Topics

Introduction

Topics Covered In This Section
    [C001]  Continuum of Care

    [E001]  Ethics Issues / Advance Care Planning

    [F001]  Fractures and Risk Management

    [L001]  Levels of Care

    [M001] Medical Direction

    [P001]  Physician Accountability

    [S001]  Subacute Care

A

B

C

[C001] Continuum of Care
Take-home point: Long-term care has evolved primarily as a residential setting with health care increasingly grafted on. But various forces require that health care be fully integrated with personal, functional, and social support. In a managed care era, technical proficiency is both efficient and improves the outcomes of personal care. The astute provider will recognize the need to transform systems and processes rather than trying to cling to the status quo.

In the past decade, both the role of long-term care and the population needing its services have expanded greatly. More elderly individuals require or desire some assistance with various aspects of their lives. Also, more individuals of all ages require some form of short-term or longer-term care after an acute episode of illness or injury.

E

[E001] Ethics Issues / Advance Care Planning
   Article: Maryland's 1993 Health Care Decisions Act: Implications for Health Care Practitioners
        In 1993, Maryland passed the Health Care Decisions Act. As with many states, it has attempted to address the procedures for allowing people to make health care choices and the requirements for health care providers to implement the care plans that accommodate those choices. This article reviews procedural issues common to all states, explains how they are addressed under the Maryland statute, and discusses in depth the problems and prospects for effective physician participation in addressing end-of-life issues and assuring compliance with pertinent laws and regulations.

    Click here to read the article entitled "Maryland's 1993 Health Care Decisions Act: Implications for Health Care Practitioners" (downloadable in Adobe Acrobat .PDF format. It may take a few minutes to download, depending on modem speed)

    Click here for access to forms related to end-of-life decision making (Note: these are provided for reference and must be adapted to be consistent with state regulations and individual patient needs.]

F

[F001] Fractures and Risk Management 
   Summary:  Nursing facility residents who fall may not show a hip fracture until several days later. Even though this occurrence is not uncommon, it may trigger accusations of negligence. Policies and procedures are recommended to help prevent the potential negative implications.
       Some surprises occur in nursing facility care. One of the biggest and most potentially hazardous to the facility is the resident who falls and does not appear to sustain an injury, but then several hours or days later has pain, swelling, or rotation of a hip. Subsequent X-Ray reveals a fracture. When they receive a report of this new finding so long after an event, family members may believe that the staff did something wrong, overlooked the problem, or failed to report it honestly when the original call was made to report the fall. Sometimes, lawyers have sued facilities, alleging negligence. Some juries have awarded damages, believing such allegations and not understanding that delayed fractures are not unusual.
       There is little discussion of this issue in the medical literature. Apparently, the initial impact of the fall, or even just a twisting of the leg with the foot planted the wrong way, may stress the hip bone or cause a crack, producing few if any symptoms. Elsewhere (cracked ribs, for example) the injury would cause pain but still heal uneventfully. In the hip, however, the strong contraction of the muscles attached to the hip may pull the bone apart hours or even days later. Thus, even a nonambulatory resident can have a delayed appearance of a hip fracture. Hip fractures can also occur from twisting in bed, or even spontaneously without any apparent precipitating cause. Thus, a hip fracture that shows up several days after a fall may or may not be related to the fall itself.
        What can a facility do to anticipate this and cover itself appropriately? It is neither realistic nor desirable to X-Ray all those who fall yet have no symptoms referable to the hips. However, following and documenting a consistent assessment process is a prudent way to show that the potential problem was recognized.
       Suggested policy implications. Every patient who falls should be examined by a nurse who knows how to systematically examine the joints. Major joints (shoulders, elbows, wrists, hips, knees, and ankles) should always be percussed and moved through the range of motion (to the limits of pain), even if there are no complaints referable to that joint. The hips should be assessed for at least two days after the fall, looking for progressive swelling, deformity, pain to palpation, or black-and-blue areas. This is especially important in cognitively impaired residents who may not be able to note progressive pain and who may just suddenly become confused when the hip abruptly breaks apart and the pain intensifies.
        After the initial fall, nursing documentation should cover the pertinent findings. Documenting pertinent negative findings is as important as noting obviously positive findings such as pain and swelling in a joint. A note such as the following is suggested: "No pain to pressure noted in shoulders, elbows, wrists, hips, knees, and ankles, or in putting them through range of motion. No swelling, deformity, rotation, or discoloration over either hip. No complaints of worsening joint pain." A similar note should be written daily for at least two days after the fall until the problem is considered resolved.
       While an X-Ray may not be needed initially for mild discomfort at a joint, it should be obtained for any new deformity, or for pain that seems excessive for the degree of movement or for gentle percussion. If the physical examination remains negative and the pain complaints are stable or improving, an X-Ray is probably unnecessary.
        If, when a delayed fracture is reported, the family asks how this could have happened, the staff should not state or imply that something may have been missed, or try to speculate as to when the hip actually broke or came apart. A quality assurance investigation may be indicated to ensure that there was nothing observed or documented that may have been overlooked or should have been reported sooner.
        When reporting a fall to a family initially, staff should report it in a certain way. Saying, "She fell but is fine" or "There was no injury" are not as good as "She fell; we examined her joints, including both her hips; at this time there does not appear to be any serious injury or evidence of a fracture; we will continue to check her over the next several days, looking for delayed complications that sometimes are known to occur."
        This problem illustrates how small changes in procedure can help reduce potentially significant legal risks.

L

[L001] Levels of Care
    There are many different approaches to providing long-term-care services to various populations, just as there are many attempts to understand, regulate, and accredit these providers. Currently, substantial duplication and overlap exist in all of them, according to where a person receives care. While various programs are superficially different, ultimately they all do the same things in different combinations and to varying degrees. Understanding this, it becomes possible to base licensing, regulation, and reimbursement of providers on levels of needed care provided rather than on the provider‘s characteristics. Providers throughout the long-term-care continuum must recognize their similarities more than their differences.
        Click here to read an article entitled "Innovations in Care: Levels of Care" (downloadable in Adobe Acrobat .PDF format. It may take a few minutes to download, depending on modem speed)

M

[M001] Medical Direction
    Medical directors are physicians with management responsibilities. Regulations require them in all U.S. nursing homes (both long-term care and postacute (skilled) care facilities.

    An article entitled "Nursing Home Medical Directors: Ideals and Realities" discusses the roles of medical directors including the differences between their potential and actual roles. Click here to read the article entitled "Nursing Home Medical Directors: Ideals and Realities" (downloadable in Adobe Acrobat .PDF format. It may take a few minutes to download, depending on modem speed)
 

P
[P001] Physician Accountability

Take-home point: Facilities need more effective physician performance than in the past. Physicians need guidance about expectations. Medical rules and regulations can be an effective way to articulate those expectations, when combined with appropriate medical director feedback and action related to insufficient compliance.

MEDICAL RULES AND REGULATIONS

    How can a long-term care facility effectively influence the performance of its attending physicians? Historically, many owners and administrators have been loathe to push physician compliance out of fear that the physicians will refer their patients elsewhere.
    However, the contemporary economic and regulatory climate has changed the ball game. An effective, efficient care delivery system requires the coordinated efforts of all participants, including physicians. Furthermore, referrals to long-term care facilities increasingly come from families, case managers, and hospital discharge planners. They are based more on need and are often less influenced by physicians.
    Every long-term care facility has the right to expect certain physician performance. These expectations should be written and explicit. Otherwise, physicians are unlikely to consider themselves to be part of a care system.
    A common way to formulate these expectations is via Physician Rules and Regulations, regardless of whether there is an organized medical staff. The following summarizes items that should be included in those Rules and Regulations.
    The attending physician should perform the following functions and tasks associated with his or her roles.

1) The attending physician should accept responsibility for each resident/patient’s care, which includes:
    - Assess a new admission in a timely fashion, depending on the individual=s medical stability, recent and previous medical history, presence of significant or previously unidentified medical conditions, or problems that cannot be handled readily by phone
    - Seek, provide, and analyze needed information regarding a patient's current status, recent history, and medications and treatments, to enable safe, effective continuing care and appropriate regulatory compliance.
    - Provide appropriate information and documentation to support a designated level of care for a new admission.
    - Authorize admission orders in a timely fashion, to enable the nursing facility to provide safe, appropriate, and timely care.
    - For a patient who is to be transferred to the care of another health care practitioner, continue to provide all necessary medical care and services pending transfer until another physician has accepted responsibility for the patient.

2) The attending physician should support resident/patient discharges and transfers, which includes:
    - Follow up as needed with a physician or another health care practitioner at a receiving hospital within 48 hours of the transfer of an acutely ill or unstable patient
    - Provide whatever summary or documentation may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual.
    - Provide a pertinent medical discharge summary within 30 days of discharge or transfer.

3) The attending physician should make periodic, pertinent patient visits in the facility, which includes:
    - Visit each newly admitted patient a)at least once every 30 days for the first 90 days after admission, and b)at least once every 60 days thereafter (or have an appropriately supervised NP or PA make alternate visits, in accordance with federal and state requirements).
    - Get a pertinent update on each patient=s condition at the time of a visit by evaluating the patient and, as needed, talking with staff and reviewing relevant information.
    - Review and respond to issues requiring a physician=s expertise, including the patient's current condition, the status of any acute episodes of illness since the last visit, test results, other actual or high risk medical problems affecting the individual's functional, physical, or cognitive status, and staff, patient, or family questions regarding the individual=s care and treatments.
    - At each visit, provide a legible progress note in a timely fashion for placement on the chart, which includes relevant information about significant ongoing, active, or potential problems, including reasons for changing or maintaining current treatments or medications, and a plan to address significant actual or high risk situations.

4) The attending physician should provide adequate ongoing coverage, which includes:
    - Designate an alternate physician(s) who will respond in an appropriate, timely fashion in case the attending physician is unavailable, and intervene with them when informed of problems regarding such coverage.
    - Update the facility about his or her current office address, phone, fax, and pager numbers to enable appropriate, timely communications, as well as those of designated alternate physicians.
    - Adequately inform covering physicians about patients with active acute conditions or other significant problems that may need medical follow-up during their on-call time.
    - Help ensure that covering physicians provide adequate, timely support while covering and intervene with them when informed of problems regarding such coverage

5) The attending physician should provide appropriate patient care, which includes:
    - Perform accurate, timely, relevant medical assessments.
    - Properly define and describe patient symptoms and problems, clarify and verify diagnoses, relate diagnoses to patient problems, and help establish a realistic prognosis and care goals.
    - In consultation with the facility=s staff, determine appropriate services and programs for a patient, consistent with diagnoses, condition prognosis, and patient wishes.
    - In consultation with the facility staff, ensure that treatments are medically necessary and negative outcomes are medically unavoidable, in accordance with nursing facility regulatory requirements.
    - Respond in an appropriate time frame to emergency and routine notification of condition changes, diagnostic test results, etc. to enable the facility to meet its clinical and regulatory obligations.
    - Analyze the significance of abnormal test results and explain the medical rationale for interventions or decisions not to intervene based on those results.
    - Adequately assess and manage each patient’s chronic illnesses and respond to reported acute and other significant clinical condition changes in patients
    - In consultation with the facility staff, help guide and document ethics decisions consistent with relevant laws, regulations and patients' wishes, including a)advising residents/patients and families about formulating advance directives or other care instructions and b) helping identify individuals for whom aggressive medical interventions may not be indicated.
    - Ensure that individuals receiving palliative care have appropriate comfort and supportive care measures.

6) The attending physician should provide appropriate, timely medical orders, which includes:
    - Provide timely medical orders based on an appropriate patient assessment, review of relevant pre- and post-admission information, and age-related and other pertinent risks of various medications and treatments.
    - Provide sufficiently clear, legible written orders to avoid misinterpretation and potential medication errors, such orders to include pertinent information such as the medication strength and formulation (if alternate forms available); route of administration; frequency and, if applicable, timing of administration; and the reason for which the medication is being given.
    - Verify the accuracy of verbal orders at the time they are given and co-sign them in a timely fashion, no later than the next patient visit.   

7) The attending physician should provide appropriate, timely, and pertinent documentation, which includes:
    - Provide documentation required to explain medical decisions, enable effective care, and allow a nursing facility to comply with relevant legal and regulatory requirements.
    - Complete death certificates in a timely fashion, including all information required of a physician.   

TO GUIDE YOUR PHYSICIANS
You can order a series of charts to help your physicians better understand their responsiblities. These can be printed in Word Perfect or Microsoft Word format, and then copied and distributed to your physicians. To see an example CLICK HERE.

[P002] Prospective Payment

 Take-home point: Prospective Payment for Skilled Nursing Facilities is making a major impact on reimbursement. But it has the potential to positively influence the care. More than ever, effective clinical systems and skills are needed to provide appropriate, efficient care.

        You are aware that reimbursement methods and amounts for Skilled Nursing Facilities are changing significantly. If your objective is (hopefully) to survive and thrive under Prospective Payment (PPS) and managed care, you may wonder just how. This month’s column addresses the basis for survival.
        Improving the "bottom line" ultimately results from two things: enhancing revenues or reducing expenses. Regardless of payer, maximizing revenue results from maintaining patient flow, based on the ability to provide the care appropriately, and on trying to get the most reimbursement for the services rendered under a limited payment system. Minimizing costs comes from providing essential care appropriately; minimizing unnecessary, questionable, or harmful treatment; limiting the use of ancillary tests and treatments; and properly identifying and managing the factors known to increase costs.
        Key principles. All patient outcomes arise from two primary factors: patient characteristics and care processes.
        Patient characteristics (the conditions, problems, and impairments that they come in with) cannot be controlled prospectively (before admission), but the key elements known to affect both patient outcomes and care costs can be identified and addressed concurrently (while they are receiving care) (Table 1).

===========
Table 1
Summary of relevant patient-related factors influencing or predicting outcomes, including care costs

Physical
      Severity of illness; comorbidities (number and severity); significantly impaired nutritional status; depression; delirium; "general deconditioning;" presence of unstable diabetes, infection or neurological, cardiac, or cancer diagnosis

Functional
      Impaired baseline ADL status; number of ADL dependencies; weighted ADL dependency score; self-reported limitations on physical functioning; hearing loss, gait velocity, balance function, and grip strength Physical
      Severity of illness; comorbidities (number and severity); significantly impaired nutritional status; depression; delirium; "general deconditioning;" presence of unstable diabetes, infection or neurological, cardiac, or cancer diagnosis

Functional
      Impaired baseline ADL status; number of ADL dependencies; weighted ADL dependency score; self-reported limitations on physical functioning; hearing loss, gait velocity, balance function, and grip strength Physical
      Severity of illness; comorbidities (number and severity); significantly impaired nutritional status; depression; delirium; "general deconditioning;" presence of unstable diabetes, infection or neurological, cardiac, or cancer diagnosis

Functional
      Impaired baseline ADL status; number of ADL dependencies; weighted ADL dependency score; self-reported limitations on physical functioning; hearing loss, gait velocity, balance function, and grip strength

Psychosocial
        Discharge to a place other than home; level of available community-based support
===========

        Of all patient characteristics, comorbidities (active illnesses and conditions related to, caused by, or accompanying a primary illness or diagnosis) predict costs and outcomes across all settings. That is, the more active illnesses or conditions a person has, the higher the likely cost of care to achieve the same objective. For instance, a patient who is admitted after treatment for a fractured hip or stroke may be called a "rehabilitation" patient, but other active conditions such as depression, heart failure, and diabetes will invariably affect the course of care, the end result, and the duration of treatment needed to attain the desired goal (discharge home, etc.). In my experience, perhaps the biggest mistake many postacute care programs make is to ignore other conditions because they are not the primary diagnosis or principal reason for referral. Such patients often have complications, take more nursing time, require more tests or monitoring, or wind up having to be sent back to the hospital (often unnecessarily). Many of these costly problems can be anticipated and prevented. Or, it may be possible to recognize ahead of time that the patient is actually more unstable or complicated than the program can manage.
        Key methods. Create and implement approaches that will identify and address the factors known to influence patient outcomes and care costs. It is more critical than ever to optimize your care processes to minimize inefficiency, error, duplication, and inadequate, inappropriate, or harmful treatment. Organize and implement all support systems and processes (those not related to direct hands-on care) to maximize the support for those delivering and overseeing the hands-on care. Focus on maximizing valuable care and minimizing harmful or wasteful care (Table 2). Psychosocial
        Discharge to a place other than home; level of available community-based support
===========

        Of all the patient characteristics, comorbidities (active illnesses and conditions related to, caused by, or accompanying a primary illness or diagnosis) are a major predictor of costs and outcomes across all settings. That is, the more active illnesses or conditions a person has, the higher the likely cost of care to achieve the same objective. For instance, a patient who is admitted after treatment for a fractured hip or stroke may be called a "rehabilitation" patient, but other active conditions such as depression, heart failure, and diabetes will invariably affect the course of care, the end result, and the duration of treatment needed to attain the desired goal (discharge home, etc.). In my experience, perhaps the biggest mistake many postacute care programs make is to ignore other conditions because they are not the primary diagnosis or principal reason for referral. Such patients often have complications, take more nursing time, require more tests or monitoring, or wind up having to be sent back to the hospital (often unnecessarily). Many of these costly problems can be anticipated and prevented. Or, it may be possible to recognize ahead of time that the patient is actually more unstable or complicated than the program can manage.
        Key methods. Create and implement approaches that will identify and address the factors known to influence patient outcomes and care costs. It is more critical than ever to optimize your care processes to minimize inefficiency, error, duplication, and inadequate, inappropriate, or harmful treatment. Organize and implement all support systems and processes (those not related to direct hands-on care) to maximize the support for those delivering and overseeing the hands-on care. Focus on maximizing valuable care and minimizing harmful or wasteful care (Table 2). Psychosocial
        Discharge to a place other than home; level of available community-based support
===========

        Of all the patient characteristics, comorbidities (active illnesses and conditions related to, caused by, or accompanying a primary illness or diagnosis) are a major predictor of costs and outcomes across all settings. That is, the more active illnesses or conditions a person has, the higher the likely cost of care to achieve the same objective. For instance, a patient who is admitted after treatment for a fractured hip or stroke may be called a "rehabilitation" patient, but other active conditions such as depression, heart failure, and diabetes will invariably affect the course of care, the end result, and the duration of treatment needed to attain the desired goal (discharge home, etc.). In my experience, perhaps the biggest mistake many postacute care programs make is to ignore other conditions because they are not the primary diagnosis or principal reason for referral. Such patients often have complications, take more nursing time, require more tests or monitoring, or wind up having to be sent back to the hospital (often unnecessarily). Many of these costly problems can be anticipated and prevented. Or, it may be possible to recognize ahead of time that the patient is actually more unstable or complicated than the program can manage.
        Key methods. Create and implement approaches that will identify and address the factors known to influence patient outcomes and care costs. It is more critical than ever to optimize your care processes to minimize inefficiency, error, duplication, and inadequate, inappropriate, or harmful treatment. Organize and implement all support systems and processes (those not related to direct hands-on care) to maximize the support for those delivering and overseeing the hands-on care. Focus on maximizing valuable care and minimizing harmful or wasteful care (Table 2).

        Base your services on the evidence in the medical and nursing literature about what is most likely to accomplish care objectives at the lowest possible costs (factoring in both direct and indirect costs such as staff time). Use protocols, guidelines, and care maps in conjunction with process improvement activities as a way to summarize and organize that evidence so that it can be used effectively. Get your clinical leadership (Director of Nursing, Medical Director, and others) to help ensure that nurses, physicians, and other direct-care disciplines will use the protocols and guidelines correctly and consistently. Collect data about your results, complications, problems, patient satisfaction, unplanned hospital transfers, and other issues to give your practitioners and staff feedback. Use the results to adjust subsequent approaches to care management.
        Quality improvement approach. Process optimization is more vital than ever before. Emphasize and implement initiatives to support effective problem solving. Organize a more unified approach to care processes and determining treatments. Try to reduce excessive individual variation, which is often based on habits and personal preferences rather than on evidence. Ensure consistent individual accountability. Instil a higher sense of professionalism at all levels of the organization, whether or not the individuals are directly involved in the care, are in support departments not directly providing care, or are not directly involved in the facility (for example, those at corporate headquarters).
        Severely damaging behaviors and habits include anything that diverts attention from a patient-centered focus; for example, tolerating indifferent attitudes, permitting unfounded individual variation, tolerating unprofessional conduct among various direct and support staff and management, administrative and management failures to hold individuals and departments accountable for inadequate performance, allowing undermining of efforts to make change, and failing to provide effective systems support to maximize productivity.

        If you would like to know more about the above, click here to learn more about the Subacute and Transitional Care Handbook, the most detailed coverage of the clinical aspects of postacute care available anywhere.

S

[S001] Subacute Care 
The Future of Subacute Care
      Subacute care is a program of treatment for individuals with recent or current illness or injury. Over the past 3 decades, such care has been provided under various names in several settings. Its nature is often misunderstood, and its rationale is still often challenged. Its future status depends on addressing the following issues to clarify its purpose and practice: 
        Defining subacute care clearly, and understanding what it is and is not
        Recognizing requirements for providing subacute care properly
        Identifying rational approaches to clinical issues of the subacute patient
        Improving the process for proper patient placement and transfer
        Ensuring that the care is reimbursed adequately and appropriately

        An article entitled "The Future of Subacute Care" addresses these and other issues, describing the details of subacute care, and its likely future role. Click here to read the article on The Future of Subacute Care  (downloadable in Adobe Acrobat .PDF format. It may take a few minutes to download, depending on modem speed)
 

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