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ACOs, 3-Day Rule, Team Roles Are Top Issues

      “Vigilance” could have been the official theme of the annual meeting presentation on AMDA's policy priorities, part of the Saturday general session of Long Term Care Medicine – 2011 in Tampa. AMDA is positive but remains on guard about new models of care, such as accountable care organizations (ACOs), as well as decades-old issues such as patient eligibility for skilled nursing care, said Public Policy Chair Eric Tangalos, MD, CMD.
      On these and other fronts, he added, patients and caregivers were at the core of AMDA's 2010-2011 public policy achievements.
      Dr. Tangalos explained that ACOs, as they are presently described in models, do not include the long-term care setting. In December, the association responded to a Centers for Medicare & Medicaid Services request for input on ACOs. AMDA recommended that ACOs establish relationships with LTC organizations, especially to ensure smooth and successful transfers of patients between LTC facilities and other care sites within the ACO framework. Related issues include easy access for LTC practitioners to the electronic medical records of patients in ACOs and efforts to provide cost-effective, high-quality, and person-centered care to LTC patients, whether or not they enter ACOs.
      “ACOs are attempting to manage care in a fee-for-service universe,” said Dr. Tangalos. “Our role is not to forget the nursing home patients.”
      AMDA's comments to the CMS served as a springboard for a resolution from AMDA's Public Policy Committee and the Missouri Association of Long-Term Care Medicine. The policy, passed by the House of Delegates on Saturday after the general session, directs AMDA to encourage investment by ACOs in infrastructure to improve processes and deliver high-quality and efficient care in all settings. It further recommends that ACO program standards allow for the generally lesser technologic capabilities of small practices and those involved with long-term care.

      Three-Day Stay

      Dr. Tangalos also reviewed new developments concerning the longstanding Medicare policy on patient eligibility for care in skilled nursing facilities. He recalled that as far back as 1991, AMDA, within the framework of the American Medical Association, was raising the problem of the requirement for a 3-day inpatient hospital stay for skilled nursing care. “Twenty years later, we are still having the same problem,” said Dr. Tangalos.
      Furthermore, some hospital patients today are being held for extended periods in observation status, which doesn't count toward Medicare eligibility for skilled nursing care. A patient may be in observation status for many reasons, said Dr. Tangalos, including not being well enough to be discharged but still not fulfilling criteria for inpatient status. Or, the hospital simply might not have an inpatient bed available. “The care furnished in these other settings within the hospital is often indistinguishable from the inpatient care that follows the formal admission,” Dr. Tangalos said in an interview.
      AMDA's Connecticut chapter worked with Rep. Joe Courtney (D-Conn.) when he authored the Improving Access to Medicare Coverage Act of 2010, which he introduced last year. The legislation would force Medicare to count observation in a hospital exceeding 24 hours toward satisfying the 3-day-inpatient eligibility requirement.
      Although the legislation died at the end of last year's Congress, Rep. Courtney has pledged that it will be reintroduced this year, and AMDA will support the bill.
      AMDA also testified on the issue at an August 2010 CMS Listening Session. Testimony pointed out that AMDA members directly observe the placement of patients in skilled nursing facilities and have long opposed efforts that interfere with the timely admission of individuals who require that level of care versus acute care hospitalization.

      Team Approach to Care

      Last fall, the Institute of Medicine issued a report calling for a maximum level of performance for nurse practitioners. “The Future of Nursing: Leading Change, Advancing Health” suggested that nurse practitioners should be allowed to perform nursing home–admission assessments as well as certifications for hospice and home-health care services. “If there are indeed shortages, simply throwing more [nurse practitioners] at it won't fix the situation,” said policy-session copresenter and incoming Public Policy Committee chair Charles Crecelius, MD, PhD, CMD.
      Even before the report, AMDA had authored a paper on the roles of attending physicians and advanced practice nurses in long-term care. AMDA's position is that the policy makers should focus on building the most effective care team, said Dr. Crecelius. “We shouldn't promote one profession over another. … The regulatory definition [of supervision and collaboration] is brief and may not cover every circumstance in long-term care,” and it is hard to extrapolate definitions from other fields of medicine.
      AMDA created its paper by convening a work group that included representation from the Gerontological Advanced Practice Nurses Association, the American Academy of Family Physicians, and the American College of Physicians, explained Dr. Crecelius. “If you collaborate, read this paper,” he advised the audience. The report was published in the January 2011 issue of the Journal of the American Medical Directors Association (J. AMDA 2011;112:12-18).
      DR. WILSON is director of government affairs for AMDA.