September 01, 2009

No one can dispute the growing acceptance of assisted living as an option for long-term care residents. Is it time for physicians to become more attentive to the needs of AL residents? Sheryl Zimmerman, PhD, and her colleagues have evidence that it is. Dr. Zimmerman, a researcher at the University of North Carolina at Chapel Hill, noted that the dependence and care needs of AL residents have increased such that this population resembles that of nursing home residents a decade ago. She reports that more than half of assisted living residents have cognitive impairment and require assistance with bathing, dressing, and taking medications. Physician involvement in AL is beneficial because it can result in fewer nursing home placements and less hospitalization, emergency department use, inappropriate prescribing, and underprescribing.

Research on AL Physicians, Staff

Dr. Zimmerman participated in the most recent AMDA Annual Symposium on AL, entitled “Medical Practice in Assisted Living: Medication Management, Falls Prevention, and Physician Care,” along with Paula Carder, PhD; Kirsten Nyrop; Barbara Resnick, PhD, CRNP, FAAN, FAANP; John Schumacher, PhD; and Philip Sloane, MD, MPH. The session covered several AL research projects.

Dr. Sloane, a professor of family medicine at the University of North Carolina at Chapel Hill, presented findings on medication errors in AL. He reported that serious drug-administration errors by facility staff are relatively uncommon. Nonetheless, some drug categories are especially prone to serious administration errors, particularly drugs with low therapeutic ratios (for example, insulin and warfarin) and medications that are not unit dosed (such as eye drops and inhaled medications). These should be targets of staff-education efforts, he said.

The biggest medication problem in assisted living, said Dr. Sloane, is prescribing errors. He recommended that attention be directed not only to the Beers criteria drugs but also to those with any degree of anticholinergic effect and to antipsychotics and other sedating drugs with significant adverse event potential.

Over-the-counter medicines are unstudied but probably important in AL, said Dr. Carder of Portland State University, Oregon. She asserted that the picture of medication use in AL is incomplete because nonprescription products are not included in most research. She said that physicians need to routinely discuss the use of these products with AL residents. Dr. Carder also raised the question of how unlicensed medication aides decide when to administer PRN (as needed) medications—certainly an important issue to the prescribing AL physician.

Dr. Resnick, a professor of nursing at the University of Maryland, Baltimore, discussed an approach to care called Restorative Care in Assisted Living Intervention. This method focuses on changing the philosophy of direct care in AL communities to optimize resident physical activity in all interactions with staff (such as bathing, dressing, and transporting).

Dr. Resnick said she believes that having all AL health care professionals use this approach could improve residents' function and quality of life, and possibly lead to a reduced rate of transfers to hospitals and nursing homes. Physicians, nurse practitioners, and physician assistants providing primary care for residents in these sites have a role in restorative care by optimally treating congestive heart failure, anemia, and other clinical problems that impact function, said Dr. Resnick.

Ms. Nyrop, a doctoral student at the University of North Carolina at Chapel Hill, presented preliminary data about physician perspectives on fall prevention in AL. The early results of her study suggest that physicians strongly agree that AL patients should be assessed for fall risk and that knowing the result will affect physician and staff actions.

Yet a minority of physicians report they conduct such assessments, and most believe AL staff are not capable of doing them. Ms. Nyrop's conclusion was that physicians need to assume more ownership of this activity and better equip AL staff to conduct fall-risk assessments.

Dr. Schumacher of the University of Maryland, Baltimore County, then related falls in AL to principles of physician communication. He said that his research indicates that physicians need to address four Cs: colossal heterogeneity in AL settings; complexity in physician-AL-patient relationships; communication and managing AL relationship issues; and the collective action of physicians to attend to AL issues. Attending to these items could ensure seamless community-based care, promote preventive care and wellness, identify patient sentinel events earlier in the process, and contribute to quality of life outcomes, said Dr. Schumacher.

Concerted Action in AL?

What is the ideal physician practice in assisted living? That question may be impossible to answer because of the great variety of AL communities. Alec Pruchnicki, MD, of the department of geriatrics at Mount Sinai Medical Center, New York, has reported that the incidence of falls decreases and that residents benefit in other ways when a physician practices full time in the AL setting.

Most communities have no on-site physician, though. There's no primer or course about physician care in AL, and there isn't even a mandate for having a medical director in these settings (a concept that failed to reach consensus approval by the Assisted Living Workgroup early in this decade).

AMDA is working to provide some guidance. A position paper on the physician's role in AL passed at this year's House of Delegates meeting in March, and the AMDA board subsequently approved it.

The document suggests AL policies regarding medication management and disclosures of facilities' clinical capabilities and service limitations. It also emphasizes, in agreement with Dr. Schumacher's sentiments, the importance of good communication between AL facilities and physicians. Those practicing in the AL setting are urged to understand the AL policies in order to provide better patient care.

Another strong recommendation in the position paper is to “form a core committee of qualified individuals (including nurses in AL care) to … lay a foundation upon which education, research and new developments can be shared with our members and those of other related organizations.” Establishment of an AL subsection in AMDA, similar to home care and hospice subsections of the past, was alluded to.

Such concerted action by physicians could lead to improved care in many different areas:

▸ Guiding AMDA policy and action in AL.

▸ Working with other medical organizations that have expressed interest in AL (such as the American Society of Consultant Pharmacists, the American Geriatrics Society, and the American Academy of Home Care Physicians) to achieve quality goals.

▸ Establishing better ties with the American College of Physicians, the American Society of Internal Medicine, and the American Academy of Family Physicians to improve geriatric care and medication management by primary care physicians.

▸ Increasing physician involvement in the Center for Excellence in Assisted Living to provide more health care-related expertise.

▸ Suggesting and becoming involved in AL research with the AMDA Foundation.

▸ Developing innovative services, such as AL medical director primers, and sharing AL-specific in-service education to foster improved collaboration between physicians and midlevel practitioners in the AL setting.

Political action by physicians in AL is another intriguing subject. In most states, laws and regulations are handed down from the state without significant input from the physicians who are supposed to follow and use them. It would be sensible to foster physician input with legislators. This issue along with many already mentioned could be addressed by Assisted Living Workgroups in individual states (something, for example, that Virginia has done). Concerted physician action might be a good way to accomplish this.

There are many unanswered questions about strengthening physician involvement in AL. Without a specific national organization for AL physicians, how can physician interest be ascertained? If a group is developed, what would its structure be? What would be its priorities? What are the fiscal implications?

These are difficult issues, but there are definitely physicians willing to work at answers. AMDA currently is developing an online community to network and discuss AL topics (those interested should e-mail contact information to Kathleen Wilson at

kwilson@amda.com

These initiatives are welcome. AMDA has an important responsibility to teach nonmember physicians about AL and what special considerations are required when they see AL patients in their offices. For instance, giving an AL patient a prescription is a nightmare if the resident is not able to take meds independently and the physician doesn't know what services are and are not available in the facility. The challenge is imminent and growing, and AMDA should take it on with vigor.

<- Back to: Board Room