Redesigning Care for Cognitively Impaired in Skilled Nursing Facilities

1. Redesigning Care for Cognitively Impaired in Skilled Nursing Facilities Arif Nazir MD Assistant Professor, IU School of Medicine Feb 18, 2014

2. Mr. Polly • 78 yo Widower lives alone in a single story home • Retired realtor, Mr. P is fully independent and drives • Daughter lives 20 miles away and visits 2/week • Diabetes, heart disease, high cholesterol and blood pressure • Admitted to hospital with fever and pneumonia • Daughter states “No memory problems but…forgets occasional appointments, twice lost his keys, once got lost while driving”

3. Mr. P (contd.) • 3rd hospital day he has no fever • “Slept like a baby” but in morning confused about where he was; calling his wife • Weak and poor balance; therapy recommends sub-acute care in a nursing facility • For skilled rehab and ongoing IV antibiotics • Daughter selects Shabby Meadows close to her home • Mr. P is discharged at 4 pm

4. Shabby Meadows • Nurse Rhonda receives Mr. P • Was reported to her, “78 yo demented male with sundowning” • Calls Dr. Z to confirm orders • Requests a “sleeping pill” so she doesn't have to “bother” Dr. Z • “Xanax 0.5 mg as needed every 4 hrs” ordered • At 10 pm Mr. P starts calling for “dead wife” • Receives Xanax at 11 pm and 4 am

5. Mr. Polly is too sick • At 7 am half naked, with legs hanging off the bed • Incontinent, drooling & “swings” at the nurse • The director of nursing (DON) calls Dr. Z who cant visit • As per his request Mr. P transferred to inpatient psych • 1 week later pt. returns with 3 new meds (2 antipsychotics) • Now “calm and friendly” with “no complaints”; poor intake • 2 weeks later patient found unresponsive and 911 is called

6. Delirium and SNFs • Delirium:A serious and sudden disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. • Onset: Within hours or days • 15-23% on admission to SNF have delirium • Only <30% recognized by clinical teams • Persists weeks to months • In >60% it will persist or be worse in 1 week Marcantonio et al. JAGS 2003; Kiely et al. J Gerontol A BiolSci Med Sci. 2004

7. Consequences of Delirium in SAR • Persistent delirium confers 2.9 greater risk of death • Poor functional recovery • Higher long-term placement • Association of persistent delirium with more geriatric syndromes (falls, ulcers, pain, depression, malnutrition, urinary retention) • Higher healthcare costs • More survey deficiencies for SAR Anderson et al. JAGS 2012; Jones et al. JAMDA 2010

8. Usual Care in SNFs • >90% nursing homes provide rehab • Of 15 M annual Medicare admits • >20% (500,000) require SAR • Most care provided by Licensed Practice Nurses (LPNs) • Certification entails 5 semester training (45 credit hrs) • Can collect data but cannot assess patients • Regulation mandates “interdisciplinary” care: • Physicians to sign orders in 48 hours (can be via fax) • At least monthly visit for 3 months

9. Barriers to Effective SNF care • Inadequate staff training • Staffing levels • Lack of protocols for admission and f/u assessments • Multidisciplinary care, as opposed to interdisciplinary • Resource adequacy • Level of Physician supervision • On-call teams • Regulatory “distractions” • Lack of evidence-base

10. Enhancing Care of Cognitively Impaired in SAR DELIRIUM DEMENTIA • Back to the Drawing Board?

11. Imagine it is 2063 and you get admitted to a SNF with delirium. You get terrible care and you are DYING! You want to come back to 2014 and “fix” the issues

12. Clarifying Questions

13. How will you redesign care for cognitively impaired patients in SNFs? • Key elements will you focus on • New resources will you provide • Other healthcare venues that we can learn from • Regulations you will lobby for • Other industries that can guide us? Full Definition of REDESIGN : to revise in appearance, function, or content — redesign noun

14. Evidence for High Quality geriatrics Care in SAR • Interdisciplinary care • Involvement of facility physicians and pharmacists

15. Potential Ingredients for an Effective Model for Delirium Care in SAR -Environmental Modifications -Staff training - Systems for hand-off to other shifts and weekend staff

16. Delirium Abatement in SAR • 1 Randomized trial in 8 Boston facilities • Delirium Abatement Program (DAP) • Nurse-led intervention for early detection and screening • Primary outcome: persistence of delirium • Assessment and treatment of reversible causes; prevention and management of complications; and restoration of function • Delirium education for all staff • Facility handouts and environmental modifications • Did not achieve the outcome to decrease length of duration • Less than ideal adherence with protocols

17. Models that can be used as examples • Healthcare • ICU model • Inpatient rehabilitation Care • Acute care for elders (ACE) model • Outside Healthcare: • Adherence to protocols (six sigma, Lean)

18. Evidence for Delirium Prevention • RCT with protocols for 6 risk factors for delirium • CI, sleep deprivation, immobility, visual and hearing impairment and dehydration • Intervention decreased incidence, and duration of delirium • Geriatric consultation decreased delirium by 30% in hip fracture patients (NNT=5.6) • Mean of 10 recommendations with 77% acceptance • Nurse-led consultation in hip fracture patients • Staff education, pain control, cognitive screening • Decreased delirium duration and severity Marcantonio et al. JAGS 2001; milisen et al. JAGS 2001