Long Term Care Past, Present, and Future Daniel Swagerty , MD, MPH, CMD AMDA Foundation Chair

1. Long Term CarePast, Present, and FutureDaniel Swagerty, MD, MPH, CMD AMDA Foundation Chair

2. Themes Health Care Delivery is changing Nursing Facilities are transforming from sites of custodial care into sites of high intensity care for sick, complex patients Expectations are rising Much more is and will be expected of facilities, attending physicians, and medical directors

3. Themes Long-Term Care Medicine is a legitimate specialty More and more care will be provided by fewer practitioners AMDA is committed to meeting the needs of LTC practitioners for information, education, support, advocacy, and recognition

4. LTC: Past “Rest Homes” The road to the nursing home is said to be ONE WAY Custodial care for patients with severe cognitive impairment, functional impairment, or both Physicians absent or inadequate Skilled care absent or low intensity

5. LTC: Present • Form follows finance: Increased focus on shorter-term ‘skilled care’ = increased revenue/profit for facilities • Patients discharged from hospital ‘sicker and quicker’ with greater and more acute needs • Frequent mismatches between patient and family needs/expectations and available resources • Rapid access to pain medications, availability of physicians, information from hospitals, provider skills, etc. • The job of nurses and doctors are different from the job for which they were trained • Increased governmental/payor emphasis on quality measures, especially for issues/areas of high cost (hospital readmission rates, antipsychotic drug use)

6. Common Care Delivery Problems in SNFHospital Related Issues • Facility not able to provide necessary, appropriate or desired care • Lack of communication/ handoff of care between hospital/LTC physicians, staff • Inadequate medication reconciliation in hospital = Prescribing errors • Unprofessional practices in hospital • Lying about patient care needs or omitting important facts in order to get SNF to accept patient • Failure of hospital to provide medication and treatmentson day of transfer resulting in pain and other acute problems upon arrival to SNF

7. Common Care Delivery Problems in SNF Hospital Related Problems • Inappropriate and/or unnecessary care in hospital - Excessive medication doses, chemical/physical restraints, PPIs, heparin • Inadequate patient communication • Lack of accurate explanation of patient diagnoses, prognosis, hospital course, goals by hospital staff with unrealistic expectations created • Ignorance of health care delivery, SNF Care, regulatory environment by hospital staff with unrealistic expectations created • Failure to provide specialty physician follow-up

8. CommonCare Delivery Problems in SNFFacility Related Problems • Lack of preparation/planning at facility to begin care • Necessary equipment, narcotic and other medications not quickly available in SNF • Lack of communication with families • Realistic expectations for care, likely outcomes, timeline, goals, preferences including advance directives, identification of decision maker with contact information • Lack of physician availability at SNF • Assess patient, meet with family, provide orders • Lack of availability of facility staff at peak admit times • Begin care in timely manner and inspire confidence in patients/ families • Overpromising and underdelivering

9. Common Care Deliver Problems in SNFOngoing Care Concerns • Gaps in resources, communication, and collaboration of greatest concern • Movement of sick, complex patients into facility has proceeded faster than the movement of resources into facility to provide necessary care • Mismatch between patient needs and available staff/other resources • Ability to accurately assess patients with changing conditions

10. Common Care Deliver Problems in SNFOngoing Care Concerns • Ability to respond quickly to meet changing care needs • IVs, labs, medications • Ability to monitor sick or unstable conditions continuously for an extended time • Skill set of providersoften lacking • Assessment skills, communication skills, geriatric prescribing, and knowledge of regulations • Inconsistent provision of care due to variable attitudes, knowledge, and skills of staff

11. Common Care Delivery Problems in SNFOngoing Care Concerns • Poor communication/teamwork between disciplines • Poor communication/teamwork between facility and family • Poor communication/teamwork between physicians • Poor availability of physician services

12. Common Care Delivery Problems in SNFAttending Physicians • Often unavailable/busy elsewhere • Not part of the team • On-call or covering physicians may be unqualified and/or unwilling to provide orders, see patient, be responsive • May be ignorant of regulatory issues, Medicare coverage/payment issues

13. Common Care Delivery Problemsin SNFAttending Physicians May be ignorant of health care delivery/LTC processes of care Failure of facility staff to plan and/or communicate may result in emergencies for physicians (e.g.running out of narcotic pain medication after hours) Lack of accountability to facility administration and medical director

14. Common Care Delivery Problems in SNF Medical Directors Many facilities don’t know what to do with a (good) medical director Many medical directors don’t know what to do with themselves, other than accept new admissions Lack of awareness of medical director responsibilities Lack of availability/willingness to fulfill roles/responsibilities required by regulations

15. Current Trends • Facilities want more complex patients, fewer custodial care patients • Facilities want to offer more services i.e. cardiac monitoring • More SNFs providing post-acute care only; no long-term care • Need physician services continues to rise as a result • Increased interest in full-time LTC physicians nationwide among both facilities and physicians • Greater scrutiny of quality and cost as overall health care costs rise • Atypical antipsychotic drug use in dementia will be actively discouraged (> $15 billion /yrvs $4 billion/yr for LTC practitioner compensation) • Hospital readmission rates scrutinized • Rehabilitation outcome measures being introduced • Reduced access for certain patients (Medicaid patients with dementia)

16. LTC: Future • Facilities, patients, families, regulators, others will expect more of attendingphysiciansand medical directors • Quality assurance/Process Improvement (QAPI) a CMS requirement of SNFs • Physicians must expect more of themselves • Physicians involved in LTC need more from facilities • Teamwork, support, qualified staff, communication,etc • AMDA must meet the needs of physicians and other LTC professionals in order to fulfill mission of improving quality

17. LTC : Future • Emergence of LTC specialists (a la Hospitalists) • Fewer physicians overall, providing more care to more SNF patients • Full-time practitioners in nursing facilities • Increasingly will be employees of NH chain or LTC physician group • Specific set of competencies required -Knowledge/skills/attitudes/behaviors • Attractive compensation and lifestyle compared to hospital and office-based primary care practice

18. LTC : Future • Greater emphasis on patient outcomes • Reporting of outcomes • Changing payment structures to incentivize quality, preferred outcomes, resource utilization • Greater scrutiny of costs, service utilization(esp. rehabilitation andmedications), and quality measures

19. LTC : Future • Labor shortages (especially for lower wage workers) will create greater challenges for facilities • Greater involvement and scrutiny by family members • Use of internet • Role of hospital diminishing- May be bypassed in future • Less access for custodial care in NH, especially Medicaid patients with dementia

20. AMDA • Missionis to promote quality LTC • AMDA uniquely concerned about meeting needs of patients, families, and practitioners in LTC • What do patients/families need? • What do LTC practitioners need in order to meet patient/family needs and improve quality of care ?

21. What Is AMDA doing for you? • Education • Providing information/education to medical directors, LTC practitioners to achieve clinical, administrative excellence, thrive in changing environment • Articulating Core Competencies and developing training materials related to those competencies for attending physicians and NPs • Clinical Practice Guidelines • Education materials for nurses and other disciplines, such as “Know it All Before You Call” cards to enhance assessment and communication skills

22. What Is AMDA doing for you? • Education • Annual Education Symposium : March, 2013 • Gaylord Hotel - Suburban Washington DC • Core Curriculum in Medical Direction • Advanced Course on Medical Direction

23. What is AMDA doing for you? • Development of broader menu of focused educational offerings • On line, self paced • Related to core competencies • Education to support teamwork • Education for interdisciplinary team members

24. What is AMDA doing for you? • Internal Reorganization: • New CEO fall 2012 • Complete reassessment of organizational effectiveness • Strategic planning 2012/2013 to identify member needs, develop new products, and services to meet those needs • Increased support of state chapters • Needs assessment of members • Enhancement of products and services to meet those needs

25. What Is AMDA Doing for You ? Advocacy Public Policy: Monitoring and influencing external environment (government, consumers) in a strategic wayto improve care and careers in LTC Demonstrate value of CMD to Government, Industry, and public Demonstrate value of Competence in LTC Medicine to government, industry, and public Enhance recognition of CMDs and Competencies in LTC Medicine

26. What Is AMDA Doing for You ? Advocacy Strong advocacy for payment to LTC practitioners Provide invaluable expertise to CMS and other others in regulations, standards,quality promotion, and measurement Position ourselves as advocates for patients in order to improve care and enhance our role

27. What is AMDA Doing for You: • Mentorship and Career support • Increased reimbursement for LTC service codes • Develop LTC workforce • AMDA Futures program • Supportive network of LTC professionals • AMDA Foundation Capital Campaign • Increased recognition for LTC practitioners and CMDs

28. What is AMDA Doing for You: • Pursue other benefits and opportunities for members • Health information technologies/ EMR/e-prescribing for LTC • Set research agenda for LTC • Evaluate effectiveness of CPGs • Define quality in LTC population/setting

29. Summary – General • Health care delivery rapidly changing • Status quo not an option • Tremendous opportunities and challenges in LTC • LTC is considered a solution, not a problem in health care reform

30. Summary - AMDA Professional society for LTC practitioners One “Stop Shop” for LTC and Medical Director education Shape long-term care delivery by emphasizing quality and advocating for LTC practitioners and consumers Providing all of the necessary tools for excellence and professional satisfaction