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In this month’s column, Dr. Jeff continues to answer the question from the November/December 2020 issue, focusing on deprescribing.
Dear Dr. Jeff:I recently completed a geriatrics fellowship and joined a multispecialty group practice in a small city. A few months ago, I agreed to serve as the Medical Director for a nearby 4-star nursing home. We have survived the pandemic rather successfully, but as I reviewed patient charts, I was pleased by the nursing documentation but appalled at the medical care our residents receive. Our physicians have all been on staff for years and generally have practices in the community. One is even from my group. But polypharmacy, overmedication, and inappropriate medications for the elderly seem like the standard while documentation of actually speaking with residents and families or examining the residents is sparse. Medical orders are largely entered remotely with little time spent in the facility. Our corporatesponsoris beginning a strategic planning process to prepare for the nursing home of the future, but I am not sure we are ready for the nursing home of today. Any suggestions?
Dr. Jeff responds:
Changing outcomes requires changing the systems that produce those outcomes. In my last column, I discussed possible changes in the care delivery system through strengthening the medical staff itself, including adding more providers and more on-site medical presence, particularly those committed to the care of the special demographic living in our facilities.
Over the last decade, nursing homes have been admitting new residents with increasingly complex medical needs and struggling to avoid hospitalization for patients whose medical status is decompensating. The Patient Driven Payment Model (PDPM) adopted by Medicare provides financial incentives for skilled nursing facilities to provide care for higher acuity patients. Hospitals will be encouraged to discharge even “quicker and sicker,” a process that had already begun a decade ago. Those with minimal supportive needs or requiring only custodial care will increasingly go to the assisted living programs of the future or some variant of enhanced home care program, although many already in nursing homes are likely to stay as residents. These changes will be accelerated by the fears of individuals and families stoked by COVID-19 outbreaks in many facilities and the new unfavorable and usually unfair media attention these have elicited.
Searching for Allies
Some change is inevitable. But despite occasional nods in the direction of a need to rethink long-term care, there appears very little political will to address the complicated changes and major investment that would be required on the national and local levels for any major planned transformation. Responses to the devastation that COVID 19 has produced in many facilities have concentrated on more investment in facilities and higher staffing models with increased training requirements and skill levels for staff.
Despite muttering about the need to eliminate nursing homes, even transformational plans are aimed at alternate (and typically less expensive) care delivery models for those who require less care. There are no serious plans to address the needs of the high-acuity patients cared for in today’s nursing home. Although large numbers of voters have identified health care as their major concern for the 2020 elections, neither party put forward a platform to address the needs of long-term care. Indeed, the Republicans did not even update their health care platform from 2016. With global warming, there might not even be sufficient ice floes to send every nursing home resident out to sea. The proposal that frail seniors sacrifice themselves to the needs of the economy, made openly by Texas Lieutenant Governor Dan Patrick and quietly by all the politicians who have systematically underfunded long-term care for years, is the de facto plan for the future. All these patients deserve patient-centered, goal-concordant care from skilled and knowledgeable practitioners. Unfortunately, few are likely to receive it.
Before you despair of your ability to impact the quality of care, I want to reassure you that committed and knowledgeable medical directors have the ability to significantly improve care in their facilities and have demonstrated this many times in a wide variety of facilities over decades. Moreover, the national organization AMDA – The Society for Post-Acute and Long-Term Care Medicine and your state chapter have abundant resources to help you. These include podcasts and an email discussion forum plus publications like Caring for the Ages and the Journal of the American Medical Directors Association. Other helpful resources include Choosing Wisely recommendations directed at long-term care medical decisions, virtual conferences and lectures (including many archived for review), as well as colleagues and mentors for support and feedback.
Although most geriatrics programs expose their fellows to various sources of academic information regarding the field, some of which do contain useful information regarding quality improvement in long-term care, few programs expose their fellows to the wealth of information and support dedicated specifically to the long-term care space and its particular needs and concerns. The major exception to that has been the participants in the AMDA Foundation Futures program. Academic detailing — using experts in a particular focus of concern — has had only marginal success at best for addressing physician prescribing practices. Distribution of articles or guidelines without individual discussions and reinforcement has been even less successful.
Information by itself will usually not improve care systems. Fortunately, you do have potential allies within your building who can assist you toward your goals. These include your vendor pharmacy, your consultant pharmacist, and the director of nurses along with the nursing staff. Polypharmacy and inadequate documentation can significantly cost your facility in lost reimbursement, medication acquisition costs, and the nursing time required to administer and monitor medications. Administration buy-in and support should be relatively easy to obtain. Although the justification for your quality improvement efforts should not be cost saving per se but rather improved resident quality of life and reduction in medication side effects, the reallocation of the vast amounts of wasted resources to hire more frontline staff and free up nursing time to more productive care are giant potential benefits.
Most dispensing pharmacies provide monthly renewal forms for medications and other provider orders. These may be preprinted for facilities that still maintain paper charts or linked into the electronic health record (EHR), which the commonly used EHR systems can accommodate. These pharmacies will typically attach standardized note forms for provider history and physicals, which they will either print on the back of the orders or collaborate with the vendor of the EHR to link with the order. These standardized forms can be individualized to the needs and preferences of your facility but are typically user friendly and comprehensive. From the viewpoint of your providers, they document and justify higher billing levels, but for the facility and resident care they direct provider attention to issues such as weight, cognitive status, and skin integrity, which are often overlooked in spontaneously created notes. They typically offer check boxes for many issues, which increases compliance while decreasing documentation time. Because they are attached to the monthly orders, they encourage routine visits and offer a convenient format to ensure that medication regimens include only therapies that match resident needs and are effective.Given their knowledge and perspective, consultant pharmacists should be viewed as logical allies of a committed medical director.
Every facility has a consultant pharmacist or pharmacists whose task is to review and improve prescribing practices in the facility. Consultant pharmacists often have a broader perspective on prescribing practices within the facility and how they compare with similar facilities, and most are knowledgeable regarding the specialized pharmacologic issues of a population of frail older adults. They are the logical allies of a committed medical director, particularly as they are reimbursed for the time spent performing monthly reviews of every individual resident’s medication regimen. Medical directors need to check that these reviews are being done and that practitioners are responding to them. Medical directors need to be alerted immediately to any critical issues identified.
Most of the suboptimal practices that concern you take a different approach. Regular meetings, whether in person or remotely, will permit you to develop a strategy to work on your goals. I would strongly encourage involving the nursing administration in this process. Confirmation from the director of nursing and floor nurses that various medications are no longer needed can encourage practitioners to discontinue them, and most practitioners will be reluctant to discontinue medications that frontline staff consider necessary.
One ideal place to start medication reduction is the near-total elimination of fingerstick glucose measurements with insulin coverage. Despite multiple expert guidelines from the American Diabetes Association, the American Geriatrics Society, and our Society, which condemn management of stable diabetics with this regimen, its use remains surprising common in skilled nursing facilities. Sometimes patients with orders for monitoring four times daily with potential coverage have never or rarely received insulin. Sometimes they remain on short-term insulin doses and are never converted to long-acting insulin once daily or have their existing dose readjusted. Some are not even diabetics — they might have had elevated sugars in the hospital because of an acute infection or intravenous dextrose or corticosteroid administration, but these orders continued after transfer to a post-acute setting, where they have been renewed for months or years.
For infection control, insulin vials must be individualized to each patient. Irrationally expensive insulin vials, including unused or barely used vials, must be discarded and replaced after 30 days at considerable cost to the health care system as a whole and, depending on Medicare Part A status or other reimbursement issues, often directly to the facility.
Obviously, the regimen is a painful one for residents, who suffer for no benefit and may be placed at risk of dangerous episodes of hypoglycemia. Few clinicians consider the massive time commitment that these needless glucose measurements represent for the nursing staff. Residents must be brought to their rooms while where a licensed nurse — using equipment that must undergo routine quality determinations with controls — then must perform and document the determinations. The nurse must then safely dispose of the lancets and other blood-contaminated supplies. All this represents from five minutes to 20 unpleasant minutes per day per diabetic resident. Many hours of valuable nursing time are wasted.
Federal requirements list relatively few mandatory roles for the medical director. One of these is to advise the facility regarding care practices, and another is to participate in the Quality Assurance Performance Improvement process. Your desire to lead improvements in documentation and medication utilization are central to your role. As with nearly everything else in long-term care, it will be a process rather than instantaneous change and will be more effective with the collaboration of an interdisciplinary team. But, in the end, you have the potential to lead meaningful change.
Dr. Nichols is past president of the New York Medical Directors Association.