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Physicians Biggest Obstacle in Smooth Transitions of Care

Wednesday April 23, 2014
transition

Maybe not a smooth transition!

Poor communication between physicians is the No. 1 issue hurting patient transitions between hospitals and nursing homes, according to a recent survey of long-term care professionals.

Researchers with the University of Missouri Sinclair School of Nursing devised a survey to gauge problems with care transitions. They received responses from care teams at 178 nursing homes in Missouri. The teams included a variety of workers, including nurses, physicians, Minimum Data Set coordinators and administrators.

The most common problem identified was "no communication between hospital physician and accepting physician," the researchers found.

Thirty percent of re-hospitalizations in nursing homes occur for residents who have been there for seven days or less. Getting care right from the start makes a big difference in whether a nursing home stay is successful.

Transitions can be traumatic, especially when people are frail. For people coming into a nursing home from the hospital, that transition is smoother when there is good coordination and hand-offs between the nursing home and the hospital and when there is good coordination internally within the nursing home across shifts and departments.

There is a considerable base of evidence about practices that can alleviate transfer trauma. These practices focus on ways of anticipating and meeting people's psycho-social needs, helping them acclimate to unfamiliar surroundings, and providing immediate comfort and security.

More at McKnight's Long-Term Care News and Assisted Living

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Medicaid Fraud Unit Issues 2013 Report - Home Health on Naughty List

Monday April 21, 2014
fraud

The Office of the Inspector General Medicaid Fraud Control Unit (MFCU or Unit) issued its Fiscal Year (FY) 2013 Annual Report highlights statistical achievements from the investigations and prosecutions conducted by 50 MFCUs nationwide. The Unit recovered $2 billion through its enforcement.

MFCUs investigate and prosecute Medicaid provider fraud and patient abuse and neglect in health care facilities or board and care facilities. About three-quarters of criminal convictions involved fraud; about one-quarter involved patient abuse and neglect.

FY 2013 criminal convictions for fraud: 74 percent

Fraud convictions included convictions for (1) conspiracy to commit health care fraud, (2) health care fraud, (3) submitting false statements related to health care matters, (4) making a false statement in regard to health care reimbursements, (5) grand larceny, and (6) violations of anti-kickback statutes. For example, in August 2013, the New York MFCU obtained a conviction of the owner of several pharmacies for stealing $7.7 million from the New York State Medicaid program. The pharmacist submitted phony bills for drugs that were never dispensed to patients. He was sentenced to a prison term of up to 3 years and was ordered to repay the stolen money to the New York Medicaid program.

FY 2013 criminal convictions for patient abuse and neglect: 26 percent

Cases of patient abuse and neglect included aggravated assaults; injury to an elderly or disabled person; and theft of patient funds. For example, in September 2013, the Maryland MFCU obtained a conviction of a nursing home aide for abuse of a vulnerable adult in the second degree. The convicted aide was placed on 2 years of probation, during which time he is prohibited from being employed in any position that includes the supervision of vulnerable adults.

Criminal Convictions

Convictions related to fraud consistently represented the majority of all criminal convictions. FY 2013 criminal convictions involved a variety of provider types, most notably home health agencies. Criminal convictions most frequently involved home health care aides (26 percent of all criminal convictions), other medical support (7percent), and physicians (7 percent).

Home health care aides: 26 percent of criminal convictions

Home health care aides weremost commonly convicted of fraud, often for claiming to have rendered services that were not provided to vulnerable beneficiaries.

Other medical support: 7 percent of criminal convictions

The category "other medical support" includes individuals, facilities, or organizations, whether licensed or unlicensed, that provide medical support services. This category specifically excludes pharmacies; pharmaceutical manufacturers; suppliers of durable medical equipment; laboratories; providers of transportation; home health care agencies and aides; nurses; physician assistants; nurse practitioners; and radiologists. Individuals in this provider category were convicted of a wide variety of offenses.

Physicians: 7 percent of criminal convictions

Criminal convictions of physicians involved offenses such as fraud (including prescription fraud) and billing for services not rendered.

Medicaid Fraud Control Units recovered about $10.3 million from nursing facilities in fiscal year 2013. Civil fraud settlements and judgments accounted for the majority of nursing home recoveries. These cases led to $8.3 million in recoveries. Criminal fraud investigations led to about $1.1 million being recovered. Civil abuse and neglect cases represented about $771,000 in recoveries, and criminal abuse and neglect convictions resulted in roughly $155,000 being recovered, the report stated.

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Inpatient Rehabilitation Hospital Patients Have Better Outcomes Industry Sponsored Study Claims

Friday April 18, 2014
rehab

Can dedicated rehabilitation hospitals reduce readmissions more effectively than nursing homes? This sponsored study suggests yes. What do you think?

A study released at a meeting of the March meeting of the American Medical Rehabilitation Providers Association (AMRPA) shows that patients treated in inpatient rehabilitation hospitals and units had better long-term clinical outcomes than those treated in nursing homes.

The ARA Research Institute, an affiliate of the AMPRA, commissioned Dobson-DaVanzo & Associates, LLC, to conduct a retrospective study of inpatient rehabilitation hospital and unit patients and clinically similar nursing home patients to examine the downstream comparative utilization, effectiveness of post-acute care pathways, and total cost of treatment during the five years following the implementation of the 60 percent rule.

"This study shows that patients treated in inpatient rehabilitation hospitals and units have better outcomes, go home earlier and live longer than those treated in skilled nursing facilities," said Bruce M. Gans, M.D., AMRPA board chair, and executive vice president and chief medical officer of Kessler Institute for Rehabilitation.

Key Findings

The study's key findings show:

  • Over a two-year episode of care, inpatient rehabilitation hospital and unit patients clinically comparable to skilled nursing facility patients, on average: returned home from their initial hospital rehabilitation stay two weeks earlier; remained home nearly two months longer; stayed alive nearly two months longer.

  • Of matched patients treated: inpatient rehabilitation hospital and unit patients showed an 8 percent lower mortality rate than skilled nursing facility patients; inpatient rehabilitation hospital and unit patients with 5 of the 13 diagnostic conditions showed significantly fewer hospital readmissions than skilled nursing facility patients; inpatient rehabilitation hospital and unit patients made 5 percent fewer emergency room visits per year than skilled nursing facility patients.

See the full study.

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The staff experience: employees have human needs too!

Wednesday April 16, 2014

Here is an excerpt from my recent Hospital Impact blog. In essence, healthcare must heal itself before it can heal others.

This month's blog post extends from both my January and February posts. In January, I shared how short-sighted financial decisions hurt patient experience. In February, I discussed my new role as primary caregiver to my mom, suggesting that instead of focusing on patient experience, we should look at the human experience.

One comment on the January post serves as a good segue for the rest of this piece.

"Health and wellness, just as death and dying, affect all of us. Clinicians and administrators share in the wins and defeats in healthcare. As nurses, we need to be in the mix, collaborating with various stakeholders, while holding the hand of another human being to ease their suffering."

[More:]

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Quality Indicators No Good If Staff Does Not Understand Them

Monday April 14, 2014
culture

A survey in the Journal of Research in Nursing shows that most nursing home staff do not fully understand the meaning and value of MDS 3.0.

A survey was used to measure clinical leadership's perceptions of staff understanding of the minimum data set (MDS) quality indicators (QIs) and ways to improve staff understanding of this system, as well as specific perceived training needs among Department of Veterans Affairs (VA) nursing home care unit (NHCU) clinical leadership.

An online survey using structured (quantitative) and open-ended (qualitative) items was conducted in 97 VA NHCUs nationwide. A total of 289 leadership staff including directors of nursing, medical directors, MDS coordinators participated.

Most respondents rated their frontline staff as having "good" to "fair" understanding of how the Quality Indicators are computed through MDS data. Lack of involvement with the MDS is the greatest barrier to greater understanding, the respondents indicated. Workers are often excluded from MDS processes, and there is a lack of training, the researchers found.

Respondents recommended education/training, involvement, reinforcement and other methods to increase understanding. Of specific training strategies/needs, the most frequently identified were using the MDS as a clinical assessment tool.

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22 Percent of Medicare Beneficiaries Experienced Adverse Events During SNF Stays

Friday April 11, 2014
readmission

More of this will happen if SNFs don't get their act together.

The Office of the Inspector General conducted a series of studies from 2008-2012 about hospital adverse events, defined as harm resulting from medical care. This work included a Congressionally mandated study to determine a national incidence rate for adverse events in hospitals. They continued that work by evaluating post-acute care provided in skilled nursing facilities (SNF). SNF care is second only to hospital care among inpatient costs to Medicare. What they found - almost one on four people experience an adverse effect during a SNF stay.

The study estimated the national incidence rate, preventability, and cost of adverse events in SNFs by using a two-stage medical record review to identify events for a sample of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care. Sample beneficiaries had SNF stays of 35 days or less.

An estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.

The OIG recommends that:

  • AHRQ and CMS raise awareness of nursing home safety and seek to reduce resident harm through methods used to promote hospital safety efforts.

  • There be collaboration to create and promote a list of potential nursing home events-including events not commonly associated with SNF care-to help nursing home staff better recognize harm.

  • CMS should also instruct State agency surveyors to review nursing home practices for identifying and reducing adverse events.

This report would indicate that nursing homes are failing as quality partners to hospitals in reducing readmissions. And that spells opportunity for assisted living and even skilled home health providers to fill the gap. After all, being in a nursing home is not much better than being in a hospital in terms of your likelihood to acquire an infection or other illness. A less acute setting coupled with the right care might be the right recipe in reducing readmissions.

McKnight's Long-Term News and Assisted Living editor staff writer Tim Mullaney has an interesting take on this too.

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Significant Gap in Healthcare Workers Predicted

Wednesday April 9, 2014
workforce

We need a lot more people getting interested in our elders.

The U.S. is unprepared to meet the current and future workforce needs for its older adult population, according to a set of state-specific issue briefs released by the Eldercare Workforce Alliance (EWA). The Alliance, a coalition of 30 national organizations committed to strengthen the workforce trained to care for older adults, cited data from the Health Resources and Services Administration and the Administration on Community Living showing the amount of federal funding going to each state to help develop a competent geriatrics workforce and support family caregivers.

Despite the growing need for eldercare, currently there are not enough healthcare professionals, including direct-care workers, trained to care for older adults. "We need a well-trained workforce and supports for family caregivers to meet the unique needs of older adults," said Alliance co-convener and American Geriatrics Society chief operating officer Nancy Lundebjerg. "Person- and family-centered interdisciplinary team care has been the hallmark of geriatrics and is the key to older adults receiving quality care and remaining independent for as long as possible."

"Nationwide we will require over a million new direct-care workers alone to provide critical care to people with long-term care needs," said Alliance public policy committee chair and PHI national policy director Steve Edelstein. Data from the Bureau of Labor Statistics cited in the issue brief finds that Personal Care Aides and Home Health Aides are among the fastest-growing occupations with demand expected to increase 49% by 2022.

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New Report Shows Other Side of Consistent Assignment - Isolated and Overburdened Staff

Monday April 7, 2014
chris perna

Chris Perna, CEO of Eden Alternative, respectfully disagrees!

Consistently assigning nursing home aides to particular residents could cause the aides to feel isolated and overburdened, suggests a study forthcoming in the Western Journal of Nursing Research. However, a prominent voice in the nursing home culture change movement says the study simply shows that providers must adhere to best practices to see the benefits of consistent assignment.

See the full post at McKnight's Long-Term Care News & Assisted Living.

Chris Perna

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Family Participation at Meal Time Has Benefits; Does Not > Food Intake

Friday April 4, 2014
Food

While family participation in meal time has its benefits, apparently it does not help a loved one eat more.

Seventy-four nursing home residents from two Veterans Affairs (VA) and four community facilities in one geographic region were studied at mealtime periods in which family was present and compared with mealtime periods when family was not present for the same resident.

Results showed that family visitation was infrequent during mealtime; however, feeding assistance time was significantly higher when visitors were present. Despite the increase in assistance time, there was not a significant difference in intake.

Strategies that encourage the involvement of family in mealtime assistance may have additional benefits not directly associated with meal consumption, including providing family members with meaningful activity during a visit and enhancing residents' quality of life and well-being.

According to Alzheimer's Disease International and cited in an earlier post here, up to 30% of residents in long-term care are undernourished. In a report it recommended that:

  • Nutritional standards of care for people with dementia should be introduced throughout the health and social care sectors, and monitored for compliance.

  • All people with dementia should have their weight monitored and nutritional status assessed regularly.

  • All people with dementia, and their family carers, should receive dietary advice from a dietitian as a part of post-diagnostic care, updated, as appropriate, as their condition evolves, particularly with the onset of weight loss, aversive feeding behaviours, and need for feeding assistance.

  • Undernutrition, once established, is a serious health concern requiring medical attention and input from a dietitian and occupational therapy as appropriate. Those at risk of undernutrition require a detailed assessment of diet, feeding behaviors and need for feeding assistance. This should inform an immediate and intensive nutritional intervention to restore and maintain normal nutrition.

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CMS Pauses RAC

Wednesday April 2, 2014
rac

CMS will takes it eyes off RAC for a bit!

In an update on its web site, CMS stated that it is in the procurement process for the next round of Recovery Audit Program contracts and it is important that it transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts.

In addition, they state, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program.

It is is reviewing:

  • Additional Documentation Request (ADR) limits

  • Timeframes for review and communications between Recovery Auditors and providers

June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment.

CMS will continue to update its website with more information on the procurement and awards as information is available. Providers should contact RAC@cms.hhs.gov for additional questions.

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