Long Term CarePast, Present, and Future

Daniel Swagerty, MD, MPH, CMD AMDA Foundation Chair

ThemesHealth Care Delivery is changingNursing Facilities are transforming from

sites of custodial care into sites of high intensity care for sick, complex patients

Expectations are risingMuch more is and will be expected of

facilities, attending physicians, and medical directors

ThemesLong-Term Care Medicine is a legitimate

specialtyMore and more care will be provided by

fewer practitionersAMDA is committed to meeting the needs

of LTC practitioners for information, education, support, advocacy, and recognition

LTC: Past

“Rest Homes” The road to the nursing home is said to be ONE WAY

Custodial care for patients with severe cognitive impairment, functional impairment, or both

Physicians absent or inadequate Skilled care absent or low intensity

LTC: Present Form follows finance: Increased focus on shorter-term

‘skilled care’ = increased revenue/profit for facilities Patients discharged from hospital ‘sicker and quicker’ with

greater and more acute needs Frequent mismatches between patient and family

needs/expectations and available resources– Rapid access to pain medications, availability of

physicians, information from hospitals, provider skills, etc.

– The job of nurses and doctors are different from the job for which they were trained

Increased governmental/payor emphasis on quality measures, especially for issues/areas of high cost (hospital readmission rates, antipsychotic drug use)

Common Care Delivery Problems in SNFHospital Related Issues

Facility not able to provide necessary, appropriate or desired care – Lack of communication/ handoff of care between hospital/LTC

physicians, staff– Inadequate medication reconciliation in hospital = Prescribing

errors– Unprofessional practices in hospital

Lying about patient care needs or omitting important facts in order to get SNF to accept patient

– Failure of hospital to provide medication and treatments on day of transfer resulting in pain and other acute problems upon arrival to SNF

Common Care Delivery Problems in SNF Hospital Related Problems

Inappropriate and/or unnecessary care in hospital - Excessive medication doses, chemical/physical restraints, PPIs, heparin

Inadequate patient communication – Lack of accurate explanation of patient diagnoses,

prognosis, hospital course, goals by hospital staff with unrealistic expectations created

Ignorance of health care delivery, SNF Care, regulatory environment by hospital staff with unrealistic expectations created

Failure to provide specialty physician follow-up

Common Care Delivery Problems in SNFFacility Related Problems

Lack of preparation/planning at facility to begin care– Necessary equipment, narcotic and other medications

not quickly available in SNF– Lack of communication with families

Realistic expectations for care, likely outcomes, timeline, goals, preferences including advance directives, identification of decision maker with contact information

Lack of physician availability at SNF – Assess patient, meet with family, provide orders

Lack of availability of facility staff at peak admit times – Begin care in timely manner and inspire confidence in patients/

families

Overpromising and underdelivering

Common Care Deliver Problems in SNF Ongoing Care Concerns

Gaps in resources, communication, and collaboration of greatest concern

Movement of sick, complex patients into facility has proceeded faster than the movement of resources into facility to provide necessary care

Mismatch between patient needs and available staff /other resources – Ability to accurately assess patients with changing

conditions

Common Care Deliver Problems in SNF Ongoing Care Concerns

Ability to respond quickly to meet changing care needs – IVs, labs, medications– Ability to monitor sick or unstable conditions continuously for an

extended time

Skill set of providers often lacking – Assessment skills, communication skills, geriatric prescribing, and

knowledge of regulations

Inconsistent provision of care due to variable attitudes, knowledge, and skills of staff

Common Care Delivery Problems in SNFOngoing Care Concerns

Poor communication/teamwork between disciplines

Poor communication/teamwork between facility and family

Poor communication/teamwork between physicians

Poor availability of physician services

Common Care Delivery Problems in SNF Attending Physicians

Often unavailable/busy elsewhere– Not part of the team

On-call or covering physicians may be unqualified and/or unwilling to provide orders, see patient, be responsive

May be ignorant of regulatory issues, Medicare coverage/payment issues

Common Care Delivery Problems in SNF Attending Physicians

May be ignorant of health care delivery/LTC processes of care

Failure of facility staff to plan and/or communicate may result in emergencies for physicians (e.g. running out of narcotic pain medication after hours)

Lack of accountability to facility administration and medical director

Common Care Delivery Problems in SNF Medical Directors

Many facilities don’t know what to do with a (good) medical director

Many medical directors don’t know what to do with themselves, other than accept new admissions

Lack of awareness of medical director responsibilities Lack of availability/willingness to fulfill

roles/responsibilities required by regulations

Current Trends Facilities want more complex patients, fewer custodial care patients

– Facilities want to offer more services i.e. cardiac monitoring – More SNFs providing post-acute care only; no long-term care

Need physician services continues to rise as a result– Increased interest in full-time LTC physicians nationwide among

both facilities and physicians Greater scrutiny of quality and cost as overall health care costs rise

– Atypical antipsychotic drug use in dementia will be actively discouraged (> $15 billion /yr vs $4 billion/yr for LTC practitioner compensation)

– Hospital readmission rates scrutinized– Rehabilitation outcome measures being introduced

Reduced access for certain patients (Medicaid patients with dementia)

LTC : Future

Facilities, patients, families, regulators, others will expect more of attending physicians and medical directors

Quality assurance/Process Improvement (QAPI) a CMS requirement of SNFs

Physicians must expect more of themselves Physicians involved in LTC need more from facilities

– Teamwork, support, qualified staff, communication, etc AMDA must meet the needs of physicians and other LTC

professionals in order to fulfill mission of improving quality

LTC : Future

Emergence of LTC specialists (a la Hospitalists)– Fewer physicians overall, providing more care to more

SNF patients– Full-time practitioners in nursing facilities– Increasingly will be employees of NH chain or LTC

physician group– Specific set of competencies required -

Knowledge/skills/attitudes/behaviors– Attractive compensation and lifestyle compared to

hospital and office-based primary care practice

LTC : Future

Greater emphasis on patient outcomes– Reporting of outcomes

Changing payment structures to incentivize quality, preferred outcomes, resource utilization

Greater scrutiny of costs, service utilization (esp. rehabilitation and medications), and quality measures

LTC : Future

Labor shortages (especially for lower wage workers) will create greater challenges for facilities

Greater involvement and scrutiny by family members– Use of internet

Role of hospital diminishing- May be bypassed in future

Less access for custodial care in NH, especially Medicaid patients with dementia

AMDA

Mission is to promote quality LTC AMDA uniquely concerned about meeting

needs of patients, families, and practitioners in LTC – What do patients/families need?– What do LTC practitioners need in order to meet

patient/family needs and improve quality of care ?

What Is AMDA doing for you?

Education– Providing information/education to medical directors,

LTC practitioners to achieve clinical, administrative excellence, thrive in changing environment

– Articulating Core Competencies and developing training materials related to those competencies for attending physicians and NPs

– Clinical Practice Guidelines– Education materials for nurses and other disciplines,

such as “Know it All Before You Call” cards to enhance assessment and communication skills

What Is AMDA doing for you?

Education– Annual Education Symposium : March, 2013

Gaylord Hotel - Suburban Washington DC– Core Curriculum in Medical Direction– Advanced Course on Medical Direction

What is AMDA doing for you?

Development of broader menu of focused educational offerings– On line, self paced– Related to core competencies

Education to support teamworkEducation for interdisciplinary team

members

What is AMDA doing for you?

Internal Reorganization:– New CEO fall 2012– Complete reassessment of organizational effectiveness– Strategic planning 2012/2013 to identify member

needs, develop new products, and services to meet those needs

– Increased support of state chapters– Needs assessment of members– Enhancement of products and services to meet those

needs

What Is AMDA Doing for You ?

Advocacy Public Policy: Monitoring and influencing external

environment (government, consumers) in a strategic way to improve care and careers in LTC

Demonstrate value of CMD to Government, Industry, and public

Demonstrate value of Competence in LTC Medicine to government, industry, and public

Enhance recognition of CMDs and Competencies in LTC Medicine

What Is AMDA Doing for You ?

Advocacy Strong advocacy for payment to LTC practitioners Provide invaluable expertise to CMS and other

others in regulations, standards, quality promotion, and measurement

Position ourselves as advocates for patients in order to improve care and enhance our role

What is AMDA Doing for You:

Mentorship and Career support Increased reimbursement for LTC service codes Develop LTC workforce

– AMDA Futures program– Supportive network of LTC professionals– AMDA Foundation Capital Campaign

Increased recognition for LTC practitioners and CMDs

What is AMDA Doing for You:

Pursue other benefits and opportunities for members

Health information technologies/ EMR/e-prescribing for LTC

Set research agenda for LTC Evaluate effectiveness of CPGs Define quality in LTC population/setting

Summary – General

Health care delivery rapidly changingStatus quo not an optionTremendous opportunities and challenges in

LTCLTC is considered a solution, not a problem

in health care reform

Summary - AMDA

Professional society for LTC practitioners One “Stop Shop” for LTC and Medical

Director educationShape long-term care delivery by

emphasizing quality and advocating for LTC practitioners and consumers

Providing all of the necessary tools for excellence and professional satisfaction