Upgrading the Nursing Home Survey Process: Continuing the Dialogue

Best Practices for Increasing Compassion Resiliency and Moral Wellness in Post-Acute and Long-Term Care Settings

Wit, Wisdom, and Hard Work Make a Model Medical Director of the Year

Key Insights Into Schizophrenia Misdiagnosis and the Use of Antipsychotics

When I call, state chapter leaders wonder if they really want to answer their phones. “Yes, it’s Mary Evans calling, asking that you please do your utmost to join me in not only evangelizing about the Foundation for Post-Acute and Long-Term Care Medicine’s Futures Program, but also that you raise money and send a check.” They usually answer, I think, because our chapter leaders understand that we are all working to recruit the next generation of medical directors and that Futures is a gateway to achieving that. Some forthrightly say, “Yes, Mary, I am doing this because I would like to see more facilities have qualified directors — and, truth be told, I’d like to retire someday, and I want to have a successor who is skilled and also shares our values.” Since 2001, the Foundation has funded the attendance of over 1,000 practitioners to the Futures Program — 67 enthusiastic practitioners joined us in 2018 alone. Being a medical director is among the most satisfying and challenging positions in medicine today. And the range of required knowledge keeps expanding as the demographics and both the post-acute and long-term care aspects of facilities change. Hence, the purpose of this column: If you are a member of a state chapter of AMDA — The Society for Post-Acute and Long-Term Care Medicine, please contribute to your chapter’s efforts to fund one or more Futures candidates. If you are a chapter leader, please budget for Futures — and send a check ASAP. FUTURES IS NOT A FRILL! It’s a strategic imperative! Prospects for our work in PA/LTC rest on the shoulders of those who succeed us. We need more capable, well-trained, enthusiastic, and dedicated talent to provide informed care for the millions of patients who are knocking at our doors. And we need them to become leaders in our fight for quality, specialized care. Financially, it’s quite simple. Based on the needs of the individual, we provide free training and transportation costs. A single sponsorship is $3,000, and we also offer two spots for $5,000. How about sending four to six trainees? In the last few years, we have also had practices funding their own trainees so that physicians are ready to step in when the contributors retire. This is really an act of leadership, caring, and great philanthropy. Instead of waiting for my call, I’d like to ask each member of the Society to contribute to Futures, to contribute to their chapter initiatives for Futures, or to consider sponsoring their own trainee. You can also e-mail me at [email protected], contact Chris Ewing at the Foundation office at [email protected] or (410) 992-3134, or donate online at http://paltcfoundation.org/index.php/support-us/online-donations. Dr. Evans is chair of the Foundation for PA/LTC Medicine’s State Chapter Campaign.

Pragmatic Trials and Improving Long-Term Care: Recommendations From a National Institutes of Health Conference.

I first stepped into a nursing home when I was six years old. My mother was a certified nursing assistant who always worked 12-hour shifts. Since my father was also working, sometimes she had no choice but to have the bus drop me off at the long-term care facility where she worked. On those days I would sit in the dining hall with the residents who were under my mother’s care. I vividly remember playing bingo and poker with them. Those memories, glimpses of a moment in time, became the foundation for my career. Pursuing a geriatric medicine fellowship was an easy decision for me. During my interview with University of Pittsburgh Medical Center (UPMC) Presbyterian–Shadyside, I expressed an interest in post-acute and long-term care settings. That was when I first heard of the Futures Program, an opportunity that immediately appealed to me. I wanted to spend more time improving the ways that we care for our most vulnerable populations, and I also wanted to seek guidance and support for becoming a certified medical director. And after two years under a pandemic, I looked forward to an in-person conference! When we gathered in Baltimore, MD, at the 2022 Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine, I felt invigorated by the small group sessions, the Q&As, and the larger events that Futures Program participants could take part in. It was rewarding just to be in the same room with so many people who shared my passion for this field, and the learning opportunities were seemingly endless. Throughout the conference I looked for pieces of advice that could follow me back to UPMC. Wayne Saltzman, MD, PhD, CMD, delivered an excellent presentation in which he asked us to remember five simple rules that would help us prevent adverse events. At one point in his presentation Dr. Saltzman said, “A good day starts with a good morning,” and that has stuck with me. He spoke of entering his facility at the start of busy days, and despite challenging situations, he said he always will take time to wish his staff a good morning. Since then, I have introduced myself to more of the staff at our nursing home, which has fostered better communication and better overall care. The leadership session, hosted by Suzanne Gillespie, MD, RD, CMD, and Elizabeth Galik, PhD, CRNP, opened my eyes to how many mentors had already helped me get to this point. It was then that I truly understood how the Futures Program gives rising clinical leaders in geriatrics a chance to find new mentors. Drs. Gillespie and Galik also asked us to reflect on our goals and values and consider how we bring them into the work that we do. In doing so, I was reminded of the little girl who enjoyed sitting with the residents, the one who went on to become a medical student and physician who spent all her electives in PALTC. Joining the Futures Program felt like a natural fit. I left that session with a solidified goal: become a certified medical director but never lose sight of that bingo-playing little girl. I could not be more thankful for the foundation that the Futures Program provides for us, and for the friendships and connections it has helped me make. I look forward to getting more involved with the Society very soon! Dr. Assadzandi is a graduate of Mercyhurst University and West Virginia University School of Medicine, where she also completed her family medicine residency. This June, she is finishing a fellowship with UPMC’s Division of Geriatric Medicine and will then join the department as a clinical assistant professor focusing on post-acute and long-term care.

Are you skillful at arguing and debating, at standing your ground, and at using your rank, position, or influence when dealing with conflict? Or are you better in conflict situations with forgoing your desires, yielding to others, and acting with selflessness? According to the Thomas-Kilmann Conflict Mode Instrument (TKI), your conflict-handling style would be either “competing” or “accommodating,” respectively. And if you had certain other dominant skills, your most natural conflict mode might be “collaborating,” “compromising,” or “avoiding.” No one of the five conflict-handling styles is necessarily good or bad, said Yuya Hagiwara, MD, at AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Annual Conference. “All are good if used appropriately,” he said. The point is that conflict management skills are essential for the interdisciplinary practice of post-acute and long-term care, and “we want to be more aware of our own intrinsic conflict management [preferences] and be able to assess what’s appropriate in [each] situation,” he said. Dr. Hagiwara, who practices geriatrics and palliative care medicine at the University of Texas Health Science Center at San Antonio (UT Health San Antonio), led physicians, nurses, and others through the TKI model — a tool developed in 1974 by Kenneth W. Thomas and Ralph H. Kilmann to measure an individual’s response to conflict situations. The five conflict-handling styles defined in the TKI model are described in terms of two basic characteristics: assertiveness and cooperativeness. Each style, or mode, has different levels of these two dimensions. The “competing mode” is high in assertiveness and low in cooperativeness, for instance, while the “accommodating” mode is high in cooperativeness and low in assertiveness. Each of the modes can be overused or underused to one’s detriment, Dr. Hagiwara explained. A “competing” style might be appropriate when you need to take quick action, make unpopular decisions, stand up for vital issues, or protect yourself. “Like when you need to send someone from the nursing home to the emergency room,” he said. If the style is underused, “you can end up having restricted influence,” whereas its overuse can result in indecision and delayed action — if “you’re always in the competing mode, you might not get feedback, and in the end you might be surrounded only by ‘yes people’,” he said. Or take the “collaborating” mode — this style is usually appropriate for committee meetings and other instances when you’re trying to integrate solutions, merge perspectives, gain commitment, or improve relationships. Yet if it’s overused, “you might spend too much time on trivial matters, which can lead to work overload,” he said. “Or there might be people who try to take advantage.” Underuse, on the other hand, may lead to lack of commitment, low empowerment, and loss of innovation. Neela Patel, MD, MPH, CMD, chief of the division of geriatrics and palliative care at UT Health San Antonio and medical director of UT Health Geriatrics & Palliative Care, said she became familiar with the TKI tool when she was a resident. Today, her colleagues find it useful as well, she told Caring. “We work in the clinic, the hospital, and the nursing home … and with hospice,” she said. Developing effective conflict resolution skills is important “for getting results across different settings, getting everyone on the same page, and trying to stay person-centered.” Christine Kilgore is a freelance writer in Falls Church, VA.

View Large Image Figure ViewerDownload Hi-res image Download (PPT)The American Society of Consultant Pharmacists (ASCP) is a membership association that was founded in 1969 to represent pharmacists and other health care professionals who work with older adults. ASCP’s mission is “to promote healthy aging by empowering pharmacists with education, resources, and innovative opportunities” (“ASCP: Empowering Pharmacists; Transforming Aging,” https://www.ascp.com/page/about). The Pharmacy Quality Alliance (PQA) is a nonprofit and consensus-based “national quality organization dedicated to improving medication safety, adherence, appropriate use” (“About PQA,” https://www.pqaalliance.org/our-story). They provide medication management services through performance measurement, research, and education, and are in a public-private partnership with the Centers for Medicare & Medicaid Services (see “PQA Measure Development Process, Version 4.0,” Oct. 25, 2021, https://bit.ly/369SPRx). The relationships between PQA and ASCP and between ASCP and AMDA – The Society for Post-Acute and Long-Term Care Medicine highlight the benefits of collaboration to optimize patient care. By aligning the clinical and financial goals among these organizations to improve outcomes, this model of collaboration has demonstrated its value for successful results. As a PQA member organization, ASCP works with PQA in multiple ways. ASCP contributes subject matter expertise during measure development and maintenance. ASCP also serves in an advisory role as measures are vetted and finalized for adoption to support measure implementation strategies via its professional relationships. ASCP’s interest in promoting adoption of measures is inclusive of the regulatory level by government agencies and at the grassroots level with allied pharmacy organizations and their membership. ASCP’s consultant pharmacists partner with other ASCP members and any aligned health care team members, including facility data collection providers (e.g., Minimum Data Set [MDS] coordinators) to ensure education about measures and accuracy in the data coding process. Additionally, they provide traditional medication regimen review services, comprehensive medication reviews for Medicare D beneficiaries in post-acute and long-term care, additional residential care settings, and novel emerging community and telehealth practices. One example of how ASCP has collaborated with PQA to provide subject matter expertise on a specific PALTC concern is the “Antipsychotic Use in Persons with Dementia (APD)” measure, which “evaluates the percentage of individuals with dementia with a prescription claim for an antipsychotic medication without evidence of a psychotic disorder or related condition.” It was also “adapted for the long-term care setting using MDS data” (“PQA Measures Overview,” Sept. 23, 2021, https://bit.ly/3oUKx6w). ASCP also collaborated with PQA to understand the intent of the current APD quality measure and identify opportunities for continued quality improvement, which informed ASCP’s policy and position statement on the “Use of Antipsychotic Medications in Nursing Facility Residents” (Apr. 1, 2018, https://bit.ly/3HZLH8u). The position statement aligns the partnership and mission of ASCP with that of AMDA. ASCP members work closely with their facility clients at the corporate ownership, medical leadership, and administrative executive levels to complement the entity’s focus on quality measures. ASCP consultant pharmacists, ASCP member provider pharmacies, and pharmacy managed care organizations ensure alignment with these mutual goals. They work side by side with the Society’s members to ensure that quality measures are shared, strategized, and implemented to ensure individual providers are held accountable for meeting the goals. Finally, the partnership between ASCP and the Society uses publicly collected data on outcomes statistics related to the measures and compares performance with benchmark state and national averages. Data indicators of poor performance become a focus for attention, including the use of vehicles such as facility Quality Assurance Performance Improvement (QAPI) activities. “PQA’s mission to optimize health by advancing the quality of medication use is supported by collaboration with ASCP,” said PQA Chief Quality and Innovation Officer Lisa Hines, PharmD, CPHQ. “Our work together and ASCP’s collaboration with AMDA enhances our strategies and ability to promote safe and appropriate medication use for older adults.” The information presented is a selective summary of publicly available information and is accurate as of the date of writing. Please consult the sources for complete reference information. Dr. Manzi has been a licensed pharmacist since 1990 and a Board Certified Geriatric Pharmacist since 1998. She is the director of LTC clinical services at Managed Health Care Associates, Inc. The views expressed in this article are those of the author(s) alone and not of Managed Health Care Associates, Inc. Robert C. Accetta is the president/owner of Rivercare Consulting, LLC. A Board-Certified Geriatric Pharmacist, Rob currently serves on the Board of Directors of the American Society of Consultant Pharmacists (ASCP). He is a graduate of St. John’s University College of Pharmacy and Health Sciences in New York.

The Promise of Nursing Home Medical Direction: A Work in Progress

Putting an end to the blame game with incontinence

There Is No Place Like Assisted Living: Can the Setting Evolve While Staying True to Itself?

From Sleeplessness to Slumber: Person-Centered Approach to Insomnia

PA/LTC Goes Around the World in Online Communities

Learning Together About Racism

ORLANDO, FL — The Society House of Delegates (HoD) passed several significant resolutions and white papers at its recent meeting. “It was an incredibly productive and interesting meeting. We made tremendous progress on several key issues within a limited time frame,” said 2015–2016 HoD Chair Milta Little, DO, CMD. “The issues addressed — and the items passed — highlight the amount of public policy work that is being done and what additional work the Society is being asked to do. There is a big push on public policy efforts, and that will be a key part of HoD efforts in the year ahead,” said Dr. Little. Among the policy-related resolutions: •%Ensuring Appropriate Risk Adjustment Prior to Implementation of Value-Based Purchasing (B16): This directs the Society to work with stakeholder organizations and federal agencies to require the Centers for Medicare & Medicaid Services to clearly define risk stratification indices and develop a cost-to-risk algorithm. This algorithm is to be based on previous utilization data and will incorporate unique patient characteristics including age and frailty.•%Reimbursing Physician Practices for Administrative Costs of VBP Programs (C16): This directs the Society to work with the American Medical Association and other interested parties to seek legislative action modifying the CMS value-based purchasing regulations to ensure that all eligible professionals who participate in the VBP programs receive appropriate compensation on their Medicare charges for the attributed population and for added administrative costs.•%Support for the End of the Meaningful Use Program by CMS (I16): This calls for the Society to seek legislative and regulatory action to remove PA/LTC patient encounters from the Meaningful Use program. This would include any future iterations of Meaningful Use under the Merit-Based Incentive Payment System, until such time that interoperable certified technology is widely available in these settings. It also directs the Society to work with appropriate stakeholders to incentivize health information technology systems that support the interoperability, continuity of care, and care coordination specific to PA/LTC residents. The HoD also passed two resolutions about establishing specialty of post-acute and long-term care medicine that call for the Society to work with CMS to seek full recognition of PA/LTC medicine as a medical specialty and engage American Board of Medical Specialties to prepare for this recognition. The HoD also passed three white papers on the following topics: •%Capacity for Sexual Consent in Dementia in Long-Term Care (A16)•%Dementia Care in Transitions (M16)•%Post-Acute and Long-Term Care Population Served (N16) Suzanne Gillespie, MD, RD, CMD, 2016–2017 HoD chair, noted that the topics addressed “reflect the diversity of our membership and the issues that affect and interest us all.” She was impressed by the level of knowledge demonstrated by House delegates and the “robust dialogue that took place on the various topics.” For details about the white papers and resolutions passed by the HoD, go to http://www.paltc.org/papers?type=All&topic=All. Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations.