Charting the Course of Post-Acute and Long-Term Care Medicine

1. Charting the Course of Post-Acute and Long-Term Care Medicine The Mid-Atlantic Society for Post-Acute and Long-Term Care Medicine

2. Our Panelists: • Joanna Frankel, LCSW-C • Harold Bob MD • Mary Evans MD - Moderator • Renee Joyner MA • Barry Grofic MA • The panelists, unless otherwise noted, have no relevant financial disclosures

3. Critical Role of Leadership in Managing Day-to-Day and Complex Situations

4. Objectives: • Outline strategies for effective management of difficult cases in changing populations in long-term care • Integrate conflict resolution and other problem-solving tools in managing diverse populations in long-term care

5. Plan for the session (90 min): • Introduction of panelists • Moderator comments • Presentation of Case #1 for panelist discussion • Presentation of Case #2 for attendees – panelists will circulate to tables and discuss • Tables designate spokesperson • Discussion of Case #2 with spokespeople • Wrap up

6. Factors in our environment: • Medically complex patients • “Sicker and quicker” • Pressure to discharge to community • Pressure to avoid rehospitalization • Challenging psychosocial situations • Difficult “safe” discharge planning • Increased regulatory scrutiny

7. Factors to Consider: • Patient’s well being • Decision making capacity • Elder Care Justice Act reporting requirements • Legal risks • Ethical ramifications • Regulatory risks • Family/caregiver stress and burnout

8. Ethical Principles • “First of all, do no harm” • Autonomy • Justice • Beneficence • Non-maleficence

9. Possible Resources: • LTC Ombudsman • APS referral • Report to State • Report to local Police • Ethics committee • Consult with facility’s legal team • Escalation of concern to company’s field support team

10. Case #1- Panelists Discussion • Henry, a 67 year old man with cirrhosis, diabetes, hypertension and chronic pain, was recently hospitalized after a stroke. He was sent to your PALTC facility and made slow progress toward his therapy goals. Two days before his planned discharge (to home with a caregiver), the nursing staff note a Stage 4 sacral ulcer. He will have exhausted his Medicare Part A benefits on the day of discharge. What happens now?

11. Case #2 – Table Discussions • 88 yo female long term resident in a skilled nursing facility. Has dementia and has been determined to lack DMC. Daughter is very involved with her care, is in the facility daily, and is documented to be very demanding with staff, sometimes yelling at the staff and making demeaning comments about her mother’s care. Daughter calls the physician regularly to complain about mom’s care, physicians are very frustrated about requests for unnecessary tests and interventions

12. Case #2 • 88 yo female long term resident in a skilled nursing facility. Has dementia and has been determined to lack DMC. Daughter is very involved with her care, is in the facility daily, and is documented to be very demanding with staff, sometimes yelling at the staff and making demeaning comments about her mother’s care. Daughter calls the physician regularly to complain about mom’s care, physicians are very frustrated about requests for unnecessary tests and interventions

13. Case #2 • Daughter brings concern about vaginal discharge to nursing staff, demands a vaginal exam be performed • Physician performs exam, sees no abnormal vaginal discharge • Daughter demands vaginal cultures, physician declines to do cultures

14. Case #2 • Daughter takes vaginal cultures herself, demands that they be sent to lab. She also asks for a pelvic ultrasound to further evaluate the discharge. Physician declines • Daughter asks pt to be sent to ER for eval, ER finds “UTI” and admits pt per daughter’s demand and is treated with antibiotics. After 3 days pt is returned to SNF. • Daughter is unhappy with care and demands an MRI to further evaluate her perception of vaginal discharge. Calls the State to complain

15. Case #2 • The latest attending physician fires the pt because of daughter’s demands, Medical Director has to take on pt as no other physician will care for her • State survey complaint investigation yields no tags, complaint unsubstantiated • Administrator is wishing to discharge patient, daughter refuses to take her mother elsewhere, stating “this is her home and she will stay here”

16. Case #2 • What should be done now? • What could we have done earlier to prevent this case going down this path?

17. Case #2 • Small group discussion with panelists • Election of spokesperson • Sharing of ideas

18. PALTC is a Team Sport • “Never be unhappy alone”