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

1. Charting the Course of Post-Acute and Long-Term Care Medicine How to Think About Patient Care in Current Times

2. Dr. Levenson has no financial disclosures

3. Objectives • Identify strategies to implement meaningful, sustained improvement in a nursing facility, using efficient and effective clinical and management strategies • Identify and address challenges to improvement, including the major impact of cognitive biases on care quality • Clarify the critical role of medical directors and practitioners in leading a nursing home to analyze and improve its approaches to care

4. Thinking Right • 6+ years • 20 states • ME / NH / CT / NJ / PA / MD / DE / VA / NC / KY / WV / TN / OH / FL / NM / CO / ID / UT / CA / WA • 125+ facilities • Multiple desirable outcomes • Patient satisfaction, clinical, regulatory, financial, legal, quality, practitioner performance, coordination of care • Utilizes basic clinical and management principles • Almost entirely free

5. Why?

6. One Thing After Another

7. Overstretched

8. Patients Come With Complex Issues • Psychotic disorder with delusions due to known physiological condition, • Encephalopathy, unspecified • Personal history of traumatic brain injury • Dementia in other diseases classified elsewhere with behavioral disturbance • Dementia in other diseases classified elsewhere without behavioral disturbance • Unspecified mood [affective] disorder • Anxiety disorder, unspecified • Other specified mental disorders due to known physiological condition • Major depressive disorder, single episode, unspecified • Unspecified psychosis not due to a substance or known physiological condition • Mood disorder due to known physiological condition, unspecified, alcohol abuse, uncomplicated • Other specified problems related to psychosocial circumstances • Unspecified symbolic dysfunctions • Other symbolic dysfunctions • Cognitive communication deficit

9. Patients Have Many Medications With CNS Effects • Trazodone 50mg tablet 50mg tablet 1 tab by mouth twice a day (am & hs) for mood lability • Namenda XR 28mg capsule 28mg capsule 1 cap by mouth every morning for cognition • Gabapentin 600mg tablet 600mg tablet 1 tab by mouth twice a day • Baclofen 20mg tablet 20mg tablet 1 tab by mouth three times a day • Hydroxyzine 25mg tablet 25mg tablet 1 tab by mouth three times a day • Donepezil 10mg tablet 10mg tablet 1 tab by mouth at bedtime • Divalproex sodium ER f/c 500mg tab.sr 24h 500mg tab.sr 24h; 2 tabs by mouth (1000mg) at bedtime • Olanzapine 7.5mg tablet 7.5mg tablet 1 tab by mouth at bedtime for depression • Divalproex sodium 250mg tablet 250mg tablet 1 tab by mouth every morning • Clonazepam 1mg tablet 1mg tablet 1 tab by mouth three times a day -scheduled • Duloxetine 60mg capsule 60mg capsule 1 cap by mouth twice a day (8am,4pm) for depression • Hydromorphone 2mg tablet 2mg tablet 1 tab by mouth three times a day scheduled * 1 tab by mouth every day as needed • Mirtazapine 45mg tablet 45mg tablet 1 tab by mouth at bedtime

10. Psychiatric and Behavioral Issues in LTC (1999-2010) • Depression (major and minor depression) 20– 40 % • Major neurocognitive (dementia) 40– 90% • Cognitive impairment but no dementia 5– 30 % • Delirium 6– 16 % • Delirium in a postacute setting or a skilled nursing facility 5– 30 % • Psychotic symptoms 8– 12 % • Severe mental illness (e.g., schizophrenia) 0.2– 5 % • Behavioral symptoms occurring at least once a week 30– 35% • Behavioral symptoms affecting others 15– 22 % • Aggressive behavior once a week 13– 20% • Aggressive behavior injuring staff 3– 6 % • Abnormal circadian rhythms 90– 99 % • Nonaggressive behavioral symptoms once a week 20– 30 % • Frequent screaming 10– 20 % • Daytime sleeping 65– 75 % • Disturbed nighttime sleep 55– 65 % • Resistance to taking medications 13– 15 % • Resistance to activities of daily living 13– 15 % • Self-injurious behavior (pinching or scratching oneself) 20– 25 % • Residents who spend most of the time in a bed and/ or chair 4– 16 % • Psychotropic medication prescriptions 30-60 % • Antipsychotic use in the absence of a psychotic condition 16-22 % • Desai, Abhilash K; Grossberg, George T.. Psychiatric Consultation in Long-Term Care (p. 8). Johns Hopkins University Press. Kindle Edition, p. 6-22 (data from 1999-2010)

11. Key Elements of High-Quality Care • High quality care has been defined as care that is simultaneously • Safe • Effective • Patient-centered • Timely • Efficient • Equitable • Source: Institute of Medicine . Committee on Quality of Health Care in America. Crossing the Quality Chasm. Washington, DC: National Academy Press; 2001.

12. Desirable Methods • Efficient and effective • Gets diverse desirable results for the time and effort • Well tested and proven • Reproducible • Universal and timeless • Clinical and nonclinical alike • Inexpensive

13. Jumping on the Bandwagon

14. What We Get vs. What We Need

15. Why We Must Do Better

16. The question… How do we improve performance and minimize mistakes?

18. Geriatrics • Geriatrics is becoming, in the mid-1980s, an area of concentration within internal medicine, family medicine, and psychiatry • Many conditions now can be treated or alleviated • Physicians and nurses in nursing homes are not always aware of advances in geriatrics • IOM Report - 1986 • “Much of geriatric care is, in effect, remedial. It addresses problems produced by the care of others, errors of both commission and omission. Were other medical practitioners to become more sensitized to the needs of their frail older patients, the need for geriatric care as a separate activity would decline.” • How Effective is Geriatrics? - 1994

19. Basic Principles of Diagnosis • “A fundamental principle in medicine is that if you get the diagnosis wrong, you'll probably apply the wrong therapy.” • “A corollary is that if the therapy isn't working, increasing the dose may make things worse.” • Ed Marsh, Reflections of a Medical Ex-Practitioner; http://online.wsj.com/article/SB10001424127887324789504578380382204116270.html

20. OIG Report 2014

21. OIG Report Findings • Estimated 22 percent of Medicare beneficiaries experienced adverse events during SNF stays • Additional 11 percent of Medicare beneficiaries experienced temporary harm events • Physician reviewers: 59 percent of these adverse events and temporary harm events were clearly or likely preventable • Much of the preventable harm attributed to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care • Over half of individuals who experienced harm returned to a hospital for treatment • Estimated cost to Medicare of $208 million in August 2011 • $2.8 billion spent on hospital treatment for harm in FY 2011

22. Diagnostic Error As a Patient Safety Issue – AIM 2013

23. Teaching Clinical Reasoning – July 2015 • “There are no shortcuts to developing excellent clinical reasoning” • American College of Physicians. Teaching Clinical Reasoning, Kindle Edition. Kindle Location 690

24. What Is thinking right?

25. Good Care Requires Clear Thinking and Excellent Detective Work

26. Thinking Right • Systematic, collaborative problem solving • Everyone is involved • Quality—not quantity—of targeted interventions • Effective and efficient problem solving • All care plans and approaches integrated • Collaborative accountability and strict discipline

27. Auto repairs Describe problem fully Including symptom details Don’t offer premature diagnosis May lead to inappropriate services Avoid unnecessary costly procedures Beware of misdiagnosis and associated costs Avoid high-priced routine services Delivering care Describe problem fully Including symptom details Don’t offer premature diagnosis May lead to inappropriate and ineffective care Avoid unnecessary costly interventions Beware of misdiagnosis and related costs and complications Avoid high-priced consultations for routine care Comparing Universal Problem-Solving Approaches

28. Evidence-Based Care: Three Key Components • Knowledge of the nature and course of illnesses and conditions (topical knowledge) • Knowledge of patient-specific details (adequate assessment) • Knowledge of how to combine #1 and #2 above to reason to a conclusion, identify causes, and select interventions (clinical reasoning)

29. Each Patient is a Puzzle

30. The Whole and the Sum of Its Parts

31. Pain WeightLoss Behavior Falls Other issues past hx Hx present illness medications Swallowing cOnFuSiOn 1 patient 1 story1 plan

32. Pain Swallowing cOnFuSiOn Behavior WeightLoss Falls

34. The Domino Effect

35. “Thinking Right” to Stop the Dominoes

36. Causes and Consequences

38. Medications Galore

39. Drugs That May Cause Psychiatric Symptoms - 2008

40. Med-alomania

41. The Whole and the Sum of Its Parts

43. Cognitive Biases Are Universal

44. HOW?

45. Path to Quality Care

46. Thinking Right: Schedule • Part 1 - How to Think About Patient Care • Part 2 - What Gets in the Way: Cognitive Bias • Part 3 - Thinking Right Case Studies • Part 4 - A Unified Approach to Care • Part 5 - Care Delivery Process • Part 6 - Strategic Planning for Optimal Outcomes

47. Turn On Your Brain

48. Thinking Like a “Scientist” • “Whether we call the job at the start ‘solving problems’ or ‘improving processes,’ the method is the same: act like a scientist in your daily work. State questions, make a plan, formulate hypotheses, gather data to test those hypotheses, draw conclusions, and test those conclusions.” • Using the Scientific Method to Define Problems • Berwick D. Curing Health Care. Jossey-Bass, 1990.

49. Critical thinking for problem solving Key steps and related skills

50. Crucial Clinical Management Role