- As a result, exciting possibilities have SHC Medical Partners. He is also im- crucial puzzle piece in the complex spec- tive approaches and strategies. Yes, there spawned, augmenting our traditional mediate past president of AMDA – The trum of PALTC makes for terrible busi- have been mistakes and neglect, but for domains of education, clinical guid- Society for Post-Acute and Long-Term ness. As physicians and practitioners in the most part failures in PALTC have ance, and advocacy with a focus on new Care Medicine. Mr. Laxton is the execu- this setting, members of AMDA – The partnerships, innovative solutions, and tive director of the Society.

Table. AMDA New Initiatives

Initiative Strategic Rationale Progress

Enhance PALTC chief nursing officer To add the perspective of CNOs, who are key to clinical Ongoing communications with CNOs on how AMDA might bet- (CNO) role in AMDA initiatives outcomes, to the Society’s influence on care. ter collaborate and support them and the interprofessional teams.

Help chief medical officers engage in To prove the Society’s influence on quality outcomes • Flu initiative resulting in hundreds of SNFs now mandating flu key care issues to move the needle on through objective data to key partners such as the Centers vaccines for staff. quality for Medicare & Medicaid Services (CMS), the Centers for • Polypharmacy initiative kicked off in collaboration with phar- Disease Control and Prevention (CDC), health systems, macy partners to create standards of measurement and imple- and payers. mentation to promote consistency in deprescribing.

Promote the SNF Survey Reimagine To assess the current accountability systems, including A think tank of national leaders invested in SNF quality that has Think Tank survey approaches and the need to be more supportive of met several times to review the intent behind, and execution of, SNF teams. federal survey processes and to brainstorm ideas for fresh, evidence- based approaches.

Organize participation of specialties to To provide a formal platform for other specialties integral Official steering committees kicked off to represent the physical enhance AMDA impact to PALTC (physical medicine and rehabilitation, behav- medicine and rehabilitation as well as behavioral health specialists ioral health) to operate within and influence the Society. practicing in PALTC.

Continue to integrate innovations into To initiate a formal process for disseminating point-of-care Innovations Platform Advisory Council leading on innovation AMDA “fabric” PALTC innovations to define the Society as a true leader “products” such as I-Portal and new partnerships with innovation in PALTC redesign. leaders both within and outside of PALTC.

Support the AMDA Leadership Arm To develop inward- and outward- facing leadership skills A leadership group assigned the task of creating a three-tiered lead- among members as a key to the Society’s success. ership framework: (1) frontline leadership, (2) internal leadership, and (3) leaders to represent the Society externally.

Add robustness to AMDA educational To promote educational products that are user-friendly New Learning Management System (APEX) provides more inter- offerings and on-demand to induce behavioral change. activity and user-friendliness. In addition, the AMDA Talk-Project was introduced for inspirational coaching.

Counter PALTC negativity by sharing As a key leader in PALTC, to lead serious dialogue about Editorials/podcasts on negative media bias published in peer- AMDA perspectives irrational approaches that threaten PALTC culture and reviewed/industry publications, social media posts supporting a spirit. positive culture, and a letter to CMS on the negative consequences of the “Red Hand” approach.

Continue the AMDA Consultative To partner with industry CEOs to bring customized Excellent responses received from several CEOs on the role the Platform solutions on care and physician leadership and generate Society could play in bringing customized solutions for better care. revenue. We are finalizing a “business plan” for board approval. 4 CARING FOR THE AGES JUNE 2018 A Supplement to

Hospitals

DEAR DR. JEFF By Jeffrey Nichols, MD, CMD

The Future of Hospitals in the Geriatric Continuum

Dear Dr. Jeff: Our nursing home fills its which operates 184 hospitals across the medical school for women), and recently inevitable mistakes, but the incentives to beds with patients being discharged from country, made $3.5 billion for its share- the major teaching hospital for the inte- accept more medically complex transfers the hospital. We have tried to position our- holders last year. grated Drexel Medical School. will not change. selves as a useful resource and reliable care Despite the robust financial health of Hahnemann was in downtown We seem to be going from “drive-by partner. But as everything in health care some hospitals, there has been a general Philadelphia and served primarily the delivery” to drive-by intensive care unit changes, how should we prepare ourselves pattern of hospitals struggling finan- poorer populations of the inner city, while stays, where patients go from being in as partners to the hospital of the future? cially, particularly those serving rural the insured or better-insured patients shock and intubated to post-acute pro- populations and the poor. Although the used the University of Pennsylvania and grams, sometimes without even a com- Dr. Jeff replies: Affordable Care Act brought millions Temple systems, including the suburban plete transfer to a regular hospital bed. Most of the discussions advocating the of Americans out of the uninsured cat- hospitals that ring the city. The equity The transformation of nursing homes restructuring of nursing homes assume egory, providing some temporary finan- investor who bought the hospital and into mini-hospitals is the inevitable that everything else in the health care cial relief to hospitals and patients alike, closed it recognized that the under- outcome. system, including federal and state millions more remain without insurance lying land was more valuable than a regulations or payment structures, will of any kind to pay medical bills. Unpaid money-losing hospital and felt no sense Home and Hospital stay the same. Of course, the maxim medical bills are still the single major fac- of responsibility for the 571 residents Many may find this shocking and mourn that nothing in health care is constant tor in family and personal bankruptcy. in 30 training programs who abruptly the loss of the quiet, friendly “home” except change applies here. Long-term Over the last few years, legal attacks by lost their jobs in September, much less that many professionals saw as the ideal care facilities are financially challenged. right-wing ideologues have left much the patient population the hospital had for long-term care. But it is simply the The average nursing home in the United of the ACA in tatters, with significant served. world coming full circle. In the 1960s States lost money last year, which in a potential that the protection of coverage and early 1970s, there were many facili- portion of health care dominated by for those with preexisting conditions will Patient Driven Payment Model ties named “Home and Hospital.” State for-profit facilities is the ultimate sin. be the next to go or possibly the entire The pattern of hospital closures has not regulations and the Joint Commission However, the picture in the world of enhanced coverage. produced a corresponding increase in the (then JCAHO) forced them to choose hospitals is not sunshine and flowers Despite the aging of the population occupancy rates of the surviving hospi- one or the other for certification. either. and the impressive advances in ortho- tals. The national occupancy rate for I was the medical director for a facil- pedic and cardiovascular surgery, there operated hospital beds has not increased ity that still had in-house radiology (we Hard Times for Hospitals has been a progressive decline in the by even a percentage point over the last did intravenous pyelograms and barium Some hospitals are doing very well — number of hospital beds from 1.5 mil- decade. Governmental and private insur- enemas), pharmacy, and laboratory indeed some are doing so well that gov- lion in 1975 to 921,000 in 2019. Much ers will undoubtedly continue the poli- services. But the Home and Hospital ernment has threatened to step in. The of this has been at the expense of rural cies that seek to limit hospital use, which wound up moving the beauty parlor into University of Pittsburgh Medical Center hospitals. More than 100 have closed will translate into a more limited pool of the space where the operating room had (UPMC) system in western Pennsylvania over the last decade, and 600 more are potential transfers. been, and the autopsy suite was used has been so profitable as a nonprofit teetering on the edge. Many more hos- As your facility attempts to position for file storage (although the pathologist (with more than $760 million earnings pitals have sought bankruptcy protec- itself in the future market, it is impor- retained his appointment on the medi- on $19 billion revenue) that its not- tion, on trajectories to shrink or close. tant to take a hard look at the viability cal staff in recognition of his service). I for-profit status has been challenged in Financially successful nonprofit systems of your potential partners. Although no followed several long-term residents who court, and state officials have threatened are still closing their less financially suc- one wishes to put the final nail in the had had their gallbladders removed or to replace its board for failure to address cessful components. The Mayo Clinic, coffin of a beloved local institution, it hips pinned without a hospital transfer! its mission. The system’s profitability is Cleveland Clinic, and UPMC have all would be unwise to develop extensive I don’t recommend this as a goal for your largely based on the ownership of its own announced hospital closures in the last new plans with a partner unlikely to future planning, but it emphasizes that highly successful insurance company, year for smaller facilities within their survive as a referral source when the plan the distinction between hospital-level which covers more than 3 million people. systems. matures. care and nursing home care is largely The hospital system has defended itself Although the closure of smaller “safety The Patient Driven Payment Model determined by the infrastructure in place by pointing to the Mayo and Cleveland net” hospitals in rural areas has attracted (PDPM) is designed to encourage post- to support the care of residents with a Clinics, which have been equally or even political attention, primarily from leg- acute nursing home programs to accept higher level of acuity and more complex more successful. The hospital’s rosy islators whose districts are affected, sicker patients, shortening their hospital needs. financial picture is, of course, helped by many urban hospitals have closed as length of stay. It is the next step in Although some of the needed elements its tax-exempt status, which eliminates well, including a few large and promi- the “discharge quicker discharge sicker” include enhanced access to laboratory real estate taxes; successful competition nent facilities. Perhaps the best known trend, which has only grown since the and radiology evaluation — such as for government research grants, which among these was Hahnemann University DRG payment methodology for hos- point-of-care testing and rapid-turn- provide huge overhead rewards; and the Medical Center, once the training cen- pitals was introduced. The Centers for around radiology providers — much of ability to accept tax-deductible contribu- ter for Women’s Medical College of Medicare & Medicaid Services have this depends on staffing. Nurses will tions. Some for-profit hospitals have also Pennsylvania (originally Female Medical already admitted that they plan to revise succeeded financially. HCA Healthcare, College, founded in 1850 as the first it again in a year or two to correct the Continued to next page CARINGFORTHEAGES.COM CARING FOR THE AGES 5

Continued from previous page evaluation units have generally not proven successful. Tune in to the Society’s Podcast: need to have significantly lower patient The hierarchical structure of hospital loads and to develop both increased skills care teams along with hospital staffing and increased confidence in caring for patterns are major barriers to collab- sicker patients. Provider coverage will orative care, even in acute care of the AMDA On-The-Go need to dramatically increase as well. elderly (ACE) units. There is simply no Teams of physicians, nurse practitioners, time for nurses, social workers, the mul- and physician assistants will be needed tiple restorative therapists — much less to provide seven-day-per-week coverage, for pastoral care — to spend with each with enhanced availability outside the other, the patient, and the family to traditional eight to six hours. complete a comprehensive assessment The expectation regarding how many and create a nuanced care plan. The patients a single provider can cover obvi- potentially valuable input of nursing ously changes when most patients must assistants, housekeepers, and night staff be seen daily. The cardiologists, pulmo- is never sought, much less incorporated nologists, and other specialists whose into a unified plan. AMDA patients will no longer be in the hospital The hospital of the future will incor- will need to come to the nursing home, porate the functions hospitals do best: On-The-Go or potentially provide regular telemed- intensive care and complex surgery. icine availability, to support complex Somewhere in the middle will be the patients. Certainly, an endoscopy suite sick patients on the road to recovery and minor ambulatory surgery are con- from the acute aspect of their illness — ceivable. All of this turns the standard and the medical providers who care for notion of “potentially avoidable” rehos- them. Nursing homes will strive to do pitalizations on its head. what we have the capacity to do best: Explore the eld of post-acute and long-term care, provide restorative and palliative care to Collaborative Care seniors with complex diseases. The roles with expert interviews, journal article reviews, Hospitals are not ideal locations for the are changing, and we must find ways to innovations news, and more. interdisciplinary care of complex frail get patients the care that they need.  seniors once their acute condition is Visit paltc.org/podcast stabilized. This is particularly true for “frequent fliers,” whose multiple hospi- Dr. Nichols is past president of or search for “AMDA On The Go” on: talizations suggest a need for a different the New York Medical Directors plan of care. Even formally designated Association.

JAMDA Compiles a Special Issue on NEW Urinary Tract Infections Hospital Care in the Post-Acute

staggering 7.5 million older adults of same-day physician access in and Long-Term Care Setting Awere hospitalized in 2017 (Centers reducing hospitalizations. for Disease Control and Prevention, • Measurement-related recommen- Pocket Guide 2018, http://bit.ly/39Zycoc; Adminis- dations to address complications tration for Community Living, 2017, and sequelae of hospitalization, http://bit.ly/3a1zijp), including 1.5 mil- including hospital-associated dis- Based on the consensus lion of the oldest old. Some were hos- ability, delirium, and use of med- statement published in pitalized more than once. Hospital care ications with potential adverse is an issue for post-acute and long-term effects are addressed in the issue. JAMDA earlier this year, care providers and the theme of the April • To reduce hospitalization-asso- this pocket guide 2020 issue of JAMDA. ciated disability, repeated moni- The papers compiled in the issue re- toring of functional change in the provides clinicians with flect the interest areas of PALTC re- hospital to inform rehabilitation vital, evidence-based searchers studying hospital care: was recommended. • Preventable hospitalization and • Emerging innovations in clini- information to help them readmission: Key risk factors for cal care relevant to the geriatric with the challenging task hospitalization and rehospital- population were presented in the ization were discussed, as well theme issue as well. Those include of diagnosing and as ways to predict and prevent the use of point-of-care chest managing urinary rehospitalization. ultrasound in bedside diagnosis, • Publications on transitions placing the bed by the window tract infections. between the hospital and post- to reduce the risk of falls, and acute settings highlight the administering statins after hos- importance of bidirectional com- pitalization for acute coronary Go to paltc.org for information munication between the acute care syndromes, with caution. hospital and the nursing home of “The intent behind this issue was to on AMDA products. information on functional and promote better hospital care and out- cognitive status, medications, comes for post-acute and long-term advance care planning, and key care populations, and spur additional contact information. Another research,” said Sheryl Zimmerman, article reported the importance coeditor in chief of JAMDA.  6 CARING FOR THE AGES April 2020

ON MY MIND By Karl Steinberg, MD, CMD, HMDC

Communication With Our Hospital Partners: A Vital Pursuit

or the first several decades of my and other self-defined metrics (such as (ED) and on whatever unit the patient because they didn’t bother to look at and Fpractice in post-acute and long- the use or nonuse of Interventions to lands in. verify the recently executed orders, or term care, it was a constant battle to Reduce Acute Care Transfers, medical There is good evidence that a trip to because they just give every new admis- get information or cooperation from director’s affiliation with a hospital or the hospital can be harmful for nurs- sion a POLST form and require that it our local hospitals. For all the wonder- Accountable Care Organization), and ing home residents, especially those be completed de novo. ful, life-saving treatments they provided began “narrowing their networks” of with dementia. Even cognitively intact Readers, please, if your facility is hand- to our mutual patients, they seemed to preferred nursing homes they recom- patients have a much higher probability ing out POLST as part of the admission have little interest in communicating mended to their patients, with the bless- of developing delirium — which carries paperwork, put a stop to it! POLST is with skilled nursing facilities to promote ing of CMS. Whatever our opinion of a poor prognostic implication — when not for every nursing home resident and smooth, safe transitions of care. We’d get making 30-day readmissions such a criti- they are sent to the hospital, placed in is never mandatory. If a patient comes a sick post-acute patient with 40 pages cal benchmark — and there’s plenty of a bright, noisy place, poked and prod- in with a valid POLST, it is unnecessary of paperwork, most of it irrelevant — evidence that it hasn’t really achieved its ded, have lines and catheters placed, and inappropriate to request a new one. reams of therapy notes, cardiac monitor goal of improving quality of care — we and often are given medications like opi- Hospitals also lament that nursing tracings, a seemingly random medley of have to acknowledge that communica- oids, benzodiazepines, or antipsychotics. homes send patients to them who are records — plus, if we were lucky, the tion between hospitals and its nursing These risks can be reduced by having a totally inappropriate, including patients history and physical that had been done home partners has improved substan- family member, especially a knowledge- with severe dementia who should by all five days earlier. But it would almost tially. And that is a very good thing. able one, accompany the resident to the accounts be treated in place. Or that take an act of Congress (and indeed, Obviously, we need hospitals to look hospital. our facilities wait too long to make a this got a lot worse after a particular act after our most seriously ill patients, They may also be diagnosed with a decision to send patients in, so by the of Congress — the Health Insurance including those who need pressors, sur- urinary tract infection in the ED when time they arrive at the hospital they are Portability and Accountability Act!) to gical procedures, continuous cardiovas- the patient has no criteria beyond some in septic shock or have florid pulmonary get a discharge summary from the hos- cular monitoring, ventilatory support, pyuria and bacteriuria with no symp- edema that could and should have been pital, often days later. Trying to call the transfusions, or advanced imaging that toms, and they may be given unnecessary identified, treated, and/or prompted a hospitalist who had cared for the patient we can’t provide on-site in our nursing antibiotics. The hospitalist or intensiv- transfer sooner. if there seemed to be critical information homes. However, we need to consider ist may start them on a proton pump How do we resolve these issues? lacking was a tricky challenge, and other that a fair proportion of our residents inhibitor or an antipsychotic, and most Keeping the lines of communication covering hospitalists, when you could do not want these kinds of interventions; diabetics wind up on sliding scale insulin open is key. Identify cases where a trans- reach them after sitting on hold for 10 they may want to concentrate on com- even though they may be able to take fer did not go as well as it could and do a minutes, often failed to yield the needed fort measures, and we are well equipped their oral medications. Those of us with root cause analysis in a collaborative way. data points. to provide comfort care, with or without expertise in caring for frail elders know These days, hospitals and nursing homes Up until 2012 or so, if a patient was hospice support, in our facilities. that these types of prescribing decisions, have much to gain and little to lose readmitted to the hospital at any time Short of intensive care unit (ICU) and however well intended, are harmful to from working together on improving our after a hospitalization, it created a new operating room (OR) services, we can our residents but happen all the time processes. Geriatric EDs, delirium reduc- payment under the Diagnosis Related provide many high-level interventions at the hospital. Improved education of tion programs, and improved education Guidelines (DRGs) and essentially “reset in our nursing homes — intravenous our hospital-based colleagues and com- around geriatric principles for hospital- the meter” for hospital compensation. So antibiotics and hydration, reasonably munication with them on behalf of our based clinicians can also be of benefit. there was no real disincentive to avoid high-level wound care, prompt labo- patients can help move the needle on Hospitalists who spend a lot of clini- rehospitalizations, and in fact there was a ratory work, and skilled rehabilitation these potentially harmful and unneces- cal time in nursing homes should join sort of financial incentive to rehospitalize services. We should try to be selective sary orders. AMDA – The Society for Post-Acute patients — the more times, the better for about what kinds of conditions — and Another problem that we observe and Long-Term Care Medicine and its the bottom line. Once the Centers for for what patients — we consider a trip with hospitalizations is that Physicians state affiliate societies, and those who Medicare & Medicaid Services initiated to the hospital, and we should handle Orders for Life-Sustaining Treatment serve as medical directors should take the the Hospital Readmissions Reduction what we can in-house. After all, in most (POLST) forms or similar orders may Certified Medical Director (CMD) Core Program in 2012, hospitals began to cases our staff know the patient’s indi- not be honored at the hospital. A JAMA Curriculum. And in PALTC, we should be penalized for excess 30-day rehospi- vidual needs and preferences; a trip to study demonstrated that some 30% of all try our best to treat our residents talization rates for certain conditions. the hospital will mean dealing with at patients who had documented orders in place whenever it’s safe and feasible, For many of us, this program marked least two sets of all-new staff, and new for comfort care on a POLST form in rather than sending patients to the hos- the first time in decades that hospitals doctors in the emergency department fact received treatment in the ICU. In pital when that is part of their care goals, had expressed any real interest in hav- some cases, patients or their agents may and not taking the path of less resistance ing a collaborative working relationship be changing their minds, but in other by punting problems to the Big House with local nursing facilities. Suddenly, If your facility is handing cases it is probable that the physicians that we should be managing in our own we were valued partners in the effort to at the hospital are making a conscious house. We owe that to the patients we reduce unnecessary readmissions. This out POLST as part of the decision not to follow valid orders such serve.  was a welcome change as our facilities admission paperwork, as do not resuscitate/attempt resuscita- and the local hospital systems worked tion [DN(A)R]. together to improve the quality of care put a stop to it! POLST This lapse occurs in both directions, Dr. Steinberg is president-elect of transitions and medication reconcilia- though. A common lament of hospital- AMDA – The Society for Post-Acute tion, and even to recommend the “warm is not for every nursing based palliative care clinicians is that and Long-Term Care Medicine and handoff.” (I know, “the patient is not a home resident; it is never they spend hours with a patient and editor emeritus of Caring for the Ages. ball.” But we all know what that term family at the bedside, finally coming to He serves as chief medical officer for means.) mandatory, and if a patient consensus on a “No CPR” decision on a Mariner Health Central in California and We began getting actual, dictated POLST form, only to send the patient has been a nursing home and hospice discharge summaries along with the comes in with a valid out to a nursing home with the POLST medical director since 1995. He may be patient. Hospitals began evaluating POLST, it is unnecessary and have them land back in the ED two reached at [email protected] nursing homes with respect to 30-day days later with a brand-new, full-code and he can be followed on Twitter readmissions, Five-Star Quality Rating, and inappropriate. POLST completed at the nursing home @karlsteinberg.

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Patient Driven Payment Model (PDPM): Impact on Hospitals By Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

he Patient Driven Payment Model hospitals — and SNFs would benefit by means that SNFs need to work individual needs. It’s similar to the T(PDPM), as we all know by now, is providing them with guidance. with their hospital channel to en- new CMS home health providers’ pay- the new reimbursement system model The biggest change for SNFs is the sure they provide the SNF with ment systems — the Patient-Driven that Medicare is currently using to deter- shift from therapy minutes as a basis the required information in their Groupings Model (PDGM) as well as mine payments for skilled nursing facili- for payment to the individual patient’s Discharge Summary during tran- the Hierarchical Condition Category ties, which started on October 1, 2019. clinical needs as the basis. Under the sitions. (HCC) risk adjustment for the Medicare PDPM replaces the previous Resources RUGs system, patients who required a 2. Hospital length of stay: SNFs Shared Savings Program (MSSP) and Utilization Groups (RUGs) model. The high degree of therapy were the most are now drawn more toward ac- Medical Advantage reimbursement and major impact is on SNFs, but there are profitable; under the PDPM system, cepting medically complex pa- total cost of care benchmarking. also challenges and opportunities for clinically complex patients will be most tients because of the potential for In the end, SNFs can assist their profitable. increased reimbursement. Hos- hospital channel partners in managing It’s important to keep in mind that pitals should see a reduction in PDPM for improved clinical and finan- Despite all that’s despite all that’s changing under PDPM, length of stay for these medically cial outcomes for patients and as well as changing under PDPM, the new model is still a fee-for-service, complex patients who need post- all stakeholders.  per-diem arrangement. This means SNFs acute SNF care. the new model is still still have a powerful incentive to increase 3. Hospital readmissions: With a their volume. The type of patients who 2% downward adjustment made Dr. Stefanacci is coeditor in chief of a fee-for-service, per- are most profitable for SNFs will clearly to the physical therapy and oc- Caring for the Ages. maintains active diem arrangement. The change in the new system, but the core cupational therapy components clinical practice in PACE programs drivers of SNF profitability will remain for the daily rate starting on day with AtlantiCare and Mercy LIFE. He type of patients who the same. 21 of a resident’s stay in a SNF, also maintains a faculty appointment The impact of PDPM for hospitals SNFs will work to decrease length at the Thomas Jefferson College of are most profitable for falls into three primary areas: of stay. This could result in an Population Health as well as at the SNFs will clearly change 1. Hospital discharge information: increased readmission rate upon CMD program of AMDA – The Society The SNF Request for PDPM discharge from SNFs. for Post-Acute and Long-Term Care in the new system, but Information requires verifiable, Further, hospitals need to appreci- Medicine. Dr. Stefanacci serves as resident-specific characteristics,ate that PDPM is part of the broad medical director for both AtlantiCare in the core drivers of SNF treatments, and diagnoses, which push by the Centers for Medicare & Population Health, PACE and profitability will remain includes information on length Medicaid Services toward “patient- Post-Acute Services and also for of time during the acute hospital centered” reimbursement models that Eversana. He may be reached at the same. stay on intravenous therapy. This match payment rates to the patients’ [email protected]. APRIL 2-5 ANNUALPALTC CONFERENCE20

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Evolution An almshouse [is] a kind of hos- community hospital. It had a tiny emer- Those of us caring for the elderly are from page 1 pital from the Middle Ages … (as gency department and a single intensive acutely aware that hospitals have reduced the French called it, Hotel-Dieu — care unit. A few accessible administrators inpatient days by shifting complex and God’s Hotel) that evolved as a way oversaw the fiscal side, but the practic- often less remunerative patients (the help the nurses with physical tasks. I of taking care of those who couldn’t ing doctors — though they were not aged, the infirm, the poor) into other was told again and again by the doc- take care of themselves. At one time, the owners — ran the show. Nothing settings — rehabilitation facilities, long- tors rotating through PGH during my almost every county in the U.S. had related to patient care happened with- term acute care facilities, skilled nursing one month there that I was witnessing an almshouse … In practice, the out approval and oversight by a robust facilities, and long-term care (LTC). And history passing, the medical care from almshouse had been a catchall for medical staff, all working for the benefit not only are our SNF and LTC patients another century. “Good riddance,” they everyone who didn’t fit someplace of “our” hospital and “our” patients. sicker, requiring more acute services than said to me. I was impressionable and else — it was a shelter, a farm for Despite the hours we put in outside of in years past, we and our facilities are idealistic, and my eyes were open: I felt the unemployed, a halfway house, our clinical practices — for committee being penalized should we dare to send there was something to take away from and a rehabilitation center, as well meetings and planning meetings and someone back into an acute care hospital my experience at PGH. But PGH — as a hospital. budget meetings — no doctor received too soon after they were sent to us. This after decades of neglect from publicly any additional recompense for the time is a malignant and intimidating message. elected officials — had become a dilapi- I spent the rest of my medical school and effort. Ask yourself: Who benefits from such dated, deteriorating mess. It closed per- training at the Hospital of the University In my almost 40-year association with policies? manently in 1977, then was bulldozed. of Pennsylvania, a poster child for the this hospital, I was an active observer Maybe hospitals ought to become Except for an ancient brick and iron modern medical-industrial complex. I and participant as it evolved into a mega obsolete. After all, our view of hospitals fence to mark its place in medical his- worked in state-of-the-art, specialized complex, with services to rival any aca- has changed, compared with another tory, no trace of PGH remains. Mega units: Medical ICU, Surgical ICU, demic medical center. Along the way century, as Emanuel pointed out: modern hospital facilities have risen in Neuro ICU, CCU, Shock and Trauma, it was acquired by a national hospital its stead. Neonatal, Pediatrics, Transplant, Renal chain. So, too, were many of the medical Hospitals now seem less therapeu- There no longer exist any public alms- Dialysis, and on and on. I learned, and practices, though not mine. The practic- tic and more life-threatening. In houses in America. The last to close was I learned. And yet, all the time it seemed ing medical staff is now “in charge” of 2002, researchers from the Centers Laguna Honda in Los Angeles, originally I was being drawn farther and farther nothing. A few have “graduated” to paid for Disease Control and Prevention opened in 1866 to help care for the gold away from what I believed I had gone administrative positions and joined the estimated that there were 1.7 mil- rush seekers (though a modern hospital to medical school to do: care for the legions of MBA types who micromanage lion cases of hospital-acquired infec- bearing that name remains). Dr. Victoria patient. all aspects of hospital operations. The tions that caused nearly 100,000 Sweet wrote about her years there as a I moved to San Antonio, Texas, and in staff meetings are but a rubber stamp on deaths. Other problems — from staff member in her remarkable memoir 1976 opened my office as a solo practi- policies plotted by others, and they per- falls to medical errors — seem too God’s Hotel (Riverhead Books, 2012). tioner of general internal medicine. I tain mostly to maximizing profitability. frequent … a hospital admission is This is how she described it: worked in a small but modern nonprofit Hired emergency department doctors, not a rejuvenating stay … but a trial hospitalists, intensivists, cardiologists, to be endured. nocturnists, and other “key” special- ists render the emergency and inpatient Perhaps some of those to whom we treatment. minister might do better with “home But what they provide is not “hospital hospital care” (see the study from care” but technology — state of the art Boston; Ann Int Med 2020;172:77–85). AMDA’s Know-It-All™ system is though it may be. When I use the term This is a 20-year-old idea, and its appli- “care” I mean it in the way you would cability to today’s increasingly frail and designed to maximize quality care want to receive hospital treatment for comorbidly aging population remains yourself or a loved one. inadequately tested but worth further and avoid unnecessary emergency I wrote about the horrendous experi- investigation. We now expect our LTC ences my mother endured in “my” hospital facilities to do what hospitals of yore room visits and hospitalizations. after her stroke (Caring 2010;11[10]:22– routinely did. Yet for the most part 23) and then after a hip fracture (Caring they do not have (as featured in the 2017;18[5]:10). “My” community hos- Boston home hospital study) doctors It includes: pital has not yet embraced the small but who visit their patients daily or spe- growing movement to provide geriatric cialized nurses coming twice daily, not Know-it-All™ emergency and inpatient care to at-risk to mention the lack of “RT, infusion elders in specialized units designed for pumps, radiology services, and point- Before You Call this demographic. Very few hospitals have of-care blood diagnostics” (Ann Int Med such facilities. Ask yourself: Why haven’t 2020; 172:145–146). Data Collection System these caught on? And let us not forget the growing in PA/LTC and Those of us doing our best to care for number of the aged, the infirm, the poor frail elders like my mother have many who have inadequate or no insurance, Assisted Living Settings such stories to tell. In our workaday lives who are homeless or ill-housed, ill-fed; we have learned from often bitter experi- who have no available family members to Know-It-All™ ence to do anything and everything we can assist and oversee. Where do these people to avoid putting our patients and loved go for care in a world where hospitals try When You’re Called ones in the hospital. So when Ezekiel to exclude them for fiscal reasons? Diagnosing System J. Emanuel, ethicist and vice provost at Should “cheaper and faster” be the the University of Pennsylvania, asked, mantra for a new paradigm of care, or “Are Hospitals Becoming Obsolete?” should we look back in time? If only (New York Times, Feb. 25, 2018), I was places like Old Blockley and Laguna primed for the message. Even though Honda were still extant among us, per- For more information or to order, today’s modern hospitals account for haps we might learn something new. visit https:/paltc.org/. $1.1 trillion of spending — one-third Again.  of all medical expense — their numbers are in decline. The zenith for admissions occurred in 1981, with 39 million hospi- Dr. Winakur practiced internal and ge- talizations, but currently there is a lower riatric medicine for 36 years, founded a rate of per capita admissions than in hospital SNF, and taught medical ethics 1946. Hospitals have declined in number and humanities to medical students for from 6,900 to 5,500. 16 years. CARINGFORTHEAGES.COM CARING FOR THE AGES 9

Transitions our peers in a format and language we services and provider behaviors associ- payment structure: check the boxes in from page 1 accept. Project ACHIEVE: Achieving ated with achieving the excellence we the guidelines for payment, and consider Patient-Centered Care and Optimized seek: the job done. The other is to understand (Disclosure: The author sits on the NQF Health in Care Transitions by Evaluating 1. Use empathic language and ges- why our patients are crying out and to Post-Acute Care and Long-Term Care the Value of Evidence — a 5-year, $15 tures. (What we say and the body meet their needs, even if doing so devi- Workgroup, and there are patient advo- million study funded by the Patient- language we present are acutely ates from actions that promise the most cate organizations represented.) I can Centered Outcomes Research Institute seen and felt.) reimbursement. attest to the efforts of all these entities (PCORI) — rigorously evaluated care 2. Anticipate the patient’s needs to I feel we should respond to the needs to represent the perspective of patients transition strategies to understand what support self-care at home. (The of our patients — and the demands and families. matters most to patients and caregiv- social determinants of health are of the payment system should answer As clinicians we have become inti- ers (Ann Fam Med 2018;16:225–231). demonstratively crucial.) them as well. If not, we need to advo- mate with the programs that dissemi- Their results were derived from focus 3. Use collaborative discharge plan- cate for changes in the measures now nate and manage the measurements groups and interviews with 248 patients ning. (All members of the dis- being used. To do so means creating regarding transitions. Thus the Hospital and family caregivers. charge planning team should join a coalition with our patients to begin Readmission Reduction Program So what do our patients (as well in one discharge plan, rather prof- to “measure what matters” as we move (HRRP), the Improving Medicare Post- as our families and ourselves) tell us fering multiple, sometimes con- forward in these tumultuous times. An Acute Care Transformation (IMPACT) is important about transitions in their tradictory and unrealistic conver- alliance with patients, families and care- Act, and Protecting Access to Medicare own words? Patients and caregivers in sations and plans.) givers is so natural a kinship for us and Act of 2014 (PAMA) are familiar pro- the ACHIEVE study emphasized three 4. Provide actionable information. our Hippocratic Oath that it scarcely grams and acronyms to us. But it is desired outcomes of care transition (That is, provide realistic next requires my elaboration. my personal opinion that those who services: steps.) So, VBP can, and should, support bear the burden of transitions — the 1. To feel cared for and cared about 5. Provide uninterrupted care with through its measures what is important patients, the families, and the caregiv- by medical providers. minimal hand-offs. (Communi- to patients and families. If not, clinicians ers — would recognize no more than one 2. To have unambiguous account- cate to the clinicians at the next should continue to perform the type of of the organizations (most often CMS) ability from the health care sys- site of care what needs to be done, care to “ACHIEVE” the type of quality involved in determining a successful tem. what the patient’s goals of care that patients and family anticipate.  transfer. Additionally, I would venture 3. To feel prepared and capable of are, and who should be contacted that a poll of those involved in transi- implementing care plans. for questions.) tions on the patient side would reveal a The PCORI investigators concluded, The major concern that arises after Dr. Lett is a past president of AMDA total lack of awareness of the existence of “Clear accountability, care continu- reading the ACHIEVE study is that – The Society for Post-Acute and the programs driving transitions such as ity, and caring attitudes across the care we now support two parallel avenues Long-Term Medicine, past chair of the HRRP, IMPACT, and PAMA. continuum are important outcomes for for patient care during care transitions. Society’s Transitions of Care Commit- Based on my personal and professional patients and caregivers. When these out- One course is dictated by the prevailing tee, and previous editor of this column. experience, the current state of care tran- comes are achieved, care is perceived as sitions receives a failing grade. As I was excellent and trustworthy. Otherwise, the repeatedly told in medical school, when care transition is experienced as transac- things are failing, go look at the patient. tional and unsafe, and leaves patients Thus, it is time to look at the patient, and caregivers feeling abandoned by the my esteemed colleagues! Where are the health care system.” Together We Can Make a Difference measures originating from those who My first thought upon reading these actually undergo these care transitions, concerns from patients and families along with their caregivers and families? was denial. It can’t be possible that the What does success look like for them? patients I care for could ever feel that they How do they judge a successful move weren’t valued and respected, that they from one site of care to another? don’t know who to call with their con- It is refreshing to see those questions cerns, and that they don’t know how to not only asked and answered at last, pursue their own care after returning to in a clinical, methodological fashion, what they considered home. My second but also published in a scientific jour- thought was embarrassment and alarm. nal so that clinicians can learn from By consensus, our patients are clearly telling us that our collective perfor- More From JAMDA mance in care transitions is suboptimal. Unquestionably many of us are doing Two papers in the April, hospital- high-level transitions — but many are themed issue of JAMDA focus on the not. A point to consider is that the dis- We nature of transitions between hospi- charge process is a true team effort. If Need tal and post-acute care and highlight even one member of a 10-person inter- the important role of communication disciplinary team does not perform well, Your and physician presence: the discharge plan is disrupted, leaving • An editorial by Dale et al pro- the patient and family feeling abandoned Support! poses geriatric-specific standards and unprepared. for bi-directional information The question at this point is to dis- transfer between nursing homes cover how to attain the goals of a good and acute care hospitals, with transition, as seen by the patient and Your donation combined with the generosity of others foci on functional and cognitive family. Currently we seem to celebrate will ensure that the vulnerable elderly will always have status, medications, advance care a good transition almost as a miracle to high-quality, skilled and compassionate care. planning, and key contact infor- be glorified rather than the standard for mation. each discharge. The question is how to • A research study by Kobewka et achieve a transition where the patient al underscores the importance of and family perceive the excellence we physician presence in long-term strive for with each movement within the care. It suggests that same-day health care system, each and every time. physician access could prevent Fortunately for us, the answers are almost one in six hospitaliza- outlined in the ACHIEVE study. The Make a donation today! tions. clear message of what needs to occur is found in the five reported care transition www.paltcfoundation.org 10 CARING FOR THE AGES April 2020

INTERDISCIPLINARY TEAM CASE STUDIES By Barbara Resnick, PhD, CRNP, and Paige Hector, LMSW

Clostridioides Difficile Management in a Patient With Barrett’s Esophagus

rs. S is an 85-year-old woman who infection for her peers, which is why she levels. Anemia is linked to loss of appetite resulting in stimulating effects with Mmoved into the nursing home needs to be placed on gown-and-glove as well as diarrhea and may be improved appetite suppression. five years ago when her husband could isolation, with staff assistance with her with iron supplementation. Although Mrs. S’s mirtazapine dosage is appro- no longer provide care for her due to personal hygiene and a deep cleaning of Mrs. S is taking an iron supplement it priate for the treatment of depression but her progressive weakness and failure to her room once the infection is deemed may be less effective due to the PPI, may be contributing to appetite suppres- thrive. She has a history of Barrett’s treated. omeprazole. Iron requires an acidic envi- sion. Consideration should be given to esophagus and significant reflux and Evaluating whether she continues to ronment to be absorbed, and PPIs work decreasing the mirtazapine dose to 15 subsequent dysphagia, a long history of manifest symptoms of C. difficile is not by blocking gastric acid secretions. mg at bedtime, which may increase her depression, allergic rhinitis, dementia always easy. If her white blood cell count It is unclear what her iron studies/ appetite as well as cause some sedation with a Brief Interview for Mental Status has normalized, if she is having some panel findings are, but to minimize this and allow for removal of her melatonin. (BIMS) score of 12, basal cell carcinoma, form to her stools, if she is having fewer interaction I would recommend separat- Furthermore, her current dosage of nor- insomnia, iron deficiency anemia, and than three stools per day, and if she ing the two medications by at least four triptyline, at 80 mg once daily, should a pneumonitis due to aspiration. She is is symptomatically better in terms of hours: moving the iron to bedtime and be reconsidered. This is greater than the oxygen dependent. nausea and anorexia, she is likely over keeping the omeprazole for mornings geriatric daily dosing limits, especially in Her medications include mirtazapine, this episode. She has an obvious risk before breakfast. Omeprazole is most light of her weight loss, and obtaining 30 mg daily; nortriptyline, 80 mg daily; for recurrence. Retesting of her stool effective after a prolonged period of her nortriptyline levels also should be melatonin, 3 mg daily; omeprazole, 40 may still give a positive result because of satiety because this is when the parietal considered (the specimen should be col- daily; ferrous sulfate, 325 mg daily; vita- Clostridioides colonization, so it does cells are stimulated. Because they block lected >12 hours after the dose). min D3, 2,000 units daily; and poly- not answer the question of whether she gastric acid secretions, PPIs create an ethylene glycol 3350 and senna daily. needs treatment again. Because she has ideal environment for organisms such Activities Director Over the years her diet has decreased to already acquired the Clostridioides bac- as C. difficileto grow, which is why Diane Mockbee BS, AC-BC include mostly just soft or liquid intake teria, it is not clear whether her PPI still PPIs are associated with an increased Ms. Mockbee is an activity consultant, such as supplements, ice cream, yogurt, represents a risk. risk of initial and recurrent C. difficile educator, and trainer. and milkshakes. She has generally main- There has been a lot of discussion infections. I would review infection control pre- tained her weight. A month ago, she was about probiotic replacement of the The Barrett’s esophagus diagnosis lim- cautions with the staff of the activities noted to have loose stools, and the nurses gut microflora, which might be easily its the opportunities to deprescribe Mrs. department. I would talk with Ms. S to immediately stopped the polyethylene achieved in this resident by the use of S’s PPI, so consideration may be given to identify what activities would be mean- glycol 3350 and senna. The loose stools one of her chosen foods: yogurt with initiating a probiotic to aid in the treat- ingful for her while she is being iso- continued, and she was noted to have live culture (i.e., unpasteurized yogurt) ment and prevention of the C. difficile lated for her infection. Possible activities less appetite and started to lose some or any of several probiotic regimens. Any infection. Both Saccharomyces boulardii may include playing her favorite music, weight. future contemplated use of antibiotics and Lactobacillus mixtures have been singing to (or with) her, gentle mas- A complete blood count and compre- with this resident — or indeed in any studied and have demonstrated mixed sage with lotion (the person providing hensive metabolic panel were obtained, resident — must be weighed against clinical results. Although the literature the massage should be wearing gloves), and a stool was sent for Clostridioides the risk of recurrence of this serious and for recommendation of probiotics in this soothing lighting, and reading to her. I difficile testing. Her white cell count was potentially life-threatening infection. case is not strong, the potential benefits would reassess her spiritual needs and up to 17.3 x 109/L, hemoglobin down She seems to have a justifiable need outweigh the risks for Mrs. S, especially preferences and help ensure those are to 9.6 g/dL; hematocrit 32.9%, total for her PPI and unfortunately is already in light of her recent treatment with met. The activities department can help protein 5.5 g/dL, and albumin 2.3 g/ colonized with C. difficile. Otherwise, vancomycin. support her nutritional needs by offering dL. All other tests were within normal in terms of deprescribing, perhaps her Approximately 25% of patients treated nutritious snacks such as milkshakes and limits. The stool specimen tested posi- nortriptyline dosage could be tapered for C. difficileinfection with metroni- yogurt. Until the C. difficile infection tive for Clostridium difficile, and she was off, given that she is taking mirtazapine; dazole or vancomycin experience recur- has resolved, we need to avoid the use started on vancomycin, 125 mg orally the latter could be reduced to 15 mg or rent symptoms, typically within four of any activity aids or supplies that are four times a day for 10 days. even 7.5 mg, with an inquiry into how weeks of completing antibiotic therapy. difficult to disinfect. Instead, we would At the end of the 10-day period she the diagnosis of iron deficiency anemia Furthermore, some nuances with oral encourage her husband to supply such was still having at least a few episodes originally was made. Her diet is possibly vancomycin need to be considered such items if she requests them. of loose stools daily, and she had a low in iron (with iron replacement), and as Mrs. S’s continued loose stools. Oral 14-pound weight loss over the past 6 she has a history of Barrett’s esophagitis, vancomycin is relatively safe due to its Social Worker weeks. The team is asked to discuss best so we should reconsider the source of her low systemic absorption, but it may have Paige Hector, LMSW ways to facilitate care for Mrs. S. iron deficiency and the extent to which caused prolonged disruption of Mrs. S’s Ms. Hector is a social work expert and a the treatment is necessary in this patient. normal gut flora, which may be why she coeditor of this column. Attending Provider Vitamin C might be added to enhance is experiencing persistent loose stools. In Physically, mentally, and emotionally, Melvin Hector, MD, FAAFP, CAQ her iron adsorption and minimize her addition, oral vancomycin could have Mrs. S. has endured significant life chal- Geriatrics, CMD dosing of iron. added to her reduced appetite as it has lenges, and her current health changes Dr. Hector is a Tucson-based physician known to cause dysgeusia. are presenting her with more: declining with over 30 years of medical director Pharmacist In addition to the vancomycin, tricy- health, loss of independence, depression, experience. Nicole Brandt, PharmD, MBA clic antidepressants such as nortriptyline oxygen dependence, and now an illness Medically it should be recognized Dr. Brandt is a professor and the execu- also affect taste. This is noteworthy in that impacts her overall well-being, com- that Mrs. S’s risk factors for acquiring tive director of the Lamy Center on Drug light that she is also taking mirtazapine. fort, and appetite. Added to all this is C. difficile include her advanced age, Therapy and Aging at the University of The mirtazapine dosage can be opti- diarrhea, which necessitates frequent the communal setting, chronic use of Maryland School of Pharmacy. mized to encourage appetite stimulation. pericare and infection control precau- a proton pump inhibitor (PPI) such as A review of this interesting case pres- At lower doses (7.5–15.0 mg), mirtazap- tions in which she is only touched by omeprazole, and a history of pneumo- ents many potential medication-related ine binds to histaminic sites, leading staff wearing gloves and gowns. She can nitis and presumptive prior treatment concerns. For instance, Mrs. S’s loose to sedation and appetite stimulation. only have soft foods or liquids because with a course of antibiotic therapy for stools and suppressed appetite may be At higher doses (30–45 mg), mirtazap- same. She represents an increased risk of associated with her low hemoglobin ine’s norepinephrine properties emerge, Continued to next page CARINGFORTHEAGES.COM CARING FOR THE AGES 11

Continued from previous page director of nursing, I will review the In the morning stand-up meeting, the She is Chief Nursing Executive at Lantis resident’s care plan and the interdisci- interdisciplinary team (IDT) will dis- Enterprises. she chokes. Her cognition is changing plinary documentation to make sure we cuss how we are meeting Ms. S’s needs One of the first considerations for a as well — either because of depression, are following the facility’s policies, meet- medically, socially, and emotionally and resident diagnosed with C. difficileis dementia, trauma, or a combination of ing the regulations, and providing the how we can best support her husband to prevent transmission to other resi- all three. The move from her home where best resident care possible. We should so that their mutually supportive visits dents. Because C. difficile can be spread she had created a life with her husband identify how staffing responsibilities continue. by direct and indirect contact with the may not be “new,” but the effects of that need to be modified to accommodate resident and their environment, isolation move and all the other changes have not the extended time it requires to care Director of Nursing and contact precautions are necessary. gone away simply because she has grown for someone with C. difficile and the Judi Kulus, MSN, MAT, RN, NHA, From a nursing perspective, the focus older or time has passed. Indirect screen- additional supplies the staff will need to RAC-MT, DNS-CT of care would be to encourage adequate ing for trauma means that staff need to care for Ms. S. Some staff may require Ms. Kulus has been a certified AANAC know the signs and symptoms of delayed education and training on C. difficile. RAC-CT Master Teacher since 2004. Continued to next page (or current) response to trauma. With a trauma-informed lens, we consider the cumulative effect of all these events on GAPNA_DCC_CFTA_ads_20.qxp_Island - Dementia Care Course 3/3/20 10:38 AM Page 1 Ms. S’s well-being. Consider that the definition of psy- chological trauma includes “any situa- tion that leaves you feeling overwhelmed and isolated can result in trauma, even if it doesn’t involve physical harm” (HelpGuide, Feb. 20, 2020; http://bit. ly/2Po3cWy). It would be easy to dis- Introducing a count the potential impact of trauma because Ms. S’s situation is not uncom- mon, and staff are accustomed to see- ing it regularly in the post-acute and long-term care setting. One of the big- DEMENTIA gest barriers to incorporating a trauma- informed care approach is an incorrect assumption that “common” events are not traumatic, individually or cumula- Care Course tively. Another challenge in recognizing trauma is that dementia and post-trau- matic stress can make accurate diagnosis difficult and the “behaviors” are often similar. With Mrs. S’s change in condition, With the support of The John A. Hartford Foundation and GAPNA, the this would be a good time to review her UCLA Alzheimer’s and Dementia Care program developed The Dementia advance directives, but more importantly Care Specialist (DCS) Curriculum. This 22-module online curriculum to engage in advance care planning dis- cussions with her (to the degree she is provides a basic knowledge base for Advanced Practice Nurses who are capable) and her husband to learn what looking to advance their expertise in caring for patients with dementia. they understand about this current ill- ness and her overall well-being. What are her values and wishes that would inform the type of care she would want should

To learn more about The overall goal of this course is to provide Nurse Practitioners with knowledge necessary to provide emotional and high quality dementia care management. psychological trauma, go to http://bit.ly/2Po3cWy. her condition continue to decline? It is also important to educate her husband on C. difficile infections to help prevent 9.00 transmission yet still allow compassion- ate and caring visits with his wife. For access, go to contact hours available Nursing Home Administrator gapna.org/DCS Nigel Santiago, MBA Member Price: $39.00 Mr. Santiago is the executive director of Haven of Phoenix in Arizona with 12 Standard Price: $59.00 years’ experience in long-term care. He holds an MBA from the University of Arizona. When a resident has a contagious infection like C. difficile, we still must uphold the resident’s rights, but they may have to be temporarily modified CNE accreditation information can be found before learner begins each module of the course. under the circumstances to decrease the risk of transmission. Together with the 12 CARING FOR THE AGES April 2020

Continued from previous page normally resolve in about two weeks. In KEY POINTS the case of Mrs. S, this may apply to the intake to maintain and improve Mrs. diagnosis of C. difficile, the loose stools, The interdisciplinary approach was important in combining each discipline’s S’s weight, monitor her fluid balance and the weight loss. Staff should monitor unique perspective in a balanced set of recommendations: due to the diarrhea, continue manage- her condition to determine whether an • The team was very consistent about the care of Mrs. S and the diagnosis of ment of the loose stools, and assess and SCSA will be necessary. C. difficile.There were some recommendations across multiple disciplines monitor her depression, which might be for medication changes, including deprescribing of her antidepressants, exacerbated by the illness and isolation. Nutritionist addition of vitamin C to help with iron absorption, careful evaluation of Additionally, efforts should be made to Rebecca Myrowitz, MHS, RDN, any further antibiotic treatment, and continued use of the PPI, given her replenish Mrs. S’s normal gastrointesti- CSOWM, LDN, CPH Barrett’s esophagitis. nal tract flora, which naturally will be Ms. Myrowitz is a registered dietician who • Concerns about her psychosocial status were noted across multiple disci- depleted from antibiotic therapy and currently provides dietary consultation in plines including addressing trauma, advance care planning, and engaging C. difficile infection.Even with a BIMS a continuing care retirement community. her in meaningful activities while managing the isolation required. score of 12 (“moderately impaired”), In caring for Mrs. S, the dietitian • The IDT also provided important reviews of facility policy on infection Mrs. S may be able to participate in her should perform a physical assessment control and the relevant regulations, and ensured that the resident rights recovery plan and share her food-related to determine if fat or muscle losses are of Mrs. S were considered. likes and dislikes, which may help to evident because these help to classify the increase her appetite and intake. severity of malnutrition. Some weight The Significant Change of Status loss may be expected due to lack of appe- weights with a goal of no further weight to increase energy density. Hydration Assessment (SCSA) Minimum Data Set tite, antibiotic therapy, and a prolonged decline. Mrs. S should be encouraged to should be a consideration as well, and is required when a resident has two or period of loose stools, but I would rec- have small, frequent meals. She may find she should be encouraged to replete elec- more changes in condition that will not ommend close monitoring of weekly it easier to incorporate fortified foods trolytes with broths, Gatorade, or a clear liquid supplement. Due to the continued loose stools, I would encourage Mrs. S to pick fewer milk-based foods and incorporate more soluble fiber such as OUR FOUNDATION oatmeal. By James E. Lett, II, MD, CMDR Additionally, it is imperative that the team be aware of her advance directives and whether Mrs. S chooses to receive intravenous fluids or enteral nutrition, Stewardship in the Modern World should it be suggested. She may benefit from a nocturnal meal to help support her oral intake and meet her estimated nutrition needs. Because Mrs. S has a history of dys- n last month’s column I addressed the and caregivers, and by demonstrat- facility then working all day, holding phagia and aspiration, and is tending Iconcept of stewardship. I applied this ing the value such a workforce brings evening meetings or presentations, and toward softer or liquid foods, the team concept to the emotions of my father to the table. We have the knowledge finally staying in a hotel in order to work may consider a speech consultation to and his fellow pilot cadets in World War and experience to construct the best again the next day. Without this doctor’s assess her swallowing ability. If she has II, which I found in dad’s letters home environment in which to provide dedication, some of these facilities would dentures, she may want a dental consul- during the war. The word “stewardship” care and effectively, safely transition likely close. tation because weight loss can contribute is defined in the Oxford dictionary as the increasingly complex and often In the award winner’s nomination let- to ill-fitting dentures. Due to her history “the job of supervising or taking care of vulnerable patients within PALTC. ter, one administrator wrote, “Residents of depression coupled with her current something.” For my father and his fel- These two goals are exactly those of are never a disease or a number ... [this lack of appetite and the contact isola- low pilots in training that “something” the Foundation for PALTC Medicine. individual] takes time with each and tion, I would recommend a behavioral was their country and a way of life that The pathway to these goals is through every resident to ensure that they know health referral. they felt would be destroyed if they stewardship, focusing on “taking care they are heard. It is a talent and a gift The team may consider adding a pro- did not personally intervene. Nearly 80 of something.” ... a gift that is even rarer in doctors biotic like Florastor to restore her gut years ago my father, his friends, and Stewardship can take two potential who have so much responsibility and flora, and vitamin C with the ferrous some 10 million other American men forms. The first is through contrib- so much territory to cover, with so little sulfate to aid absorption. If the ferrous and women of the Greatest Generation uting financially to the Foundation. time to accomplish this. Yet [this indi- sulfate is causing nausea, she may want made a commitment. They were not The second is by performing exem- vidual] handles all situations with grace, to take it with food.  going to allow their world to be con- plary actions that aid our patients and patience, and the utmost dignity and trolled by outside forces — it would inspire others to be the best, most respect ... it is never about going through be shaped only from within, and only compassionate clinicians they can be. the motions.” Dr. Resnick is the Sonya Ziporkin by them. Unsurprisingly, AMDA – The Society I ask that each of you follow the Gershowitz Chair in Gerontology at the I would not for a moment suggest for Post-Acute and Long-Term Care stewardship examples of our award win- University of Maryland School of Nurs- that the challenges we face today in Medicine is the home of both avenues ners — who will be celebrated in an ing in Baltimore. She is also a member our post-acute and long-term care of stewardship. upcoming issue of this publication — in of the Editorial Advisory Board for world compare to the magnitude of The 2020 winners of the Medical 2020 and beyond. Doing so will create Caring for the Ages. the events in World War II. However, Director of the Year Award, the a stronger Foundation and consequently well-meaning (and some not-so-well- William Dodd Founder’s Award, and a Society better able to shape a PALTC meaning) entities are pushing for ill- the James Pattee Award for Excellence world that is best prepared for patients, Ms. Hector is a clinical educator and advised, profit-minded changes based in Education all have the attributes I clinicians, and caregivers. professional speaker specializing in on a lack of understanding as to how have noted. For example, one of these clinical operations for the interdisci- care functions best for our patients. PALTC stewards has sponsored young plinary team, process improvement Changes in PALTC, when done cor- clinicians to the Futures Program for Dr. Lett has practiced in the PALTC and statistical theory, risk manage- rectly, should originate internally and several years, has incentivized young continuum for more than three decades ment and end-of-life care, and pallia- reflect those who best understand the clinicians to become Certified Medical as a hands-on clinician and medical di- tive care, among other topics. She is environment and have the best interests Directors (CMDs), and makes regular rector. He has served AMDA in multiple a member of the Editorial Advisory of patients in the forefront. That is to donations at the Wall of Caring during capacities including as president, on Board for Caring for the Ages. She is say, by us. the Annual Conference. multiple committees, and is the cur- passionate about nursing homes and We can drive this positive change Another of our award winners exhibits rent chair of the Foundation for PALTC supporting staff to care for the most only by generating an ample supply of commitment to PALTC every day, often Medicine. vulnerable people in their communi- committed, well-trained practitioners driving four to six hours one way to the ties. CARINGFORTHEAGES.COM CARING FOR THE AGES 13

Proton Pump Inhibitors and Dementia By Sanaz MoharramZadeh, BSc, Nader Tavakoli, MD, and Amrit Parhar, MD

ospitals can be dangerous places — they concluded that patients receiv- they found no convincing association studies) or acute cognitive impairment Hfor older adults. One of these dan- ing PPI medication had a significantly between PPI use and cognitive func- (seven studies). Although the majority gers is inappropriate medications — the increased risk of any dementia. tion or dementia risk (Gastroenterology observed a positive association for acute most common of which is proton pump When Paul Lochhead, MBChB, PhD, 2017;153:971–979.e4). Riley Batchelor, cognitive impairment, the methodologi- inhibitors (PPIs). Patients who are dis- and colleagues of the Massachusetts MBBS(Hons) MMed, and colleagues cal issues and conflicting results with charged taking a PPI often continue to General Hospital in Boston examined of Monash University in Melbourne, these studies limited the value of their receive it after their admission to a skilled the prospective data on medication use Australia, conducted a systematic nursing facility. But care needs to be tak- collected in the Nurses’ Health Study II review of 11 studies on the relation- en: if the PPI is inappropriate, it must be from the 13,864 participating women, ship of PPI use and dementia (four See PPI INHIBITORS • page 15 discontinued. As this article highlights, PPIs have many risks to be considered when assessing their continued use with GNCC_Reach_Excellence_CFTA_ads_20.qxp_Island - Dementia Care Course 3/3/20 10:54 AM Page 1 long-term care patients. Proton pump inhibitors (PPIs) have become one of the most commonly prescribed medications worldwide. In 2017, over 100 million prescrip- tions were written in the United States alone for these medications (Fed Pract 2017;34:19–23). Some of the known side effects of PPIs are interference with calcium, magnesium, iron, and vitamin B12 absorption. They also increase the risk of Clostridium difficile infection, pneumonia, and interstitial nephritis. Therefore, prescribing these medica- tions should be based on a valid clinical indication. There have been conflicting studies on the association between long-term use of PPIs and increased risk of demen- tia in elderly patients (Gastroenterology 2017;153;35–48). Some studies that have explored long-term use of PPIs found that they may accelerate senes- cence in human endothelial cells and also may change amyloid metabolism, which can lead to Alzheimer’s disease (AD). PPIs can also increase the risk of vitamin B12 deficiency by suppressing- gastric acid in the long term (JAMA Neurol. 2016;73(4):410–416). Although some large studies have shown significant associations between PPI use and incident dementia, other studies have contradicted them. Multiple confounders — including age, depres- sion, diabetes, stroke, ischemic heart disease, AD, genetics, and polyphar- macy — can interfere with attributing dementia solely to long-term use of PPIs. Specific considerations also should be noted: in individual patients, the benefits of using PPIs may outweigh the potential adverse effects. Britta Hänisch, PhD, of the German Center for Neurodegenerative Diseases and her fellow researchers in the German Study on Aging, Cognition and Dementia in Primary Care Patients conducted a multicenter cohort study to explore PPI use in long-term care and dementia (Eur Arch Psychiatry Clin Neurosci 2015;265:419–428). Of the 3,323 participants aged 75 and older who were observed for 18 months, 431 patients developed dementia, and AD was diagnosed in 260. Even allowing for potential confounders — includ- ing age, sex, education, polypharmacy, and comorbidities such as stroke, diabe- tes, and apolipoprotein E4 allele status 14 CARING FOR THE AGES April 2020

OBRA REGS REVISITED By Steven A. Levenson, MD, CMD

Responding to Regulatory Pressure About Nursing Home Abuse

If you define the problem correctly, you Aggression Is Common What Else Can We Do? The correct care delivery process almost have the solution. Unquestionably, VPA is found through- The abuse issue clearly has multiple requires that symptoms like “agitation” —Steve Jobs out society, including in nursing homes. dimensions. The numerous approaches and “aggression” be characterized in Even the CMS State Operations Manual by CMS to addressing abuse include detail to enable proper diagnosis, but n this month’s column, we will con- (SOM) acknowledges — and cites rel- requirements related to staff education they often are not. Medical causes of Isider the regulations related to abuse evant studies — that aggression affects and training, higher staffing numbers, behavioral issues (such as delirium) are in post-acute and long-term care set- both residents and staff (J Gen Intern improved psychosocial and environmen- actually quite common in people both tings, focus on verbal and physical ag- Med 2013;28:660–667). tal interventions, expanded nursing home with and without dementia, and they gression (VPA) as a key precursor of Agitation and aggression have a strong competency and compliance require- must be screened for and addressed abuse, identify how clinicians can help neurological foundation (primarily, the ments, background checks, antipsychotic adequately. reduce abuse, and discuss whether cur- brain’s limbic system). Many social, medication reduction, increased num- Furthermore, we cannot assume that rent approaches to identifying and curb- psychological, and medical factors bers of surveys, additional reporting and aggression in individuals with demen- ing abuse are on the right track or are affect how and when we respond to investigation requirements, and manda- tia is necessarily due to their dementia possibly having unintended and undesir- our own anxiety, fear, and anger and tory financial penalties and calling out of (so-called behavioral and psychologi- able consequences. that of others. Many altercations are facilities on the Nursing Home Compare cal symptoms of dementia, “BPSD”). Abuse and neglect are two of the most not the result of deliberate actions, and website. In addition, the Department of Both experience and the literature dem- challenging, complex, and contentious we cannot possibly know the underly- Justice undertakes prosecutions under onstrate that many individuals with issues in society generally, not just in ing motives. the Elder Justice initiative and False dementia have diverse causes of aggres- long-term care facilities. Recent years In addition, medical conditions (e.g., Claims Act. sive behavior, including behavior that is have seen expanded scrutiny of abuse strokes, electrolyte abnormalities, delir- With all of this and more, we might part of a long-standing or problematic and neglect in nursing homes. The ium, thyroid disorders) and medications wonder why the problem allegedly pattern of dysfunction (e.g., personal- widely publicized 2019 congressional profoundly affect brain function and persists so widely. Unfortunately, cur- ity disorders) and psychotic and mood hearings on abuse further intensified the the subsequent expression and inhibi- rent approaches — including investi- disorders that often respond well to tar- pressure on the Centers for Medicare & tion of aggression. Many categories of gations, sanctions, and embarrassing geted treatment (Desai and Grossberg, Medicaid Services to increase the inves- medications (e.g., steroids, antiepilep- disclosures — cannot take us any further Psychiatric Consultation in Long-Term tigation and reporting requirements and tics, benzodiazepines, muscle relaxants, without a much sharper focus on the Care, Cambridge UP, 2017). the penalties for abuse. In addition, as anti-Parkinson medications, anticholin- underlying clinical issues. In addition, the evidence is weak for of October 2019 CMS added an “alert ergic medications, and analgesics such Specifically, we must improve our urinary tract infections and conflicting icon” to the Nursing Home Compare as opioids and tramadol) often cause definition, diagnosis, and management for pain as causes of VPA. Although these website for facilities cited on inspection behavior or psychiatric symptoms such of the underlying medical and psychi- conditions may lead to confusion or reports for abuse that led to harm of a as restlessness, dysphoria, depression, atric causes of agitation and aggression. resistance to care, they are less likely to be resident within the past year or abuse confusion, disinhibition, and psychosis Again, aggression is a nonspecific symp- associated with such behavior compared that could potentially have led to harm that not infrequently lead to VPA (Med tom, which may result from diverse with fighting with other residents, wan- of a resident in each of the last two years. Lett, Dec. 15, 2008; https://secure.medi- causes, alone and in combination. For dering, or trying repeatedly to leave the The definition of abuse essentially calletter.org/w1301c). example, it may be related to a medi- facility (BMC Geriatr 2013;13:14–21). implies that any aggressive action or In relation to the “Hospitals” theme cal condition, an adverse consequence However, VPA is commonly associated interaction must be considered as poten- of this issue of Caring, many newly of medication, a personality disorder, with depression and psychosis, which tial abuse until proven otherwise. That admitted post-acute patients have seri- a substance abuse disorder, or an anxi- makes the appropriate diagnosis and casts a very wide net and demands exten- ous behavioral and psychiatric issues ety disorder. As discussed in the March management of these conditions essen- sive investigation, documentation, and that cause or predispose them to VPA. 2020 Caring column, applying the care tial (Arch Intern Med 2006;166:1295– reporting in virtually every nursing home During a hospitalization, there could be delivery process appropriately to make a 1300). The article that CMS cites in its nationwide. A facility can be penalized inadequate or incorrect prevention, iden- correct diagnosis is crucial to addressing surveyor guidance reinforces the asso- for abuse even if they made every reason- tification, or management of delirium or all situations — especially with behav- ciation of disordered behavior (which able effort to try to prevent it. various psychiatric or behavioral symp- ioral and psychiatric symptoms (DSM-5 can have multiple causes) and affective toms such as anger, psychosis, and anxi- Handbook of Differential Diagnosis, symptoms (e.g., depression) with res- An All-encompassing Definition ety (N Engl J Med 1999;340:669–676). American Psychiatric Publishing, 2013). ident-to-staff aggression (J Gen Intern The definition of abuse in In F-tag 540 Dementia also can predispose patients to We need a shift from the current Med 2013;28:660–667). is all-encompassing: the willful inflic- delirium and vice-versa (N Engl J Med heavily metaphorical perspective about Clinicians must recognize and manage tion of injury, unreasonable confine- 2013;369:1306–1316; J Am Med Dir behavior, which often minimizes or effectively the behavioral effects of medi- ment, intimidation, or punishment with Assoc 2014;15:349–354). ignores crucial medical and diagnostic cations in many categories. For example, resulting physical harm, pain, or mental Both primary care practitioners and components. For instance, the SOM too many medications with serotonergic anguish. It includes verbal abuse, sexual psychiatric consultants in the nursing states that “behavioral or psychological properties (e.g., opioids, antidepressants, abuse, physical abuse, and mental abuse. home may not recognize or address expressions are occasionally related to trazodone, buspirone, tramadol, lithium, Verbal abuse includes any language in underlying treatable medical conditions the brain disease in dementia; however, central nervous system stimulants, val- any form that willfully includes dispar- and medication-related adverse conse- they may also be caused or exacerbated proate, dextromethorphan, metoclo- aging and derogatory terms or threatens quences. Aggressive nursing home resi- by environmental triggers. Such expres- pramide) and/or too high doses may lead or intimidates someone. Mental abuse is dents are often transferred to emergency sions or indications of distress often to akathisia (motor restlessness) or other any conduct that causes or has the poten- departments or to acute medical and represent a person’s attempt to com- varieties of serotonin syndrome, which is tial to cause a resident to experience psychiatric hospitals. A limited or vague municate an unmet need, discomfort, or then mistaken for “anxiety” and treated humiliation, intimidation, fear, shame, exchange of information between the thoughts that they can no longer articu- with even more medications, ultimately agitation, or degradation. An individual nursing home and the inpatient facility late” (CMS, State Operations Manual, resulting in even more agitated and (e.g., staff, a resident, or a visitor) needs may lead to misdiagnosis and inadequate Appendix PP: Guidance to Surveyors for aggressive behavior (Mayo Clinic Staff, only to act deliberately, regardless of any or inappropriate management of causes Long Term Care Facilities, §483.40(b) intention to inflict injury or harm. of aggression. (3); https://go.cms.gov/2I3aevU). Continued to next page CARINGFORTHEAGES.COM CARING FOR THE AGES 15

Continued from previous page seen thousands of patients over the years who were helped greatly by get- “Serotonin Syndrome,” Dec. 10, 2019; ting the right psychopharmacological https://mayocl.in/2VSdkv0). We must medications in the right doses based on review carefully (e.g., look up side effects effective diagnosis and clinical reason- on Google or Medscape) and address ing. In contrast, prescribing based on WEBINARS existing medications before getting psy- guessing rarely improves — and often chiatric consultations and adding more exacerbates — aggression. medications. In summary, many things have been It is true that simple nonpharmaco- done over the years to try to reduce logical interventions can be very helpful abuse, with some success. There is a lot or sufficient in addressing situations that we can all do to improve the situation might otherwise culminate in VPA. Over further, but it requires going beyond the The Society provides webinars the years, we have often reduced aggres- usual and customary approaches that can sion successfully by removing unneces- only get us so far. It is time to reopen a throughout the year for all those sary and excessive restrictions and care largely closed dialogue and get our facts that patients don’t need or want (such and methods straight.  as sliding-scale insulin and modified tex- practicing in the post-acute and long- ture diets and liquids), which often lead to conflict and a substantial risk of VPA. Dr. Levenson has spent 42 years work- term care (PALTC) medicine continuum. While nonpharmacological interven- ing as a PALTC physician and medical tions and prudent medication reduc- director in 22 Maryland nursing homes Access live and recorded webinars for tions are sometimes sufficient, we all and in helping guide patient care in need to recognize the value of medi- facilities throughout the country. He CME, CMD and MOC credits! cations used appropriately (Lyketsos et has helped lead the drive for improved al., Psychiatric Aspects of Neurological medical direction and nursing home Diseases, Oxford UP, 2008; Desai and care nationwide as author of major Grossberg, Psychiatric Consultation in references in the field and through his Webinars are FREE for Society members, Long-Term Care, Cambridge University work in the educational, quality, and Press, 2017). As have others, I have regulatory realms. and only $99 for non-members.

PPI Inhibitors [Am J Gastroenterol, Jan. 2, 2020; from page 14 doi:10.14309/ajg.0000000000000500]. To summarize these findings, recent UPCOMING LIVE WEBINAR studies have reached divergent conclu- TOPICS INCLUDE: conclusions (J Gastroenterol Hepatol sions about PPIs and their potential 2017;32:1426–1435). side effects for dementia in long-term n Sexuality and Intimacy in Older Adults A study by Felicia Goldstein, PhD, care. Some studies have found that long- and colleagues at the School of Medicine term PPI use may be associated with the n International Pressure Ulcer/Injury at Emory University in Atlanta, investi- development of dementia while others gated the association between PPI use claim that PPIs may be protective against Guideline and mild cognitive decline, dementia, cognitive decline. In other words, there n and AD in a longitudinal observational is no concrete evidence that PPI use Enhancing Coordination of Care study (J Am Geriatr Soc 2017;65:1969– is associated with the development of Between Acute and Post-Acute 1974). Their 10,486 participants aged dementia; the claim that dementia may 50 and older, all with normal cognition be related to PPI use is unsubstantiated. n Prescribable Resident level, were classified into three groups: The bottom line remains the same: regular PPI users (8.4%), intermittent when prescribing any medications to Engagement is Here PPI users (18.4%), and no PPI use individual patients, the benefits must (73.2%). After two to six annual visits, be weighed against the potential adverse n Trauma Informed Care for the Provider the continuous PPI users were found to effects. With PPIs, unfortunately the be at lower risk of declining cognitive risks are many and are not entirely clear. And much more. function (hazard ratio 0.78; 95% con- But fortunately further research on long- fidence interval, 0.66–0.93 P = 0.005). term PPI use is currently underway.  The intermittent users also had a lower Recorded webinars on other hot risk of decline in their cognitive func- tion (HR 0.84; 95% CI, 0.76–0.93; Ms. Moharram-Zadeh is currently a topics are also available. P = 0.001). So interestingly their study medical student who is doing her clini- found PPI use to be associated with a cal clerkship at the University of Mary- lower risk of declining cognitive function land Prince George’s Hospital Center. See the full schedule and register today at and/or its conversion to AD. In the most recent of the meta-anal- yses, Muhammad Ali Khan, MD, of Dr. Tavakoli is a family medicine physi- the University of Alabama School of cian and the clinical director of the apex.paltc.org Medicine and his U.S. and Canadian Family Medicine Residency Program coauthors examined 11 observational at the University of Maryland Prince studies, comprising a total of 642,949 George’s Hospital Center. patients (64% women). They found no evidence for an association between PPIs and dementia, and they con- Dr. Parhar is the chief family medicine cluded that PPIs are appropriate among resident at the University of Mary- patients who have a valid indication for land Prince George’s Hospital Center their use and should not be restricted specializing in preventative medicine, because of concerns of dementia risk women’s health, and palliative care. 16 CARING FOR THE AGES April 2020

LEGAL ISSUES By Alan C. Horowitz, JD, RN

Medical Directors, Surveys and the Law

edical directors play an essential During the Survey have demonstrated their clinical com- medical director from the Society in an Mrole in the care that residents re- Surveyors will frequently interview petency and commitment to the highest appeal where a CMS enforcement action ceive in the post-acute and long-term a medical director in person or by levels of quality care. The Administrative was being challenged. Based on my own care arena. They wear many hats, rang- phone during the course of a survey. Law Judges (ALJ) who determine the experience, there is no doubt that a ing from thought leader and role model The input of a medical director can outcome of facility appeals also are aware medical director’s persuasive testimony to clinical resource and educator. In par- be critical in determining an outcome, of the Society’s high standards and the can make the difference in an appeal of ticular, medical directors have a pivotal such as whether or not there are alleged significance of the CMD status. a CMS enforcement action. role in the survey process and defending deficiencies. a facility. I am familiar with instances where a A Persuasive Role A Challenging Role As noted in a 2011 white paper from well-meaning surveyor believed that a A number of years ago I represented There are many valid reasons for chal- AMDA – The Society for Post-Acute resident’s negative outcome was caused CMS in a case involving cardiopulmo- lenging unsustainable deficiencies. and Long-Term Care Medicine, “The by substandard care, only to have the nary resuscitation (CPR). Essentially, Alleged deficiencies can result in civil Nursing Home Medical Director: Leader issue clarified by the medical director. an alert and oriented resident who had money penalties in the high six-fig- and Manager” (http://bit.ly/3ah8uLJ), For example, as every physician knows, “full-code” status had a witnessed cardiac ure range, frequently over $1 million. “the medical director is involved at all some pressure sores and some falls are arrest. The facility’s nurses and a respira- Additionally, lower 5-Star Quality rat- levels of individualized patient care and unavoidable in spite of a facility’s best tory therapist performed CPR for two ings, higher insurance premiums, and supervision, and for all persons served efforts. CMS recognizes this fact as well, cycles of chest compression (approxi- adverse publicity often follow an imme- by the facility.” When CMS published but not all surveyors fully appreciate that mately 30 seconds) and then abruptly diate jeopardy allegation. its Final Rule in October 2016, it some clinical outcomes are unavoidable. ended their efforts. They did not call When alleged deficiencies turn out to expanded the role of the medical direc- In one recent situation, a surveyor 911. When they terminated CPR after be legitimate, the medical director can tor to be responsible for “implementing was preparing to recommend an “imme- less than a minute, the resident was not assist in correcting the underlying causes. resident care policies and coordinating diate jeopardy” level deficiency to her resuscitated. CMS imposed a civil money However, when deficiencies are wrong- medical care in the facility” (Medicaid supervisors regarding the care a resident penalty, which the facility appealed. fully alleged — as often occurs — the and Medicare Programs; Reform of had received. Only when the medical At their appeal, the facility called Dr. medical director’s input can help the ALJ Requirements for Long Term Care director, who also happened to be the Cyril Wecht, MD, JD, an internationally correctly decide the case. Challenges also Facilities, Fed Regist 2016;81:68688– attending physician, intervened did the renowned forensic pathologist, as their may incentivize CMS to rethink unsup- 68872; codified at 42 CFR § 483.70(h), surveyor understand that there was no expert witness. I argued that the issue portable deficiencies. effective November 28, 2017; http://bit. basis for a deficiency. Although other was not the cause of death but whether In either case, the medical director has ly/38fnRmx). team members such as the director of the CPR administered by the facility was a key role to play. The medical director Regarding surveys, the role of the nursing and other clinical staff will be consistent with the accepted standards of can help steer the facility in the right medical director can be categorized into interviewed, the interview with the med- care. Incredibly, Dr. Wecht testified that direction and maintain the focus on pro- (1) before the survey, (2) during the ical director can be highly persuasive to only two cycles of chest compression and viding the highest quality of care.  survey, and (3) after the survey. a surveyor. no call to 911 were indeed within the standards of care for CPR in a witnessed Before the Survey After the Survey cardiac arrest. Mr. Horowitz is a partner at Arnall An old axiom states, “An ounce of pre- A medical director has two primary roles I vigorously cross-examined Dr. Golden Gregory LLP. His practice in- vention is better than a pound of cure.” after a survey. If the survey determined Wecht’s surprising testimony, but I volves regulatory compliance concern- Likewise, being prepared for surveys is legitimate and factually accurate defi- thought it would be best to have the tes- ing skilled nursing facilities, hospices, a prudent approach. Surveys by CMS ciencies, the medical director can assist timony of a physician who could rebut and home health agencies. Prior to agents, typically from the state’s depart- the facility in correcting those deficien- the world-famous pathologist: I called joining the firm, he served as Assistant ment of health, generally fall into either cies. This can be done in a number of Dr. Steven Levenson, a member of the Regional Counsel at the U.S. Depart- recertification surveys or complaint ways, ranging from reviewing and revis- Society. The ALJ found Dr. Levenson’s ment of Health and Human Services investigations. Regardless of the sur- ing policies and procedures as necessary testimony far more credible and com- and represented the Centers for Medi- vey’s source, the medical director’s role to active input in the facility’s Quality pelling: “CMS presented an expert wit- care & Medicaid Services. Mr. Horowitz is critical. Assurance Performance Improvement ness, Steven A. Levenson, M.D., who also has an extensive experience as If a facility is effectively implement- (QAPI) program and Quality Assessment has extensive experience in the long-term health care provider. ing appropriate policies and procedures and Assurance (QAA) committee. Note care field and with federal regulations. across the spectrum of issues it con- that even if the medical director delegates He testified credibly and persuasively fronts, it ought to be in good stead to his or her role on the QAA committee about the ethics of when CPR should EDITOR’S NOTE demonstrate that it is in substantial com- to another physician, the medical direc- be initiated and how long it should last.” pliance with the CMS Requirements for tor still retains responsibility, according The ALJ added, “I found the proce- Due to the COVID1-19 pandemic, Participation. to CMS. dures preferred by Dr. Levenson, who on March 4, 2020, CMS has tempo- Medical directors should be famil- For the 20 years that I have been liti- has written and studied in this area of rarily suspended surveys for certain iar with the list of responsibilities that gating CMS enforcement cases, I have medical ethics, to be far more persua- non-emergent issues. However, in- CMS and surveyors will focus on dur- always used members of the Society who sive [than those of Dr. Wecht]” (John J. spectors will still be able to able to ing surveys, as well as how CMS directs are Certified Medical Directors (CMD) Kane Regional Center – Glen Hazel v. address safety issues such as infection surveyors to determine if the medical as medical experts. The skills and exper- CMS, CRD No. CR1394 [2006], aff’d control and abuse. The medical di- director is in substantial compliance tise of these formidable medical experts DAB No. 2068 [2007]). Thus, a medi- rector can serve a critical role during with the regulatory requirements (CMS, have proved invaluable, both when I rep- cal director affiliated with the Society these unprecedented times in mak- State Operations Manual, Appendix PP: resented CMS and for the last seven and was determined to be “far more per- ing sure that proper infection control Guidance to Surveyors for Long Term a half years as I have represented nursing suasive” than a world-famous forensic precautions are put in place. Care Facilities, F841; https://go.cms. homes around the country. My reason pathologist. — Elizabeth Galik, PhD, CRNP, gov/2I3aevU). is simple: members of the Society who The CPR case is only one example coeditor in chief have achieved the CMD designation of the many times I have called on a CARINGFORTHEAGES.COM CARING FOR THE AGES 17 Caregiver’s Corner

Don’t Panic and Wash Your Hands: What You Need to Know About The Coronavirus Karl Steinberg, MD, CMD, HMDC, shares facts about the new virus and how you can protect yourself and your older loved ones. Worries always spread when • Can my loved one or I get there is a new virus. That cer- COVID-19 from a pet? tainly is true of the coronavirus • Is it safe to receive a package disease named COVID-19 by from China or another area the World Health Organization where COVID-19 is actively (WHO). First identified in the spreading? People’s Republic of China, • Is it safe to fly domestically or this highly infectious virus has to take public transportation? spread to many countries, in- cluding the United States. In- What You Can Do stead of panicking, learn the • Practice good hygiene such facts to find out how you can as frequently and thorough- protect your loved ones and ly washing your hands with

yourself. Alissa Eckert, MS; Dan Higgins, MAM soap and water or using alco- • Coronavirus disease is an in- This illustration, created at the Centers for Disease Control and Preven- hol-based sanitizing gels. fectious disease caused by a tion (CDC), shows the spikes that adorn the surface of the virus, which • Seek immediate help if you recently discovered corona- looks like a corona. experience symptoms of virus. This virus and disease COVID-19. Don’t try to self- were unknown before the • Regularly and thoroughly • To slow the spread of the treat with over-the-counter outbreak began in Wuhan, wash your hands with soap disease and protect vul- or herbal products. China, late last year. and water or use an alcohol- nerable residents, nursing • Avoid smoking. • The symptoms include fever, based hand sanitizer. Avoid homes across the nation • Stay home for 14 days if you tiredness, and dry cough. touching your mouth or nose. have implemented visitor re- feel ill or have symptoms. Some patients may have aches Cover your nose and mouth striction policies. To stay in • Talk to your practitioner if and pains, nasal congestion, when you sneeze or cough. touch with your loved ones, you have questions. Don’t lis- runny nose, sore throat, or And stay home if you feel consider using technology if ten to rumors or unfounded diarrhea. These symptoms, sick. possible. information about preventive according to WHO, are usu- • Stay six feet away from any- measures and cures related ally mild and begin gradually. one who is coughing or Feeling stressed and anxious to COVID-19. Some people may become in- sneezing. about this virus is natural. How- fected but don’t develop any • Disinfect surfaces/objects the ever, get the facts and talk to For More Information symptoms and don’t feel sick. sick person have touched. your practitioner, who is an im- • Centers for Disease Con- • Most people recover without • If you or your loved one has portant partner and can pro- trol and Prevention: Coro- treatment. However, about the symptoms of COVID-19, vide the information, help, and navirus Disease 2019 (CO- one in six individuals who get don’t panic — but do contact support you need. VID-19), https://www.cdc. COVID-19 becomes seriously a practitioner immediately, gov/coronavirus/2019-ncov/ ill and has difficulty breath- first by phone. Questions to Ask index.html ing. Older people and people • There is no vaccine to date, Your Practitioner • Sara Berg, “COVID-19: 6 with medical problems such nor is there any available • What is my risk or a loved one’s Key Points Physicians Should as heart disease or diabetes specific antiviral medicine to risk of getting COVID-19? Share with Patients,” AMA are at greater risk of getting prevent or treat COVID-19. • Should my loved one or I Public Health, Feb. 20, 2020, seriously ill. However, those affected wear a mask or other face https://www.ama-assn.org/ • COVID-19 can spread from should receive care to re- cover if we go out in public? delivering-care/public-health/ person to person through lieve their symptoms. • What is the best way to stay covid-19-6-key-points-physi- small droplets released in the • Antibiotics are not effective safe in public locations or cians-should-share-patients air during coughing or ex- in preventing or treating gatherings? • World Health Organization, haling. It also can be spread COVID-19. These drugs only • There are different stories out Q&A on Coronaviruses (CO- by contact with objects or work on bacterial infections, there about possible treat- VID-19), https://www.who. surfaces that droplets have and COVID-19 is caused by ments for COVID-19. How do int/news-room/q-a-detail/q- landed on. a virus. I know what is true? a-coronaviruses

This column originally appeared online and in print in Caring for the Ages (www.caringfortheages.com). Caring for the Ages is the official newspaper of AMDA – The Society for Post-Acute and Long-Term Care Medicine and provides post-acute and long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care. Content for Caring for the Ages is provided by writers, reporters, columnists, and Editorial Advisory Board members under the editorial direction of Elsevier and AMDA. The ideas and opinions expressed in Caring for the Ages do not necessarily reflect those of the Society or the Publisher. AMDA – The Society for Post-Acute and Long-Term Care Medicine and Elsevier Inc., will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein. ©2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. 18 CARING FOR THE AGES April 2020

JOURNAL HIGHLIGHTS

Journal Highlights From the April Issue of JAMDA

Chest Ultrasound instructions due to cognitive impair- person-days for an incidence rate of 3.15 Coeditors in Chief: Elizabeth Galik, PhD, CRNP, Point-of-care chest ultrasound may ment, both of which can reduce the per 1,000 person-days. and Richard Stefanacci, DO,MGH, MBA, AGSF, CMD represent a valid bedside diagnostic aid diagnostic accuracy of chest X-ray or The results may be due to adverse Editorial Advisory Board when caring for older individuals with CT scans. “Ultrasound is only margin- effects of circadian misalignment. Chairs: Elizabeth Galik, PhD, CRNP, Maryland; an acute respiratory disease, according ally influenced by these factors, exhibit- “In-hospital fall incidence shows clear Richard Stefanacci, DO, MGH, MBA, AGSF, CMD, to a study conducted in Italy. ing good performance also in the sickest circadian and seasonal patterns as per New Jersey Nicole Brandt, PharmD, CGP, BCPP, FASCP, Led by Andrea Ticinesi, MD, PhD, and in those with severe disability,” the the highest incidence in early morn- Maryland of the University of Parma, researchers researchers said. ing and winter,” the researchers said. Ian L. Cordes, MBA, Florida conducted a literature search using the Finally, ultrasound tends to be cheaper “Additionally, risk factors for falls Phyllis Famularo, DCN, RD, New Jersey terms “chest ultrasound,” “lung ultra- and safer than traditional imaging exam- include sleep disturbances, cognitive Janet Feldkamp, RN, JD, BSN, Ohio sound,” “geriatric,” and “older individu- inations. “Its routine use optimizes fol- impairment, and depressed mood; the Nina Flanagan, PhD, GNP-PC, APMH-BC, New York als.” Of the 16 manuscripts they found low-up of critical patients, reducing the pathophysiology of these medical con- Daniel Haimowitz, MD, FACP, CMD, Pennsylvania with a focus on geriatric patients, only number of X-rays and, possibly, CTs, ditions is significantly involved in circa- Paige Hector, LMSW, Arizona Jeanne Manzi, PharmD, BCGP, FASCP, New York five reported original data. with lower costs and radiation exposure,” dian misalignment between internal and Barbara Resnick, PhD, CRNP, Maryland Reporting on studies that enrolled the researchers said. “This advantage is environmental rhythms.” Steven Levenson, MD, CMD, Maryland patients with a mean age of 70 or older, particularly useful in geriatric patients, According to the researchers, a large- Karl Steinberg, MD, CMD, HMDC, California the researchers found several advantages who have often a high level of clinical scale, prospective, multi-center study is Caring for the Ages is the official newspaper of to chest ultrasound, including versatility complexity requiring several diagnostic required. AMDA – The Society for Post-Acute and Long- and portability. Specifically, the techni- resources.” Source: Iwamoto J, et al. Lower Term Care Medicine and provides long-term care professionals with timely and relevant news and cian can perform the test at the bedside, Source: Ticinesi A, et al. The Incidence of In-Hospital Falls in Patients commentary about clinical developments and avoiding the transfer of the patient, and Geriatric Patient: The Ideal One for Hospitalized in Window Beds Than about the impact of health care policy on long- term care. Content for Caring for the Ages is with the patient lying supine or seated. Chest Ultrasonography? A Review From Nonwindow Beds [published online ahead provided by the Society and by Elsevier Inc. Also, modern ultrasound equipment is the Chest Ultrasound in the Elderly of print August 22, 2019]. Am Med Dir The ideas and opinions expressed in Caring for portable, and smaller, handheld pocket Study Group (GRETA) of the Italian Assoc. doi: https://doi.org/10.1016/j. the Ages do not necessarily reflect those of the devices are achieving good levels of diag- Society of Gerontology and Geriatrics jamda.2019.07.006. Society or the Publisher. The Society and Elsevier Inc., will not assume responsibility for damages, nostic accuracy in individuals with inter- (SIGG) [published online ahead of loss, or claims of any kind arising from or related stitial lung disease. (The researchers did print August 6, 2019]. J Am Med Dir Exercise Programs to the information contained in this publication, including any claims related to the products, drugs, note, however, that the image quality of Assoc. doi: https://doi.org/10.1016/j. A simple inpatient exercise program can or services mentioned herein. handheld pocket devices is considered jamda.2019.06.018/. significantly decrease the risk of hospi- ©2020 AMDA – The Society for Post-Acute and inferior to that of standard ultrasound talization-associated disability, defined as Long-Term Care Medicine devices.) Also in JAMDA: Long- the loss of ability to perform one or more Caring for the Ages (ISSN 1526-4114) is published An additional advantage of chest ultra- basic activities of daily living (ADL), in 8 times year in January/February, March, April, sound is its ability to diagnose pre-test term care facilities and acutely hospitalized geriatric patients, May, June/July, August/September, October and November/December by Elsevier by Elsevier 230 clinical suspicions. Artifacts appear on the coronavirus epidemic: according to a randomized controlled Park Avenue, Suite 800, New York, NY 10169 USA. the ultrasound images of individuals trial conducted in Madrid, Spain. Periodicals postage paid at New York, NY and at additional mailing offices. who have common respiratory condi- Practical guidelines for a Led by Javier Ortiz Alonso, MD, POSTMASTER: Send Address changes to Caring for tions such as pneumonia, pleural effu- PhD, of Hospital General Universitario, the Ages, Elsevier Customer Services Department, sion, pulmonary edema, and interstitial population at highest risk, researchers assigned 268 patients (mean 1799 Highway 50 East, Linn, MO 65051. Subscription price is $255 a year (individual). lung disease. In addition, the researchers by David Dosa, MD, MPH, age of 88) to the intervention or con- said, chest ultrasound can help diagnose trol group. Individuals in the interven- Editorial Offices 1600 JFK Blvd., Suite 1800, Philadelphia, PA 19103; (215) 239-3900, fax (215) 239- causes of acute dyspnea and provide reli- and colleagues (http://bit. tion group performed simple exercises, 3990. Letters to the Editor: [email protected] able diagnostic signs for less common namely rising from a seated to an upright ly/2x2nD54) Society headquarters is located at 10500 Little conditions, including pneumothorax, position and supervised walking exercises Patuxent Parkway, Suite 210, Columbia, MD 21044. lung abscess, lung cancer, and pleural along the corridor, for about 20 minutes mesothelioma. Fall Prevention daily. Editorial Staff Chest ultrasound may be especially By placing older individuals in beds Using the Katz index to measure ADL Managing Editor Anna Boyum Journal Manager Robert D. Watson III useful in geriatric patients for several rea- next to a window (window beds), hos- function, the researchers found the risk Senior Contributing Writer Joanne Kaldy sons. “First, the aging respiratory system pitals may reduce the incidence of falls, of hospitalization-associated disability Display Sales Manager Denny Wang is characterized by some peculiarities that according to the results of a retrospective decreased by about 70% among the 917-816-5960, [email protected] Classified Advertising Adam Moorad make X-rays and, to a lesser extent, CT cohort study in Japan. individuals who did the exercises, and 212-633-3122, [email protected] more difficult to perform and less accu- Led by Junko Iwamoto, RN, PhD, that exercise improved their functional Customer Service Orders, claims, online, change rate to interpret even when a respiratory of Tenri Health Care University, Nara, ability. of address: Elsevier Periodicals Customer Service, 3251 Riverport Lane, Maryland Heights, disease is absent,” the researchers said. Japan, researchers compared the inci- Still, the researchers said, “this type of MO 63043; telephone (800) 654‑2452 (United ”The age-related modifications of lower dence of in-hospital falls among 2,767 intervention requires close supervision States and Canada), (314) 447‑8871 (outside United States and Canada); fax: (800) 225‑4030 airways, increases in interstitial connec- patients at a community hospital. They and thus an additional time involvement (United States and Canada), (314) 447‑8029 tive tissue, and reduction of parenchymal found a significantly lower incidence of of the hospital staff with respect to their (outside United States and Canada); e-mail: [email protected] (for vascularization may, in fact, contribute in-hospital falls among patients in win- daily duties or reliance on external staff print support); JournalsOnlineSupport-usa@ to so-called ‘dirty chest.’ Ultrasound is dow beds than in patients in beds away […](i.e., fitness specialists).” elsevier.com (for online support). Address changes influenced by all these phenomena as from a window (non-window beds). Source: Ortiz-Alonso J, et al. Effect must be submitted four weeks in advance. well, but its diagnostic performance is Among 1,273 patients in window beds, of a Simple Exercise Program on maintained thanks to its defined semi- 21 experienced falls during an observa- Hospitalization-Associated Disability in otics and the clinical interpretation of tion period of 14,038 person-days for an Older Patients: A Randomized Controlled signs.” incidence rate of 1.50 per 1,000 person- Trial [published online ahead of print Ultrasound may also prove useful days. Among the 1,494 individuals in January 20, 2020 ]. J Am Med Dir in patients who have mobility-limi- non-window beds, 36 experienced falls Assoc. doi: https://doi.org/10.1016/j. tations or who are unable to follow during an observation period of 11,412 jamda.2019.11.027  CARINGFORTHEAGES.COM CARING FOR THE AGES 19

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