Newsletter for September, 2019 (link)
Newsletter for September 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your Board of Directors met July 17-
Other News-from around our state and our partners.
Annual meeting registration-downloadable PDF at www.wamd.org/
Your association will hold its annual meeting at the Radisson in Madison October 11 and 12
Friday, October 11-
10 AM Board Meeting
11 AM Registration and Exhibits
11:55 AM Welcome, Ronald Schreiber MD, CMD, WAMD President
12:00 PM Disaster Preparedness Timothy Vayder MD and Robert Deede RN
1:30 PM The Geriatric Colon Eric Gaumnitz MD GI and Geriatrics
2:30 PM Break and Exhibits
3:00 PM Valvular heart disease: What the ECF provider needs to know Dr. Cherian Varghese
4:00 PM Megarule Implementation and Hospital Readmissions Brian Purtell JD
Preparation for Patient Driven Payment Model: Jon Ollmann, North Shore SVP Operations
5:30 PM Annual Meeting Ronald Schreiber MD, CMD, WAMD President
6:30 PM Reception – Appetizers and Drinks, Networking spouses and guest invited
Saturday October 12-
6:30 AM Industry Breakfast Janssen Pharmaceuticals: The Compass Trial and ASHD and PAD, Sean Cannone, DO, CMD
7:25 AM Welcome Comments: Pres. Kristin Severson DO
7:30 AM Pharmacy Update Douglas Engelbert
8:30 AM Mary Cohan MD Fellows Clinical Updates 3 Fellows, 20 min each, then 15 min panel
9:45 AM Pat Virnig RN, DQA update
10:30 AM Break and Hotel checkout
11:00 AM AMDA Update Christopher Laxton, CAE, Executive Director AMDA
12:00 PM Lunch in the Trenches
National Issues facing Long term Care Christopher Laxton, CAE, Executive Director, AMDA
Pat Virnig RN, DQA, Megarule Implementation
Ronald Schreiber MD Coding Ronald Schreiber MD, CMD, WAMD Past President
1:00 PM ENT Emergencies and Urgencies in LTC Perry Phillips MD
2:00 PM MD-Adv Practice-Therapies-Pharmacy Collaboration
Tanya Chapman, APNP
3:00 PM Break (15 min)
3:15 PM Infection Update 2019. Chris Crinch MD
4:15 PM Adjournment Kristin Severson DO President
Save the date for the DQA’s annual FOCUS conference November 20-21 in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights. Teepa Snow will deliver the keynote address “Dementia 360.” Go to https://www.dhs.wisconsin.gov/regulations/training/focus-2019.htm
Save the date for AMDA’s annual conference in Chicago April 2-5.
From the Trenches- questions about the meaning of PA/LTC life:
PDPM Executive Summary for Physician and non-Physician Providers-
Background: The TEFRA of 1982 created the Medicare A SNF benefit. The BBA of 1997 created the payment system we are now in, RUGS IV. In all PA/LTC settings, as in all of medicine, coding follows the money; in SNFs that’s been therapy billing minutes. The RUGS to PDPM change uses the MDS in a different way, and adds weight to ICD-10 codes in a new and different way. The change will do to SNFs what DRGs and ICD-10 did for the acute care facilities. We have experience with the change; we know ICD-10.
Additional background: There are still three of five categories related to therapy (OT, PT, and ST) and a fourth related to nursing (using a lot of GG from the MDS); what is really new is the fifth (“non-therapy ancillary” or “NTA”), driven by mapping the 68,000 ICD codes to fifty conditions or services into ten categories creating a comorbidity score (a case-mix index). Payment is frontloaded, and is largely fixed based on the initial (day 5) MDS submitted by day 8, and not subject to further change without an additional change in condition.
Now the meat: Although only a clinical provider (P or NPP) can diagnose, the hospital provider, clinical provider, and SNF provider may actually submit different diagnosis codes with their service. If you think about that for a minute, it’s not too strange: Consider a transplant patient hospitalized for UTI who goes to a SNF for rehabilitation a couple weeks later; the hospital may code for the UTI, but the SNF may not. The patient has had an organ transplant, but the clinical provider is not “treating” that, so she doesn’t bill that code (the transplant team does). The transplant team isn’t involved with the UTI, so they don’t bill for that. Again, for the purpose of review: While each provider bills using the code they think is appropriate for their services, the acute and post-acute facilities can only use diagnoses made by the clinical providers.
So in conclusion: While PDPM does not affect clinical provider work or billing directly, it may have a strong indirect effect on their work as nursing home providers (like hospital providers the last year or two) seek the most accurate ICD-10 codes.
So how can we make the “coding query” as quick and painless as possible?
Facility providers should use Epic Link wherever possible to find out the complete diagnostic list as rapidly as possible, and then in-basket their coding queries quickly and efficiently in a way that locks our answers into the record. Paper workflows will be slower and less efficient.
As clinical providers figure out what diagnoses are needed, questions will decrease over time—we’re in suspense for August and September, we’re going to be working in the fourth quarter, and things will be better in 2020.
Frequently asked questions-
Who’s at the center of this?
What is an “active” diagnosis?
How certain do I need to be to make a diagnosis?
Other Reviews-publications from around the world of geriatrics and PA/LTC
Does My Patient with Multiple Comorbidities Have Heart Failure with Preserved Ejection Fraction, and Does It Matter?
Dmitry Abramov
The Journal of the American Board of Family Medicine May 2019, 32 (3) 424-427; DOI: https://doi.org/10.3122/jabfm.2019.03.180321
Dmitry Abramov
From the Department of Cardiology, Loma Linda University, Loma Linda, CA.
Abstract-
Heart Failure with Preserved Ejection Fraction (HFpEF) is a common diagnosis and accounts for half or more of all cases of heart failure. Despite its high prevalence and significant morbidity, the pathophysiology of HFpEF remains incompletely understood. Patients diagnosed with HFpEF often have significant cardiac and extra-cardiac comorbidities. Given the availability of evidence-based treatments for common comorbidities, but not for HFpEF, the necessity of diagnosing HFpEF among symptomatic elderly patients with multiple comorbidities is unclear. This commentary raises the question of whether the search for the diagnosis of HFpEF should instead be refocused to the management of common comorbidities without necessitating the heart failure diagnosis.
Introduction-
Heart failure with preserved ejection fraction (HFpEF) comprises about half of the cases of heart failure in the United States.1 Despite its growing prevalence and significant morbidity, HFpEF remains incompletely understood and diagnosis in the community setting may be difficult. Widely used diagnostic criteria that incorporate clinical findings with laboratory values and echocardiographic parameters lack sensitivity which may result in underdiagnosis.2 Overdiagnosis based on vague symptoms and nonspecific diagnostic parameters may likewise be problematic. The concern of over- and underdiagnosis is further compounded by the lack of evidence-based treatments for those diagnosed with HFpEF. Patients with HFpEF tend to be older, with multiple cardiac and noncardiac comordbitities.3 This begs the question of whether diagnosis of HFpEF remains critical to optimize the care of predominantly older patients with multiple comorbidities.
Heart failure has been defined as the inability of the heart to generate adequate cardiac output or the ability to generate adequate cardiac output only in the setting of elevated filling pressures.4 The standard clinical diagnostic criteria for HFpEF includes heart failure symptoms (such as dyspnea, orthopnea, paroxysmal nocturnal dyspnea) and elevated filling pressures (predominantly Wedge pressure) at rest or with exercise.5 Elevated filling pressures may be clinically estimated through measurement of jugular venous distention. Confirmation of elevated filling pressures, and therefore the heart failure diagnosis, can be obtained through invasive right heart catheterization. The history and physical examination-derived signs and symptoms suggestive of heart failure may be difficult to ascertain, and their correlation with invasively derived filling pressures has largely been based on studies of acutely decompensated or end-stage patients with reduced ejection fraction.1,6 Recently, permanently implanted pulmonary artery monitors have been used to help evaluate central filling pressures as a supplement to the physical examination,7 although the utility of such devices as part of the diagnostic evaluation of heart failure may be limited.
Current diagnostic criteria for HFpEF from the American College of Cardiology and American Heart Association include clinical signs or symptoms, ejection fraction ≥50%, and evidence of diastolic dysfunction.1 Patients meeting heart failure criteria with ejection fraction of 41% to 49% can be classified as having heart failure with borderline or midrange ejection fraction, which is more clinically similar to HFpEF than to heart failure with reduced ejection fraction.1,8 Diagnostic criteria for HFpEF from the European Society of Cardiology are similar, and include signs and symptoms, ejection fraction of ≥50%, elevated B-type natriuretic peptide values and echocardiographic evidence of structural abnormalities or diastolic dysfunction.9
While seemingly straightforward, the application of these criteria to the community setting is fraught with limitations. These diagnostic criteria have been criticized for low sensitivity,2 and the reliance on echocardiographic evaluation of diastolic dysfunction may neither accurately evaluate cardiac relaxation abnormalities nor contain sufficient sensitivity or specificity to detect a clinical course consistent with HFpEF.10 Although exact criteria for grading of diastolic dysfunction have changed over time,11 diastolic abnormalities on echocardiography are common in community cohorts of patients with comorbidities such as obesity, hypertension, diabetes and coronary disease,12 and have poor correlation with heart failure symptoms.12,13 In addition, only minimal abnormalities in diastolic parameters (including a high prevalence of normal diastolic function, normal left atrial size, and normal wall thickness) are noted in cohorts with symptomatic HFpEF.10 Echocardiographic diastolic parameters may primarily estimate ventricular filling pressures,11 rather than necessarily providing an explanation for their elevation.
Clinical trials and day-to-day care of patients with HFpEF highlight the high burden of comorbidities associated with this condition. Common noncardiac comorbidities include older age, chronic kidney disease, and lung disease. Common cardiac comorbidities include diabetes, hypertension, coronary artery disease, obesity and atrial fibrillation. As dyspnea is a common symptom in patients with many of these comorbidities, and given the notable limitations of the diagnostic algorithms, how are clinicians to identify which of these patients may have HFpEF?
In light of these limitations, some have proposed scoring systems to help identify patients with HFpEF among those being evaluated for dyspnea5; identifying that the biggest predictors of elevated filling pressures (and therefore the HFpEF diagnosis) among patients with dyspnea are advanced age (>60 years old), obesity (Body Mass Index >30 kg/m2) and atrial fibrillation. Other factors having a smaller association with elevated filling pressures include elevated pulmonary artery systolic pressure, treatment with multiple antihypertensive medications, and abnormal diastolic parameter of E/e'.5 Having the 3 risk factors of advanced age, obesity, and atrial fibrillation was associated with a greater than 90% likelihood of meeting criteria for the diagnosis of HFpEF based on elevated filling pressures.5 Importantly, elevated B-type natriuretic peptide, dilated left atrium, ventricular hypertrophy, or abnormal ventricular strain—all key parameters associated with diastolic dysfunction—had either smaller or no independent predictive ability to diagnose elevated filling pressures.
This focus on comorbidities as the key contributor to pathophysiology of HFpEF raises significant questions about our current understanding of what it means to impart onto a patient the heart failure diagnosis. Dyspnea is a ubiquitous and subjective symptom in older individuals,14 and is particularly common in patients with comorbidities including obesity and atrial fibrillation. Dyspnea may also be multifactorial, and not primarily caused by elevation in intracardiac filling pressures.15 Elevated filling pressures, even in the presence of dyspnea, may not always reflect heart failure, as every patient with end-stage renal disease on dialysis is not generally considered to have “heart failure” before a dialysis session.
Instead of focusing on the diagnosis of HFpEF, (ie, attempting to determine whether dyspnea is cardiac in origin or whether echocardiographic abnormalities are relevant to the clinical presentation), perhaps a better approach would be to return to the diagnosis and management of key cardiac and extracardiac comorbidities3 that are common in elderly patients with limitations to functional capacity. It should be acceptable to diagnose and manage conditions associated with fluid retention, such as anemia, obesity, diabetes, kidney disease, or atrial fibrillation without invoking the heart failure diagnosis. Each of these comorbidities is a significant stand-alone diagnosis, associated with its own symptoms (often dyspnea), diagnostic criteria, and evidence-based treatments.3 Whether these comorbidities contribute to fluid retention through: their association with diastolic abnormalities, other ventricular myocardial abnormalities, their own unique pathophysiologies, or a combination of these remains unclear. Diuretics are the mainstay treatment of symptoms of volume overload regardless of etiology, and can be used to control symptoms regardless of whether the patient is diagnosed with HFpEF, is suspected as having HFpEF, or is presumed to have volume overload from a noncardiac etiology. Among patients with HFpEF, the diuretic spironolactone is primarily effective at lower ejection fractions (<50%), and the benefits among patients with higher ejection fractions are less certain.16
While the search for underlying pathophysiology continues, there is increasing evidence that comorbidities are the most prominent contributors to symptoms among patients labeled as having HFpEF. If symptomatic comorbidities require another name or label, perhaps a better one is “comorbidity associated heart failure” or even “comorbidity associated diuretic dependence.” Employing terminology to more closely correlate with etiology based on subpopulations of HFpEF patients may simplify the diagnosis of a widely encountered clinical syndrome and help guide management in a way not currently possible with HFpEF.
May the diagnosis of HFpEF become more clinically relevant if ongoing trials of novel therapies, including sacubitril valsartan, empagliflozin, and others demonstrate improvement in clinical outcomes? The answer to that question has yet to be determined, as these medications may yield similar benefit in high risk primary prevention populations without the necessity of a HFpEF diagnosis. While diagnosing specific diseases that have previously fallen under the HFpEF umbrella such as Amyloid or Fabry's cardiomyopathy are increasingly critical as treatments become available, the benefit of diagnosing comorbidity associated HFpEF remains unclear. In addition, while diagnosing HFpEF may carry prognostic implications, the associated adverse prognosis may result more from a particularly advanced comorbidity burden rather than primary cardiac pathology or heart failure itself.
In conclusion-
Diagnosing HFpEF in the community may not be easy or even clinically relevant, and the answer to the question of, “does my patient with multiple comorbidities have HFpEF?” may be less important than using available treatments to improve the quality of life of symptomatic patients.
To see this article online, please go to: http://jabfm.org/content/32/3/424.full.
References omitted to shorten the copy and paste
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Reflections-
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
(b) various long-term care associations, and
(c) officials of various government agencies.
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 5329 Fayette Ave., Madison, WI 53713
Newsletter for July, 2019 - Link
wis-paltcm_newsletter_2019.07_.pdf
Newsletter for July 2019
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
The next WAMD board meeting, by teleconference, is Wednesday, July 17 at 5:15 PM. We will have a brief presentation by the Alzheimer's Association. Please forward any agenda items for discussion to Karen and myself.
Thanks—President Ron
Save the date for our annual meeting October 11-12 2019 at the Radisson in Madison
Other News-from around our state and our partners.
Save the date for the DQA’s annual FOCUS conference November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”
Save the date for AMDA’s annual meeting April 2-5 2020 at the Hyatt Regency in Chicago
From the Trenches- questions about the meaning of PA/LTC life:
Readmission rates and other starry subjects--
Recently president-elect Kristin asked other board members how their buildings were doing with readmission rates, and I said that what I was hearing didn’t sound well-authenticated. If you go to www.medicare.gov/nursinghomecompare/search.html , the official readmission rates are published, separately for short- and long-stay, along with a lot of other detail you are probably quite familiar with. If asked a medical director today what the great commandments are in long-term care, s/he’d probably say “avoid readmissions, and (another like unto it) discharge people home”—so, I made this table that with the five buildings I’m most closely related to, plus a number of Madison-area buildings of interest. To restart the benchmarks: WI short-stay readmissions, 21.2%; WI long-stay readmissions, 1.40 per 1000 patient days. Please note this is NOT 30-day readmission data.
Home Overall Stars Short Stay Readmit Long Stay Readmit Percent sent home
WI avg 21.2% WI avg 1.40/1000 National avg 48.6%
A Two stars 17.0/100 1.49/1000 Worse
B Two stars 22.6/100 2.28/1000 Worse
C Five stars 19.8/100 1.91/1000 Better
D Five stars 20.2/100 1.27/1000 Worse
E Four stars NA NA NA
F Three stars 19.2/100 NA Better
G Three stars 24.4/100 1.39/1000 Better
H Two stars 15.8/100 1.07/1000 Worse
I One star 25.1/100 1.96/1000 Better
J Four star 20.9/100 1.26/1000 Worse
K Five star 25.2/100 1.66/1000 Worse
J Five star 16.7/100 0.70/1000 Worse
Personally, I’m associated with above average overall-rated, better than average readmissions for short- and long-stay admissions, and average on discharge home to home rate facilities. How’d you do? What does it mean? The highest LS readmitter is three times the least. The highest SS readmitter is fifty percent more than the last.
Other Reviews-publications from around the world of geriatrics and PA/LTC
Do review the June 24, 2019 JAMA Internal Medicine article " Anticholinergic Drug Exposure and the Risk of Dementia". The authors conclude that exposure to several types of strong anticholineric drugs is associated with an increased risk of dementia. This has made headlines in the lay press.
Investigating the Avoidability of Hospitalizations of Long Stay Nursing Home Residents: Opportunities for Improvement
Kathleen T. Unroe, MD, MHA, Susan E. Hickman, PhD, Jennifer L. Carnahan, MD, MPH, Zach Hass, PhD, Greg Sachs, MD, and Greg Arling, PhD
Innovation in Aging, 2018, Vol. 2, No. 2, 1–9 (doi:10.1093/geroni/igy017)
Abstract
Background and Objectives: To examine the relationship between hospital diagnoses associated with hospital transfers of long stay nursing home residents, ratings of avoidability of transfer, and RN-identified quality improvement opportunities.
Research Design and Methods: Prospective clinical demonstration project, named OPTIMISTIC, with trained RNs embedded in nursing homes that performed root cause analyses for 1,931 transfers to the hospital between November 2014 and July 2016. OPTIMISTIC RNs also rated whether transfers were avoidable, identified quality improvement opportunities, and recorded hospital diagnoses. Resident characteristics were obtained from Minimum Data Set assessments. Relationships between six hospital diagnoses commonly considered “potentially avoidable” and OPTIMISTIC RN root cause analysis findings were examined. Facilities were participating in the OPTIMISTIC demonstration project designed to reduce hospital transfers during the study period.
Results: Twenty-five percent of acute transfers associated with six common diagnoses were considered definitely or probably avoidable by project RNs versus 22% of transfers associated with other diagnoses. The most common quality improvement opportunity identified for transfers rated as avoidable was that the condition could have been managed safely if appropriate resources were available, a factor cited in 45% of transfers associated with any of the six diagnoses. Problems with communication among stakeholders were the most commonly noted area for improvement (48%) for transfers associated with other diagnoses. Many other areas for quality improvement were noted, including earlier detection of change in status and the need for understanding patient preferences or a palliative care plan.
Discussion and Implications: Although some nursing home transfers may later be deemed potentially avoidable based on post-transfer hospital diagnosis from Medicare claims data, OPTIMISTIC nurses caring for these residents at time of transfer categorized the majority of these transfers as unavoidable irrespective of the hospital diagnosis. Multiple quality improvement opportunities were identified associated with these hospital transfers, whether the transfer was considered potentially avoidable or unavoidable.
It will be the purpose of this organization:
(b) various long-term care associations, and
(c) officials of various government agencies.
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org, 5329 Fayette Avenue, Madison, WI 53713
Newsletter for June, 2019 - Link:
Wis-PALTCM_newsletter_2019.06.pdf
Newsletter for June 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Save the date for our annual meeting October 11-12, 2019 at the Radisson in Madison.
Save the date for the DQA’s annual FOCUS conference November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will be “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”.
Save the date for AMDA’s annual meeting April 2-5, 2020 at the Hyatt Regency in Chicago.
Other News-from around our state and our partners. There is a link in this to get the AMDA guidelines free on-line; you need the AMDA guidelines free on-line.
The Nursing Home team wants to ensure you are aware of important new resources, updates and webinars.
Upcoming Webinars
Success Stories Webinar Series | Achieving Community Goals by Partnering with Aging and Disability Resource Centers
Tuesday, June 25, Noon - 1:00 p.m. CT
Aging and Disability Resource Centers (ADRCs) are key partners in many communities. Their collaborations with other community organizations have been proven to be successful in bringing about effective community change.
Past Recorded Events
Pressure Injuries: Prevent, Treat and Sustain Gains
A wonderful presentation by Dr. Joyce Black, a leading expert in pressure injuries. This covers intervention and sustainment strategies.
Trauma Informed Care (TIC) in Long Term Care (LTC)
Presented by Scott Webb, the TIC Coordinator in Wisconsin, this presentation is a great overview of TIC including key concepts and terminology to prepare you and your staff for the new regulations in November.
Achieving Psychotropic Medication Reduction in Long Term Care
From our partners in Michigan, a well-done series of five short videos entitled "Reducing Psychotropic Medication Use". Great for just-in-time training! Learn more about our national partnership to improve dementia care.
Resources
Dementia/Antipsychotics
Clinical Resource Center (CRC) AMDA Updates
The CRC is a great site for evidence-based tools/resources including pain, medication management, diabetes, chronic obstructive pulmonary disease (COPD) and pain. Create and account to access all the materials.
Please let us know if there are additional resources you may need, or if we can be of assistance in some other way.
Diane Dohm, MT, IP, CIC, CPHQ - (800) 362-2320 or ddohm@metastar.com
Toni Kettner, BSN, MHA, NHA, CPHQ - (800) 362-2320 or tkettner@metastar.com
From the Trenches- questions about the meaning of PA/LTC life:
“I attended the AMDA State Chapter Open Mic Conference Call on May 29. Here are the highlights for you to know and use:
Ron Schreiber, MD,CMD
President, WAMD
Other Reviews-publications from around the world of geriatrics and PA/LTC
Can CBD Really Do All That? How one molecule from the cannabis plant came to be seen as a therapeutic cure-all.
By Moises Vaelasquez-Manoff in the New York Times 14 May 2019
When Catherine Jacobson first heard about the promise of cannabis, she was at wits’ end. Her 3-year-old son, Ben, had suffered from epileptic seizures since he was 3 months old, a result of a brain malformation called polymicrogyria. Over the years, Jacobson and her husband, Aaron, have tried giving him at least 16 different drugs, but none provided lasting relief. They lived with the grim prognosis that their son — whose cognitive abilities never advanced beyond those of a 1-year-old — would likely continue to endure seizures until the cumulative brain injuries led to his death.
In early 2012, when Jacobson learned about cannabis at a conference organized by the Epilepsy Therapy Project, she felt a flicker of hope. The meeting, in downtown San Francisco, was unlike others she had attended, which were usually geared toward lab scientists and not directly focused on helping patients. This gathering aimed to get new treatments into patients’ hands as quickly as possible. Attendees weren’t just scientists and people from the pharmaceutical industry. They also included, on one day of the event, families of patients with epilepsy.
The tip came from a father named Jason David, with whom Jacobson began talking by chance outside a presentation hall. He wasn’t a presenter or even very interested in the goings-on at the conference. He had mostly lost faith in conventional medicine during his own family’s ordeal. But he claimed to have successfully treated his son’s seizures with a cannabis extract, and now he was trying to spread the word to anyone who would listen.
The idea to try cannabis extract came to David after he found out that the federal government held a patent on cannabidiol, a molecule derived from the cannabis plant that is commonly referred to as CBD. Unlike the better-known marijuana molecule delta-9-tetrahydrocannabinol, or THC, CBD isn’t psychoactive; it doesn’t get users high. But in the late 1990s, scientists at the National Institutes of Health discovered that it could produce remarkable medicinal effects. In test tubes, the molecule shielded neurons from oxidative stress, a damaging process common in many neurological disorders, including epilepsy.
Jacobson had a Ph.D. in neuroscience. She had started her postdoctoral research at the University of California, San Francisco, by studying how cancer cells metastasize and spread, but after Ben was born, she moved to Stanford and switched her focus to epilepsy — a shift that compounded her anguish. She often wept in the parking lot before heading into the lab, overwhelmed by dread at the prospect of deliberately causing epilepsy in rodents. “I couldn’t watch animals seize all day and then watch Ben seize all night,” she told me. “It was just too much.”
After meeting David and reading through the small body of published work on CBD, Jacobson changed postdoctoral directions once again, from primary research to the study of this community of parents who were treating their epileptic children with cannabis extracts. In reality, she was preparing to join it herself. One small, double-blind study particularly caught her attention. In 1980, scientists in Brazil treated eight epileptic patients with CBD and eight patients with sugar pills as a placebo. For half the group that received CBD, the seizures almost completely disappeared; another three experienced a reduction in the intensity of their seizures. Only one person in the placebo group got better.
The epilepsy drugs that had been approved to date, none of which had helped Ben much, typically targeted the same few ion channels and receptors on the surface of neurons. But CBD worked on different and still somewhat mysterious pathways. If she could find a suitable CBD extract, Jacobson thought, she might have a truly new class of drug for Ben. The other experimental drugs and devices she had heard about at epilepsy conferences were under development, unapproved by the F.D.A. and thus largely unavailable. But medical marijuana had been legal in California since 1996, so CBD was theoretically accessible right away.
Seven years later, cannabidiol is everywhere. We are bombarded by a dizzying variety of CBD-infused products: beers, gummies, chocolates and marshmallows; lotions to rub on aching joints; oils to swallow; vaginal suppositories for “soothing,” in one company’s words, “the area that needs it most.” CVS and Walgreens each recently announced plans to sell CBD products in certain states. Jason David now sells a cannabis extract called Jayden’s Juice, named for his son — one of several extracts on the market, including Haleigh’s Hope and Charlotte’s Web, that are named after children who are said to have benefited from being treated with CBD.
Many of these products are vague about what exactly CBD can do. (The F.D.A. prohibits unproven health claims.) Yet promises abound on the internet, where numerous articles and testimonials suggest that CBD can effectively treat not just epilepsy but also anxiety, pain, sleeplessness, Crohn’s disease, arthritis and even anger. A confluence of factors has led to this strange moment. Plenty of legitimate, if still inconclusive, research is being done on CBD. Many scientists are truly excited about it. The laws governing cannabis and its chemical components have loosened up. And the anecdotes that have emerged from what Elizabeth Thiele, an epileptologist at Harvard, calls the “vernacular” cannabis movement have lent emotional force to the claims made for CBD.
Amid the current deluge of products, it now seems almost quaint that, back in 2012, after deciding to try treating Ben with CBD, Jacobson couldn’t actually locate the stuff. Other parents of epileptic children were using D.I.Y. techniques to treat their children: tinctures; cannabis-infused butter in baked goods; crushed cannabis buds in capsule form; even cannabis suppositories. Some reported positive results. Over the years, Jacobson has had many of these products tested at labs; almost invariably they contained very little or no CBD and too much THC. It has psychoactive effects, and there wasn’t much science suggesting THC could treat seizures.
[Redacted for citation; you can find the full text on line, or contact me]
CBD is not always an unqualified success, even in the best-known case studies. For Sam Vogelstein, the inspiration behind Epidiolex, it helped control his seizures for years, limiting them to around six per day. But in the fall of 2015, Sam began suffering from a new type of seizure. These were more severe, causing him to fall to the floor writhing, which hadn’t occurred in the past. “You instantly understand why people used to say that people who have epilepsy are possessed by the devil,” Fred, Sam’s father, told me, “like some external force has taken control of this person.”
Higher doses of Epidiolex didn’t help, so Sam’s doctor, the neurologist Roberta Cilio, recommended an anti-seizure drug called Depakote. He had taken it before, without benefit, but this time, in combination with Epidiolex, it worked wonders: Sam has been completely seizure free for more than three and a half years. He’s a tall, lanky 17-year-old who likes to fence, run and engages in “normal aggravating boy teenager stuff,” his father says — and “cause for celebration,” both parents say.
Ben Jacobson’s condition is more ambiguous. In an effort to stop the seizures, doctors surgically removed half of Ben’s parietal lobe in 2015, but the procedure didn’t mitigate the epilepsy. His doctor, Cilio, didn’t think the Epidiolex was aiding him, either, and recommended he stop taking it. Jacobson, who like many mothers of epileptic children keeps a detailed diary about seizure activity, disagreed. By her count, the number of Ben’s seizures had declined by 40 percent while on Epidiolex, particularly the severe grand mal seizures that caused him to stop breathing.
This disagreement between doctor and mother prompted Jacobson to find a new neurologist who, she told me, took one look at Ben and told her to do whatever she felt might help. Except for a few breaks, Ben, who’s now 10 and can’t walk unaided, has remained on Epidiolex, but his prognosis isn’t great. “He’s still going downhill,” Jacobson told me. “His life expectancy is short enough that we don’t like to think about it.”
Charlotte Figi, now 12, continues to be almost entirely seizure-free. She’s developmentally delayed, Paige Figi told me. And she suffers from osteoporosis caused, Figi thinks, by the high doses of steroids she took to control seizures at a young age. But she is otherwise a happy, playful girl, Figi says. And what Figi discovered about CBD on Charlotte’s behalf came in handy for Charlotte’s fraternal twin sister, Chase.
Two years ago, Chase, who until then had exhibited no problems, began to have seizures out of the blue. Figi didn’t even bother with allopathic drugs this time. She turned straight to the Charlotte’s Web CBD extract, and the seizures stopped. “If I hadn’t done this,” Figi says — that is, experiment with CBD extracts on Charlotte — “Charlotte would be dead. And Chase would now be starting all those drugs.”
Meanwhile, as the science inches forward, CBD has become a pop-culture phenomenon. Kim Kardashian recently hosted a CBD-themed baby shower. In April, Carl’s Jr. tested a CBD-infused burger in Colorado. Some scientists are concerned by how far the CBD craze has moved beyond the science. But Staci Gruber, associate professor of psychiatry at Harvard Medical School, does not think the two are necessarily in conflict. This might seem odd, given her work. She has found that recreational users, particularly those who begin using cannabis earlier in life, exhibit some cognitive difficulties and altered brain structure and function.
In 2014, Gruber started the Marijuana Investigations for Neuroscientific Discovery, or MIND, program to examine the effects of medical cannabis, and so far, she has found exactly the opposite in people who use cannabis as medicine. Their cognitive function appears to improve over time and preliminary evidence suggests that, after initiation of medical-cannabis treatment, their brain activity begins to normalize. Although Gruber is not certain what accounts for the contrasting effects, she has several theories. Seeking a euphoric high, recreational users often gravitate toward products higher in THC. Medical patients, meanwhile, want to control symptoms and may thus seek whole-plant products that not only contain more CBD than what recreational users typically encounter but also other potentially healthful cannabinoids. Medical users tend to be older, too, and some evidence suggests that THC is less toxic to older brains than younger and may in some cases benefit older brains.
Gruber has likewise observed that medical cannabis patients tend to reduce their use of conventional medications over time, which might itself be beneficial to brain structure and function. Whatever the explanation, Gruber believes greater scientific engagement with the CBD phenomenon is as important as more careful regulation. “People have been using cannabis forever,” she told me. “The question now is, how do we as scientists catch up?”
Advertisement
Supported by
Reflections-
Sandra Draus (center), one of ten honorees of the Wisconsin State Journal’s “Celebrate Nurse’s Week” shown with her collaborating physician T R Flygt, MD and manager Deirdre Suchomel.
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
(b) various long-term care associations, and
(c) officials of various government agencies.
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org, 5329 Fayette Ave., Madison, WI 53713
Newsletter for May, 2019 (link)
wis-paltcm_newsletter_2019.05.pdf
Newsletter for May, 2019
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your society’s board of directors teleconferenced April 11; issues addressed included-
Save the date for our annual meeting October 11-12 2019 at the Radisson in Madison
Save the date for the DQA’s annual FOCUS conference for providers and DQA staff November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”
Save the date for AMDA’s annual meeting April 2-5 2020 at the Hyatt Regency in Chicago
Other News-from around our state and our partners(in this case, the Wisconsin Quality Coalition of Metastar): Useful “big data” benchmarking information you can’t find anywhere else
This slide shows we are close to our neighbors in antipsychotic use, and decreasing that at a reasonable rate
This slide is hard to follow, but shows we’re close to our neighbors in reducing antipsychotic use, but will probably never get to zero.
This slide suggests more Wisconsin homes are “above average” than our neighbors; you are probably unfamiliar with this composite score, based on quality indicators, which seems more useful to Metastar than those of us in the business.
And here’s some stuff you didn’t know about Clostridium difficile infection.
If you’re interested in getting more information from Metastar, contact jgile@metastar.com for a list of their products and resources; they’re really there to help, and never to punish!
From the Trenches- questions about the meaning of PA/LTC life:
We tried to survey the membership as attendings, directors, and non-physician providers, but the response rate for the latter two was too low to report-
Other Reviews-publications from around the world of geriatrics and PA/LTC
Advertisement
Supported by
the new old age: Assisted Living—Where There’s Rarely a Doctor in the House
As residents become older and more frail, some facilities are bringing in doctors and nurses instead of relying on 911.
By Paula Span in the New York Times March 29, 2019
The patient moved into a large assisted living facility in Raleigh, N.C., in 2003. She was younger than most residents, just 73, but her daughter thought it a safer option than remaining in her own home.
The woman had been falling so frequently that “she was ending up in the emergency room almost every month,” said Dr. Shohreh Taavoni, the internist who became her primary care physician.
“She didn’t know why she was falling. She didn’t feel dizzy — she’d just find herself on the floor.” At least in a facility, her daughter told Dr. Taavoni, people would be around to help.
As the falls continued, two more in her first three months in assisted living, administrators followed the policy most such communities use: The staff called an ambulance to take the resident to the emergency room.
There, “they would do a CT scan and some blood work,” Dr. Taavoni said. “Everything was O.K., so they’d send her back.”
Such ping-ponging occurs commonly in the nation’s nearly 30,000 assisted living facilities, a catchall category that includes everything from small family-operated homes to campuses owned by national chains.
It’s an expensive, disruptive response to problems that often could be handled in the building, if health care professionals were more available to assess residents and provide treatment when needed.
But most assisted living facilities have no doctors on site or on call; only about half have nurses on staff or on call. Thus, many symptoms trigger a trip to an outside doctor or, in too many cases, an ambulance ride, perhaps followed by a hospital stay.
Twenty years after the initial boom in assisted living — which now houses more than 800,000 people — that approach may be shifting.
Early on, assisted living companies planned to serve fairly healthy retirees, offering meals, social activities and freedom from home maintenance and housekeeping — the so-called hospitality model.
But from the start, the assisted living population was older and sicker than expected. Now, most residents are over age 85, according to government data. About two-thirds need help with bathing, half with dressing, 20 percent with eating.
Like most older Americans, they also generally contend with chronic illnesses and take long lists of prescription drugs — and more than 80 percent need help taking them correctly.
Moreover, “these places became the primary residential setting for people with dementia,” said Sheryl Zimmerman, an expert on assisted living at the University of North Carolina at Chapel Hill.
About 70 percent of residents have some degree of cognitive impairment, her studies have found. So residents can find it difficult to coordinate medical appointments and tests, and to travel to offices and labs, even when facilities provide a van.
“The assisted living industry has to recognize that the model of residents going out to see their own doctors hasn’t worked for a long time,” said Christopher Laxton, executive director of AMDA, a society that represents health care professionals in nursing homes and assisted living.
His recent editorial in McKnight’s Senior Living, an industry publication, was pointedly headlined: “It’s time we integrate medical care into assisted living.” AMDA is considering developing model agreements.
“There has to be more attention to medical and mental health care in assisted living,” Dr. Zimmerman agreed. “Does everyone who falls really need to go to an emergency department?”
Lindsay Schwartz, an executive at the National Center for Assisted Living, a trade association, said in an email that “assisted living has certainly expanded its role in providing medical care over the years by adding nursing staff and partnering with other health care providers, among other ways.”
But persuading most operators to provide medical care likely won’t happen without a fight. They’ve built their marketing strategies on looking and feeling different from the dreaded nursing home, and they object to “medicalizing” their communities.
“They don’t want the liability,” said Dr. Alan Kronhaus, an internist who, with Dr. Taavoni (they are married), started a practice called Doctors Making Housecalls in 2002.
The facilities also “live in mortal fear of bringing down heavy-handed federal regulation,” he said. That can happen when Medicare and Medicaid, which cover most residents’ health care, get involved.
Doctors Making Housecalls provides one example of how assisted living can offer medical care. The practice dispatches 120 clinicians — 60 doctors, plus nurse-practitioners, physician assistants and social workers — to about 400 assisted living facilities in North Carolina.
“We see patients often, at length and in detail, to keep them on an even keel,” Dr. Kronhaus said. By contracting with labs, imaging companies and pharmacies, the practice can provide most of the medical care for more than 8,000 residents, on site and around the clock.
Working with a local emergency medical service, he and his colleagues reported in a 2017 study that the practice could reduce emergency room transfers by two-thirds.
The Lott Assisted Living Residence in Manhattan, on the other hand, relies on a single geriatrician, Dr. Alec Pruchnicki, to provide medical care for most of its 127 or so residents.
If they’re feeling sick, a family member calls or the resident just knocks on the door of “Dr. P’s” basement office. “Sometimes it’s just a cold — chicken soup,” Dr. Pruchnicki said. “But this winter we had a few cases of flu and pneumonia, things you need to treat.”
Nearby Mount Sinai Hospital employs him and provides emergency services when needed. Often, they’re not. In 2005, Dr. Pruchnicki reported at medical conferences, he decreased hospitalizations by a third. “I can’t be in the only place in the country where this would work,” he said.
Spending time in emergency rooms and hospitals often takes a toll on residents, even if their ailments can be treated. They get exposed to infections and develop delirium; they lose strength from days spent in bed.
Perhaps that contributes to short stays in assisted living. Adult children often see these facilities as their parents’ final homes, but residents stay just 27 months on average, after which many move on to nursing homes.
Adding doctors to assisted living could also cause problems, advocates acknowledge; in particular, it might increase the already high fees facilities charge.
But something has clearly got to give. “There can be health care in assisted living without making it feel like a nursing home,” Dr. Zimmerman said.
Family members tell of frightened and confused residents arriving unaccompanied at emergency rooms, unable to give clear accounts of their problems. Dr. Kronhaus recalls a resident with dementia taken to the local E.R. by ambulance; discharged, she was sent home by taxi. The address she gave the driver was her former home, where neighbors spotted her and called the police.
By contrast, the North Carolina woman with a history of falls is doing well.
Dr. Taavoni discovered that her hypertension medications were causing such low blood pressure that she fainted. Reducing the dose and discontinuing a diuretic, Dr. Taavoni also weaned the patient off an anti-anxiety drug she suspected was causing problems, substituting a low dose of an antidepressant instead.
The falls and the related emergency room visits stopped. Doctors Making Housecalls is still caring for her, and for most of the neighbors in her assisted living facility.
https://www.nytimes.com/2019/03/29/health/assisted-living-doctors-house-calls.html accessed 3 April 2019
Reflections-
The Wis-PALTCM Mission Statement- It will be the purpose of this organization:
(b) various long-term care associations, and
(c) officials of various government agencies.
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 5329 Fayette Ave., Madison, WI 53713
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your society’s board of directors teleconferenced April 11; issues addressed included-
Save the date for our annual meeting October 11-12 2019 at the Radisson in Madison
Save the date for the DQA’s annual FOCUS conference for providers and DQA staff November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”
Save the date for AMDA’s annual meeting April 2-5 2020 at the Hyatt Regency in Chicago
Other News-from around our state and our partners(in this case, the Wisconsin Quality Coalition of Metastar): Useful “big data” benchmarking information you can’t find anywhere else
This slide shows we are close to our neighbors in antipsychotic use, and decreasing that at a reasonable rate
This slide is hard to follow, but shows we’re close to our neighbors in reducing antipsychotic use, but will probably never get to zero.
This slide suggests more Wisconsin homes are “above average” than our neighbors; you are probably unfamiliar with this composite score, based on quality indicators, which seems more useful to Metastar than those of us in the business.
And here’s some stuff you didn’t know about Clostridium difficile infection.
If you’re interested in getting more information from Metastar, contact jgile@metastar.com for a list of their products and resources; they’re really there to help, and never to punish!
From the Trenches- questions about the meaning of PA/LTC life:
We tried to survey the membership as attendings, directors, and non-physician providers, but the response rate for the latter two was too low to report-
Other Reviews-publications from around the world of geriatrics and PA/LTC
Advertisement
Supported by
the new old age: Assisted Living—Where There’s Rarely a Doctor in the House
As residents become older and more frail, some facilities are bringing in doctors and nurses instead of relying on 911.
By Paula Span in the New York Times March 29, 2019
The patient moved into a large assisted living facility in Raleigh, N.C., in 2003. She was younger than most residents, just 73, but her daughter thought it a safer option than remaining in her own home.
The woman had been falling so frequently that “she was ending up in the emergency room almost every month,” said Dr. Shohreh Taavoni, the internist who became her primary care physician.
“She didn’t know why she was falling. She didn’t feel dizzy — she’d just find herself on the floor.” At least in a facility, her daughter told Dr. Taavoni, people would be around to help.
As the falls continued, two more in her first three months in assisted living, administrators followed the policy most such communities use: The staff called an ambulance to take the resident to the emergency room.
There, “they would do a CT scan and some blood work,” Dr. Taavoni said. “Everything was O.K., so they’d send her back.”
Such ping-ponging occurs commonly in the nation’s nearly 30,000 assisted living facilities, a catchall category that includes everything from small family-operated homes to campuses owned by national chains.
It’s an expensive, disruptive response to problems that often could be handled in the building, if health care professionals were more available to assess residents and provide treatment when needed.
But most assisted living facilities have no doctors on site or on call; only about half have nurses on staff or on call. Thus, many symptoms trigger a trip to an outside doctor or, in too many cases, an ambulance ride, perhaps followed by a hospital stay.
Twenty years after the initial boom in assisted living — which now houses more than 800,000 people — that approach may be shifting.
Early on, assisted living companies planned to serve fairly healthy retirees, offering meals, social activities and freedom from home maintenance and housekeeping — the so-called hospitality model.
But from the start, the assisted living population was older and sicker than expected. Now, most residents are over age 85, according to government data. About two-thirds need help with bathing, half with dressing, 20 percent with eating.
Like most older Americans, they also generally contend with chronic illnesses and take long lists of prescription drugs — and more than 80 percent need help taking them correctly.
Moreover, “these places became the primary residential setting for people with dementia,” said Sheryl Zimmerman, an expert on assisted living at the University of North Carolina at Chapel Hill.
About 70 percent of residents have some degree of cognitive impairment, her studies have found. So residents can find it difficult to coordinate medical appointments and tests, and to travel to offices and labs, even when facilities provide a van.
“The assisted living industry has to recognize that the model of residents going out to see their own doctors hasn’t worked for a long time,” said Christopher Laxton, executive director of AMDA, a society that represents health care professionals in nursing homes and assisted living.
His recent editorial in McKnight’s Senior Living, an industry publication, was pointedly headlined: “It’s time we integrate medical care into assisted living.” AMDA is considering developing model agreements.
“There has to be more attention to medical and mental health care in assisted living,” Dr. Zimmerman agreed. “Does everyone who falls really need to go to an emergency department?”
Lindsay Schwartz, an executive at the National Center for Assisted Living, a trade association, said in an email that “assisted living has certainly expanded its role in providing medical care over the years by adding nursing staff and partnering with other health care providers, among other ways.”
But persuading most operators to provide medical care likely won’t happen without a fight. They’ve built their marketing strategies on looking and feeling different from the dreaded nursing home, and they object to “medicalizing” their communities.
“They don’t want the liability,” said Dr. Alan Kronhaus, an internist who, with Dr. Taavoni (they are married), started a practice called Doctors Making Housecalls in 2002.
The facilities also “live in mortal fear of bringing down heavy-handed federal regulation,” he said. That can happen when Medicare and Medicaid, which cover most residents’ health care, get involved.
Doctors Making Housecalls provides one example of how assisted living can offer medical care. The practice dispatches 120 clinicians — 60 doctors, plus nurse-practitioners, physician assistants and social workers — to about 400 assisted living facilities in North Carolina.
“We see patients often, at length and in detail, to keep them on an even keel,” Dr. Kronhaus said. By contracting with labs, imaging companies and pharmacies, the practice can provide most of the medical care for more than 8,000 residents, on site and around the clock.
Working with a local emergency medical service, he and his colleagues reported in a 2017 study that the practice could reduce emergency room transfers by two-thirds.
The Lott Assisted Living Residence in Manhattan, on the other hand, relies on a single geriatrician, Dr. Alec Pruchnicki, to provide medical care for most of its 127 or so residents.
If they’re feeling sick, a family member calls or the resident just knocks on the door of “Dr. P’s” basement office. “Sometimes it’s just a cold — chicken soup,” Dr. Pruchnicki said. “But this winter we had a few cases of flu and pneumonia, things you need to treat.”
Nearby Mount Sinai Hospital employs him and provides emergency services when needed. Often, they’re not. In 2005, Dr. Pruchnicki reported at medical conferences, he decreased hospitalizations by a third. “I can’t be in the only place in the country where this would work,” he said.
Spending time in emergency rooms and hospitals often takes a toll on residents, even if their ailments can be treated. They get exposed to infections and develop delirium; they lose strength from days spent in bed.
Perhaps that contributes to short stays in assisted living. Adult children often see these facilities as their parents’ final homes, but residents stay just 27 months on average, after which many move on to nursing homes.
Adding doctors to assisted living could also cause problems, advocates acknowledge; in particular, it might increase the already high fees facilities charge.
But something has clearly got to give. “There can be health care in assisted living without making it feel like a nursing home,” Dr. Zimmerman said.
Family members tell of frightened and confused residents arriving unaccompanied at emergency rooms, unable to give clear accounts of their problems. Dr. Kronhaus recalls a resident with dementia taken to the local E.R. by ambulance; discharged, she was sent home by taxi. The address she gave the driver was her former home, where neighbors spotted her and called the police.
By contrast, the North Carolina woman with a history of falls is doing well.
Dr. Taavoni discovered that her hypertension medications were causing such low blood pressure that she fainted. Reducing the dose and discontinuing a diuretic, Dr. Taavoni also weaned the patient off an anti-anxiety drug she suspected was causing problems, substituting a low dose of an antidepressant instead.
The falls and the related emergency room visits stopped. Doctors Making Housecalls is still caring for her, and for most of the neighbors in her assisted living facility.
https://www.nytimes.com/2019/03/29/health/assisted-living-doctors-house-calls.html accessed 3 April 2019
Reflections-
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
(b) various long-term care associations, and
(c) officials of various government agencies.
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 5329 Fayette Ave., Madison, WI 53713
Newsletter for April, 2019
Newsletter for April 2019
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
President Ron Schreiber led the Wisconsin delegation to the AMDA House of Delegates, which also included Paula Hardgrove, Raul Mateo, Curt Hancock and Rex Flygt (pictured below). We considered seven resolutions-two were passed to the Board of Directors, and two were referred to the Board of Directors for analysis and re-direction.
o A19-a white paper on “Stopping eating and drinking by advance directive (SED by AD) in the ALF and PALTC settings” passed. For full text go to https://paltc.org/sites/default/files/A19-WHITE%20PAPER-SED%20AD%20Ethics%20Committee%20White%20Paper%20HOD%20submission.pdf This is a very careful review worth your time to read.
o D19-dealt with the studying impact of medical direction on quality outcomes; this was referred to the board
o E19-dealt with two separate issues, 1) recognizing (again) medical director’s compensation is for direction, not referrals to the facility, but also 2) requiring CMS to maintain a list of medical directors. That resolution was divided; both passed, with a lot of moaning and groaning about how little is likely to be accomplished.
o F19-dealt with permitting medical direction by telecommunication technology; this was referred to the board
We again shared a state chapter reception with Minnesota Friday March 8 starting at 6:30 PM; a good time was had by all, mostly.
Irene Hamrick from the UW and a previous WIS-PALTCM officer and director received honorable mention in the poster competition for an article she’s published in JAMDA (see below); she also presented “SNF Five-Star Quality Metrics 101”
And, of course, save the date for our annual meeting October 11-12 at the Radisson in Madison.
President Schreiber will be attending the state DQA meeting on Tuesday, April 16th.
Other News-from around our state and our partners:
Our president Ron Schreiber provided this letter in lieu of testimony to the state senate, after testifying before the assembly:
President Ron (second from left) with John Sauer, Craig Ubbelohde, & Joey Pettis
Wisconsin Medical Directors Support Assembly Bill 76 and Senate Bill 103
“Chairman Testin and Members of the Senate Health and Human Services Committee, my name is Dr. Ronald Schreiber, MD, CMD. I am from Appleton, and serve as the President of the Wisconsin Society for Post-Acute and Long-Term Care Medicine, also known as the Wisconsin Association of Medical Directors (WAMD). I have been a practicing physician in Wisconsin for more than 25 years. I am Board Certified in Internal Medicine, and am a Certified Medical Director, through the American Medical Directors Association. I serve in the Appleton-Neenah-Menasha area at several skilled nursing facilities.
Thank you for the opportunity to provide written testimony in support of Assembly Bill 76 and Senate Bill 103, which would ensure that the training standards for Certified Nursing Assistants (CNAs) in Wisconsin mirror the federal CNA training standards.
CNAs are a vital component of the post-acute (post-hospital) and long-term care continuum. We as a society must recognize this, and must encourage growth in this field, especially as our population ages at historic rates. Unfortunately, Wisconsin’s shortage of CNAs is worsening over time. We must best prepare for the future to ensure quality care for our aging population.
WAMD recognizes that current state requirements put us at a competitive disadvantage in recruiting CNAs compared to our neighboring states of Minnesota, Iowa, and Michigan, which adhere to federal guidelines. WAMD requests that this be rectified through this important legislation.
The reality is that facilities are largely regulated on the basis of federal regulations. In fact, the Centers for Medicare and Medicaid Services (CMS) just a few years ago went through a significant overhaul of the Requirements of Participation governing facilities participating in the Medicaid program, and the federal CNA training standard of 75 hours was not adjusted in any way. Medical Directors who serve in Wisconsin’s skilled nursing facilities across the state – professionals who ensure that quality care is being delivered to the residents that we serve – believe that putting CNA certification standards in line with the federal government establishes consistency of the standards by which long-term and post-acute care facilities are measured and evaluated.
While some may attempt to make this issue about quality of care, in fact, there is actually very little in the medical literature regarding number of training hours as related to quality measures. What data we do have comes from the CMS website Medicare.gov in terms of nursing home ratings. In Wisconsin, 36% of nursing homes rate as "much above average" (5 star), compared to a range of 36-39% for Minnesota, Iowa, and Michigan. Those ranked "much below average" (1-star) are 9% in Wisconsin, and 5-9% in our bordering states. There is no statistical difference between Wisconsin and our neighbors. Although the five-star rating system does not focus on CNA work exclusively, their level of care and competence certainly affects a facility's rating. Our neighboring states do not suffer in the CMS star rating as a result of their federally-aligned CNA training.
It is important to note several items about this legislation: the bill does not alter testing/competency requirements – all CNAs have to pass the same test regardless of how many hours are in their training program. All required core competencies for CNAs will be covered following passage of this legislation. This legislation does not limit the ability of programs to offer CNA training classes with higher hours, which some programs may elect to do; it only affects whether the Department of Health Services is able to require a program to offer training above the federal level.
Thank you for your attention to this matter. I am happy to answer any questions that you may have about WAMD’s support for this important legislation that deserves your support.”
Ronald Schreiber, MD, CMD
President, Wisconsin Association of Medical Directors
From the Trenches- questions about the meaning of PA/LTC life:
“Things I thought I heard at AMDA”
o Have you looked at the New York “algorithm for the unbefriended”? —an estimated 3 to 4 percent of long-stay residents have no proxy decision-maker.
o Autonomy is the experience of authorship of behavior, not simply the experience of noninterference.
o How much do you understand about the new PDPM (patient driven payment model), including the role in non-case mix basal rate, and front end load?
o PDPM will replace payment therapy with payment management of complexity as the touchstone of post-acute medicine. The biggest thing that’s happened since the BBA of 1997, which led to the last big wave of bankruptcies in long-term care.
o AMDA is working on a marijuana clinical practice guideline; they say they’re not, but you know they must be.
o There is a lot of congressional interest in resolving the surprising billing complications of observation; the solution to the three-night rule might get bundled into that, but don’t hold your breath.
o Probably regretfully, the nursing home quality measures are not physician quality measures.
o No one gets participation trophies in long-term care. Do we need a state medical director of the year award, or a young medical director of the year award?
o What would you say to this: “This is why I came to post-acute/long-term care… This is why I stay….”
o I can’t—we can.
o After adequate compensation, professional satisfaction is about autonomy, mastery, and purpose—which is why PA/LTC providers tend to stay in the business.
o Providers really don’t want to be paid for call: They want no meaningless call.
o Adequate nurse triage upgrades the work done by provider…. Strong nurse triage can stop 80% of calls and organize work more productively.
o Why do you need to be notified for the sake of notification along? The bar should be at notification that asks you to do something.
o Recruitment Retention Productivity
o Telemedicine is among the interventions that probably reduce readmissions, although deployment of the Interact tools is better-evidenced.
o Do you have online access to the AMDA guidelines? Why not?
o Do you know how to evaluate and treat the Krumholz post-hospital syndrome?
o Heart failure increases the risk of readmission by 50%, but furosemide will not fix two of the three conditions the HFpEF (heart failure with preserved ejection fraction) patient will be readmitted for.
o In other words, since HFpEF really isn’t a “heart” problem, you have to manage the complications (including complications of therapy) and the comorbid conditions.
o Thirty-day readmission is now the key quality indicator (“it’s about the economy, stupid”); functional capacity and percent discharge home should be.
o Do you know what’s in section GG of the MDS?
o Do you have the provider resilience app on your phone? What’s the equivalent, in self-maintenance, to singing happy birthday while hand washing?
o Working with your specialty society can help prevent “lone ranger” isolation at work.
o The real touchstone about “avoidability”, suggests Crecelius, is not the nature and scope of the intervention at the change in condition, but identifying and treatment what is reversible before the change in condition.
o The PA/LTC workforce is small and aging. Nurture it. --Of the 37 certified medical directors in Wisconsin, more than half plan to reduce or discontinue practice in the next five years; this parallels, of course, other reports that a similar proportion of Wisconsin physicians plan to cut back on clinic time or duties due to the more and more burdensome “administrative load” on the same timeline.
o Speaking of administrative load, coding has become more and more complex, although there are proposals on the table to make things simpler to bill (even if service is more complicated). For more info, go to https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlngeninfo/index.html.
o Nursing home physicians remain relatively immune from professional liability claims, but not so facilities.
o If you haven’t read the AMDA white paper on “SED by AD” (Stopping eating and drinking by advance directive), do so (citation above)
o Silos continue to harden and separate and the hospital remains best funded silo.
o Only the long-term care medical director is looking beyond the door, realizing we care for populations and not sites of service.
o Should a provider-provider handoff at the transition of care be a quality measure?
o Firm touch pharmacy review reduces high impact medication errors at the transition of care.
o There is plenty of consternation with the electronic medical record nationwide. You are not alone.
o Here’s a script for you: “I’m not sure I understand what you’re saying: Do the SBAR and I’ll call you back…”
Other Reviews-publications from around the world of geriatrics and PA/LTC
Transitioning from Insulin to DDP-4 Inhibitors for Type 2 Diabetes
by I. Hamrick, MD, M. Goblirsch, BS; and W.-J. Tuan, MS (University of Wisconsin)
“Introduction: Dipeptidyl-peptidase 4 (DPP-4) inhibitors are a relatively new treatment regimen for Type II Diabetes Mellitus (T2DM) and are associated with less hypoglycemia than insulin. There are no published data regarding the effects of these drugs on insulin therapy. This case series presents findings from a cohort of older adults on insulin who received DPP-4 treatment with the intention of discontinuing insulin, if possible. Using data from electronic health records, we reviewed all residents in nursing homes with T2DM who were on insulin and started on DPP-4 inhibitors. We tapered insulin dosages when finger stick blood glucose levels were <200mg/dL and noted when insulin treatment was stopped altogether. …
Conclusion: More than half (59%) of patients were able to transition off insulin therapy onto DPP-4 inhibitors with subsequent improvement in weight by 4.1 pounds and HgA1c by 1%. These findings suggest that DPP-4 inhibitors provide a new care option in the treatment of Type II Diabetes Mellitus in older nursing home patients and can be used to transition patients off insulin therapy. Because it may take several months, patience and close monitoring is required to succeed. This report provides a starting point for larger studies to confirm our findings and develop a protocol for transitioning patients.”
For full text go to https://doi.org/10.1016/J.JAMDA.2019.01.054
Reflections-
Your Wisconsin delegation at AMDA, Raul Mateo, Rex Flygt (standing), Ron Schreiber, Curt Hancock, and Paula Hardgrove
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
· To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
· To establish better communication among physicians serving as medical directors and other providers.
· To promote better communication between medical directors and
(a) other post-acute and long-term care professionals,
(b) various long-term care associations, and
(c) officials of various government agencies.
· To represent medical directors in defining their roles and equitable compensation.
· To serve as a conduit between AMDA and the WAMD membership.
· To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
· To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
· To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 6000 Gisholt Dr., Suite 200, Madison, WI 53713
Newsletter for March, 2019
Newsletter for March 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Event Website: https://paltc.org/annual-conference
President Ron Schreiber will lead the Wisconsin delegation to the AMDA House of Delegates, which will also include Paula Hardgrove, Raul Mateo, Curt Hancock and Rex Flygt.
We will again share a state chapter reception with Minnesota Friday March 8. All encouraged to attend. This is a great opportunity to meet and network with colleagues from across the state.
And, of course, save the date for our annual meeting October 11-12 at the Radisson in Madison:
While the structure and content of our 2019 annual meeting is set, and the program will start being shown in a couple months, the board decided it was time to poll the membership as a whole on preferences for how the meeting is done. Survey links to that and the other semi-annual surveys are below.
Other News-from around our state and our partners:
All members who are medical directors should take this survey-
· https://www.surveymonkey.com/r/FWV9PVX
All physician members who attend patients should take this survey-
· https://www.surveymonkey.com/r/FJQZKTC
All non-physician providers who attend patients should take this survey- From the Trenches- questions about the meaning of PA/LTC life
Yeah, yeah, we all learned how to write discharge summaries as medical students and ours are pretty good, right? Well, that’s actually an empiric point—can yours standard up to the scrutiny of research? Do you need to share this document with people you handoff too (and from)? “Evaluation of an Enhanced Discharge Summary Template: Building a Better Handoff Document” by Christopher Smith, Micah Beachy, Andrew Vasey, Trek Langenhan, and Jason Shiffermiller in the Journal of Clinical Outcomes Management. 2017 December; 24(12): 542-550·
Objective: To design and implement an enhanced discharge summary for use by internal medicine providers and evaluate its impact.
· Methods. Pre/post-intervention study in which discharge summaries created in the 3 months before (n = 57) and 3 months after (n = 57) introduction of an enhanced discharge summary template were assessed using a 24-item scoring instrument. Measures evaluated included a composite discharge summary quality score, individual content item scores, global rating score, redundant documentation of consultants and procedures, documentation of non-active conditions, discharge summary word count, and time to completion. Physician satisfaction with the enhanced discharge summary was evaluated by survey.
· Results: The composite discharge summary quality score increased following the intervention (19.07 vs. 13.37, P < 0.001). Ten items showed improved documentation, including documented need for follow-up tests, cognitive status, code status, and communication with the next provider. The global rating score improved from 3.04 to 3.46 (P = 0.01). Discharge summary word count decreased from 717 to 701 (P = 0.002), with no change in the time to discharge summary completion. Surveyed physicians reported improved satisfaction with the enhanced discharge summary compared with the prior template.
· Conclusion: An enhanced discharge summary, designed to serve as a handoff between inpatient and outpatient providers, improved quality without negative effects on document length, time to completion, or physician satisfaction.
Other Reviews-publications from around the world of geriatrics and PA/LTC
Hallucinations Are Everywhere
Experiences like hearing voices are leading psychologists to question how all people perceive reality.
Joseph Frankel in The Atlantic 2 October 2018
There’s a good chance you’ve hallucinated before.
If you’ve ever felt the buzz of your phone against your thigh only to realize the sensation was entirely in your head, you’ve had a sensory perception of something that isn’t real. And that, according to the psychologist Philip Corlett, is what makes a hallucination.
To many, this definition may seem shockingly broad. Hallucinations were long considered the stuff of psychoses or drug trips, not a regular and inconsequential part of life. But Corlett operates on the idea that hallucinations exist within a hierarchy. At the highest level, according to Corlett’s collaborator Albert Powers, they would be something like hearing “whole sentences of clearly spoken speech of a being who seems quite real.” But, moving further down the line, hallucinations can be far more banal: an imagined text message, a phantom raindrop, a new parent’s mistaken sense of her child by her bedside.
This hierarchy perspective represents an ongoing revelation in how widespread and varied hallucinations can be. A survey in the early 1990s found that 10 to 15 percent of the population of the United States experienced vivid sensory hallucinations at some point in their lives. And scientists have begun to take seriously the idea that voice hearing and other forms of auditory hallucination can be benign or “nonclinical.” This newfound ubiquity has come with a host of questions. Why is it so common for people to perceive what isn’t there, and how does the brain allow this to happen in the first place? To find answers, researchers have turned to the mechanics of how we perceive reality itself.
For Corlett and Powers, both from the Yale School of Medicine, hallucinations have everything to do with expectations. In a new paper in Science, they explore how the mysterious experiences fit into a larger, speculative idea about how the brain works—and, in a sense, what the brain is. The pair recounts a 2017 study they conducted, in which their group tried to induce hallucinations both in people who commonly report hallucinations across the psychotic spectrum and in people who don’t normally hallucinate. The participants were taught to expect to hear a tone after being shown a flashing light, and then were made to press a button when they thought they heard a tone. They were told to hold down the button longer to rate their confidence in what they heard. People who regularly hallucinate held the button—that is, they hallucinated—significantly longer than those who don’t.
Corlett and Powers see this experiment as evidence for their perspective on how people understand the world around them. By their way of thinking, the brain works by “predictive coding”: integrating new information based on the beliefs built on old information. “When we go about the world, we’re not just passively perceiving sensory inputs through our eyes and ears,” Corlett says. “We actually build a model in our minds of what we expect to be present.”
This mental setup works great for allowing us to move smoothly through the world, taking in each detail without a second thought. But sometimes, Corlett and Powers say, the brain has the capacity to overpredict: It can expect something that isn’t there, and this expectation can be so strong that we actually perceive the nonexistent thing. Thus, a hallucination.
The idea of predictive coding is part of a way out of a knotted, overlapping, and sometimes competing lineage of trying to explain hallucinations. Another model, inner-speech theory, was popularized in part by the writings of the 20th-century psychologist Julian Jaynes. It holds that people who hear voices are really hearing their own thoughts that feel like someone else’s. This explanation has been propped up more recently by corollary-discharge theory, which states that the body’s tracking of its boundaries and actions (the neural machinery that makes your arm feel like your arm and your foot feel like your foot) fails for the thoughts and voices of people with psychotic disorders who experience auditory hallucinations.
“We’re still working to see how our model fits in with those models,” Corlett says.
This quest for a leg to stand on in researching hallucinations has yielded some theatrical—and sometimes even poetic—experiments. In his book on the science and history of auditory hallucinations, Charles Fernyhough, a psychologist at Durham University, tells how a psychiatrist in the ’40s found that as a group of people with schizophrenia hallucinated voices, muscles in their throats responsible for speech would twitch along with the words they heard. The voices seemed to be their own words hidden elsewhere.
Decades later, researchers recorded the voices of hallucinators with psychotic disorders and presented these subjects with electronically distorted copies. They wanted to see if the hallucinators could identify their own distorted voices. In the same vein, researchers have explored using computerized avatars à la Second Life in the past decade to try and help hallucinating psychotics assign their “presumed persecutors” a face to talk to, with the goal of softening the things these voices said to them.
Corlett also pointed me toward sine-wave speech, a particularly stunning example of the way expectation can seem to shape our reality when it comes to language. You can try it yourself: Listen to this sound (don’t turn your volume too loud). Most people will hear an R2-D2-like swell of vocoder-tinged whistling. Next, listen to this recording of a woman saying, “It was a sunny day, and the children were going to the park,” in a soothing, southern English accent. Now try R2-D2 again. Listening to the whistling sine-wave speech, you’ll likely hear a distorted version of the same “sunny day” sentence. And in all likelihood, you won’t be able to un-hear the words in the first recording now.
Hallucinators may have an easier time parsing the R2-D2-like sounds, even before listening to the other recording. In a 2017 study, nonclinical voice hearers were far better at recognizing the presence of a voice in sine-wave speech than their non-voice-hearing counterparts. And as a group, their brains fired along a pattern distinct from those who couldn’t tell that the sine-wave speech was a voice. This example, Corlett says, builds the case that auditory hallucinations are linked to the processes of expectation and prediction.
Still, Fernyhough points out, there are some potential holes in the idea of predictive coding. “Compared to the conventional view of the brain as a device that processes information coming from the environment, predictive coding starts with a different set of assumptions about how the brain makes predictions about what is in the environment and then learns from them,” he said.
Corlett, meanwhile, argues that there’s a gap in inner-speech theory. Citing a study in which people rendered mute from birth reported hearing voices in their heads, he says that the phenomenon can’t be completely explained as the brain misreading itself.
Whatever explanations stand the test of time, the stakes of this science are much higher than understanding why many of us imagine text messages. For some people, hallucinations can be more persistent and disturbing. The science of how these hallucinated touches, sounds, and sights manifest in the mind is still unclear. It’s too early to say how much the causes of auditory hallucinations and other kinds might overlap, Fernyhough says. So far, the research has focused on auditory hallucinations. And to many, the need for that work is quite clear. Eleanor Longden, a mental-health researcher and advocate, has publicly recounted how her own auditory hallucinations have shifted between neutral and distressing at different points in her life. She’s made the case that the social stigma and judgment she received from her doctor at the time made them more negative.
“Hallucinations can be very distressing and debilitating. They can also be neutral or positive,” Fernyhough says. “A better understanding of how they occur and how they can be managed could alleviate a great deal of mental distress.
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
· To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
· To establish better communication among physicians serving as medical directors and other providers.
· To promote better communication between medical directors and
(a) other post-acute and long-term care professionals,
(b) various long-term care associations, and
(c) officials of various government agencies.
· To represent medical directors in defining their roles and equitable compensation.
· To serve as a conduit between AMDA and the WAMD membership.
· To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
· To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
· To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 6000 Gisholt Dr., Suite 200, Madison, WI 53713
Newsletter for February, 2019
Newsletter for February 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your board teleconferenced Wednesday January 16 at 5 PM:
Event Website: https://paltc.org/annual-conference
President Ron Schreiber will lead the Wisconsin delegation to the AMDA House of Delegates, which will also include Paula Hardgrove, Raul Mateo, Curt Hancock and Rex Flygt.
We will again share a state chapter reception with Minnesota Friday March I; RSVP optional, but President Ron would like to know who’s coming.
And, of course, save the date for our annual meeting October 11-12 at the Radisson in Madison!
Other News-from around our state and our partners:
All members who are medical directors should take this survey-
Newsletter for January 2019-
Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant karenmiller.rio@gmail.com
News-from around our organizations and our members:
Your board will teleconference Wednesday January 16 at 5 PM; agenda items to Karen and President Ron now, please.
Save the Date: 2019 WAMD Annual Conference October 11-12, Radisson Hotel, Madison. The CME committee is working on another great line-up of topics and speakers. Thanks for all the suggestions.
We also need additional persons for the Wisconsin delegation at the House of Delegates at the AMDA meeting in March; express interest in involvement to Ron now, please.
Speak of AMDA-Atlanta, we will share a state chapter reception with Minnesota Friday, March 8; responses optional, but Ron would like to know who’s coming.
Event Website: https://paltc.org/annual-conference
Other News-from around our state and our partners:
New opioid guidelines arrive not a moment too soon
Elizabeth Newman Senior Editor, in McKnight’s Long-term Care News published 7 December 2018
· Following my C-section earlier this year, I was fortunate to be able to access heavy-duty pain medication. Until we discovered my pain pump wasn’t working.
· That was unfortunate, but luckily I was young(ish), in good health(ish) and had a new baby. But as AMDA – The Society for Post-Acute and Long-Term Care (PALTC) Medicine President Cari Levy, M.D., Ph.D., recounts, many nursing home professionals have stories of people they’ve cared for who couldn’t access pain medication.
· “Everybody has one of those in their brains, where the resident was suffering,” she told me Thursday following the announcement of new guidelines from AMDA. “We had to get prescriptions faxed, and it was a weekend and there were all of these hurdles. That’s so unnecessary. That’s a lot of what drives the motion around it.
· AMDA has two main goals with its new policies: One, “provide access to opioids when indicated to relieve suffering and to improve or maintain function” and two, “Promote opioid tapering, discontinuation and avoidance of opioids when the above goals are not achievable, to prevent adverse events, dependence and diversion.”
· While it’s always been challenging to make sure nursing home residents receive the right amount of pain medication, the opioid epidemic has resulted in some states cracking down to a point that paralyzes effective pain management. Providers have to balance the responsibility to prevent theft of medications with making sure residents are not in pain.
· “The epidemic of opioid addiction has affected every sector. That’s the most difficult thing,” said AMDA Executive Director Chris Laxton. “One of the federal responses to the opioid epidemic has been to restrict them. That has resulted in some of our residents who have been well managed to not get access to pain meds when they have needed them.”
· He noted that states vary tremendously on rules, which can make it difficult for a national organization to give blanket guidelines.
· “We would really like to see a more consistent approach from state to state,” he said.
· Of course, how states manage opioids can often depend on how badly hit citizens have been by opioid addiction. In communities devastated by overdoses, it would follow that a clampdown on the drugs would result in perhaps overcorrection in nursing homes.
· “Opioids are poorly understood,” Laxton said. “When people say, ‘We can’t ever use opioids,’ that’s not an appropriate approach to take.”
· At the same time, AMDA and other organizations know drug division happens across all settings. Staffers have to be screened appropriately, and a “team-based” approach is needed to managing cases.
· “Pain management is the poster child for team-based care,” Laxton says.
· When discussing when opioids are appropriate, clinicians should look at side effects, Levy notes. For example, a resident may be very constipated, or immobile from the opioids. That might mean tapering the drug.
· It all can feel like a lot to take in, which is why medical directors should appreciate AMDA’s work on the guidelines. There is no magic switch to better opioid management, but we can move forward.
· “I don’t think it will ever be possible to prevent 100 percent [of diversions], but we can do a better job,” Laxton said.
· On behalf of those coming out of surgery pressing their pain pump, we thank every provider who agrees.
If the hyperlink doesn’t open, go to https://paltc.org/opioids%20in%20nursing%20homes
From the Trenches- questions about the meaning of PA/LTC life
From time to time we survey the membership about medical director and attending physician practices. This is the sample list of questions for polling by Survey Monkey—reply to Karen Miller or myself if you have other questions that are yearning for answers, and we’ll get it out in January.
For medical directors-
· CME? Yes or No
· # of buildings
· # of residents
· Hourly rate ($)
· Travel time/month?
· Call time/month?
· Paid for call?
· Satisfied?
For attending physicians-
· Certification?
· # of visits/month?
· # residents on service in a month?
· Paid salary, FFS, or blend?
· Travel time/month?
· Frequency of night call?
· Paid for call?
· Satisfied?
For NPs-
· Certified
· %FTE?
· # visits/FTE/month
· # residents on service/FTE/month
· Travel time/FTE/month
· Frequency of night call?
· Satisfied?
Other Reviews-publications from around the world of geriatrics and PA/LTC:
The Illness Is Bad Enough. The Hospital May Be Even Worse.
The elderly are particularly vulnerable to “post-hospital syndrome,” some experts believe, and that may be why so many patients return.
By Paula Span in the New York Times 3 August 2018
· When she moved from Michigan to be near her daughter in Cary, N.C., Bernadine Lewandowski insisted on renting an apartment five minutes away.
· Her daughter, Dona Jones, would have welcomed her mother into her own home, but “she’s always been very independent,” Ms. Jones said.
· Like most people in their 80s, Ms. Lewandowski contended with several chronic illnesses and took medication for osteoporosis, heart failure and pulmonary disease. Increasingly forgetful, she had been diagnosed with mild cognitive impairment. She used a cane for support as she walked around her apartment complex.
· Still, “she was trucking along just fine,” said her geriatrician, Dr. Maureen Dale. “Minor health issues here and there, but she was taking good care of herself.”
· But last September, Ms. Lewandowski entered a hospital after a compression fracture of her vertebra caused pain too intense to be managed at home. Over four days, she used nasal oxygen to help her breathe and received intravenous morphine for pain relief, later graduating to oxycodone tablets.
· Even after her discharge, the stress and disruptions of hospitalization — interrupted sleep, weight loss, mild delirium, deconditioning caused by days in bed — left her disoriented and weakened, a vulnerable state some researchers call “post-hospital syndrome.”
· They believe it underlies the stubbornly high rate of hospital readmissions among older patients. In 2016, about 18 percent of discharged Medicare beneficiaries returned to the hospital within 30 days, according to the federal Centers for Medicare and Medicaid Services.
· Ms. Lewandowski, for example, was back within three weeks. She had developed a pulmonary embolism, a blood clot in her lungs, probably resulting from inactivity. The clot exacerbated her heart failure, causing fluid buildup in her lungs and increased swelling in her legs. She also suffered another compression fracture.
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· “These hospitalizations can lead to big life changes,” Dr. Dale said. Having grown too frail to live alone, Ms. Lewandowski, now 84, moved in with her daughter.
· Dr. Harlan Krumholz, a cardiologist at Yale University, coined the phrase “post-hospital syndrome” in a New England Journal of Medicine article in 2013.
· As Medicare began penalizing hospitals for 30-day readmissions under the Affordable Care Act, he looked at the national data and noticed that most readmissions involved conditions seemingly unrelated to the initial diagnoses.
· Patients came in with heart failure or pneumonia, were treated and discharged, then returned with internal bleeding or injuries from a fall.
· “Our general approach in a hospital is, all hands on deck to deal with the problem people come in with,” Dr. Krumholz said. “All the other discomforts are seen as a minor inconvenience.”
· He has argued instead that discharge marks the start of a 60- to 90-day period of increased vulnerability to a range of other health problems, stemming from the stress of hospitalization itself.
· “This is more than inconvenience,” he said. “This is toxic. It’s detrimental to people’s recovery.”
· Any hospital patient, or hovering family member, knows those stresses: Disrupted sleep, as staff draw blood and take vital signs at 4 a.m. A distorted sense of day and night. Unappetizing meals often served at inopportune times.
· Reduced muscle mass and poor balance following even a few days in bed. New prescriptions with unpredictable consequences. Shared rooms. Delirium. Pain.
· “It affects your hormones, your metabolism, your immune system,” Dr. Krumholz said. “All these things have widespread effects,” leaving people depleted and less able to stave off other health threats.
· The ripple effects vary considerably.
· Researchers at Yale followed discharged Medicare patients after hospitalizations for heart failure, heart attacks and pneumonia.
· Readmissions for gastrointestinal bleeding and anemia, they found, peaked four to 10 days after discharge. The risk of trauma from falls or other accidents, on the other hand, remained elevated for three to five weeks.
· While post-hospital syndrome remains a hypothesis for now, research on several fronts may help establish its validity.
· Donald Edmondson, a behavioral medicine researcher at Columbia University Medical Center, has pointed out links between the stress levels that heart attack victims report and their likelihood of readmission.
· In a meta-analysis, he and his colleagues found that 12 to 16 percent of heart attack patients, most of them older adults, actually develop post-traumatic stress syndrome.
· As Dr. Edmondson acknowledged, people experiencing heart attacks have multiple sources of stress, from fear of death to financial worries. But he and his colleagues also have measured the impact of the hospital environment itself. They compared patients (average age: 63) who came to the New York-Presbyterian Hospital emergency room when it was crowded and chaotic (median time in a crowded ER: 11 hours) to those who arrived when it was calmer.
· “The more crowded it is when you come in, the more PTSD symptoms you’ll have a month later,” he concluded.
· Now the Columbia researchers are following 1,000 E.R. patients with heart attacks, tracking their weight and stress levels and giving each a wearable device to measure physical activity and sleep. The results may help substantiate the effects of post-hospital syndrome.
· “We’ve gotten better and better at treating disorders, but we haven’t gotten to the point where we avoid some of the collateral damage to the patient,” Dr. Edmondson said.
· Making hospitals less destabilizing, more conducive to healing, seems an achievable goal. Hospitals do it for children, Dr. Krumholz has pointed out.
· They could enable older patients, too, to wear their own clothes, get out of bed for walks (even with IV poles), eat enough to maintain their weight. They could assess how many lab tests patients actually need, and whether blood needs to be drawn before dawn.
· “We should never wake a sleeping patient unless there’s a compelling reason, and that reason shouldn’t be our own convenience,” Dr. Krumholz said.
· But while we’re waiting for hospitals to adopt such policies, we could try a D.I.Y. approach.
· Families can bring in favorite foods and help their relatives eat. They can ensure that patients have their hearing aids, dentures, eyeglasses, and walkers or canes to help them stay oriented and mobile.
· With a physician’s O.K., they can accompany relatives on short strolls down the corridor to ward off deconditioning, and ask about curtailing wee-hour tests and readings.
· “It’s unfair to put families in this position,” Dr. Krumholz said. “It should come from the institution.” But cultural change takes time.
· Some hospitals already offer less stressful environments for older patients, including specialized geriatric emergency rooms.
· Among those moving in that direction is the University of North Carolina Hospitals Hillsborough Campus, where Bernadine Lewandowski had a private room, as all its geriatrics patients do. She was helped into a chair every day and encouraged to use a walker to reach her bathroom.
· The aftereffects proved profound, nonetheless. Already thin, she lost 15 pounds over two months. After her second hospitalization, she began wandering at night, apparently because of a new pain medication, and fell twice in two days. In April, she developed pneumonia, necessitating a third hospital stay.
· She’s doing better now, her daughter said. After physical therapy, Ms. Lewandowski can climb the stairs, with someone at her elbow, to her second-floor room. Her weight has stabilized. She enjoys spending time with her family and visiting the hair salon every other week.
· But, Ms. Jones said, “We were hoping she’d be with us for a short period and then return to her apartment.” And that never happened.
I try to not get too speculative about the future, but this article https://www.nejm.org/doi/full/10.1056/NEJMp1808427 does outline a potentially different role for the long-term care specialist in the MACRA era of healthcare reform; let me know if you need help getting full text.
Reflections-
902 Ott Lane, Baraboo WI, early 1980’s
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
· To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
· To establish better communication among physicians serving as medical directors and other providers.
· To promote better communication between medical directors and
(a) other post-acute and long-term care professionals,
(b) various long-term care associations, and
(c) officials of various government agencies.
· To represent medical directors in defining their roles and equitable compensation.
· To serve as a conduit between AMDA and the WAMD membership.
· To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
· To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
· To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 6000 Gisholt Dr., Suite 200, Madison, WI 53713
Newsletter for November 2018
Newsletter for November 2018-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your WAMD held its Annual Meeting at the Mead Hotel, Wisconsin Rapids, October 5-6, 2018.
CME topics included
At the annual meeting itself
· The financial position of the organization remains sound
· Recruitment and retention is a full-time job for everyone
· Malik Ali and Paula Hardgrove were re-elected to the board of directors
· Membership fees will be increased somewhat
· If you want to be a delegate or alternate delegate the AMDA meeting, contact President Ron (address above); we will have a joint reception with Minnesota again—information to follow
· Past-president and long-term director Robert Smith and long, long-term aNewsletter
Newsletter for September 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your Board of Directors met July 17-
- We heard a presentation from the Wisconsin Alzheimer’s Association.
- We reviewed and accepted the financial report.
- We chose to continue to use Impact as the association’s management company.
- We chose to continue to use the Wisconsin Medical Society as the accreditor of the educational program at the annual meeting.
- We testified before the state assembly earlier this year, and the state senate at mid-year, supporting legislation that would align the CNA training hours more closely with the federal minimum.
- We chose to table indefinitely forming a charitable foundation at the state level.
- We are advertising to replace our executive assistant Karen Miller on her proposed retirement.
- We plan to hold our 2020 meeting at the Holiday inn in Pewaukee.
- We voted to support legislation in the state senate to permit physicians’ assistants and nurse practitioners to authenticate do not resuscitate orders and to be one of two signers of the activation of powers of attorney for healthcare and living wills.
Other News-from around our state and our partners.
Annual meeting registration-downloadable PDF at www.wamd.org/
Your association will hold its annual meeting at the Radisson in Madison October 11 and 12
Friday, October 11-
10 AM Board Meeting
11 AM Registration and Exhibits
11:55 AM Welcome, Ronald Schreiber MD, CMD, WAMD President
12:00 PM Disaster Preparedness Timothy Vayder MD and Robert Deede RN
1:30 PM The Geriatric Colon Eric Gaumnitz MD GI and Geriatrics
2:30 PM Break and Exhibits
3:00 PM Valvular heart disease: What the ECF provider needs to know Dr. Cherian Varghese
4:00 PM Megarule Implementation and Hospital Readmissions Brian Purtell JD
Preparation for Patient Driven Payment Model: Jon Ollmann, North Shore SVP Operations
5:30 PM Annual Meeting Ronald Schreiber MD, CMD, WAMD President
6:30 PM Reception – Appetizers and Drinks, Networking spouses and guest invited
Saturday October 12-
6:30 AM Industry Breakfast Janssen Pharmaceuticals: The Compass Trial and ASHD and PAD, Sean Cannone, DO, CMD
7:25 AM Welcome Comments: Pres. Kristin Severson DO
7:30 AM Pharmacy Update Douglas Engelbert
8:30 AM Mary Cohan MD Fellows Clinical Updates 3 Fellows, 20 min each, then 15 min panel
9:45 AM Pat Virnig RN, DQA update
10:30 AM Break and Hotel checkout
11:00 AM AMDA Update Christopher Laxton, CAE, Executive Director AMDA
12:00 PM Lunch in the Trenches
National Issues facing Long term Care Christopher Laxton, CAE, Executive Director, AMDA
Pat Virnig RN, DQA, Megarule Implementation
Ronald Schreiber MD Coding Ronald Schreiber MD, CMD, WAMD Past President
1:00 PM ENT Emergencies and Urgencies in LTC Perry Phillips MD
2:00 PM MD-Adv Practice-Therapies-Pharmacy Collaboration
Tanya Chapman, APNP
3:00 PM Break (15 min)
3:15 PM Infection Update 2019. Chris Crinch MD
4:15 PM Adjournment Kristin Severson DO President
Save the date for the DQA’s annual FOCUS conference November 20-21 in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights. Teepa Snow will deliver the keynote address “Dementia 360.” Go to https://www.dhs.wisconsin.gov/regulations/training/focus-2019.htm
Save the date for AMDA’s annual conference in Chicago April 2-5.
From the Trenches- questions about the meaning of PA/LTC life:
PDPM Executive Summary for Physician and non-Physician Providers-
Background: The TEFRA of 1982 created the Medicare A SNF benefit. The BBA of 1997 created the payment system we are now in, RUGS IV. In all PA/LTC settings, as in all of medicine, coding follows the money; in SNFs that’s been therapy billing minutes. The RUGS to PDPM change uses the MDS in a different way, and adds weight to ICD-10 codes in a new and different way. The change will do to SNFs what DRGs and ICD-10 did for the acute care facilities. We have experience with the change; we know ICD-10.
Additional background: There are still three of five categories related to therapy (OT, PT, and ST) and a fourth related to nursing (using a lot of GG from the MDS); what is really new is the fifth (“non-therapy ancillary” or “NTA”), driven by mapping the 68,000 ICD codes to fifty conditions or services into ten categories creating a comorbidity score (a case-mix index). Payment is frontloaded, and is largely fixed based on the initial (day 5) MDS submitted by day 8, and not subject to further change without an additional change in condition.
Now the meat: Although only a clinical provider (P or NPP) can diagnose, the hospital provider, clinical provider, and SNF provider may actually submit different diagnosis codes with their service. If you think about that for a minute, it’s not too strange: Consider a transplant patient hospitalized for UTI who goes to a SNF for rehabilitation a couple weeks later; the hospital may code for the UTI, but the SNF may not. The patient has had an organ transplant, but the clinical provider is not “treating” that, so she doesn’t bill that code (the transplant team does). The transplant team isn’t involved with the UTI, so they don’t bill for that. Again, for the purpose of review: While each provider bills using the code they think is appropriate for their services, the acute and post-acute facilities can only use diagnoses made by the clinical providers.
So in conclusion: While PDPM does not affect clinical provider work or billing directly, it may have a strong indirect effect on their work as nursing home providers (like hospital providers the last year or two) seek the most accurate ICD-10 codes.
So how can we make the “coding query” as quick and painless as possible?
- Clinical providers will figure out pretty quickly what diagnoses the facilities are looking for, and get them into the medical record (if they’re not there already) as indicated, recursively reducing questions in the long run.
- Facility providers should use Epic Link (or whatever electronic health record system their clinical providers use) to find out the complete diagnostic list as rapidly as possible, and then in-basket their coding queries quickly and efficiently in a way that locks our answers into the record. Buildings that rely on paper workflows will be less accurate and timely.
- Who has the responsibility, authority, accountability for this? It’s about the MDS nurse and GNP
Facility providers should use Epic Link wherever possible to find out the complete diagnostic list as rapidly as possible, and then in-basket their coding queries quickly and efficiently in a way that locks our answers into the record. Paper workflows will be slower and less efficient.
As clinical providers figure out what diagnoses are needed, questions will decrease over time—we’re in suspense for August and September, we’re going to be working in the fourth quarter, and things will be better in 2020.
Frequently asked questions-
Who’s at the center of this?
- It’s about the MDS nurse and the first provider who sees the patient.
What is an “active” diagnosis?
- Active diagnoses are those bearing a direct relationship to the resident’s current function, cognition, mood or behavior status, medical treatments, nursing monitoring, or risk at or up to seven days before admission.
- The building
- No
- Morbid obesity doesn’t matter much in the hospital or clinic; it matters now in PA/LTC. The cause probably does not matter.
- Mood disorders are frequently not explicitly diagnosed in primary care, or in non-psychiatry specialty care; it matters now in PA/LTC. The exact type probably does not matter.
- Amputations are frequently not carried on the problem list in primary care, or noted in the hospital; they matter now in PA/LTC.
- Diabetes mellitus is sometimes present, but not diagnosed; strange but true.
- Can I say “I don’t know”? --Yes; it is also permissible to say “I do know”
- If asked to characterize complicated fracture morphology, refer to the imaging report.
- If asked to characterize the kind of heart failure present, refer to the echo report: If the EF is low, it’s HFrEF; if the EF is normal or near normal it’s HFpEF. Acute or chronic—your call.
- If asked to characterize the kind of stroke present, refer to the imaging report. It will say acute (vs chronic), ischemic (vs hemorrhagic) and anatomic distribution; if the referring clinicians did not discriminate between atheroembolic and cardioembolic, nothing will be clearer from the bedside.
- Spontaneous and most fall-related fractures are pathologic; most other fractures are not pathologic.
How certain do I need to be to make a diagnosis?
- A reasonable degree of medical certainty = more likely than not. That’s all.
Other Reviews-publications from around the world of geriatrics and PA/LTC
Does My Patient with Multiple Comorbidities Have Heart Failure with Preserved Ejection Fraction, and Does It Matter?
Dmitry Abramov
The Journal of the American Board of Family Medicine May 2019, 32 (3) 424-427; DOI: https://doi.org/10.3122/jabfm.2019.03.180321
Dmitry Abramov
From the Department of Cardiology, Loma Linda University, Loma Linda, CA.
Abstract-
Heart Failure with Preserved Ejection Fraction (HFpEF) is a common diagnosis and accounts for half or more of all cases of heart failure. Despite its high prevalence and significant morbidity, the pathophysiology of HFpEF remains incompletely understood. Patients diagnosed with HFpEF often have significant cardiac and extra-cardiac comorbidities. Given the availability of evidence-based treatments for common comorbidities, but not for HFpEF, the necessity of diagnosing HFpEF among symptomatic elderly patients with multiple comorbidities is unclear. This commentary raises the question of whether the search for the diagnosis of HFpEF should instead be refocused to the management of common comorbidities without necessitating the heart failure diagnosis.
Introduction-
Heart failure with preserved ejection fraction (HFpEF) comprises about half of the cases of heart failure in the United States.1 Despite its growing prevalence and significant morbidity, HFpEF remains incompletely understood and diagnosis in the community setting may be difficult. Widely used diagnostic criteria that incorporate clinical findings with laboratory values and echocardiographic parameters lack sensitivity which may result in underdiagnosis.2 Overdiagnosis based on vague symptoms and nonspecific diagnostic parameters may likewise be problematic. The concern of over- and underdiagnosis is further compounded by the lack of evidence-based treatments for those diagnosed with HFpEF. Patients with HFpEF tend to be older, with multiple cardiac and noncardiac comordbitities.3 This begs the question of whether diagnosis of HFpEF remains critical to optimize the care of predominantly older patients with multiple comorbidities.
Heart failure has been defined as the inability of the heart to generate adequate cardiac output or the ability to generate adequate cardiac output only in the setting of elevated filling pressures.4 The standard clinical diagnostic criteria for HFpEF includes heart failure symptoms (such as dyspnea, orthopnea, paroxysmal nocturnal dyspnea) and elevated filling pressures (predominantly Wedge pressure) at rest or with exercise.5 Elevated filling pressures may be clinically estimated through measurement of jugular venous distention. Confirmation of elevated filling pressures, and therefore the heart failure diagnosis, can be obtained through invasive right heart catheterization. The history and physical examination-derived signs and symptoms suggestive of heart failure may be difficult to ascertain, and their correlation with invasively derived filling pressures has largely been based on studies of acutely decompensated or end-stage patients with reduced ejection fraction.1,6 Recently, permanently implanted pulmonary artery monitors have been used to help evaluate central filling pressures as a supplement to the physical examination,7 although the utility of such devices as part of the diagnostic evaluation of heart failure may be limited.
Current diagnostic criteria for HFpEF from the American College of Cardiology and American Heart Association include clinical signs or symptoms, ejection fraction ≥50%, and evidence of diastolic dysfunction.1 Patients meeting heart failure criteria with ejection fraction of 41% to 49% can be classified as having heart failure with borderline or midrange ejection fraction, which is more clinically similar to HFpEF than to heart failure with reduced ejection fraction.1,8 Diagnostic criteria for HFpEF from the European Society of Cardiology are similar, and include signs and symptoms, ejection fraction of ≥50%, elevated B-type natriuretic peptide values and echocardiographic evidence of structural abnormalities or diastolic dysfunction.9
While seemingly straightforward, the application of these criteria to the community setting is fraught with limitations. These diagnostic criteria have been criticized for low sensitivity,2 and the reliance on echocardiographic evaluation of diastolic dysfunction may neither accurately evaluate cardiac relaxation abnormalities nor contain sufficient sensitivity or specificity to detect a clinical course consistent with HFpEF.10 Although exact criteria for grading of diastolic dysfunction have changed over time,11 diastolic abnormalities on echocardiography are common in community cohorts of patients with comorbidities such as obesity, hypertension, diabetes and coronary disease,12 and have poor correlation with heart failure symptoms.12,13 In addition, only minimal abnormalities in diastolic parameters (including a high prevalence of normal diastolic function, normal left atrial size, and normal wall thickness) are noted in cohorts with symptomatic HFpEF.10 Echocardiographic diastolic parameters may primarily estimate ventricular filling pressures,11 rather than necessarily providing an explanation for their elevation.
Clinical trials and day-to-day care of patients with HFpEF highlight the high burden of comorbidities associated with this condition. Common noncardiac comorbidities include older age, chronic kidney disease, and lung disease. Common cardiac comorbidities include diabetes, hypertension, coronary artery disease, obesity and atrial fibrillation. As dyspnea is a common symptom in patients with many of these comorbidities, and given the notable limitations of the diagnostic algorithms, how are clinicians to identify which of these patients may have HFpEF?
In light of these limitations, some have proposed scoring systems to help identify patients with HFpEF among those being evaluated for dyspnea5; identifying that the biggest predictors of elevated filling pressures (and therefore the HFpEF diagnosis) among patients with dyspnea are advanced age (>60 years old), obesity (Body Mass Index >30 kg/m2) and atrial fibrillation. Other factors having a smaller association with elevated filling pressures include elevated pulmonary artery systolic pressure, treatment with multiple antihypertensive medications, and abnormal diastolic parameter of E/e'.5 Having the 3 risk factors of advanced age, obesity, and atrial fibrillation was associated with a greater than 90% likelihood of meeting criteria for the diagnosis of HFpEF based on elevated filling pressures.5 Importantly, elevated B-type natriuretic peptide, dilated left atrium, ventricular hypertrophy, or abnormal ventricular strain—all key parameters associated with diastolic dysfunction—had either smaller or no independent predictive ability to diagnose elevated filling pressures.
This focus on comorbidities as the key contributor to pathophysiology of HFpEF raises significant questions about our current understanding of what it means to impart onto a patient the heart failure diagnosis. Dyspnea is a ubiquitous and subjective symptom in older individuals,14 and is particularly common in patients with comorbidities including obesity and atrial fibrillation. Dyspnea may also be multifactorial, and not primarily caused by elevation in intracardiac filling pressures.15 Elevated filling pressures, even in the presence of dyspnea, may not always reflect heart failure, as every patient with end-stage renal disease on dialysis is not generally considered to have “heart failure” before a dialysis session.
Instead of focusing on the diagnosis of HFpEF, (ie, attempting to determine whether dyspnea is cardiac in origin or whether echocardiographic abnormalities are relevant to the clinical presentation), perhaps a better approach would be to return to the diagnosis and management of key cardiac and extracardiac comorbidities3 that are common in elderly patients with limitations to functional capacity. It should be acceptable to diagnose and manage conditions associated with fluid retention, such as anemia, obesity, diabetes, kidney disease, or atrial fibrillation without invoking the heart failure diagnosis. Each of these comorbidities is a significant stand-alone diagnosis, associated with its own symptoms (often dyspnea), diagnostic criteria, and evidence-based treatments.3 Whether these comorbidities contribute to fluid retention through: their association with diastolic abnormalities, other ventricular myocardial abnormalities, their own unique pathophysiologies, or a combination of these remains unclear. Diuretics are the mainstay treatment of symptoms of volume overload regardless of etiology, and can be used to control symptoms regardless of whether the patient is diagnosed with HFpEF, is suspected as having HFpEF, or is presumed to have volume overload from a noncardiac etiology. Among patients with HFpEF, the diuretic spironolactone is primarily effective at lower ejection fractions (<50%), and the benefits among patients with higher ejection fractions are less certain.16
While the search for underlying pathophysiology continues, there is increasing evidence that comorbidities are the most prominent contributors to symptoms among patients labeled as having HFpEF. If symptomatic comorbidities require another name or label, perhaps a better one is “comorbidity associated heart failure” or even “comorbidity associated diuretic dependence.” Employing terminology to more closely correlate with etiology based on subpopulations of HFpEF patients may simplify the diagnosis of a widely encountered clinical syndrome and help guide management in a way not currently possible with HFpEF.
May the diagnosis of HFpEF become more clinically relevant if ongoing trials of novel therapies, including sacubitril valsartan, empagliflozin, and others demonstrate improvement in clinical outcomes? The answer to that question has yet to be determined, as these medications may yield similar benefit in high risk primary prevention populations without the necessity of a HFpEF diagnosis. While diagnosing specific diseases that have previously fallen under the HFpEF umbrella such as Amyloid or Fabry's cardiomyopathy are increasingly critical as treatments become available, the benefit of diagnosing comorbidity associated HFpEF remains unclear. In addition, while diagnosing HFpEF may carry prognostic implications, the associated adverse prognosis may result more from a particularly advanced comorbidity burden rather than primary cardiac pathology or heart failure itself.
In conclusion-
Diagnosing HFpEF in the community may not be easy or even clinically relevant, and the answer to the question of, “does my patient with multiple comorbidities have HFpEF?” may be less important than using available treatments to improve the quality of life of symptomatic patients.
To see this article online, please go to: http://jabfm.org/content/32/3/424.full.
References omitted to shorten the copy and paste
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Reflections-
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
- To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
- To establish better communication among physicians serving as medical directors and other providers.
- To promote better communication between medical directors and
(b) various long-term care associations, and
(c) officials of various government agencies.
- To represent medical directors in defining their roles and equitable compensation.
- To serve as a conduit between AMDA and the WAMD membership.
- To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
- To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
- To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 5329 Fayette Ave., Madison, WI 53713
Newsletter for July, 2019 - Link
wis-paltcm_newsletter_2019.07_.pdf
Newsletter for July 2019
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
The next WAMD board meeting, by teleconference, is Wednesday, July 17 at 5:15 PM. We will have a brief presentation by the Alzheimer's Association. Please forward any agenda items for discussion to Karen and myself.
Thanks—President Ron
Save the date for our annual meeting October 11-12 2019 at the Radisson in Madison
Other News-from around our state and our partners.
Save the date for the DQA’s annual FOCUS conference November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”
Save the date for AMDA’s annual meeting April 2-5 2020 at the Hyatt Regency in Chicago
From the Trenches- questions about the meaning of PA/LTC life:
Readmission rates and other starry subjects--
Recently president-elect Kristin asked other board members how their buildings were doing with readmission rates, and I said that what I was hearing didn’t sound well-authenticated. If you go to www.medicare.gov/nursinghomecompare/search.html , the official readmission rates are published, separately for short- and long-stay, along with a lot of other detail you are probably quite familiar with. If asked a medical director today what the great commandments are in long-term care, s/he’d probably say “avoid readmissions, and (another like unto it) discharge people home”—so, I made this table that with the five buildings I’m most closely related to, plus a number of Madison-area buildings of interest. To restart the benchmarks: WI short-stay readmissions, 21.2%; WI long-stay readmissions, 1.40 per 1000 patient days. Please note this is NOT 30-day readmission data.
Home Overall Stars Short Stay Readmit Long Stay Readmit Percent sent home
WI avg 21.2% WI avg 1.40/1000 National avg 48.6%
A Two stars 17.0/100 1.49/1000 Worse
B Two stars 22.6/100 2.28/1000 Worse
C Five stars 19.8/100 1.91/1000 Better
D Five stars 20.2/100 1.27/1000 Worse
E Four stars NA NA NA
F Three stars 19.2/100 NA Better
G Three stars 24.4/100 1.39/1000 Better
H Two stars 15.8/100 1.07/1000 Worse
I One star 25.1/100 1.96/1000 Better
J Four star 20.9/100 1.26/1000 Worse
K Five star 25.2/100 1.66/1000 Worse
J Five star 16.7/100 0.70/1000 Worse
Personally, I’m associated with above average overall-rated, better than average readmissions for short- and long-stay admissions, and average on discharge home to home rate facilities. How’d you do? What does it mean? The highest LS readmitter is three times the least. The highest SS readmitter is fifty percent more than the last.
Other Reviews-publications from around the world of geriatrics and PA/LTC
Do review the June 24, 2019 JAMA Internal Medicine article " Anticholinergic Drug Exposure and the Risk of Dementia". The authors conclude that exposure to several types of strong anticholineric drugs is associated with an increased risk of dementia. This has made headlines in the lay press.
Investigating the Avoidability of Hospitalizations of Long Stay Nursing Home Residents: Opportunities for Improvement
Kathleen T. Unroe, MD, MHA, Susan E. Hickman, PhD, Jennifer L. Carnahan, MD, MPH, Zach Hass, PhD, Greg Sachs, MD, and Greg Arling, PhD
Innovation in Aging, 2018, Vol. 2, No. 2, 1–9 (doi:10.1093/geroni/igy017)
Abstract
Background and Objectives: To examine the relationship between hospital diagnoses associated with hospital transfers of long stay nursing home residents, ratings of avoidability of transfer, and RN-identified quality improvement opportunities.
Research Design and Methods: Prospective clinical demonstration project, named OPTIMISTIC, with trained RNs embedded in nursing homes that performed root cause analyses for 1,931 transfers to the hospital between November 2014 and July 2016. OPTIMISTIC RNs also rated whether transfers were avoidable, identified quality improvement opportunities, and recorded hospital diagnoses. Resident characteristics were obtained from Minimum Data Set assessments. Relationships between six hospital diagnoses commonly considered “potentially avoidable” and OPTIMISTIC RN root cause analysis findings were examined. Facilities were participating in the OPTIMISTIC demonstration project designed to reduce hospital transfers during the study period.
Results: Twenty-five percent of acute transfers associated with six common diagnoses were considered definitely or probably avoidable by project RNs versus 22% of transfers associated with other diagnoses. The most common quality improvement opportunity identified for transfers rated as avoidable was that the condition could have been managed safely if appropriate resources were available, a factor cited in 45% of transfers associated with any of the six diagnoses. Problems with communication among stakeholders were the most commonly noted area for improvement (48%) for transfers associated with other diagnoses. Many other areas for quality improvement were noted, including earlier detection of change in status and the need for understanding patient preferences or a palliative care plan.
Discussion and Implications: Although some nursing home transfers may later be deemed potentially avoidable based on post-transfer hospital diagnosis from Medicare claims data, OPTIMISTIC nurses caring for these residents at time of transfer categorized the majority of these transfers as unavoidable irrespective of the hospital diagnosis. Multiple quality improvement opportunities were identified associated with these hospital transfers, whether the transfer was considered potentially avoidable or unavoidable.
It will be the purpose of this organization:
- To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
- To establish better communication among physicians serving as medical directors and other providers.
- To promote better communication between medical directors and
(b) various long-term care associations, and
(c) officials of various government agencies.
- To represent medical directors in defining their roles and equitable compensation.
- To serve as a conduit between AMDA and the WAMD membership.
- To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
- To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
- To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org, 5329 Fayette Avenue, Madison, WI 53713
Newsletter for June, 2019 - Link:
Wis-PALTCM_newsletter_2019.06.pdf
Newsletter for June 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Save the date for our annual meeting October 11-12, 2019 at the Radisson in Madison.
Save the date for the DQA’s annual FOCUS conference November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will be “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”.
Save the date for AMDA’s annual meeting April 2-5, 2020 at the Hyatt Regency in Chicago.
Other News-from around our state and our partners. There is a link in this to get the AMDA guidelines free on-line; you need the AMDA guidelines free on-line.
The Nursing Home team wants to ensure you are aware of important new resources, updates and webinars.
Upcoming Webinars
Success Stories Webinar Series | Achieving Community Goals by Partnering with Aging and Disability Resource Centers
Tuesday, June 25, Noon - 1:00 p.m. CT
Aging and Disability Resource Centers (ADRCs) are key partners in many communities. Their collaborations with other community organizations have been proven to be successful in bringing about effective community change.
Past Recorded Events
Pressure Injuries: Prevent, Treat and Sustain Gains
A wonderful presentation by Dr. Joyce Black, a leading expert in pressure injuries. This covers intervention and sustainment strategies.
Trauma Informed Care (TIC) in Long Term Care (LTC)
Presented by Scott Webb, the TIC Coordinator in Wisconsin, this presentation is a great overview of TIC including key concepts and terminology to prepare you and your staff for the new regulations in November.
Achieving Psychotropic Medication Reduction in Long Term Care
From our partners in Michigan, a well-done series of five short videos entitled "Reducing Psychotropic Medication Use". Great for just-in-time training! Learn more about our national partnership to improve dementia care.
Resources
Dementia/Antipsychotics
- Dementia Capable Wisconsin
- Person Directed Care Assessment Tool
- The DICE Approach™
- IA ADAPT Improving Antipsychotic Appropriateness in Dementia Patients (Registration is free)
Clinical Resource Center (CRC) AMDA Updates
The CRC is a great site for evidence-based tools/resources including pain, medication management, diabetes, chronic obstructive pulmonary disease (COPD) and pain. Create and account to access all the materials.
Please let us know if there are additional resources you may need, or if we can be of assistance in some other way.
Diane Dohm, MT, IP, CIC, CPHQ - (800) 362-2320 or ddohm@metastar.com
Toni Kettner, BSN, MHA, NHA, CPHQ - (800) 362-2320 or tkettner@metastar.com
From the Trenches- questions about the meaning of PA/LTC life:
“I attended the AMDA State Chapter Open Mic Conference Call on May 29. Here are the highlights for you to know and use:
- The AMDA IOU (Improving Outcomes in UTI) tool kit is available for downloading on the internet. You are encouraged to use this!
- AMDA webinars are free for members, $99 per session for non-members. Previous webinars are archived. CME, CMD, and ABIM MOC credits are available. The schedule is on the AMDA website, paltc.org (Post-Acute and Long-Term Care) . The next webinar is on June 26, the topic is "Integration of Medical Marijuana in Long Term Care: Positives and Pitfalls".
- AMDA has on-the-go podcasts (short reports on various PALTC issues) and on-the-hill podcasts (legislative issues) on their website. These are very informative. Please check them out.
- DO NOT adjust or alter a diagnosis of dementia to schizophrenia in order to justify use of an antipsychotic. Several physicians across the country are getting cited for misdiagnosis.
- Several state legislatures are now pushing through legislation requiring informed consent for nursing home patients for prescription of antipsychotic/anxiolytics/antidepressants. Several high ranking AMDA members are vehemently opposed to the legislation of physicians' prescribing patterns. I reported that this has been the lay of the land in the Badger State for many years.
- The next upcoming controversy for which you should prepare : remote video recording of residents in their rooms. Multiple legal/ethical/privacy issues involved.
- Enjoy your summer ! Don't text and drive ! Join us for our annual conference in Madison, October 11-12. We have a great list of speakers.”
Ron Schreiber, MD,CMD
President, WAMD
Other Reviews-publications from around the world of geriatrics and PA/LTC
Can CBD Really Do All That? How one molecule from the cannabis plant came to be seen as a therapeutic cure-all.
By Moises Vaelasquez-Manoff in the New York Times 14 May 2019
When Catherine Jacobson first heard about the promise of cannabis, she was at wits’ end. Her 3-year-old son, Ben, had suffered from epileptic seizures since he was 3 months old, a result of a brain malformation called polymicrogyria. Over the years, Jacobson and her husband, Aaron, have tried giving him at least 16 different drugs, but none provided lasting relief. They lived with the grim prognosis that their son — whose cognitive abilities never advanced beyond those of a 1-year-old — would likely continue to endure seizures until the cumulative brain injuries led to his death.
In early 2012, when Jacobson learned about cannabis at a conference organized by the Epilepsy Therapy Project, she felt a flicker of hope. The meeting, in downtown San Francisco, was unlike others she had attended, which were usually geared toward lab scientists and not directly focused on helping patients. This gathering aimed to get new treatments into patients’ hands as quickly as possible. Attendees weren’t just scientists and people from the pharmaceutical industry. They also included, on one day of the event, families of patients with epilepsy.
The tip came from a father named Jason David, with whom Jacobson began talking by chance outside a presentation hall. He wasn’t a presenter or even very interested in the goings-on at the conference. He had mostly lost faith in conventional medicine during his own family’s ordeal. But he claimed to have successfully treated his son’s seizures with a cannabis extract, and now he was trying to spread the word to anyone who would listen.
The idea to try cannabis extract came to David after he found out that the federal government held a patent on cannabidiol, a molecule derived from the cannabis plant that is commonly referred to as CBD. Unlike the better-known marijuana molecule delta-9-tetrahydrocannabinol, or THC, CBD isn’t psychoactive; it doesn’t get users high. But in the late 1990s, scientists at the National Institutes of Health discovered that it could produce remarkable medicinal effects. In test tubes, the molecule shielded neurons from oxidative stress, a damaging process common in many neurological disorders, including epilepsy.
Jacobson had a Ph.D. in neuroscience. She had started her postdoctoral research at the University of California, San Francisco, by studying how cancer cells metastasize and spread, but after Ben was born, she moved to Stanford and switched her focus to epilepsy — a shift that compounded her anguish. She often wept in the parking lot before heading into the lab, overwhelmed by dread at the prospect of deliberately causing epilepsy in rodents. “I couldn’t watch animals seize all day and then watch Ben seize all night,” she told me. “It was just too much.”
After meeting David and reading through the small body of published work on CBD, Jacobson changed postdoctoral directions once again, from primary research to the study of this community of parents who were treating their epileptic children with cannabis extracts. In reality, she was preparing to join it herself. One small, double-blind study particularly caught her attention. In 1980, scientists in Brazil treated eight epileptic patients with CBD and eight patients with sugar pills as a placebo. For half the group that received CBD, the seizures almost completely disappeared; another three experienced a reduction in the intensity of their seizures. Only one person in the placebo group got better.
The epilepsy drugs that had been approved to date, none of which had helped Ben much, typically targeted the same few ion channels and receptors on the surface of neurons. But CBD worked on different and still somewhat mysterious pathways. If she could find a suitable CBD extract, Jacobson thought, she might have a truly new class of drug for Ben. The other experimental drugs and devices she had heard about at epilepsy conferences were under development, unapproved by the F.D.A. and thus largely unavailable. But medical marijuana had been legal in California since 1996, so CBD was theoretically accessible right away.
Seven years later, cannabidiol is everywhere. We are bombarded by a dizzying variety of CBD-infused products: beers, gummies, chocolates and marshmallows; lotions to rub on aching joints; oils to swallow; vaginal suppositories for “soothing,” in one company’s words, “the area that needs it most.” CVS and Walgreens each recently announced plans to sell CBD products in certain states. Jason David now sells a cannabis extract called Jayden’s Juice, named for his son — one of several extracts on the market, including Haleigh’s Hope and Charlotte’s Web, that are named after children who are said to have benefited from being treated with CBD.
Many of these products are vague about what exactly CBD can do. (The F.D.A. prohibits unproven health claims.) Yet promises abound on the internet, where numerous articles and testimonials suggest that CBD can effectively treat not just epilepsy but also anxiety, pain, sleeplessness, Crohn’s disease, arthritis and even anger. A confluence of factors has led to this strange moment. Plenty of legitimate, if still inconclusive, research is being done on CBD. Many scientists are truly excited about it. The laws governing cannabis and its chemical components have loosened up. And the anecdotes that have emerged from what Elizabeth Thiele, an epileptologist at Harvard, calls the “vernacular” cannabis movement have lent emotional force to the claims made for CBD.
Amid the current deluge of products, it now seems almost quaint that, back in 2012, after deciding to try treating Ben with CBD, Jacobson couldn’t actually locate the stuff. Other parents of epileptic children were using D.I.Y. techniques to treat their children: tinctures; cannabis-infused butter in baked goods; crushed cannabis buds in capsule form; even cannabis suppositories. Some reported positive results. Over the years, Jacobson has had many of these products tested at labs; almost invariably they contained very little or no CBD and too much THC. It has psychoactive effects, and there wasn’t much science suggesting THC could treat seizures.
[Redacted for citation; you can find the full text on line, or contact me]
CBD is not always an unqualified success, even in the best-known case studies. For Sam Vogelstein, the inspiration behind Epidiolex, it helped control his seizures for years, limiting them to around six per day. But in the fall of 2015, Sam began suffering from a new type of seizure. These were more severe, causing him to fall to the floor writhing, which hadn’t occurred in the past. “You instantly understand why people used to say that people who have epilepsy are possessed by the devil,” Fred, Sam’s father, told me, “like some external force has taken control of this person.”
Higher doses of Epidiolex didn’t help, so Sam’s doctor, the neurologist Roberta Cilio, recommended an anti-seizure drug called Depakote. He had taken it before, without benefit, but this time, in combination with Epidiolex, it worked wonders: Sam has been completely seizure free for more than three and a half years. He’s a tall, lanky 17-year-old who likes to fence, run and engages in “normal aggravating boy teenager stuff,” his father says — and “cause for celebration,” both parents say.
Ben Jacobson’s condition is more ambiguous. In an effort to stop the seizures, doctors surgically removed half of Ben’s parietal lobe in 2015, but the procedure didn’t mitigate the epilepsy. His doctor, Cilio, didn’t think the Epidiolex was aiding him, either, and recommended he stop taking it. Jacobson, who like many mothers of epileptic children keeps a detailed diary about seizure activity, disagreed. By her count, the number of Ben’s seizures had declined by 40 percent while on Epidiolex, particularly the severe grand mal seizures that caused him to stop breathing.
This disagreement between doctor and mother prompted Jacobson to find a new neurologist who, she told me, took one look at Ben and told her to do whatever she felt might help. Except for a few breaks, Ben, who’s now 10 and can’t walk unaided, has remained on Epidiolex, but his prognosis isn’t great. “He’s still going downhill,” Jacobson told me. “His life expectancy is short enough that we don’t like to think about it.”
Charlotte Figi, now 12, continues to be almost entirely seizure-free. She’s developmentally delayed, Paige Figi told me. And she suffers from osteoporosis caused, Figi thinks, by the high doses of steroids she took to control seizures at a young age. But she is otherwise a happy, playful girl, Figi says. And what Figi discovered about CBD on Charlotte’s behalf came in handy for Charlotte’s fraternal twin sister, Chase.
Two years ago, Chase, who until then had exhibited no problems, began to have seizures out of the blue. Figi didn’t even bother with allopathic drugs this time. She turned straight to the Charlotte’s Web CBD extract, and the seizures stopped. “If I hadn’t done this,” Figi says — that is, experiment with CBD extracts on Charlotte — “Charlotte would be dead. And Chase would now be starting all those drugs.”
Meanwhile, as the science inches forward, CBD has become a pop-culture phenomenon. Kim Kardashian recently hosted a CBD-themed baby shower. In April, Carl’s Jr. tested a CBD-infused burger in Colorado. Some scientists are concerned by how far the CBD craze has moved beyond the science. But Staci Gruber, associate professor of psychiatry at Harvard Medical School, does not think the two are necessarily in conflict. This might seem odd, given her work. She has found that recreational users, particularly those who begin using cannabis earlier in life, exhibit some cognitive difficulties and altered brain structure and function.
In 2014, Gruber started the Marijuana Investigations for Neuroscientific Discovery, or MIND, program to examine the effects of medical cannabis, and so far, she has found exactly the opposite in people who use cannabis as medicine. Their cognitive function appears to improve over time and preliminary evidence suggests that, after initiation of medical-cannabis treatment, their brain activity begins to normalize. Although Gruber is not certain what accounts for the contrasting effects, she has several theories. Seeking a euphoric high, recreational users often gravitate toward products higher in THC. Medical patients, meanwhile, want to control symptoms and may thus seek whole-plant products that not only contain more CBD than what recreational users typically encounter but also other potentially healthful cannabinoids. Medical users tend to be older, too, and some evidence suggests that THC is less toxic to older brains than younger and may in some cases benefit older brains.
Gruber has likewise observed that medical cannabis patients tend to reduce their use of conventional medications over time, which might itself be beneficial to brain structure and function. Whatever the explanation, Gruber believes greater scientific engagement with the CBD phenomenon is as important as more careful regulation. “People have been using cannabis forever,” she told me. “The question now is, how do we as scientists catch up?”
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Reflections-
Sandra Draus (center), one of ten honorees of the Wisconsin State Journal’s “Celebrate Nurse’s Week” shown with her collaborating physician T R Flygt, MD and manager Deirdre Suchomel.
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
- To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
- To establish better communication among physicians serving as medical directors and other providers.
- To promote better communication between medical directors and
(b) various long-term care associations, and
(c) officials of various government agencies.
- To represent medical directors in defining their roles and equitable compensation.
- To serve as a conduit between AMDA and the WAMD membership.
- To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
- To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
- To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities.
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org, 5329 Fayette Ave., Madison, WI 53713
Newsletter for May, 2019 (link)
wis-paltcm_newsletter_2019.05.pdf
Newsletter for May, 2019
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your society’s board of directors teleconferenced April 11; issues addressed included-
- The financial report, which is regretfully incomplete for 2018;
- Which CME accreditation entity to use for the educational program at the annual meeting—it’s about money;
- Follow-up on the white paper and resolutions from the AMDA meeting;
- General satisfaction with the jointly-hosted reception at the AMDA meeting;
- Preliminary approval of an AMDA foundation contribution for 2020;
- President Ron S’s testimony in the legislature on the CNA training requirement described in last month’s issue;
- Finalizing the program for our October meeting’s educational program;
- Reviewing the survey on preferences about the October meeting’s educational features;
- The proposed retirement of our dedicated executive assistant!
- Next teleconference Wednesday July 17th at 5:15 PM.
Save the date for our annual meeting October 11-12 2019 at the Radisson in Madison
Save the date for the DQA’s annual FOCUS conference for providers and DQA staff November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”
Save the date for AMDA’s annual meeting April 2-5 2020 at the Hyatt Regency in Chicago
Other News-from around our state and our partners(in this case, the Wisconsin Quality Coalition of Metastar): Useful “big data” benchmarking information you can’t find anywhere else
This slide shows we are close to our neighbors in antipsychotic use, and decreasing that at a reasonable rate
This slide is hard to follow, but shows we’re close to our neighbors in reducing antipsychotic use, but will probably never get to zero.
This slide suggests more Wisconsin homes are “above average” than our neighbors; you are probably unfamiliar with this composite score, based on quality indicators, which seems more useful to Metastar than those of us in the business.
And here’s some stuff you didn’t know about Clostridium difficile infection.
If you’re interested in getting more information from Metastar, contact jgile@metastar.com for a list of their products and resources; they’re really there to help, and never to punish!
From the Trenches- questions about the meaning of PA/LTC life:
We tried to survey the membership as attendings, directors, and non-physician providers, but the response rate for the latter two was too low to report-
- Two-thirds of our responds report certification in family medicine, one-third in internal medicine.
- The median number of visits was between 50 and 100, although the median number of residents on service was 50.
- A super-majority of respondents said their attending physician work was salaried.
- The question on call was not well-phrased; no one reported being paid for taking call.
- Only a bare majority reported being satisfied or very satisfied with their role as an attending.
Other Reviews-publications from around the world of geriatrics and PA/LTC
Advertisement
Supported by
the new old age: Assisted Living—Where There’s Rarely a Doctor in the House
As residents become older and more frail, some facilities are bringing in doctors and nurses instead of relying on 911.
By Paula Span in the New York Times March 29, 2019
The patient moved into a large assisted living facility in Raleigh, N.C., in 2003. She was younger than most residents, just 73, but her daughter thought it a safer option than remaining in her own home.
The woman had been falling so frequently that “she was ending up in the emergency room almost every month,” said Dr. Shohreh Taavoni, the internist who became her primary care physician.
“She didn’t know why she was falling. She didn’t feel dizzy — she’d just find herself on the floor.” At least in a facility, her daughter told Dr. Taavoni, people would be around to help.
As the falls continued, two more in her first three months in assisted living, administrators followed the policy most such communities use: The staff called an ambulance to take the resident to the emergency room.
There, “they would do a CT scan and some blood work,” Dr. Taavoni said. “Everything was O.K., so they’d send her back.”
Such ping-ponging occurs commonly in the nation’s nearly 30,000 assisted living facilities, a catchall category that includes everything from small family-operated homes to campuses owned by national chains.
It’s an expensive, disruptive response to problems that often could be handled in the building, if health care professionals were more available to assess residents and provide treatment when needed.
But most assisted living facilities have no doctors on site or on call; only about half have nurses on staff or on call. Thus, many symptoms trigger a trip to an outside doctor or, in too many cases, an ambulance ride, perhaps followed by a hospital stay.
Twenty years after the initial boom in assisted living — which now houses more than 800,000 people — that approach may be shifting.
Early on, assisted living companies planned to serve fairly healthy retirees, offering meals, social activities and freedom from home maintenance and housekeeping — the so-called hospitality model.
But from the start, the assisted living population was older and sicker than expected. Now, most residents are over age 85, according to government data. About two-thirds need help with bathing, half with dressing, 20 percent with eating.
Like most older Americans, they also generally contend with chronic illnesses and take long lists of prescription drugs — and more than 80 percent need help taking them correctly.
Moreover, “these places became the primary residential setting for people with dementia,” said Sheryl Zimmerman, an expert on assisted living at the University of North Carolina at Chapel Hill.
About 70 percent of residents have some degree of cognitive impairment, her studies have found. So residents can find it difficult to coordinate medical appointments and tests, and to travel to offices and labs, even when facilities provide a van.
“The assisted living industry has to recognize that the model of residents going out to see their own doctors hasn’t worked for a long time,” said Christopher Laxton, executive director of AMDA, a society that represents health care professionals in nursing homes and assisted living.
His recent editorial in McKnight’s Senior Living, an industry publication, was pointedly headlined: “It’s time we integrate medical care into assisted living.” AMDA is considering developing model agreements.
“There has to be more attention to medical and mental health care in assisted living,” Dr. Zimmerman agreed. “Does everyone who falls really need to go to an emergency department?”
Lindsay Schwartz, an executive at the National Center for Assisted Living, a trade association, said in an email that “assisted living has certainly expanded its role in providing medical care over the years by adding nursing staff and partnering with other health care providers, among other ways.”
But persuading most operators to provide medical care likely won’t happen without a fight. They’ve built their marketing strategies on looking and feeling different from the dreaded nursing home, and they object to “medicalizing” their communities.
“They don’t want the liability,” said Dr. Alan Kronhaus, an internist who, with Dr. Taavoni (they are married), started a practice called Doctors Making Housecalls in 2002.
The facilities also “live in mortal fear of bringing down heavy-handed federal regulation,” he said. That can happen when Medicare and Medicaid, which cover most residents’ health care, get involved.
Doctors Making Housecalls provides one example of how assisted living can offer medical care. The practice dispatches 120 clinicians — 60 doctors, plus nurse-practitioners, physician assistants and social workers — to about 400 assisted living facilities in North Carolina.
“We see patients often, at length and in detail, to keep them on an even keel,” Dr. Kronhaus said. By contracting with labs, imaging companies and pharmacies, the practice can provide most of the medical care for more than 8,000 residents, on site and around the clock.
Working with a local emergency medical service, he and his colleagues reported in a 2017 study that the practice could reduce emergency room transfers by two-thirds.
The Lott Assisted Living Residence in Manhattan, on the other hand, relies on a single geriatrician, Dr. Alec Pruchnicki, to provide medical care for most of its 127 or so residents.
If they’re feeling sick, a family member calls or the resident just knocks on the door of “Dr. P’s” basement office. “Sometimes it’s just a cold — chicken soup,” Dr. Pruchnicki said. “But this winter we had a few cases of flu and pneumonia, things you need to treat.”
Nearby Mount Sinai Hospital employs him and provides emergency services when needed. Often, they’re not. In 2005, Dr. Pruchnicki reported at medical conferences, he decreased hospitalizations by a third. “I can’t be in the only place in the country where this would work,” he said.
Spending time in emergency rooms and hospitals often takes a toll on residents, even if their ailments can be treated. They get exposed to infections and develop delirium; they lose strength from days spent in bed.
Perhaps that contributes to short stays in assisted living. Adult children often see these facilities as their parents’ final homes, but residents stay just 27 months on average, after which many move on to nursing homes.
Adding doctors to assisted living could also cause problems, advocates acknowledge; in particular, it might increase the already high fees facilities charge.
But something has clearly got to give. “There can be health care in assisted living without making it feel like a nursing home,” Dr. Zimmerman said.
Family members tell of frightened and confused residents arriving unaccompanied at emergency rooms, unable to give clear accounts of their problems. Dr. Kronhaus recalls a resident with dementia taken to the local E.R. by ambulance; discharged, she was sent home by taxi. The address she gave the driver was her former home, where neighbors spotted her and called the police.
By contrast, the North Carolina woman with a history of falls is doing well.
Dr. Taavoni discovered that her hypertension medications were causing such low blood pressure that she fainted. Reducing the dose and discontinuing a diuretic, Dr. Taavoni also weaned the patient off an anti-anxiety drug she suspected was causing problems, substituting a low dose of an antidepressant instead.
The falls and the related emergency room visits stopped. Doctors Making Housecalls is still caring for her, and for most of the neighbors in her assisted living facility.
https://www.nytimes.com/2019/03/29/health/assisted-living-doctors-house-calls.html accessed 3 April 2019
Reflections-
The Wis-PALTCM Mission Statement- It will be the purpose of this organization:
- To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
- To establish better communication among physicians serving as medical directors and other providers.
- To promote better communication between medical directors and
(b) various long-term care associations, and
(c) officials of various government agencies.
- To represent medical directors in defining their roles and equitable compensation.
- To serve as a conduit between AMDA and the WAMD membership.
- To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
- To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
- To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 5329 Fayette Ave., Madison, WI 53713
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your society’s board of directors teleconferenced April 11; issues addressed included-
- The financial report, which is regretfully incomplete for 2018;
- Which CME accreditation entity to use for the educational program at the annual meeting—it’s about money;
- Follow-up on the white paper and resolutions from the AMDA meeting;
- General satisfaction with the jointly-hosted reception at the AMDA meeting;
- Preliminary approval of an AMDA foundation contribution for 2020;
- President Ron S’s testimony in the legislature on the CNA training requirement described in last month’s issue;
- Finalizing the program for our October meeting’s educational program;
- Reviewing the survey on preferences about the October meeting’s educational features;
- The proposed retirement of our dedicated executive assistant!
- Next teleconference Wednesday July 17th at 5:15 PM.
Save the date for our annual meeting October 11-12 2019 at the Radisson in Madison
Save the date for the DQA’s annual FOCUS conference for providers and DQA staff November 20-21 at the Kalahari in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights—Teepa Snow will deliver the keynote address “Dementia 360”
Save the date for AMDA’s annual meeting April 2-5 2020 at the Hyatt Regency in Chicago
Other News-from around our state and our partners(in this case, the Wisconsin Quality Coalition of Metastar): Useful “big data” benchmarking information you can’t find anywhere else
This slide shows we are close to our neighbors in antipsychotic use, and decreasing that at a reasonable rate
This slide is hard to follow, but shows we’re close to our neighbors in reducing antipsychotic use, but will probably never get to zero.
This slide suggests more Wisconsin homes are “above average” than our neighbors; you are probably unfamiliar with this composite score, based on quality indicators, which seems more useful to Metastar than those of us in the business.
And here’s some stuff you didn’t know about Clostridium difficile infection.
If you’re interested in getting more information from Metastar, contact jgile@metastar.com for a list of their products and resources; they’re really there to help, and never to punish!
From the Trenches- questions about the meaning of PA/LTC life:
We tried to survey the membership as attendings, directors, and non-physician providers, but the response rate for the latter two was too low to report-
- Two-thirds of our responds report certification in family medicine, one-third in internal medicine.
- The median number of visits was between 50 and 100, although the median number of residents on service was 50.
- A super-majority of respondents said their attending physician work was salaried.
- The question on call was not well-phrased; no one reported being paid for taking call.
- Only a bare majority reported being satisfied or very satisfied with their role as an attending.
Other Reviews-publications from around the world of geriatrics and PA/LTC
Advertisement
Supported by
the new old age: Assisted Living—Where There’s Rarely a Doctor in the House
As residents become older and more frail, some facilities are bringing in doctors and nurses instead of relying on 911.
By Paula Span in the New York Times March 29, 2019
The patient moved into a large assisted living facility in Raleigh, N.C., in 2003. She was younger than most residents, just 73, but her daughter thought it a safer option than remaining in her own home.
The woman had been falling so frequently that “she was ending up in the emergency room almost every month,” said Dr. Shohreh Taavoni, the internist who became her primary care physician.
“She didn’t know why she was falling. She didn’t feel dizzy — she’d just find herself on the floor.” At least in a facility, her daughter told Dr. Taavoni, people would be around to help.
As the falls continued, two more in her first three months in assisted living, administrators followed the policy most such communities use: The staff called an ambulance to take the resident to the emergency room.
There, “they would do a CT scan and some blood work,” Dr. Taavoni said. “Everything was O.K., so they’d send her back.”
Such ping-ponging occurs commonly in the nation’s nearly 30,000 assisted living facilities, a catchall category that includes everything from small family-operated homes to campuses owned by national chains.
It’s an expensive, disruptive response to problems that often could be handled in the building, if health care professionals were more available to assess residents and provide treatment when needed.
But most assisted living facilities have no doctors on site or on call; only about half have nurses on staff or on call. Thus, many symptoms trigger a trip to an outside doctor or, in too many cases, an ambulance ride, perhaps followed by a hospital stay.
Twenty years after the initial boom in assisted living — which now houses more than 800,000 people — that approach may be shifting.
Early on, assisted living companies planned to serve fairly healthy retirees, offering meals, social activities and freedom from home maintenance and housekeeping — the so-called hospitality model.
But from the start, the assisted living population was older and sicker than expected. Now, most residents are over age 85, according to government data. About two-thirds need help with bathing, half with dressing, 20 percent with eating.
Like most older Americans, they also generally contend with chronic illnesses and take long lists of prescription drugs — and more than 80 percent need help taking them correctly.
Moreover, “these places became the primary residential setting for people with dementia,” said Sheryl Zimmerman, an expert on assisted living at the University of North Carolina at Chapel Hill.
About 70 percent of residents have some degree of cognitive impairment, her studies have found. So residents can find it difficult to coordinate medical appointments and tests, and to travel to offices and labs, even when facilities provide a van.
“The assisted living industry has to recognize that the model of residents going out to see their own doctors hasn’t worked for a long time,” said Christopher Laxton, executive director of AMDA, a society that represents health care professionals in nursing homes and assisted living.
His recent editorial in McKnight’s Senior Living, an industry publication, was pointedly headlined: “It’s time we integrate medical care into assisted living.” AMDA is considering developing model agreements.
“There has to be more attention to medical and mental health care in assisted living,” Dr. Zimmerman agreed. “Does everyone who falls really need to go to an emergency department?”
Lindsay Schwartz, an executive at the National Center for Assisted Living, a trade association, said in an email that “assisted living has certainly expanded its role in providing medical care over the years by adding nursing staff and partnering with other health care providers, among other ways.”
But persuading most operators to provide medical care likely won’t happen without a fight. They’ve built their marketing strategies on looking and feeling different from the dreaded nursing home, and they object to “medicalizing” their communities.
“They don’t want the liability,” said Dr. Alan Kronhaus, an internist who, with Dr. Taavoni (they are married), started a practice called Doctors Making Housecalls in 2002.
The facilities also “live in mortal fear of bringing down heavy-handed federal regulation,” he said. That can happen when Medicare and Medicaid, which cover most residents’ health care, get involved.
Doctors Making Housecalls provides one example of how assisted living can offer medical care. The practice dispatches 120 clinicians — 60 doctors, plus nurse-practitioners, physician assistants and social workers — to about 400 assisted living facilities in North Carolina.
“We see patients often, at length and in detail, to keep them on an even keel,” Dr. Kronhaus said. By contracting with labs, imaging companies and pharmacies, the practice can provide most of the medical care for more than 8,000 residents, on site and around the clock.
Working with a local emergency medical service, he and his colleagues reported in a 2017 study that the practice could reduce emergency room transfers by two-thirds.
The Lott Assisted Living Residence in Manhattan, on the other hand, relies on a single geriatrician, Dr. Alec Pruchnicki, to provide medical care for most of its 127 or so residents.
If they’re feeling sick, a family member calls or the resident just knocks on the door of “Dr. P’s” basement office. “Sometimes it’s just a cold — chicken soup,” Dr. Pruchnicki said. “But this winter we had a few cases of flu and pneumonia, things you need to treat.”
Nearby Mount Sinai Hospital employs him and provides emergency services when needed. Often, they’re not. In 2005, Dr. Pruchnicki reported at medical conferences, he decreased hospitalizations by a third. “I can’t be in the only place in the country where this would work,” he said.
Spending time in emergency rooms and hospitals often takes a toll on residents, even if their ailments can be treated. They get exposed to infections and develop delirium; they lose strength from days spent in bed.
Perhaps that contributes to short stays in assisted living. Adult children often see these facilities as their parents’ final homes, but residents stay just 27 months on average, after which many move on to nursing homes.
Adding doctors to assisted living could also cause problems, advocates acknowledge; in particular, it might increase the already high fees facilities charge.
But something has clearly got to give. “There can be health care in assisted living without making it feel like a nursing home,” Dr. Zimmerman said.
Family members tell of frightened and confused residents arriving unaccompanied at emergency rooms, unable to give clear accounts of their problems. Dr. Kronhaus recalls a resident with dementia taken to the local E.R. by ambulance; discharged, she was sent home by taxi. The address she gave the driver was her former home, where neighbors spotted her and called the police.
By contrast, the North Carolina woman with a history of falls is doing well.
Dr. Taavoni discovered that her hypertension medications were causing such low blood pressure that she fainted. Reducing the dose and discontinuing a diuretic, Dr. Taavoni also weaned the patient off an anti-anxiety drug she suspected was causing problems, substituting a low dose of an antidepressant instead.
The falls and the related emergency room visits stopped. Doctors Making Housecalls is still caring for her, and for most of the neighbors in her assisted living facility.
https://www.nytimes.com/2019/03/29/health/assisted-living-doctors-house-calls.html accessed 3 April 2019
Reflections-
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
- To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
- To establish better communication among physicians serving as medical directors and other providers.
- To promote better communication between medical directors and
(b) various long-term care associations, and
(c) officials of various government agencies.
- To represent medical directors in defining their roles and equitable compensation.
- To serve as a conduit between AMDA and the WAMD membership.
- To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
- To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
- To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 5329 Fayette Ave., Madison, WI 53713
Newsletter for April, 2019
Newsletter for April 2019
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
President Ron Schreiber led the Wisconsin delegation to the AMDA House of Delegates, which also included Paula Hardgrove, Raul Mateo, Curt Hancock and Rex Flygt (pictured below). We considered seven resolutions-two were passed to the Board of Directors, and two were referred to the Board of Directors for analysis and re-direction.
o A19-a white paper on “Stopping eating and drinking by advance directive (SED by AD) in the ALF and PALTC settings” passed. For full text go to https://paltc.org/sites/default/files/A19-WHITE%20PAPER-SED%20AD%20Ethics%20Committee%20White%20Paper%20HOD%20submission.pdf This is a very careful review worth your time to read.
o D19-dealt with the studying impact of medical direction on quality outcomes; this was referred to the board
o E19-dealt with two separate issues, 1) recognizing (again) medical director’s compensation is for direction, not referrals to the facility, but also 2) requiring CMS to maintain a list of medical directors. That resolution was divided; both passed, with a lot of moaning and groaning about how little is likely to be accomplished.
o F19-dealt with permitting medical direction by telecommunication technology; this was referred to the board
We again shared a state chapter reception with Minnesota Friday March 8 starting at 6:30 PM; a good time was had by all, mostly.
Irene Hamrick from the UW and a previous WIS-PALTCM officer and director received honorable mention in the poster competition for an article she’s published in JAMDA (see below); she also presented “SNF Five-Star Quality Metrics 101”
And, of course, save the date for our annual meeting October 11-12 at the Radisson in Madison.
President Schreiber will be attending the state DQA meeting on Tuesday, April 16th.
Other News-from around our state and our partners:
Our president Ron Schreiber provided this letter in lieu of testimony to the state senate, after testifying before the assembly:
President Ron (second from left) with John Sauer, Craig Ubbelohde, & Joey Pettis
Wisconsin Medical Directors Support Assembly Bill 76 and Senate Bill 103
“Chairman Testin and Members of the Senate Health and Human Services Committee, my name is Dr. Ronald Schreiber, MD, CMD. I am from Appleton, and serve as the President of the Wisconsin Society for Post-Acute and Long-Term Care Medicine, also known as the Wisconsin Association of Medical Directors (WAMD). I have been a practicing physician in Wisconsin for more than 25 years. I am Board Certified in Internal Medicine, and am a Certified Medical Director, through the American Medical Directors Association. I serve in the Appleton-Neenah-Menasha area at several skilled nursing facilities.
Thank you for the opportunity to provide written testimony in support of Assembly Bill 76 and Senate Bill 103, which would ensure that the training standards for Certified Nursing Assistants (CNAs) in Wisconsin mirror the federal CNA training standards.
CNAs are a vital component of the post-acute (post-hospital) and long-term care continuum. We as a society must recognize this, and must encourage growth in this field, especially as our population ages at historic rates. Unfortunately, Wisconsin’s shortage of CNAs is worsening over time. We must best prepare for the future to ensure quality care for our aging population.
WAMD recognizes that current state requirements put us at a competitive disadvantage in recruiting CNAs compared to our neighboring states of Minnesota, Iowa, and Michigan, which adhere to federal guidelines. WAMD requests that this be rectified through this important legislation.
The reality is that facilities are largely regulated on the basis of federal regulations. In fact, the Centers for Medicare and Medicaid Services (CMS) just a few years ago went through a significant overhaul of the Requirements of Participation governing facilities participating in the Medicaid program, and the federal CNA training standard of 75 hours was not adjusted in any way. Medical Directors who serve in Wisconsin’s skilled nursing facilities across the state – professionals who ensure that quality care is being delivered to the residents that we serve – believe that putting CNA certification standards in line with the federal government establishes consistency of the standards by which long-term and post-acute care facilities are measured and evaluated.
While some may attempt to make this issue about quality of care, in fact, there is actually very little in the medical literature regarding number of training hours as related to quality measures. What data we do have comes from the CMS website Medicare.gov in terms of nursing home ratings. In Wisconsin, 36% of nursing homes rate as "much above average" (5 star), compared to a range of 36-39% for Minnesota, Iowa, and Michigan. Those ranked "much below average" (1-star) are 9% in Wisconsin, and 5-9% in our bordering states. There is no statistical difference between Wisconsin and our neighbors. Although the five-star rating system does not focus on CNA work exclusively, their level of care and competence certainly affects a facility's rating. Our neighboring states do not suffer in the CMS star rating as a result of their federally-aligned CNA training.
It is important to note several items about this legislation: the bill does not alter testing/competency requirements – all CNAs have to pass the same test regardless of how many hours are in their training program. All required core competencies for CNAs will be covered following passage of this legislation. This legislation does not limit the ability of programs to offer CNA training classes with higher hours, which some programs may elect to do; it only affects whether the Department of Health Services is able to require a program to offer training above the federal level.
Thank you for your attention to this matter. I am happy to answer any questions that you may have about WAMD’s support for this important legislation that deserves your support.”
Ronald Schreiber, MD, CMD
President, Wisconsin Association of Medical Directors
From the Trenches- questions about the meaning of PA/LTC life:
“Things I thought I heard at AMDA”
o Have you looked at the New York “algorithm for the unbefriended”? —an estimated 3 to 4 percent of long-stay residents have no proxy decision-maker.
o Autonomy is the experience of authorship of behavior, not simply the experience of noninterference.
o How much do you understand about the new PDPM (patient driven payment model), including the role in non-case mix basal rate, and front end load?
o PDPM will replace payment therapy with payment management of complexity as the touchstone of post-acute medicine. The biggest thing that’s happened since the BBA of 1997, which led to the last big wave of bankruptcies in long-term care.
o AMDA is working on a marijuana clinical practice guideline; they say they’re not, but you know they must be.
o There is a lot of congressional interest in resolving the surprising billing complications of observation; the solution to the three-night rule might get bundled into that, but don’t hold your breath.
o Probably regretfully, the nursing home quality measures are not physician quality measures.
o No one gets participation trophies in long-term care. Do we need a state medical director of the year award, or a young medical director of the year award?
o What would you say to this: “This is why I came to post-acute/long-term care… This is why I stay….”
o I can’t—we can.
o After adequate compensation, professional satisfaction is about autonomy, mastery, and purpose—which is why PA/LTC providers tend to stay in the business.
o Providers really don’t want to be paid for call: They want no meaningless call.
o Adequate nurse triage upgrades the work done by provider…. Strong nurse triage can stop 80% of calls and organize work more productively.
o Why do you need to be notified for the sake of notification along? The bar should be at notification that asks you to do something.
o Recruitment Retention Productivity
o Telemedicine is among the interventions that probably reduce readmissions, although deployment of the Interact tools is better-evidenced.
o Do you have online access to the AMDA guidelines? Why not?
o Do you know how to evaluate and treat the Krumholz post-hospital syndrome?
o Heart failure increases the risk of readmission by 50%, but furosemide will not fix two of the three conditions the HFpEF (heart failure with preserved ejection fraction) patient will be readmitted for.
o In other words, since HFpEF really isn’t a “heart” problem, you have to manage the complications (including complications of therapy) and the comorbid conditions.
o Thirty-day readmission is now the key quality indicator (“it’s about the economy, stupid”); functional capacity and percent discharge home should be.
o Do you know what’s in section GG of the MDS?
o Do you have the provider resilience app on your phone? What’s the equivalent, in self-maintenance, to singing happy birthday while hand washing?
o Working with your specialty society can help prevent “lone ranger” isolation at work.
o The real touchstone about “avoidability”, suggests Crecelius, is not the nature and scope of the intervention at the change in condition, but identifying and treatment what is reversible before the change in condition.
o The PA/LTC workforce is small and aging. Nurture it. --Of the 37 certified medical directors in Wisconsin, more than half plan to reduce or discontinue practice in the next five years; this parallels, of course, other reports that a similar proportion of Wisconsin physicians plan to cut back on clinic time or duties due to the more and more burdensome “administrative load” on the same timeline.
o Speaking of administrative load, coding has become more and more complex, although there are proposals on the table to make things simpler to bill (even if service is more complicated). For more info, go to https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlngeninfo/index.html.
o Nursing home physicians remain relatively immune from professional liability claims, but not so facilities.
o If you haven’t read the AMDA white paper on “SED by AD” (Stopping eating and drinking by advance directive), do so (citation above)
o Silos continue to harden and separate and the hospital remains best funded silo.
o Only the long-term care medical director is looking beyond the door, realizing we care for populations and not sites of service.
o Should a provider-provider handoff at the transition of care be a quality measure?
o Firm touch pharmacy review reduces high impact medication errors at the transition of care.
o There is plenty of consternation with the electronic medical record nationwide. You are not alone.
o Here’s a script for you: “I’m not sure I understand what you’re saying: Do the SBAR and I’ll call you back…”
Other Reviews-publications from around the world of geriatrics and PA/LTC
Transitioning from Insulin to DDP-4 Inhibitors for Type 2 Diabetes
by I. Hamrick, MD, M. Goblirsch, BS; and W.-J. Tuan, MS (University of Wisconsin)
“Introduction: Dipeptidyl-peptidase 4 (DPP-4) inhibitors are a relatively new treatment regimen for Type II Diabetes Mellitus (T2DM) and are associated with less hypoglycemia than insulin. There are no published data regarding the effects of these drugs on insulin therapy. This case series presents findings from a cohort of older adults on insulin who received DPP-4 treatment with the intention of discontinuing insulin, if possible. Using data from electronic health records, we reviewed all residents in nursing homes with T2DM who were on insulin and started on DPP-4 inhibitors. We tapered insulin dosages when finger stick blood glucose levels were <200mg/dL and noted when insulin treatment was stopped altogether. …
Conclusion: More than half (59%) of patients were able to transition off insulin therapy onto DPP-4 inhibitors with subsequent improvement in weight by 4.1 pounds and HgA1c by 1%. These findings suggest that DPP-4 inhibitors provide a new care option in the treatment of Type II Diabetes Mellitus in older nursing home patients and can be used to transition patients off insulin therapy. Because it may take several months, patience and close monitoring is required to succeed. This report provides a starting point for larger studies to confirm our findings and develop a protocol for transitioning patients.”
For full text go to https://doi.org/10.1016/J.JAMDA.2019.01.054
Reflections-
Your Wisconsin delegation at AMDA, Raul Mateo, Rex Flygt (standing), Ron Schreiber, Curt Hancock, and Paula Hardgrove
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
· To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
· To establish better communication among physicians serving as medical directors and other providers.
· To promote better communication between medical directors and
(a) other post-acute and long-term care professionals,
(b) various long-term care associations, and
(c) officials of various government agencies.
· To represent medical directors in defining their roles and equitable compensation.
· To serve as a conduit between AMDA and the WAMD membership.
· To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
· To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
· To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 6000 Gisholt Dr., Suite 200, Madison, WI 53713
Newsletter for March, 2019
Newsletter for March 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Event Website: https://paltc.org/annual-conference
President Ron Schreiber will lead the Wisconsin delegation to the AMDA House of Delegates, which will also include Paula Hardgrove, Raul Mateo, Curt Hancock and Rex Flygt.
We will again share a state chapter reception with Minnesota Friday March 8. All encouraged to attend. This is a great opportunity to meet and network with colleagues from across the state.
And, of course, save the date for our annual meeting October 11-12 at the Radisson in Madison:
While the structure and content of our 2019 annual meeting is set, and the program will start being shown in a couple months, the board decided it was time to poll the membership as a whole on preferences for how the meeting is done. Survey links to that and the other semi-annual surveys are below.
Other News-from around our state and our partners:
All members who are medical directors should take this survey-
· https://www.surveymonkey.com/r/FWV9PVX
All physician members who attend patients should take this survey-
· https://www.surveymonkey.com/r/FJQZKTC
All non-physician providers who attend patients should take this survey- From the Trenches- questions about the meaning of PA/LTC life
Yeah, yeah, we all learned how to write discharge summaries as medical students and ours are pretty good, right? Well, that’s actually an empiric point—can yours standard up to the scrutiny of research? Do you need to share this document with people you handoff too (and from)? “Evaluation of an Enhanced Discharge Summary Template: Building a Better Handoff Document” by Christopher Smith, Micah Beachy, Andrew Vasey, Trek Langenhan, and Jason Shiffermiller in the Journal of Clinical Outcomes Management. 2017 December; 24(12): 542-550·
Objective: To design and implement an enhanced discharge summary for use by internal medicine providers and evaluate its impact.
· Methods. Pre/post-intervention study in which discharge summaries created in the 3 months before (n = 57) and 3 months after (n = 57) introduction of an enhanced discharge summary template were assessed using a 24-item scoring instrument. Measures evaluated included a composite discharge summary quality score, individual content item scores, global rating score, redundant documentation of consultants and procedures, documentation of non-active conditions, discharge summary word count, and time to completion. Physician satisfaction with the enhanced discharge summary was evaluated by survey.
· Results: The composite discharge summary quality score increased following the intervention (19.07 vs. 13.37, P < 0.001). Ten items showed improved documentation, including documented need for follow-up tests, cognitive status, code status, and communication with the next provider. The global rating score improved from 3.04 to 3.46 (P = 0.01). Discharge summary word count decreased from 717 to 701 (P = 0.002), with no change in the time to discharge summary completion. Surveyed physicians reported improved satisfaction with the enhanced discharge summary compared with the prior template.
· Conclusion: An enhanced discharge summary, designed to serve as a handoff between inpatient and outpatient providers, improved quality without negative effects on document length, time to completion, or physician satisfaction.
Other Reviews-publications from around the world of geriatrics and PA/LTC
Hallucinations Are Everywhere
Experiences like hearing voices are leading psychologists to question how all people perceive reality.
Joseph Frankel in The Atlantic 2 October 2018
There’s a good chance you’ve hallucinated before.
If you’ve ever felt the buzz of your phone against your thigh only to realize the sensation was entirely in your head, you’ve had a sensory perception of something that isn’t real. And that, according to the psychologist Philip Corlett, is what makes a hallucination.
To many, this definition may seem shockingly broad. Hallucinations were long considered the stuff of psychoses or drug trips, not a regular and inconsequential part of life. But Corlett operates on the idea that hallucinations exist within a hierarchy. At the highest level, according to Corlett’s collaborator Albert Powers, they would be something like hearing “whole sentences of clearly spoken speech of a being who seems quite real.” But, moving further down the line, hallucinations can be far more banal: an imagined text message, a phantom raindrop, a new parent’s mistaken sense of her child by her bedside.
This hierarchy perspective represents an ongoing revelation in how widespread and varied hallucinations can be. A survey in the early 1990s found that 10 to 15 percent of the population of the United States experienced vivid sensory hallucinations at some point in their lives. And scientists have begun to take seriously the idea that voice hearing and other forms of auditory hallucination can be benign or “nonclinical.” This newfound ubiquity has come with a host of questions. Why is it so common for people to perceive what isn’t there, and how does the brain allow this to happen in the first place? To find answers, researchers have turned to the mechanics of how we perceive reality itself.
For Corlett and Powers, both from the Yale School of Medicine, hallucinations have everything to do with expectations. In a new paper in Science, they explore how the mysterious experiences fit into a larger, speculative idea about how the brain works—and, in a sense, what the brain is. The pair recounts a 2017 study they conducted, in which their group tried to induce hallucinations both in people who commonly report hallucinations across the psychotic spectrum and in people who don’t normally hallucinate. The participants were taught to expect to hear a tone after being shown a flashing light, and then were made to press a button when they thought they heard a tone. They were told to hold down the button longer to rate their confidence in what they heard. People who regularly hallucinate held the button—that is, they hallucinated—significantly longer than those who don’t.
Corlett and Powers see this experiment as evidence for their perspective on how people understand the world around them. By their way of thinking, the brain works by “predictive coding”: integrating new information based on the beliefs built on old information. “When we go about the world, we’re not just passively perceiving sensory inputs through our eyes and ears,” Corlett says. “We actually build a model in our minds of what we expect to be present.”
This mental setup works great for allowing us to move smoothly through the world, taking in each detail without a second thought. But sometimes, Corlett and Powers say, the brain has the capacity to overpredict: It can expect something that isn’t there, and this expectation can be so strong that we actually perceive the nonexistent thing. Thus, a hallucination.
The idea of predictive coding is part of a way out of a knotted, overlapping, and sometimes competing lineage of trying to explain hallucinations. Another model, inner-speech theory, was popularized in part by the writings of the 20th-century psychologist Julian Jaynes. It holds that people who hear voices are really hearing their own thoughts that feel like someone else’s. This explanation has been propped up more recently by corollary-discharge theory, which states that the body’s tracking of its boundaries and actions (the neural machinery that makes your arm feel like your arm and your foot feel like your foot) fails for the thoughts and voices of people with psychotic disorders who experience auditory hallucinations.
“We’re still working to see how our model fits in with those models,” Corlett says.
This quest for a leg to stand on in researching hallucinations has yielded some theatrical—and sometimes even poetic—experiments. In his book on the science and history of auditory hallucinations, Charles Fernyhough, a psychologist at Durham University, tells how a psychiatrist in the ’40s found that as a group of people with schizophrenia hallucinated voices, muscles in their throats responsible for speech would twitch along with the words they heard. The voices seemed to be their own words hidden elsewhere.
Decades later, researchers recorded the voices of hallucinators with psychotic disorders and presented these subjects with electronically distorted copies. They wanted to see if the hallucinators could identify their own distorted voices. In the same vein, researchers have explored using computerized avatars à la Second Life in the past decade to try and help hallucinating psychotics assign their “presumed persecutors” a face to talk to, with the goal of softening the things these voices said to them.
Corlett also pointed me toward sine-wave speech, a particularly stunning example of the way expectation can seem to shape our reality when it comes to language. You can try it yourself: Listen to this sound (don’t turn your volume too loud). Most people will hear an R2-D2-like swell of vocoder-tinged whistling. Next, listen to this recording of a woman saying, “It was a sunny day, and the children were going to the park,” in a soothing, southern English accent. Now try R2-D2 again. Listening to the whistling sine-wave speech, you’ll likely hear a distorted version of the same “sunny day” sentence. And in all likelihood, you won’t be able to un-hear the words in the first recording now.
Hallucinators may have an easier time parsing the R2-D2-like sounds, even before listening to the other recording. In a 2017 study, nonclinical voice hearers were far better at recognizing the presence of a voice in sine-wave speech than their non-voice-hearing counterparts. And as a group, their brains fired along a pattern distinct from those who couldn’t tell that the sine-wave speech was a voice. This example, Corlett says, builds the case that auditory hallucinations are linked to the processes of expectation and prediction.
Still, Fernyhough points out, there are some potential holes in the idea of predictive coding. “Compared to the conventional view of the brain as a device that processes information coming from the environment, predictive coding starts with a different set of assumptions about how the brain makes predictions about what is in the environment and then learns from them,” he said.
Corlett, meanwhile, argues that there’s a gap in inner-speech theory. Citing a study in which people rendered mute from birth reported hearing voices in their heads, he says that the phenomenon can’t be completely explained as the brain misreading itself.
Whatever explanations stand the test of time, the stakes of this science are much higher than understanding why many of us imagine text messages. For some people, hallucinations can be more persistent and disturbing. The science of how these hallucinated touches, sounds, and sights manifest in the mind is still unclear. It’s too early to say how much the causes of auditory hallucinations and other kinds might overlap, Fernyhough says. So far, the research has focused on auditory hallucinations. And to many, the need for that work is quite clear. Eleanor Longden, a mental-health researcher and advocate, has publicly recounted how her own auditory hallucinations have shifted between neutral and distressing at different points in her life. She’s made the case that the social stigma and judgment she received from her doctor at the time made them more negative.
“Hallucinations can be very distressing and debilitating. They can also be neutral or positive,” Fernyhough says. “A better understanding of how they occur and how they can be managed could alleviate a great deal of mental distress.
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
· To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
· To establish better communication among physicians serving as medical directors and other providers.
· To promote better communication between medical directors and
(a) other post-acute and long-term care professionals,
(b) various long-term care associations, and
(c) officials of various government agencies.
· To represent medical directors in defining their roles and equitable compensation.
· To serve as a conduit between AMDA and the WAMD membership.
· To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
· To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
· To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 6000 Gisholt Dr., Suite 200, Madison, WI 53713
Newsletter for February, 2019
Newsletter for February 2019-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your board teleconferenced Wednesday January 16 at 5 PM:
- The financial position of the organization remains sound, although running a little shop like ours remains challenging.In particular, we are again investigating the cost of maintaining CME accreditation, preferring to do our own thing if it’s practical.The purchase of other contracted services is always a potential issue as well.
- The membership of the organization remains sound, although we obviously compete for loyalty with a number of others.The best way for us to grow is your recommendation to other LTC professionals.
- Brian Purtell has accepted appointment to our board representing WHCA/WiCAL (succeeding Cliff Woolever).
- President Ron has been invited to a resumed schedule of Provider-Advocates-DQA meetings in Madison.
- While the structure and content of our 2018 annual meeting is set, and the program will start being shown in a couple months, the board decided it was time to poll the membership as a whole on preferences for how the meeting is done.Survey links to that and the other semi-annual surveys are below.
Event Website: https://paltc.org/annual-conference
President Ron Schreiber will lead the Wisconsin delegation to the AMDA House of Delegates, which will also include Paula Hardgrove, Raul Mateo, Curt Hancock and Rex Flygt.
We will again share a state chapter reception with Minnesota Friday March I; RSVP optional, but President Ron would like to know who’s coming.
And, of course, save the date for our annual meeting October 11-12 at the Radisson in Madison!
Other News-from around our state and our partners:
All members who are medical directors should take this survey-
- < > < >< >https://www.dhs.wisconsin.gov/publications/dqa-update-2019-01.pdf to enable the hyperlinks
Other Reviews-publications from around the world of geriatrics and PA/LTC
In the Nursing Home, Empty Beds and Quiet Halls
Fewer patients are winding up in nursing homes, and hundreds of the facilities are closing each year.
By Paula Span in the New York Times 28 September 2018- For more than 40 years, Morningside Ministries operated a nursing home in San Antonio, caring for as many as 113 elderly residents. The facility, called Chandler Estate, added a small independent living building in the 1980s and an even smaller assisted living center in the 90s, all on the same four-acre campus.
- The whole complex stands empty now. Like many skilled nursing facilities in recent years, Chandler Estate had seen its occupancy rate drop.
- “Every year, it seemed a little worse,” said Patrick Crump, chief executive of the nonprofit organization, supported by several Protestant groups. “We were running at about 80 percent.”
- Staff at the Chandler Estate took pride in its five-star rating on Medicare’s Nursing Home Compare website. But by the time the board of directors decided it had to close the property, only 80 of its beds were occupied, about 70 percent.
- Revenue from independent and assisted living couldn’t compensate for the losses incurred by the nursing home.
- In February, the last resident was moved out. Morningside Ministries operates two other retirement communities in the San Antonio area; they took in the independent living and assisted living residents and about 30 nursing home patients, absorbing most of the staff as well.
- But more than 40 older people had to relocate to other nursing facilities or move out of town closer to family, and 30 staff members lost their jobs.
- “There was some real sadness, tears, frustration,” Mr. Crump said. “It’s hard knowing you won’t be providing services to those older folks.”
- At least the organization has the cold comfort of knowing that nursing homes across the country are grappling with the same problem.
- < >The most recent quarterly survey from the National Investment Center for Seniors Housing and Care reported that nearly one nursing home bed in five now goes unused.
- Occupancy has reached 81.7 percent, the lowest level since the research organization began tracking this data in 2011, when it was nearly 87 percent.
- “It’s a significant drop,” said Bill Kauffman, senior principal at the center. “The industry as a whole is under pressure, and some operators are having difficulty.”
- Such national statistics mask considerable local differences.
- “The best facilities still have 100 percent occupancy and waiting lists — that’s how you know they’re good,” said Nicholas Castle, a health policy researcher at the University of Pittsburgh.
- But in 2015, the National Center for Health Statistics reported that more than a third of beds were empty in some states, including Illinois, Iowa, Nebraska, Oklahoma and Utah. Texas wasn’t far behind.
- Nationally, “200 to 300 nursing homes close each year,” Dr. Castle said. The number of residents keeps shrinking, too, from 1.48 million in 2000 to 1.36 million in 2015, according to federal data.
- Given an aging population, you’d think nursing homes would be coping with the opposite problem — surging demand for their services.
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- But they also face growing financial strains and regulatory requirements intended to control costs, Mr. Kauffman pointed out.
- Under the Affordable Care Act, for instance, hospitals face financial penalties for readmissions, and some have responded by designating patients as “under observation,” rather than admitting them as inpatients. After discharge, Medicare won’t cover skilled nursing care for these patients.
- (Generally, Medicare pays for short-term rehabilitative care in nursing homes following a hospital stay; however, Medicaid, administered by the states, covers long-term care.)
- Moreover, “certain surgeries are migrating from inpatient to outpatient surgical centers,” Mr. Kauffman said. Medicare won’t cover skilled nursing for those patients, either.
- The growth of Medicare Advantage plans, which now cover a third of Medicare beneficiaries, also plays a role.
- “They have a keen interest in lowering costs, so maybe they divert people from skilled nursing to home care,” Mr. Kauffman said. “If you do go to a nursing facility, instead of a 30-day stay, maybe the plan wants the patient out in 17 days.”
- At the same time, nursing homes face stiffening competition. As their operators sometimes say themselves, they’re selling a product nobody wants to buy.
- “You have increased alternatives, like assisted living, and other ways for people to stay at home,” said Ruth Katz, senior vice president of public policy at Leading Age, which represents nonprofit senior service providers. “When people find community alternatives, they use them whenever possible.”
- Federal policy has helped propel this shift. For years, advocates protested that Medicaid covered care in nursing homes but not in the places people much preferred to live. Congress paid attention and passed legislation in 2005.
- Thirty years ago, 90 percent of Medicaid dollars for long-term care flowed to institutions and only 10 percent to home- and community-based services. Now, the proportions have flipped, and nursing homes get only 43 percent of Medicaid’s long-term care expenditures.
- A report from the federal Government Accountability Office earlier this year pointed out, for example, that Medicaid covers assisted living for 330,000 people. A demonstration program called Money Follows the Person has moved more than 75,000 residents out of nursing homes and back into community settings.
- It’s good news for consumers — but not so good for nursing homes. The 31 largest metropolitan markets have 13,586 fewer nursing home beds now than in late 2005, the investment center reports.
- This could prove a temporary crisis. When the baby boomers enter their 80s and need residential care, occupancy could pick up again.
- Even now, nursing homes can turn a profit with lower occupancy by attracting more patients for short-term rehab. Medicare reimburses for those stays at higher rates than Medicaid pays for long-term care. (About 80 percent of American nursing homes are for-profit.)
- Facilities are bracing for some tough years ahead, nonetheless. In casting about for additional revenue, they’re trying tactics like opening pharmacies and home care agencies, and accepting sicker patients, including those on ventilators, at higher reimbursement rates.
- They’re experimenting with 12-hour staff shifts, allowing them to hire fewer employees but offer more flexible schedules. Some may convert shared rooms to private ones, a popular move with residents.
- Whether emptier and fewer nursing homes benefit older adults and their families remains an open question. On the plus side, people have more choices when they need help, a long-sought goal, said Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care.
- “You no longer have to go to a nursing home because it’s the only game in town,” she said.
- But what about those who already live in nursing homes, or will move in over the coming years, because they need the round-the-clock supervision no other kind of facility offers?
- “From what I’ve observed, as occupancy goes down, so will staff levels,” Ms. Grant said. With most nursing home staffs already stretched too thin, that could hurt.
- Despite extensive federal regulations, including new rules adopted in the waning months of the Obama administration, nursing homes have no federal minimum staffing requirements (though some states have requirements).
- “You can cut with impunity,” Ms. Grant said, and with financial pressures mounting, she worries that facilities will.
- So families with relatives in nursing homes might want to pay particular attention. If occupancy falls, maybe your loved one gets a private room. Or maybe the call button takes even longer to answer.
- The new federal rules require more accurate staffing information posted on Nursing Home Compare, using time-cards rather than facilities’ self-reports. That’s one way families can keep tabs on how empty beds may affect care.
- “Monitor the data,” was Ms. Grant’s recommendation. “Talk to staff and residents. Definitely keep an eye out.”
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:- To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
- To establish better communication among physicians serving as medical directors and other providers.
- To promote better communication between medical directors and
(b) various long-term care associations, and
(c) officials of various government agencies.- To represent medical directors in defining their roles and equitable compensation.
- To serve as a conduit between AMDA and the WAMD membership.
- To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
- To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
- To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 6000 Gisholt Dr., Suite 200, Madison, WI 53713
Newsletter for January 2019-
Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant karenmiller.rio@gmail.com
News-from around our organizations and our members:
Your board will teleconference Wednesday January 16 at 5 PM; agenda items to Karen and President Ron now, please.
Save the Date: 2019 WAMD Annual Conference October 11-12, Radisson Hotel, Madison. The CME committee is working on another great line-up of topics and speakers. Thanks for all the suggestions.
We also need additional persons for the Wisconsin delegation at the House of Delegates at the AMDA meeting in March; express interest in involvement to Ron now, please.
Speak of AMDA-Atlanta, we will share a state chapter reception with Minnesota Friday, March 8; responses optional, but Ron would like to know who’s coming.
Event Website: https://paltc.org/annual-conference
Other News-from around our state and our partners:
New opioid guidelines arrive not a moment too soon
Elizabeth Newman Senior Editor, in McKnight’s Long-term Care News published 7 December 2018
· Following my C-section earlier this year, I was fortunate to be able to access heavy-duty pain medication. Until we discovered my pain pump wasn’t working.
· That was unfortunate, but luckily I was young(ish), in good health(ish) and had a new baby. But as AMDA – The Society for Post-Acute and Long-Term Care (PALTC) Medicine President Cari Levy, M.D., Ph.D., recounts, many nursing home professionals have stories of people they’ve cared for who couldn’t access pain medication.
· “Everybody has one of those in their brains, where the resident was suffering,” she told me Thursday following the announcement of new guidelines from AMDA. “We had to get prescriptions faxed, and it was a weekend and there were all of these hurdles. That’s so unnecessary. That’s a lot of what drives the motion around it.
· AMDA has two main goals with its new policies: One, “provide access to opioids when indicated to relieve suffering and to improve or maintain function” and two, “Promote opioid tapering, discontinuation and avoidance of opioids when the above goals are not achievable, to prevent adverse events, dependence and diversion.”
· While it’s always been challenging to make sure nursing home residents receive the right amount of pain medication, the opioid epidemic has resulted in some states cracking down to a point that paralyzes effective pain management. Providers have to balance the responsibility to prevent theft of medications with making sure residents are not in pain.
· “The epidemic of opioid addiction has affected every sector. That’s the most difficult thing,” said AMDA Executive Director Chris Laxton. “One of the federal responses to the opioid epidemic has been to restrict them. That has resulted in some of our residents who have been well managed to not get access to pain meds when they have needed them.”
· He noted that states vary tremendously on rules, which can make it difficult for a national organization to give blanket guidelines.
· “We would really like to see a more consistent approach from state to state,” he said.
· Of course, how states manage opioids can often depend on how badly hit citizens have been by opioid addiction. In communities devastated by overdoses, it would follow that a clampdown on the drugs would result in perhaps overcorrection in nursing homes.
· “Opioids are poorly understood,” Laxton said. “When people say, ‘We can’t ever use opioids,’ that’s not an appropriate approach to take.”
· At the same time, AMDA and other organizations know drug division happens across all settings. Staffers have to be screened appropriately, and a “team-based” approach is needed to managing cases.
· “Pain management is the poster child for team-based care,” Laxton says.
· When discussing when opioids are appropriate, clinicians should look at side effects, Levy notes. For example, a resident may be very constipated, or immobile from the opioids. That might mean tapering the drug.
· It all can feel like a lot to take in, which is why medical directors should appreciate AMDA’s work on the guidelines. There is no magic switch to better opioid management, but we can move forward.
· “I don’t think it will ever be possible to prevent 100 percent [of diversions], but we can do a better job,” Laxton said.
· On behalf of those coming out of surgery pressing their pain pump, we thank every provider who agrees.
If the hyperlink doesn’t open, go to https://paltc.org/opioids%20in%20nursing%20homes
From the Trenches- questions about the meaning of PA/LTC life
From time to time we survey the membership about medical director and attending physician practices. This is the sample list of questions for polling by Survey Monkey—reply to Karen Miller or myself if you have other questions that are yearning for answers, and we’ll get it out in January.
For medical directors-
· CME? Yes or No
· # of buildings
· # of residents
· Hourly rate ($)
· Travel time/month?
· Call time/month?
· Paid for call?
· Satisfied?
For attending physicians-
· Certification?
· # of visits/month?
· # residents on service in a month?
· Paid salary, FFS, or blend?
· Travel time/month?
· Frequency of night call?
· Paid for call?
· Satisfied?
For NPs-
· Certified
· %FTE?
· # visits/FTE/month
· # residents on service/FTE/month
· Travel time/FTE/month
· Frequency of night call?
· Satisfied?
Other Reviews-publications from around the world of geriatrics and PA/LTC:
The Illness Is Bad Enough. The Hospital May Be Even Worse.
The elderly are particularly vulnerable to “post-hospital syndrome,” some experts believe, and that may be why so many patients return.
By Paula Span in the New York Times 3 August 2018
· When she moved from Michigan to be near her daughter in Cary, N.C., Bernadine Lewandowski insisted on renting an apartment five minutes away.
· Her daughter, Dona Jones, would have welcomed her mother into her own home, but “she’s always been very independent,” Ms. Jones said.
· Like most people in their 80s, Ms. Lewandowski contended with several chronic illnesses and took medication for osteoporosis, heart failure and pulmonary disease. Increasingly forgetful, she had been diagnosed with mild cognitive impairment. She used a cane for support as she walked around her apartment complex.
· Still, “she was trucking along just fine,” said her geriatrician, Dr. Maureen Dale. “Minor health issues here and there, but she was taking good care of herself.”
· But last September, Ms. Lewandowski entered a hospital after a compression fracture of her vertebra caused pain too intense to be managed at home. Over four days, she used nasal oxygen to help her breathe and received intravenous morphine for pain relief, later graduating to oxycodone tablets.
· Even after her discharge, the stress and disruptions of hospitalization — interrupted sleep, weight loss, mild delirium, deconditioning caused by days in bed — left her disoriented and weakened, a vulnerable state some researchers call “post-hospital syndrome.”
· They believe it underlies the stubbornly high rate of hospital readmissions among older patients. In 2016, about 18 percent of discharged Medicare beneficiaries returned to the hospital within 30 days, according to the federal Centers for Medicare and Medicaid Services.
· Ms. Lewandowski, for example, was back within three weeks. She had developed a pulmonary embolism, a blood clot in her lungs, probably resulting from inactivity. The clot exacerbated her heart failure, causing fluid buildup in her lungs and increased swelling in her legs. She also suffered another compression fracture.
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· “These hospitalizations can lead to big life changes,” Dr. Dale said. Having grown too frail to live alone, Ms. Lewandowski, now 84, moved in with her daughter.
· Dr. Harlan Krumholz, a cardiologist at Yale University, coined the phrase “post-hospital syndrome” in a New England Journal of Medicine article in 2013.
· As Medicare began penalizing hospitals for 30-day readmissions under the Affordable Care Act, he looked at the national data and noticed that most readmissions involved conditions seemingly unrelated to the initial diagnoses.
· Patients came in with heart failure or pneumonia, were treated and discharged, then returned with internal bleeding or injuries from a fall.
· “Our general approach in a hospital is, all hands on deck to deal with the problem people come in with,” Dr. Krumholz said. “All the other discomforts are seen as a minor inconvenience.”
· He has argued instead that discharge marks the start of a 60- to 90-day period of increased vulnerability to a range of other health problems, stemming from the stress of hospitalization itself.
· “This is more than inconvenience,” he said. “This is toxic. It’s detrimental to people’s recovery.”
· Any hospital patient, or hovering family member, knows those stresses: Disrupted sleep, as staff draw blood and take vital signs at 4 a.m. A distorted sense of day and night. Unappetizing meals often served at inopportune times.
· Reduced muscle mass and poor balance following even a few days in bed. New prescriptions with unpredictable consequences. Shared rooms. Delirium. Pain.
· “It affects your hormones, your metabolism, your immune system,” Dr. Krumholz said. “All these things have widespread effects,” leaving people depleted and less able to stave off other health threats.
· The ripple effects vary considerably.
· Researchers at Yale followed discharged Medicare patients after hospitalizations for heart failure, heart attacks and pneumonia.
· Readmissions for gastrointestinal bleeding and anemia, they found, peaked four to 10 days after discharge. The risk of trauma from falls or other accidents, on the other hand, remained elevated for three to five weeks.
· While post-hospital syndrome remains a hypothesis for now, research on several fronts may help establish its validity.
· Donald Edmondson, a behavioral medicine researcher at Columbia University Medical Center, has pointed out links between the stress levels that heart attack victims report and their likelihood of readmission.
· In a meta-analysis, he and his colleagues found that 12 to 16 percent of heart attack patients, most of them older adults, actually develop post-traumatic stress syndrome.
· As Dr. Edmondson acknowledged, people experiencing heart attacks have multiple sources of stress, from fear of death to financial worries. But he and his colleagues also have measured the impact of the hospital environment itself. They compared patients (average age: 63) who came to the New York-Presbyterian Hospital emergency room when it was crowded and chaotic (median time in a crowded ER: 11 hours) to those who arrived when it was calmer.
· “The more crowded it is when you come in, the more PTSD symptoms you’ll have a month later,” he concluded.
· Now the Columbia researchers are following 1,000 E.R. patients with heart attacks, tracking their weight and stress levels and giving each a wearable device to measure physical activity and sleep. The results may help substantiate the effects of post-hospital syndrome.
· “We’ve gotten better and better at treating disorders, but we haven’t gotten to the point where we avoid some of the collateral damage to the patient,” Dr. Edmondson said.
· Making hospitals less destabilizing, more conducive to healing, seems an achievable goal. Hospitals do it for children, Dr. Krumholz has pointed out.
· They could enable older patients, too, to wear their own clothes, get out of bed for walks (even with IV poles), eat enough to maintain their weight. They could assess how many lab tests patients actually need, and whether blood needs to be drawn before dawn.
· “We should never wake a sleeping patient unless there’s a compelling reason, and that reason shouldn’t be our own convenience,” Dr. Krumholz said.
· But while we’re waiting for hospitals to adopt such policies, we could try a D.I.Y. approach.
· Families can bring in favorite foods and help their relatives eat. They can ensure that patients have their hearing aids, dentures, eyeglasses, and walkers or canes to help them stay oriented and mobile.
· With a physician’s O.K., they can accompany relatives on short strolls down the corridor to ward off deconditioning, and ask about curtailing wee-hour tests and readings.
· “It’s unfair to put families in this position,” Dr. Krumholz said. “It should come from the institution.” But cultural change takes time.
· Some hospitals already offer less stressful environments for older patients, including specialized geriatric emergency rooms.
· Among those moving in that direction is the University of North Carolina Hospitals Hillsborough Campus, where Bernadine Lewandowski had a private room, as all its geriatrics patients do. She was helped into a chair every day and encouraged to use a walker to reach her bathroom.
· The aftereffects proved profound, nonetheless. Already thin, she lost 15 pounds over two months. After her second hospitalization, she began wandering at night, apparently because of a new pain medication, and fell twice in two days. In April, she developed pneumonia, necessitating a third hospital stay.
· She’s doing better now, her daughter said. After physical therapy, Ms. Lewandowski can climb the stairs, with someone at her elbow, to her second-floor room. Her weight has stabilized. She enjoys spending time with her family and visiting the hair salon every other week.
· But, Ms. Jones said, “We were hoping she’d be with us for a short period and then return to her apartment.” And that never happened.
I try to not get too speculative about the future, but this article https://www.nejm.org/doi/full/10.1056/NEJMp1808427 does outline a potentially different role for the long-term care specialist in the MACRA era of healthcare reform; let me know if you need help getting full text.
Reflections-
902 Ott Lane, Baraboo WI, early 1980’s
The Wis-PALTCM Mission Statement-
It will be the purpose of this organization:
· To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.
· To establish better communication among physicians serving as medical directors and other providers.
· To promote better communication between medical directors and
(a) other post-acute and long-term care professionals,
(b) various long-term care associations, and
(c) officials of various government agencies.
· To represent medical directors in defining their roles and equitable compensation.
· To serve as a conduit between AMDA and the WAMD membership.
· To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.
· To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.
· To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilities
Wis-PALTCM: The Wisconsin Association of Medical Directors
www.wamd.org 6000 Gisholt Dr., Suite 200, Madison, WI 53713
Newsletter for November 2018
Newsletter for November 2018-
Ron Schreiber, MD, CMD, president 1707ron@gmail.com
Bob Smith, MD, CMD, immediate past-president rpsmith53@icloud.com
Curt Hancock, MD, CMD, webmaster cwhancock@gmail.com
T Rex Flygt, MD, CMD, newsletter editor Flygt@centurytel.net
Karen Miller, Executive Assistant KarenMiller.Rio@gmail.com
News-from around our organizations and our members:
Your WAMD held its Annual Meeting at the Mead Hotel, Wisconsin Rapids, October 5-6, 2018.
CME topics included
- Ophthalmology Pearls for Geriatrics (Bartow, MD)
- Fallout of Mega Rule Implementation and Revised Security Protocols (Purtell)
- Oral Health and Aging (Davidson DMD)
- Transitions in Care (Riello MD, Herbert MD, and Bruns MD)
- Fellows Panel (Hot Topics in PA/LTC)
- Department of Quality Assurance Update (Virnig RN)
- Osteoporosis and metabolic bone disease in Geriatrics (Mayeux MD)
- Building Networks on Survey Process (Virnig RN)
- Ethical Vignettes from Long-term Care (Ratner MD)
- Complying with S&C 17-30 Reducing Facility Risk for Legionella (Momont MD)
- Dementia Update (Przybelski MD)
- Bright Light Therapy in LTC (Ederer MD)
At the annual meeting itself
· The financial position of the organization remains sound
· Recruitment and retention is a full-time job for everyone
· Malik Ali and Paula Hardgrove were re-elected to the board of directors
· Membership fees will be increased somewhat
· If you want to be a delegate or alternate delegate the AMDA meeting, contact President Ron (address above); we will have a joint reception with Minnesota again—information to follow
· Past-president and long-term director Robert Smith and long, long-term aNewsletter