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The Basis For Improving and Reforming Long-Term Care. Part 4: Identifying Meaningful Improvement Approaches Steven A. Levenson MD, CMD. Objectives of This Segment. Previous segments have identified key conceptual foundations For providing high-quality care
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The Basis For Improving and Reforming Long-Term Care Part 4: Identifying Meaningful Improvement Approaches Steven A. Levenson MD, CMD
Objectives of This Segment • Previous segments have identified key conceptual foundations • For providing high-quality care • For overseeing and trying to improve care quality • This final segment • Applies earlier discussions to assess current and prospective efforts to improve and reform nursing home care
Recommended Approaches • A number of specific approaches herein • Based on the foregoing discussions • Correctly define the problems • Identify their diverse causes • Present a cohesive strategy • Many of them differ from the conventional wisdom • Should be taken seriously
Ongoing Criticism of Nursing Home Performance • Continuing allegations • Significant improvement still needed • Many important issues and conditions remain inadequately recognized and managed or, conversely, overtreated • Nursing home industry response • In past decade, significant improvement • Competent care despite challenges • More sophisticated postacute care more than in other settings
What is the Truth? • Is care as good as some claim? • If so, why so many more reform efforts? • If not, why would more of the same be any more beneficial? • Which approaches are likely to produce dramatic improvements? • Just how good are the current improvement and reform efforts?
Important Historical Context • Important to understand history of attempts to reform nursing homes • Just as patient history helps us understand his or her current condition • Attempts to reform long-term care have succeeded to some extent
Important Historical Context • Previously, much of criticism of nursing homes and their care has been warranted • Challenge for nursing home staff, practitioners, and management to identify which of the numerous alleged solutions are viable and worth pursuing
Important Historical Context • Some good intentions have gone astray • Inconsistent and incomplete implementation of pertinent ideas • Inaccurate and inappropriate advice • Questionable agendas of various interest groups • Considerable resistance or sabotage • Abundant and problematic political opportunism
Foundation For Subsequent Reforms • Further tinkering is inadequate because • Resources are limited • Waste is problematic • Results count more than ever • Important to consider reasons for success or failure of previous efforts
Recommendations to Improve & Reform Long-Term: Summary • Reconsider current improvement and reform efforts • Challenge the conventional wisdom • Vigorously subdue “political correctness” • Rethink the research agenda • Focus attention on basic care principles and processes
Recommendations to Improve & Reform Long-Term: Summary • Suppress reductionism and jurisdiction over care • Reconsider notions of competency and expertise • Change approaches to assessing and trying to improve quality • Develop biologically sound reimbursement
Sources of Efforts to Improve and Reform Long-Term Care • Governmental • Industry groups, associations, and coalitions • Public and consumer initiatives • Physician initiatives • Insurance initiatives • Non-industry organizations and associations
Types of Efforts Targeting Reform • Laws and regulations • Assessment tools • Workforce initiatives • Quality-improvement strategies • Work groups • Campaigns • Consumer initiatives (e.g., “culture change”)
Categories of Approaches Targeting Reform: Examples • Improve information systems for quality monitoring • Strengthen the regulatory process • Strengthen the care giving workforce • Provide consumers with more information
Categories of Approaches Targeting Reform • Strengthen consumer advocacy • Increase Medicare and Medicaid reimbursement • Develop and implement practice guidelines • Change the culture of nursing facilities
Problems and Solutions • Current reform initiatives • A potpourri of approaches • Still lacks a comprehensive problem statement and cohesive strategies • Inadequate to just aggregate multiple “solutions” and reform agendas, e.g. • [Agenda A] + [Idea B] + [Campaign C] + [Proposal D] + [Notion E]
Reform Misconceptions • Easy to identify that something is amiss • May not = having appropriate solutions • Analogous to care planning for a complex patient • Consequences may have multiple causes • Various causes may have multiple consequences
Reform Misconceptions • Before trying to “fix” the problems • Define issues and identify root causes • More interventions are not necessarily better • Some proposed approaches are pertinent and meaningful • Others may exacerbate situation or just circumvent underlying causes
Strategies: Reconsider Current Improvement & Reform Efforts • Evaluate compatibility of various reform efforts with key philosophical and scientific principles • Including evidence-based care and full care delivery process • Focus more on defining issues correctly and identifying root causes
Challenge the Conventional Wisdom • “Conventional wisdom” • “A belief or set of beliefs that is widely accepted, especially one which may be questionable on close examination” • Susceptibility of reform to the conventional wisdom • Only some of it is accurate and pertinent
Challenge the Conventional Wisdom • CW can impede genuine improvement and reform if it • Fails to identify issues correctly • Diverts attention and resources • Leads to inadequate or inappropriate interventions • Both political and clinical CW • Diverse sources of CW
Political CW • Political CW • Refers to platitudes about nursing homes, their staff, and quality of care, as well as to alleged solutions • Clinical CW • Refers to habitual and widespread approaches to aspects of care • Often inconsistent with evidence or fail closer scrutiny • May be so widespread that it becomes a false “standard of care”
Political CW Example: RAI and High-Quality Care • Resident Assessment Instrument (RAI) • Including Minimum Data Set (MDS) • Meant to improve on previously haphazard and inadequate assessment • Can be helpful if used as originally intended • A minimum data set with basic functional, behavioral, and psychosocial information
CW Example: RAI Misinterpretation and Misuse • Regrettably, RAI has a life of its own • Often serves as primary or sole informational basis for care • MDS has spawned new job description (MDS coordinator) and many consultants • Many efforts to validate assessments and conclusions that are based on it
RAI Use and Misuse • RAI serves a purpose • However, a limited guide to effective clinical decision making • MDS does not consider detailed, chronological patient history • RAI provides only a limited basis for more complex care planning
RAI CW: Basis for Meaningful Reform • More realistic and balanced view needed of the RAI and MDS • Intended for specific purposes • Excessive reliance on assessment instruments has become problematic • Limits to how much it can improve care or give basis for sound reimbursement • Responses to concerns have not necessarily been substantive
Political CW: The Virtues of Interdisciplinary Teams • Interdisciplinary team • Use individuals of multiple disciplines to provide care • Key tenet of geriatrics and long-term care • Also referred to as interdisciplinary care, interdisciplinary care teams, and interdisciplinary collaboration • Approach has proven beneficial
Interdisciplinary Team: Implications and Limitations • Teams are a means to an end • Not an end in themselves • Benefit of teams depends heavily on training, knowledge, qualifications, and performance of team members • Improper realization of IDT team approach may • Distort purpose • Impede care quality improvement
Team Approach: Misconceptions • Team approach can be redundant, inefficient, or hazardous • If team members exceed scope of knowledge and skills • Having more participants does not necessarily improve the care • For example, separate “teams” for issues such as weight loss, skin care, falling, and pain • A single comprehensive collaborative review may be more biologically sound
Amount of Care as a Reflection of Quality • More interventions do not necessarily produce better results • A single intervention targeted at a root cause may be preferable • For example, hypothyroidism or medication-related adverse consequences • Evidence: more care may result in more unnecessary treatment or complications • Amount of care not a reliable measure of quality
Team Approach: Basis For Meaningful Reform • Need to reexamine how nursing homes actually implement true IDT approach • Such scrutiny is likely to show significant variability and deficits • Ineffective or inappropriate team approach can contribute to redundant, irrelevant, or problematic care
Clinical CW: Alleged Virtues of Antibiotics • Many long-term care residents/patients have infections • Colonization is also very common • Antibiotics are commonly prescribed for diverse symptoms and test results • For several decades, concerns about use of antibiotics in various situations
Clinical CW: Alleged Virtues of Antibiotics • Specific criteria for antibiotics use exist • Generally inadvisable to treat colonization • Misdiagnosis and inappropriate antibiotic treatment are common • Routine use of antibiotics for behavior symptoms is largely unwarranted
Clinical CW: Alleged Evils of Antipsychotic Medications • Concerns about antipsychotic medications a major driving force behind nursing home reform efforts • Concern about inappropriate use of all medications is warranted • However, issues are far broader than any one category of medications • Including correct assessment and management of behavioral and psychiatric issues
Clinical CW: The Alleged Evils of Antipsychotic Medications • Nursing home staff and practitioners often bypass the care process • Including meaningful details about behavior • Frequent push for psychiatric consultations for changed or problematic behavior • Inadequate search for underlying causes may lead to • Poor outcomes • Unnecessary or problematic treatment
Clinical CW: The Alleged Evils of Antipsychotic Medications • Drug treatment of behavior and mood disturbances often based on guesswork • New generation of medication-related issues compared with traditional ones • Genuine reform requires attention to issues underlying medication use • Including related clinical problem-solving and decision-making activities
Clinical CW: Pressure Ulcer Prevention and Treatment • Pressure ulcers arouse strong emotions and fervent efforts at reform • Prevention and management of pressure-related wounds has improved overall in nursing homes • It remains problematic in other settings, and still in some nursing homes • Topic still influenced by mythology and misinformation
Clinical CW: Pressure Ulcer Prevention and Treatment • CW heavily promotes nutrition to prevent and heal pressure ulcers • CW promotes the idea that pressure ulcers cause increased energy expenditure • However, evidence often does not support the CW • Despite evidence, pressure ulcer care still haunted by myths and dogma
Clinical CW: Pressure Ulcer Prevention and Treatment • Poor personal, medical, and skin care still common in diverse settings, including hospitals • Continuing need for initiatives says much about widespread and longstanding inconsistent care • Genuine reform requires addressing basic care failures in all settings • Including failure to care for all relevant concerns and risks
Clinical CW: The Alleged Role of Rehabilitation • Rehabilitation is a central tenet of geriatrics and long-term care • Medical stability and illness have a major impact on function • Patients allegedly sent “for rehabilitation” commonly have multiple active medical comorbidities and risk factors • Rehabilitation therapies mostly address impairments, not underlying causes
Rehabilitation Concepts and Misconceptions • In long-term care, rehabilitation commonly equated with provision of therapy services • Physical, occupational, and speech • Rehabilitation has become erroneously equated with function and functional improvement • More discipline-centered than patient-centered
Rehabilitation Concepts and Misconceptions • Inappropriate labeling of being “sent for rehab” • Excessive jurisdiction and domination of utilization review • Diversion from seeking underlying medical causes of impaired function • Knowledge about therapy modalities not same as knowing how to identify underlying causes of impaired function
Challenging the Conventional Wisdom • Genuine reform and improvement requires rethinking and undoing much of the conventional wisdom • Many common practices in long-term care are unfounded • Many beliefs about long-term care are incorrect or misleading • Current CW often prevails because it serves diverse agendas