Archive for: Quality of care
Industry Has Responsibility for Helping with End of Life Planning
Editor’s note: This article was written by guest blogger Anthony Cirillo, FACHE, ABC, a healthcare marketing and experience management expert and expert guide in assisted living for about.com. He is also the National Health Care Channel Partner for CEO2. For more information about the author, please see our About page.
If California is reflective of the nation then the results of the 2011 Californians’ Attitudes and Experiences with Death and Dying survey are worth sharing. Compiled by the California Healthcare Foundation, here are some of the highlights (based on level of importance), which relate to people’s experiences concerning the death of a loved one, as well as their own preferences for end-of-life care:
- Making sure my family is not burdened financially by my care: 67%
- Being comfortable and without pain: 66%
- Being at peace spiritually: 61%
- Making sure my family is not burdened by tough decisions about my care: 60%
- Have loved ones around me: 60%
- Being able to pay for the care I need: 58%
- Making sure my wishes for medical care are followed: 57%
- Not feeling alone: 55%
- Having doctors and nurses respect my cultural beliefs and values: 44%
- Living as long as possible: 36%
- Being at home: 33%
- A close relationship with my doctor: 32%
Other key items worth noting include:
- Twenty-eight percent of Medicare spending occurs in the final year of life; 12% occurs during the final two months
- Thirty-eight states have obesity rates over 25%; 42 states have diabetes rates over 7%; one-in-five adults smoke cigarettes, which adds $100 billion in healthcare costs
Eighty-two percent of Californians thought it was somewhat or very important to put their wishes in writing but just 23% had done so. And 92% have never spoken to their physician about this issue.
I found it interesting that just 33% preferred dying at home. Probably based on my own personal beliefs, I thought it would be much higher. But what that means is that patients could very well be in your care, and often are, when the final moments of their life are upon them. As an industry that puts patients and residents first, it just makes sense to take responsibility in assuring that your residents die with dignity.
Last month, citing palliative care, I initiated this discussion as a kind of starter conversation into death and dying. While I alluded to available tools (Engage With Grace: The One Slide Project and Five Wishes), I don’t think I was emphatic enough in stating my belief that the industry must take a role. This California study took me to that level.
Notes from the April 12 SNF ODF
CMS covered a number of topics during the April 12 SNF Open Door Forum (ODF), leading off with an overview of the national behavioral health quality initiative, which was first introduced with a video presentation on March 29. The initiative aims to reduce the rate with which antipsychotic drugs are used unnecessarily with residents suffering from dementia, resulting in negative, unintended consequences.
The prevalence in long-staying nursing home residents is about 20-25% (national average). In addition, considerable research has revealed that these drugs, at least for the nursing home population, have very limited efficacy. These drugs also pose a risk of death in the elderly population. The initiative has set out to ensure that no one in a nursing home is receiving antipsychotic drugs unless it is deemed medically necessary based on a very detailed process that includes:
- Identifying a clinical indication
- Making sure that either the resident or a family member is involved in the decision-making
- Ensuring that medical causes of cognitive changes are ruled out
- Attempting behavioral interventions first by properly trained staff members
The initiative’s goal is to reduce the rate of antipsychotic drug use in nursing homes by 15% by the end of this year. CMS admits it is an aggressive goal, but procedures are in place to reach that goal including:
- Educating providers, subscribers, pharmacists, and consumers on the alternatives of antipsychotic drug use
- Public reporting (posting national and state rates of antipsychotic drug use by the summer; facilities will receive their own rates from CMS and compare their rate to other facilities in the state and across the country)
A two-day dementia care/nursing home care technical expert panel was recently held as part of the initiative, which included roughly 35 people from across the country. A range of individuals were present including:
- Geriatric psychiatrists
- General psychiatrists
- Geriatricians
- Nurses
- Social workers
- Policy makers
- Advocates
- Nursing home residents
- Resident family members
The panel made training curriculum recommendations for providers and nursing home surveyors. The initiative aims to complete those training programs by the end of 2012.
Through the Affordable Care Act (ACA), CMS was charged with developing abuse prevention and dementia care training for nursing assistants. A DVD titled, Hand in Hand, which was filmed in nursing homes and shows interactions between residents, family members, and staff, illustrating critical principles of exemplary dementia care, is in production. Upon completion, which should be soon, the DVD and an instructor’s manual be sent out to all nursing homes nationwide over the summer. Train-the-trainer programs are also being developed by CMS as an additional resource.
Partners in the national behavioral health quality initiative include:
- Multiple government agencies in addition to HHS and CMS (DOJ, OIG, FDA, VA, AOA)
- The Substance Abuse and Mental Health Services Administration (SAMHSA)
- Health Resources and Services Administration (HERSA)
- State survey agencies
- QIO regional offices
- Numerous advocates, who initially pushed for this initiative in 2011
The initiative is also working with professional associations, including:
- AHCA
- LeadingAge
- AMDA
- The American Geriatrics Society
- The American Society of Consulting Pharmacists
- NADONA
- CGNO
The initiative is reviewing existing surveyor guidance such as unnecessary drugs (F329), resident rights to be free from unnecessary drugs, chemical restraints, and clinical standards for dementia care and related illnesses in order to provide surveyors with the best possible information. Currently, the initiative is conducting a qualitative study in 25 nursing homes in five different states. Researchers are asking prescribers, pharmacists, and nurses about how they decide when a resident suffering from dementia may benefit from antipsychotic medication. In understanding how these decisions get made, the initiative hopes to better determine potential alternatives that may be safer and more effective than drug use.
Any questions about the national behavioral health quality initiative can be directed to dnh_behavioralhealth@cms.hhs.gov.
Additional topics explained and announcements made during the ODF include:
- The nursing home interpretive guidelines are currently being evaluated and updated. They will likely be released within the next few months.
- The ACA initiative to reduce avoidable hospitalizations among nursing facility residents is underway. It is a collaborative effort between the CMS Medicare/Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation. Currently, there are roughly nine million beneficiaries enrolled in Medicare and Medicaid. About two-thirds of nursing home residents are enrolled in both programs. It is these residents who are often susceptible to avoidable hospitalizations. Research has found that nearly 45% of hospitalizations involving dual beneficiaries were potentially avoidable. The objectives of the initiative are to reduce the frequency of avoidable hospital admissions and readmissions, to improve resident health outcome, to improve the process of transitioning between inpatient hospitals and nursing facilities, and to reduce overall healthcare spending without restricting access to care or choice of providers. Applicants must propose their own evidence-based intervention and improvement strategy. Participation is voluntary. Providers who would like to get involved must obtain letters of intent from a minimum of 15 Medicare/Medicaid-certified nursing facilities in the same state with an average resident census of 100 or more residents per facility. Providers must also obtain a letter of support from the state Medicaid agency and the state survey and certification agency. Preference will be given to proposals that are for locations where there are high Medicare costs, high hospitalization rates, and where Medicare/Medicaid beneficiaries account for a high percentage of residents within the nursing home. At least seven awards will be given involving about 150 nursing facilities. Interested parties must submit a notice of intent to apply by April 30. The complete application is due to CMS by June 14. Questions can be sent to nfinitiative2012@cms.hhs.gov. A transcript and recording from the conference call that was hosted on April 3 are posted on CMS. An educational webinar will be hosted April 17; technical requirements (how to apply, eligibility, etc.) will not be discussed.
- CMS has been informed that some vendors may not have updated their software prior to April 1 in conjunction with the changes to the MDS 3.0. For those providers affected, the CMS software (jRAVEN) can be used until updated software is provided by said vendors. jRAVEN can be downloaded from www.qtso.com. Click on the jRAVEN/RAVEN link in the box on the left.
- The MDS 3.0 public frequency reports will be posted in the near future.
- The MDS 3.0 QM reports are temporarily unavailable. CMS is working to fix this issue, and hopes to have the reports available within the next few days.
- The March 2012 SNF clarification memo has been posted to the SNF PPS website. It is currently under the title Clarifications to March 2012 National Provider Conference Presentation (V1.1) and is listed under “FY2012 RUG-IV Education and Training”.
- The RAI User’s Manual, effective April, has been moved from the MDS Training page and is located on the MDS 3.0 RAI Manual page. The Training page will only hold upcoming versions that are not active. Previous versions of the RAI User’s Manual are available at the MDS 3.0 Archive page.
- Errata documents will also be posted to the MDS 3.0 RAI Manual page. CMS will be publishing V.4 of the RAI User’s Manual and will be available on the MDS 3.0 RAI Manual page once technical issues are solved with the CMS website. The most recent errata document will correct grammar issues and will address pages with updates to the RAI User’s Manual, which were presented at the MDS National Conference.
- If you were not able to ask a question during the Q&A segment of the ODF, CMS invites you to submit your questions to the SNF ODF mailbox (SNF_LTCODF-l@cms.hhs.gov).
Palliative care can lower cost and bridge transitions and conversations
Editor’s note: This article was written by guest blogger Anthony Cirillo, FACHE, ABC, a healthcare marketing and experience management expert and expert guide in assisted living for about.com. For more information about the author, please see our About page.
We hear so much about lowering costs in healthcare today. And yet:
- 93% of physicians practice defensive medicine, ordering diagnostic tests, referring to other specialists, and prescribing medications
- 28% of Medicare spending occurs in the final year of life; 12% occurs during the final two months
- 38 states have obesity rates over 25%; 42 states have diabetes rates over 7%; one in five adults smoke cigarettes adding $100 billion of healthcare cost
We can argue malpractice reform, personal responsibility, and all of that. But we also have to learn to use what we have. And perhaps palliative care can help.
According to presenters at the Governance Institute, implementing a first-class palliative care program can cut costs and provide better quality of life not just for the dying but also those with chronic conditions and serious illness. Using palliative care saves the healthcare system $1,700 per discharged patient.
Waste in medical services is currently estimated at 20% to 35% of total healthcare spending. The following contribute to waste:
- Services necessitated by incorrect and/or unsafe practices
- The use of unproductive or counterproductive interventions
- Failure to use the least-expensive appropriate resources
- Redundant reimbursement
The argument was made that we must have a worldview of palliative care as comprehensive, interdisciplinary care focusing on promoting quality of life. In fact palliative care is the best way to have important conversations with patients and families about the right level of care given the expected outcome.
Of course we are reimbursed in a fee-for-service environment and until the shift to wellness and bundled payments takes place, there is little incentive for providers to change their ways. Yet perhaps if we realize that this could be in the best interests of the patient and truly embrace person-centered care, providers would change.
I think patients know what is right for them and I think families intervene. That is why programs such as Engage With Grace: The One Slide Project are important. It poses five questions designed to help get us talking with each other and with our loved ones about our preferences.
Most people do not die according to their wishes. And they should. That is why they need to put it in writing. And that is where another resource, Five Wishes, comes in.
It lets your family and doctors know:
Who you want to make healthcare decisions for you when you can’t make them
The kind of medical treatment you want or don’t want
How comfortable you want to be
How you want people to treat you
What you want your loved ones to know
Five Wishes has become America’s most popular living will because it is written in everyday language and helps start and structure important conversations about care in times of serious illness.
If we truly put people at the center of care we will embrace alternative care methods such as palliative care and start discussing death and dying in this culture and not avoid it. It is ultimately about quality of life at the end of life.
And providers play a role.
CMS initiative will address use of antipsychotics and behavioral health
CMS has launched a new initiative aimed at improving behavioral health and safeguarding nursing home residents from unnecessary antipsychotic drug use. As part of the initiative, the agency is developing a national action plan that will use a multidimensional approach including public reporting, raising public awareness, regulatory oversight, technical assistance/training, and research. The action plan will be targeted at enhancing person-centered care for nursing home residents, particularly those with dementia-related behaviors.
On March 29, CMS streamed an overview of the initiative live on the Internet. The video, which can be viewed at http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1098, included a detailed case study involving a fictional elderly resident who suffers from dementia. After reviewing the case study, a panel of residents, advocates, clinicians, and policy makers discussed how providers, residents, families, and CMS can work together to optimize care for residents like the one depicted in the case study.
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