ATX22-Assisted Living Day "The National Perspective on Assisted Living and Quality”
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ATX22-Assisted Living Day "The National Perspective on Assisted Living and Quality”

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  • There is no standard federal definition of residential care facilities <br /> licensed, registered, listed, certified, or otherwise regulated by a state. NSRCF is designed to produce national estimates of these places and their residents. <br /> To be included had to have 4 or more beds <br /> Serves primarily adult population <br /> At least 1 resident at time of interview <br /> Provide room and board with at least 2 meals a day <br /> Provide around the clock supervision <br /> Offer help with personal care OR health care-related services (medication management) <br /> Facilities exclusively serving adults with severe mental illness or ID/DD are excluded <br /> Stratified 2-stage design <br /> Primary strata defined by facility bed size and geographic region <br /> Within primary strata facilities sorted by MSA status (metropolitan statistical area) <br /> Then using systematic random sampling <br /> Had 3,605 facilities <br /> 2nd stage was selection of current residents. Carried out during community interviews using an algorithm programmed into CAPI <br />
  • 2009 Average home value is about $200,000 so average assets excluding home is about $230 K. The median income and assets are probably more telling about the assisted living population. ½ of all residents have incomes less than $18,972. <br /> The average age of the assisted living resident has increased by more than one year in the last 4 years as has the average age at move in. The trend toward older residents is likely to continue. <br />
  • 2009 Average home value is about $200,000 so average assets excluding home is about $230 K. The median income and assets are probably more telling about the assisted living population. ½ of all residents have incomes less than $18,972. <br /> The average age of the assisted living resident has increased by more than one year in the last 4 years as has the average age at move in. The trend toward older residents is likely to continue. <br />
  • Other health-related characteristics <br /> Included almost 20% with bowel incontinence <br /> Almost 80% needing help with medications <br /> 37% with help with 3 or more ADLs <br /> 24% admitted to a hospital in the last 12 months <br />
  • Focusing on cognitive abilities <br /> Almost half experience confusion or difficulty with memory in the last 7 days <br /> 28% experience difficulty with long-term memory in the last 7 days <br />
  • How many recognize that blue ENERGY STAR logo? Chances are, you own an ENERGY STAR qualified product in your home. Over 2.5 billion Energy Star products have been sold since 1992. These are products that use anywhere from 25%-50% less energy than non-qualified products. Research shows that it is a widely recognized and trusted symbol for quality. <br />
  • EPA works with over 12,000 organizations, from small businesses to Fortune 500 companies in almost every commercial sector; healthcare, schools, hotels, corporate real estate, supermarkets, and retail. In 2008, the ENERGY STAR program helped these organizations save $5.3 billion by improving energy efficiency. <br /> EPA’s goal is to help buildings save energy and eventually earn the ENERGY STAR. And they are now expanding the ENERGY STAR program to senior care communities. <br /> The cornerstone of their program is an ENERGY STAR rating, which over 117,000 buildings have obtained to date. <br />
  • Why are we specific with date and time? Well in the words of Donald Berwick – some is not a number and soon is not a time <br /> By March <br /> ​Target: By March 2, 2015 at 12:00 p.m., individual communities will safely reduce hospital readmissions by 15 percent (this includes any admitting diagnosis). Individual communities that have less than 5 percent of residents with hospital readmissions will maintain hospital readmissions below 5 percent. <br />
  • PAT <br /> You can see more points on our business cases on our website – we have business cases in PDFs for every goal these are just some points <br />
  • PAT <br />
  • So how are you going to achieve this goal <br /> Adopting the INTERACT Program – you have some SBAR’s and stop and watch tool in front of you – use these, copy them and implement them. The developers of INTERACT allowed us to edit their tools with the help of the American Assisted Living Nurses Association until the INTERACT team developed these tools for AL which is coming <br /> Engage others <br /> Consistent staff <br />
  • Please note that the SBAR, Stop & Watch, Measurement of Hospital Transfer Rates, and Change in Condition Cards are only parts of the overall INTERACT (Interventions to Reduce Acute Care Transfers) Program which is a comprehensive quality improvement program. Until the new INTERACT program for ALC is developed; the INTERACT for Nursing Homes which can be used for ALC can be found here. <br /> The INTERACT Project Team is revising the INTERACT program and tools to be used in Assisted Living with support from a CMS Innovations Grant. NCAL will post links to those new assisted living tools as soon as they are available. <br />
  • Estimated readmissions cost about 15 billion annually <br /> Section 3025 of the Affordable Care Act (ACA) added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires the Centers for Medicare & Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.    <br />
  • Estimated readmissions cost about 15 billion annually <br /> Section 3025 of the Affordable Care Act (ACA) added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires the Centers for Medicare & Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.    <br />
  • Estimated readmissions cost about 15 billion annually <br /> Section 3025 of the Affordable Care Act (ACA) added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires the Centers for Medicare & Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.    <br />
  • PAT <br />
  • Residents like to be cared for by the same caregivers because it allows them to establish a relationship. <br />
  • Empower staff at all <br /> Elements that lead to an enhanced work environment: <br /> organization commitment to staff <br /> training and education for all levels of staff <br /> career ladders and lattices <br /> recognition and reward programs <br /> levels to participate in problem-solving and quality improvement to ensure that solutions are based in first-hand knowledge of the systems and challenges that impact day-to-day care <br /> Resources needed to complete the job <br /> Management training for supervisory level staff (ongoing vs. one time) <br /> Timely and concise communication from management to staff <br /> Employee satisfaction <br />
  • Thinking of recognition, NCAL has an awards program <br />
  • PAT <br />
  • Residents like to be cared for by the same caregivers because it allows them to establish a relationship. <br />
  • Empower staff at all levels to participate in problem-solving and quality improvement to ensure that solutions are based in first-hand knowledge of the systems and challenges that impact day-to-day care <br />
  • List of antipsychotics <br /> Conventional – also referred to as typical – are the first class developed <br /> Atypical are your second generation <br /> Think iphone vs iPhone 5 <br />
  • Food and Drug Administration approves uses of drugs when they are approved for antipsychotics this list includes: <br /> Schizophrenia <br /> Bipolar disorder <br /> Irritability associated with Autism <br /> Treatment of depression <br /> Tourette’s <br /> Off-label use is when you prescribe a medication to a patient without an FDA Approved diagnosis – this is allowed by the FDA and medical boards <br />
  • Common off-label uses of antipsychotics include: <br /> Dementia with behavior difficulties <br /> Agitation <br /> Aggression <br /> Wandering <br /> Acute Delirium <br /> Depression <br /> Obsessive-compulsive disorder <br /> Psychotic symptoms (hallucinations, delusions) with neurological diseases <br /> Parkinson’s disease <br /> Stroke <br /> AHRQ Report <br /> I got depression and OCD from the AHQR report. <br />
  • Let’s talk about antipsychotic effectiveness in dementia <br /> Antipsychotics take effect within 3-7 days <br /> Acute responses (for example PRN) are most likely due to sedation effects NOT antipsychotic <br /> In randomized control trials, participants do a little better than on placebo but the effect beyond 3 months is unclear <br /> Not everyone who receives antipsychotics do better <br /> Many on placebos improve <br /> The net effect - which is the effect after all the pluses and minues are taken into effect <br /> Is about 10 – 20 people out of a 100 receive the medication improve actually due to the medication <br />
  • We do know antipsychotics are associated with adverse outcomes in elderly with dementia <br /> Data is from nursing facility residents but still meaningful <br /> Death is over 1 ½ times greater than placebo <br /> Hospitalization is increased 40% <br /> Falls and fractures increased <br /> Venothrombotic events includes deep vein thrombosis and pulmonary emboli <br /> Conventions antipsychotics have worse adverse events than atypical <br />
  • What about low doses? <br /> Effectiveness of low doses – but still increased adverse events <br /> Some low dose is unknown <br /> Benefits really not outweighing the harms <br />
  • There is evidence for discontinuing low doses <br /> RCTs for withdrawal show that no difference in outcomes between the placebo and continued medication – so really no reason to stay on <br /> About 75% remain off drug after the trial <br /> Less than 25% need to be restarted <br /> Placebo group – had fewer adverse events <br /> Medication Low Dose Normal Dose <br /> Aripiprazole &lt;1 mg/d 1-2 mg/d <br />
  • How we are measuring so Incidence – (new cases at AL) <br /> Individual communities will measure – we do not have a national way to measure this <br /> Incidence: % of residents who have an antipsychotic drug initiated for an off-label use within the first 90 days at assisted living community <br /> # of residents with antipsychotic drug use indicated on medical records over the first 90 days at the assisted living <br /> Divided by <br /> # of residents who have been at the assisted living for 90 or less days <br />
  • How we are measuring so Incidence – (new cases at AL) <br /> Individual communities will measure – we do not have a national way to measure this <br /> Incidence: % of residents who have an antipsychotic drug initiated for an off-label use within the first 90 days at assisted living community <br /> # of residents with antipsychotic drug use indicated on medical records over the first 90 days at the assisted living <br /> Divided by <br /> # of residents who have been at the assisted living for 90 or less days <br />
  • Calculation: Prevalence: <br /> % of resident with off-label use of an antipsychotic drug <br /> # of residents (who have been at the AL over 90 days) with antipsychotic drug use indicated on medical records at the end of the target period <br /> Divided by <br /> # of residents (who have been at the AL over 90 days) at the end of the target period <br />
  • How we are measuring so Incidence – (new cases at AL) <br /> Individual communities will measure – we do not have a national way to measure this <br /> Incidence: % of residents who have an antipsychotic drug initiated for an off-label use within the first 90 days at assisted living community <br /> # of residents with antipsychotic drug use indicated on medical records over the first 90 days at the assisted living <br /> Divided by <br /> # of residents who have been at the assisted living for 90 or less days <br />
  • How we are measuring so Incidence – (new cases at AL) <br /> Individual communities will measure – we do not have a national way to measure this <br /> Incidence: % of residents who have an antipsychotic drug initiated for an off-label use within the first 90 days at assisted living community <br /> # of residents with antipsychotic drug use indicated on medical records over the first 90 days at the assisted living <br /> Divided by <br /> # of residents who have been at the assisted living for 90 or less days <br />
  • Decreases the side effects and adverse drug reactions associated with these medications. <br /> Non-pharmacologic interventions help to enhance an individual’s ability to direct their care, which improves their independence, dignity, and quality of life. <br /> Adverse Drug Events (ADEs) may require hospitalization and the community may experience lost revenue for days the resident is not in the community. <br /> A reputation for using innovative, person-centered care approaches will provide a competitive advantage. <br />
  • PAT <br />
  • PAT <br />
  • Why do we need to measure – this says it all. Policymakers want to see data, ACOs want to see data <br />
  • State Data <br /> Why should facilities complete surveys? <br /> Does it really matter – YES <br /> If enough facilities in a state complete the surveys then you can have access to state-level data. Why do you want state level data? This gives you an overview of how your state is doing and the more sometimes the more specific the data is to your state the better for reviewing and improving quality issues. <br /> So I am considering making a pizza policy at NCAL for meetings. For every meeting we will have pizza but I need to know what kind of pizza everyone likes because we want you to be happy with this new policy. Think of your favorite toppings, crust (thin, thick, deep dish). I am going to do a quick survey to find out what kind of pizza we should have. <br /> Now – pick someone in audience and ask what type of pizza they would like. Great that is what we will all be having and that is what the policy will be – Type of pizza <br /> This is why you want data to represent you. <br /> Example – Everyone in State A has a resident council but no facility in State B has a resident council. If you are interested in looking at if having resident councils impact customer satisfaction in and you are in State B the data is not going to be representative and your conclusions based on this data will be biased. <br /> It is important to have data that is representative – that is good data. You want the data to represent you – why is this important? <br /> Let me give you an example <br />
  • PAT <br /> Two years ago, the NCAL Quality Committee identified its Tier I performance measures. <br /> Tier I measures include 10 performance measures related to: <br /> Operational performance <br /> Resident quality of life <br /> Completed two years of surveys (2010 and 2011) <br /> Currently collecting year three <br />
  • Tier 1 Performance Measures include: <br /> Resident/family satisfaction: focuses on if the resident and/or family would highly recommend this community to others as a place to live <br /> Employee satisfaction: focuses on if the staff would highly recommend this community as a place to work <br /> Staff retention- self evident <br /> Census/occupancy rate: self evident <br /> Family and Resident Councils: does the community have councils that meet regularly and does the community leadership meet regularly with the council leadership? <br /> Mission and Vision statements – does the community have them and is staff trained on them. <br /> Safety program: issues like incident reports, safety committees, employee safety <br /> Nurse availability: based on NCAL’s Guiding Principles that a nurse should be available on at least an on call basis 24 hours a day. <br /> State criminal background checks: as a minimum for new employees <br />
  • The Vacancy, Retention and Turnover Survey was launched in 2010 which looked back at 2009 data <br /> The 3rd annual survey which we are currently collecting data for 2011 <br /> The survey is supported by Leading Age (formerly American Association of Homes and Services for the Aging, <br /> The Assisted Living Federation of America and <br /> American Seniors Housing Association <br /> Links to the results are on NCAL’s web site under the quality page <br />
  • GIVE EXAMPLES OF QUESTIONS <br /> The NCAL quality committee revised the Tier II performance measures last month. The 11 areas are listed above on the slide. The committee developed 20 questions related to these areas. <br /> NCAL is currently working with the Patient Safety Organization (PSO) taskforce and has identified 3 possible PSOs that NCAL will send out a Request for proposal to for bids on the project. A draft RFP has been developed and was reviewed by the taskforce and now being revised. <br /> NCAL anticipates that data collection may begin for these measures in 2013. <br />
  • By providing both privilege and confidentiality <br /> PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data, thereby improving quality by identifying and reducing the risks and hazards associated with patient care. <br />
  • By providing both privilege and confidentiality <br /> PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data, thereby improving quality by identifying and reducing the risks and hazards associated with patient care. <br />
  • By providing both privilege and confidentiality <br /> PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data, thereby improving quality by identifying and reducing the risks and hazards associated with patient care. <br />

ATX22-Assisted Living Day "The National Perspective on Assisted Living and Quality” ATX22-Assisted Living Day "The National Perspective on Assisted Living and Quality” Presentation Transcript

  • The National Perspective on Assisted Living & Quality Dave Kyllo Texas Health Care Association Austin, Texas November 5, 2013 dkyllo@ncal.org 1
  • National Survey of Residential Care Facilities (NSRCF) Includes •Assisted living •Board and care homes •Congregate care •Enriched housing programs •Homes for the aged •Personal care homes •Shared housing Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities http://www.cdc.gov/nchs/data/databriefs/db78.htm
  • National Survey of Residential Care Facilities: Key Findings •31,100 facilities •971,900 licensed beds •733,200 residents •19% of residents covered by Medicaid •43% of facilities with at least one resident receiving Medicaid LTC services Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities http://www.cdc.gov/nchs/data/databriefs/db78.htm
  • National Survey of Residential Care Facilities: Facility Size While about half of facilities are small, most residents live in larger communities. Facility Size Percentage of Residents Extra Large (100+ beds) 29% Large (26-100 beds) 52% Medium (11-25 beds) 9% Small (4-10 beds) 10% Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities http://www.cdc.gov/nchs/data/databriefs/db78.htm
  • National Survey of Residential Care Facilities: Regional Variation Residential care facility beds per 1,000 persons aged 85 and over, by region Region Beds/1,000 persons 85+ West 245 South 164 Midwest 177 Northeast 131 Total: United States 177 Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities http://www.cdc.gov/nchs/data/databriefs/db78.htm
  • Percent of facilities offering selected services, and residents using them Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities
  • Assisted Living Residents Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living •Average Age = 86.9 •Average Age at Move-in = 84.6 •73.6% Female; 26.4% Male •Average Income = $27,260 •Average Assets (including home) = $431,020 •Median Income = $18,972 •Median Assets (including home) = $205,000
  • Common Chronic Conditions Caffrey, C. Sengupta M., Park-Lee E, et al. Residents living in residential care facilities: United States, 2010. NCHS data brief, no 91. Hyattsville, MD: National Center for Health Statistics. 2012.
  • Activities of Daily Living Caffrey, C. Sengupta M., Park-Lee E, et al. Residents living in residential care facilities: United States, 2010. NCHS data brief, no 91. Hyattsville, MD: National Center for Health Statistics. 2012.
  • National Survey of Residential Care Facilities: Other Health-Related Characteristics ∗ 19.9 % bowel incontinent in last 7 days ∗ 36.6% urinary incontinent in last 7 days ∗ 77.1% need help with medications ∗ 38% receive help with 3+ADLs ∗ 24% admitted to a hospital in last 12 months ∗ 35% treated in hospital ED in last 12 months ∗ 14% fell in last 12 months resulting in injuries other than hip fractures
  • National Survey of Residential Care Facilities: Residents’Cognitive Abilities ∗ 48.7% experience confusion ∗ 46% experienced difficulty with short term memory in the last 7 days ∗ 28% experienced difficulty with long term memory in the last 7 days ∗ 18% could not find apartment ∗ 21% could not recognize staff names & faces ∗ 15% don’t know they are in a facility ∗ 22% don’t know what season it is Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities
  • NCAL’s Policy Priorities • Keep Regulation at the state level • Keep Assisted Living Included in CMS’ definition of Medicaid HCB settings • Protect, Improve Medicaid Coverage • Ensure that AL thrives in an episodic payment/ACO Environment • Help Members navigate health care reform • Make the move to EHRs • Demonstrate that we can manage quality • Get residents’ diabetic testing strips delivered
  • Federal Regulation of AL ∗ Over the past years, the U.S. Senate Aging Committee has focused several hearings on AL quality of oversight. ∗ In 2012, Sen. Bill Nelson (D-FL) considered introducing disclosure legislation after Florida legislature failed to act following a breakdown in the state’s AL regulatory system detailed by Miami Herald series. ∗ Sen. Nelson now chair of Aging Committee and AL likely to be a focal point of committee attention. ∗ “Frontline” investigative report on AL aired July 30 and may increase scrutiny by the media. 13
  • Navigating the New Alphabet Soup • • • • • • • • • • ACO MCO OIG ACA HIT EHR EMR HIE HIE (but now you call me “HIX” if you mean insurance) LTSS • Response: (LOL, OMG,)
  • Accountable Care Organizations Advice from Hospital Sector Analysts… • Engage Early • Bring Data • Hospital Discharges • Discharges to their Hospital • DRGs (Resident conditions) • Make an Investment (time & money) ACOs will narrow who they work with and increase volume with their partners
  • Medicaid & Assisted Living Major Challenges include: ∗Rates often inadequate. ∗Payment for AL Incomplete (housing, food, utilities not covered; SSI check insufficient to fill gap). ∗States shifting to managed care. ∗Many recent federal initiatives tend to exclude AL, including CMS proposed rules defining HCBS settings. 16
  • Home & Community-based Services (HCBS) as a % of Medicaid LTC Spending State Percent HCBS New Mex. 83.2% Iowa 39.8% Texas 46.9% Minn. 67.9% Miss. 14.4% Source: CMS Percentage of LTSS Spending for HCBS Usinig FFY 2009 Data)“State Medicaid Reimbursement Policies and Practices in Assisted Living,” Robert Mollica, National Center for Assisted Living/AHCA, September 2009. Available at www.ncal.org.
  • CMS Proposed Rules Defining HCBS Settings CMS has published a series of proposed rules intending to enforce Olmstead decision in Medicaid communitybased settings. ∗Concepts being promoted include: community integration, resident-centered care, home-like settings, and individual autonomy. ∗Raises issue of whether assisted living is too institutional in nature. ∗Possible consequence: exclusion of AL from Medicaid. 18
  • CMS Issues Revised Proposed Rules Defining HCBS Settings in 2012 ∗ In April and May, 2012, CMS published a revised definition of Medicaid HCBS settings in final rule implementing Community First Choice program and proposed rules implementing revisions to 1915i program. ∗ While improved, the proposed definition still could exclude some AL communities. 19
  • Revised Proposed Definition of HCBS Settings In the latest proposed rules, CMS states: “…home and community-based settings shall have all of the following qualities, and such other qualities as the Secretary determines to be appropriate, based on the needs of the individual as indicated in their person-centered service plan: The setting is integrated in, and facilitates the individual’s full access to, the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, in the same manner as individuals without disabilities; 20
  • Revised Proposed Definition of HCBS Settings (2) • The setting is selected by the individual from among all available alternatives and is identified in the personcentered service plan; • An individual’s essential personal rights of privacy, dignity and respect, and freedom from coercion and restraint are protected; • Individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact are optimized and not regimented; • Individual choice regarding services and supports, and who provides them, is facilitated.; 21
  • Revised Proposed Definition of HCBS Settings (3) • In a provider-owned or controlled residential setting, the following additional conditions must be met. Any modification of the conditions, for example, to address the safety needs of an individual with dementia, must be supported by a specific assessed need and documented in the person-centered service plan: ∗ The unit or room is a specific physical place that can be owned, rented or occupied under another legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord tenant law of the State, county, city or other designated entity; 22
  • Revised Proposed Definition of HCBS Settings (4) ∗ Each individual has privacy in their sleeping or living unit: -- Units have lockable entrance doors, with appropriate staff having keys to doors; --Individuals share units only at the individual’s choice; and --Individuals have the freedom to furnish and decorate their sleeping or living units; ∗ Individuals have the freedom and support to control their own schedules and activities, and have access to food at any time; ∗ Individuals are able to have visitors of their choosing at any time; and ∗ The setting is physically accessible to the individual. 23
  • Revised Proposed Definition of HCBS Settings (5) We also plan to propose that home and communitybased settings do not include the following: 1) A nursing facility; 2) An institution for mental diseases; 3) An intermediate care facility for the mentally retarded; 4) A hospital providing long-term care services; or 5) Any other locations that have qualities of an institutional setting, as determined by the Secretary. 24
  • Revised Proposed Definition of HCBS Settings (6) ∗ The Secretary will apply a rebuttable presumption that a setting is not a home and community-based setting, and engage in heightened scrutiny, for any setting that is located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment in a building on the grounds of, or immediately adjacent to, a public institution or disability-specific housing complex...” 25
  • AHCA/NCAL Issues with Latest CMS Proposed Rule Defining HCBS Settings NCAL & AHCA asks CMS to: ∗Strike the “rebuttable presumption” that certain provider-controlled settings are institutional (those on or near institutional settings or disability-specific housing complexes); ∗Use care planning process to ensure resident-centered care, not arbitrary definitions related to facility location; ∗Make sure eviction procedures accommodate state standards for residential care/assisted living facilities; ∗Make sure that standards for sharing units are workable and realistic about economic constraints facing states; and, ∗Permit secure perimeters (locked units) for residents with dementia. 26
  • OIG Finds Deficiencies in State Regulation of AL Communities Providing Medicaid Services ∗ In December 2012, HHS’ OIG released a report today documenting deficiencies in meeting state and federal requirements for assisted living facilities (ALFs) providing Medicaid services. ∗ Examined data, inspection reports, and provider care plans for 2009 in the seven states with the most assisted living Medicaid beneficiaries: Georgia, Illinois, Minnesota, New Jersey, Oregon, Texas, and Washington. ∗ The study encompassed many types of facilities including private residences where beneficiaries were taken care of by relatives; singlefamily homes that served six or fewer individuals; and multi-unit residences, some serving more than 200 individuals. The report, Home and Community-Based Services in Assisted Living Facilities, can be found at: https://oig.hhs.gov/oei/reports/oei-09-08-00360.pdf. 27
  • OIG Report on State Enforcement of Medicaid Standards Report Findings: Greatest area of concern is meeting care plan standards. ∗77 percent of beneficiaries receiving HCBS resided in ALFs cited for at least one deficiency or noncompliance with state licensure or certification standards. ∗Nine percent of beneficiaries’ records did not include care plans required by the states and federal government. ∗Forty two percent of the care plans did not include the frequency of HCBS furnished, as required. ∗In five of the seven states that also required (as a state option) care plans to specify the beneficiaries’ goals and the interventions to meet them, 69 of 105 care plans did not meet that requirement. ∗In two of the seven states that required care plans to be signed by beneficiaries or their representatives, 12 of 25 care plans did not meet that 28 requirement.
  • Differences between Facilities Serving Medicaid Beneficiaries and Those That Do Not RTI study presented in November 2012 found that AL facilities accepting Medicaid payment were similar in many ways to those that do not: ∗ In general, found that Medicaid facilities are “not that different” from non-Medicaid facilities.” ∗Levels of services provided and staffing generally similar. Source: “Do Residential Care Facilities That Serve Medicaid Beneficiaries Differ From Those That Do Not?” Angela Greene, Galina Khatutsky, Joshua Wiener & Ruby Johnson, slides, Gerontological Society annual meeting, Nov. 17, 2012 29
  • RTI Medicaid study (2) RTI study found some differences between Medicaid and non-Medicaid facilities: ∗More Medicaid residential care facilities (RCFs) are smaller (4-25 beds). ∗More non-Medicaid RCFs have dementia or Alzheimer's units. ∗Higher proportion of Medicaid RCFs provide skilled nursing care. ∗A slightly higher mean number of LPN hours for direct care per resident are provided in the non-Medicaid facilities and the mean number of hours of direct care per person provided by administrators in Medicaid facilities is higher. ∗Non-Medicaid RCFs have higher monthly base rate. 30
  • RTI Medicaid study (3) ∗ Resident profiles in Medicaid facilities differ from those in non-Medicaid facilities: ∗ Medicaid residents tend to be younger (under 65) and a higher proportion are minorities. ∗ Higher proportion of Medicaid residents have diabetes. ∗ Higher proportion of non-Medicaid residents are female and a higher proportion have Alzheimer’s disease or other dementias. ∗ Higher proportion of Medicaid residents are intellectually disabled or have a serious mental illness. ∗ Higher proportion of Medicaid residents exhibit problem behaviors such as wandering, and being verbally and physically abusive. 31
  • Resident Living Arrangements ∗ Another recent RTI study attempting to explore whether AL/residential care is more “community-based” or institutional in nature found differences between Medicaid and non-Medicaid residents living arrangements. ∗ However, the study found that, with exception of living arrangements and visitors, Medicaid facilities are roughly comparable to non-Medicaid facilities. Source: “Are Residential Care Facilities ‘Community Services’?,” Joshua Wiener, Galina Khatutsky, Ruby Johnson, Angela Greene, slides, Gerontological Society annual meeting, Nov. 17, 2012 32
  • Resident Living Arrangements Non-Medicaid residents more likely to have single room or apartment. Type of Living Arrangement Total Residents (%) Non-Medicaid Residents (%) Medicaid Residents (%) Room designed for 2 or more persons 26.9 22.5 45.5 Room designed for 1 person 31.6 32.8 26.6 Apartment 41.5 44.7 27.9 33 Source: “Are Residential Care Facilities ‘Community Services’?,” Joshua Wiener, Galina Khatutsky, Ruby Johnson, Angela Greene, slides, Gerontological Society annual
  • Issue: Single Rooms for AL Medicaid Beneficiaries? ∗ Most states currently allow sharing of rooms/units for AL Medicaid services providers. ∗ Medicaid does not pay for room and board. ∗ If CMS is going to require single rooms, then a funding mechanism needs to be found to pay for them (HUD vouchers?). This might save government dollars if structured properly by substituting AL for more expensive institutional settings. ∗ If CMS requires single rooms w/o funding, then ironically many AL Medicaid residents will end up in institutional settings sharing rooms at a greater public cost. 34
  • State Regulatory Trends ∗ In 2012, at least 18 states made AL legislative/regulatory changes (January 2012-January 2013). ∗ Many states made major changes. ∗ In recent years focal points of change include: Staff education/training, more focused surveys, disclosure, fire safety, infection control/TB testing, medication management. 35 Source: NCAL 2013 State Regulatory Review
  • Innovative Survey Models ∗ Colorado: On Jan. 1, 2013, the Assisted Living Residence (ALR ) program began conducting risk-based re-licensure inspections, initially on a pilot basis. ∗ Under the new system, ALRs meeting the following criteria will be eligible for an extended survey cycle: licensed for at least three years, and, within that prior three years, having had no enforcement activity, no pattern of deficient practice, and no significant deficiency cited in response to a complaint that negatively affected the life, health, or safety of residents. 36
  • Innovative Survey Models (2) ∗ New Jersey: In 2012, the state Department of Health (DOH) collaborated with The Health Care Association of New Jersey Foundation to create a voluntary program titled Advanced Standing. To receive the department’s distinction of Advanced Standing, a facility must comply with all applicable local, state, and federal regulations as well as submit quality data that reaches benchmarks established by a peer review panel. ∗ A facility participating in the program does not receive a routine survey by DOH. However, any time a facility falls below DOH standards, such as poor performance on a complaint investigation, that facility can be removed for cause from the program by DOH. In addition, DOH provides follow-up surveys based on a random sample of facilities that participate in the program. The program is open to all licensed assisted living residences and comprehensive personal care homes. 37
  • Innovative Survey Models (3) Other Innovative Assisted Living State Oversight Models: ∗North Carolina recently extended survey cycle to two years for “Four-Star” assisted living facilities. Those with highest rating can be inspected every two years instead of annually. ∗Wisconsin has abbreviated survey for consistently good performers (based on outcomes reported to the state) ∗Many state agencies continue dealing with limited resources, personnel changes. 38
  • Life Safety – a Major Breakthrough ∗ Four-year effort led by NCAL’s life safety engineer succeeded in updating and harmonizing two major life safety standards for assisted living: ∗ The National Fire Protection Association adopted the changes in 2012 edition of Life Safety Code for existing buildings. ∗ Key committees of the International Code Committee recently adopted similar standards for new construction in 2012. 39
  • Life Safety Standards ∗ The new standards address major issues: ∗ As residents become less able to evacuate without assistance, the standards allow AL facilities to remain in residential classification while ensuring high level of safety. ∗ Results in major cost savings for many providers and improved quality of life for residents who won’t have to move to institutional settings. ∗ Over time most states adopt these two bodies’ standards. NCAL generally recommends adoption of 2012 edition of Life Safety Code. 40
  • Health Coverage Expansion under the Affordable Care Act (ACA) Major Components take effect Jan. 1, 2014. ∗Individual responsibility to maintain coverage. ∗Employer coverage requirements but the Administration has delayed penalties for not offering coverage until Jan. 1, 2015. ∗Health plan reforms. ∗Insurance exchanges offering subsidized coverage (enrollment begins in October 2013). ∗Major expansion of the Medicaid program in about ½ the states that opted to expand. 41
  • Implications for LTC Providers ∗ The new requirements for employers to offer specified levels of coverage or pay penalties may increase costs for many long term care providers in 2015. ∗ Working with employee benefit specialists and insurance brokers and carriers, providers have begun the process of analyzing their options for providing affordable coverage or potentially paying penalties. ∗ However, until more key policy decisions are made, it is impossible for employers to precisely gauge the extent of the financial impact of the new requirements. 42
  • Employer Pay-or-Play Mandates: LTC Providers Most at Risk LTC providers most at risk for financial impact include: Those with high percentage of low-wage workers. Small firms not able to self-insure. Those offering limited health benefits or not offering coverage to some full-time workers. Those with low margins. Those reliant on government reimbursement (they cannot unilaterally raise prices if their labor costs suddenly go up). 43
  • Evaluate Your Options for Compliance with ACA www.ncalbenefits.com & Learn more about the ACA at: www.ncal.org www.ahca.org 44
  • Federal Agencies with Initiatives Impacting Assisted Living • CDC-- Infection Control + Hepatitis B Outbreaks • National Labor Relations Board (NLRB) • AHRQ– LTSS Public Reporting • DOL Wage and Hour Enforcement • DEA –Disposal of Controlled Substances • EPA Disposal of Medications • FDA Disposal of Narcotics and Fentanyl patches • CPSC Ban on Portable Bedrails in Assisted Living • CMS Definition of HCB Setting • EPA Energy Star Program • CFPB Efforts on Senior Fraud and Scams
  • Fair Labor Standards Act Enforcement Continues in LTC Settings including AL ∗ Working before and after shifts ∗ Working during an employee’s scheduled meal break including interruptions of short duration ∗ Employees not being paid for staff meetings and compensable training session Why the violations? ∗ ∗ ∗ ∗ Lack of understanding of the FLSA “We did it that way the last place I worked” Caring employees LTC culture and environment
  • LTC Specific Fact Sheets are Available at: www.dol.gov/whd ∗ #31 Nursing Care Under the FLSA (Guidance applicable to all provider types) ∗ #52 Youth Employment ∗ #53 Hours Worked ∗ #54 Calculating Overtime
  • ENERGY STAR
  • Eligible for ENERGY STAR score Senior Care Communities Hospital Medical Office Building Office Building Retail Warehouse Hotel Bank/Financial Dormitory Waste Water Treatment Plant Supermarket Court House School
  • Benefits of Energy Conservation • Senior Care Providers – Margin maximization strategy – Performance management • Residents – Enhanced affordability – Quality enhancement program • Environmental Leadership – Lead on addressing climate change
  • Health Information Technology will Transform Assisted Living and All Health Care • EHR: electronic health record – across health care organizations • EMR: electronic medical record – within a health organization • eMAR: technology that automatically documents the administration of medication into certified EHR technology using radio frequency ID or bar coding • HIE: health information exchange across providers, purchasers, regulators • HIE –HIX: health insurance exchange • m-Health: health care through mobile devices
  • What Does Interoperability Mean? ∗ Basic interoperability: ability to electronically communicate health data ∗ Semantic interoperability: enable the receiving computer to display the text or data received AND accurately interpret the meaning of the data ∗ Levels of Interoperability: • Non-electronic data (paper) • Machine transportable data (fax/e-mail) • Machine-organizable data (structured messages, unstructured content –documents and images) • Machine-interpretable data (structured messages, and standardized content) – Ultimate Goal!
  • Liability: CNA Analysis of Allegations at Assisted Living Facilities Allegations at AL Facilities Highest Frequency Closed Claims: ∗Resident fall 46.2% ∗Abuse 9.5% ∗Pressure ulcer 7.7% ∗Elopement 7.1% ∗Improper care 7.1% Death occurred in 37.2% of the closed claims associated with falls. Source: “Aging Services 2012: Data Analysis Supporting the Need for Industry Change,” CNA. 53
  • Liability: CNA Analysis of Allegations at Assisted Living Facilities (2) Allegations at AL Facilities Highest Average Total Paid for Closed Claims: ∗Gross improper care $541,908 ∗Elopement $378,312 ∗Failure to follow physician’s order $360,939 ∗Delay in seeking medical treatment $256,309 ∗Pressure ulcer $251,370 Source: “Aging Services 2012: Data Analysis Supporting the Need for Industry Change,” CNA. 54
  • Liability: CNA Analysis of Injuries at Assisted Living Facilities Injuries at AL Facilities Highest Frequency Closed Claims: ∗Death 37.3% ∗Fracture(s) 32.5% ∗Pain and suffering 6.5% ∗Emotional distress 4.1% ∗Contusion/bruise 4.1% Source: “Aging Services 2012: Data Analysis Supporting the Need for Industry Change,” CNA. 55
  • Liability: CNA Analysis of Injuries at Assisted Living Facilities (2) Injuries at AL Facilities Highest Average Total Paid for Closed Claims: ∗Death $291,060 ∗Emotional distress $230, 926 ∗Contusion/bruise $215,590 ∗Loss of limb/amputation $188,080 ∗Fracture(s) $174,469 Source: “Aging Services 2012: Data Analysis Supporting the Need for Industry Change,” CNA. 56
  • HealthCap Resolved Claims 2001 – 2011 Fractures/Head Injuries 47% Minor/No Injury 31% Sudden/Unexpected Death 6% Pain/Suffering 3% Burns 2% Sexual Assault 2% Pressure Ulcer 1%
  • Average Paid for Closed Claims Choking $214,168 Burns $203,580 Unexpected Death $145,470 Pressure Ulcer $133,503 Pain & Suffering $ 92,050 Sexual Assault $ 63,769 Fractures/Head Inj. $ 49,416 *HealthCap (2001 to 2011 Data)
  • What Led to the Litigation? Source: “HealthCap Data based on resolved claims from 20012011 for residential care/assisted living/independent living Common causes: ∗ Fractures and head injuries primarily due to falls ∗ Sudden/unexpected deaths due to unnoticed change of conditions, elopements, bedrails and medication errors. ∗ Burns due to cigarette smoking and inappropriate use of hot packs
  • AHCA Quality Initiative Goals Safely reduce 30-day hospital readmissions by 15% by 2015 Maintain nursing staff turnover below 30% until 2015 Maintain customer satisfaction above 90% by 2015 Safely reduce the off-label use of antipsychotics by 15% by March 2015
  • Hospital Readmissions
  • Safely Reduce Hospital Readmissions Target: By March 2015, individual communities will safely reduce hospital readmissions by 15 percent (this includes any admitting diagnosis). Individual communities that have less than 5 percent of residents with hospital readmissions will maintain hospital readmissions below 5 percent.
  • Hospital Readmissions: Measurement Calculation: # of AL residents admitted to a hospital (excluding ER-only visits and observation stays) from the AL within 30 days of hospital discharge DIVIDED BY All AL admissions to this community within 30 days of hospital discharge
  • Let’s Practice Resident Resident 1 Resident 2 Resident 3 Resident 4 Resident 5 Resident 6 Resident 7 Resident 8 Resident 9 Resident 10 Transfer from Hospital to AL January 1 January 3 January 4 January 8 January 10 January 15 January 19 January 25 January 31 January 31 Hospital Readmission Date January 31 February 5 February 28
  • Let’s Practice # of AL Residents admitted to a hospital from the AL within 30 days of hospital discharge = 3 Divided by All AL admissions to this community within 30 days of hospital discharge: 10 3/10 = .30 or (.30 x 100) = 30% hospital readmission rate
  • Other Ways to Track Your Progress • Percent of all admissions sent to any hospital within 30, 60, and 90 days of admission to your community • Percent of all admissions sent to any hospital within 30, 60, and 90 days of admission to your community, excluding planned readmissions • Track the number of days since your last readmission
  • Using Counts: “Time Between Events” • Simple counts • # of hospitalizations last week • Time between events (e.g. OHSA employee injuries) • # of days since last hospitalization • Use for any clinical measure • As you increase the time between events you will improve on any quality measure risk adjusted or not • Simple • Easy to display where all staff can see • Rapid feedback
  • Tracking Counts & Time Between Events
  • Factors Associated with low rehospitalizations Young Y et al. Clinical and Nonclinical Factors Associated with potentially preventable hospitalizations among nursing home residents in NYS. JAMDA 2011;12:364-371. 1
  • Strategies to Reduce Hospitalizations INTERACT Is a comprehensive program that uses these strategies •Track your rehospitalizations •Improve Communication • Externally (e.g. with hospital/ER) • Internally (e.g. between nursing & physicians) •Identify small changes in a resident’s status early on •Change Staffing • Consistent Assignment • Reduce staff turnover • Utilize nurse practitioners •Advance Care Planning
  • Hospital Readmissions: The Business Case • Decreases hospital acquired infections, resulting in less opportunity for skin breakdown, injury or harm from transfers. • Decreases the exacerbation of symptoms for people with dementia. • Means less stress for nurses who must take time for the readmission and transfer requirements. • Better outcomes make your facility more attractive as a preferred provider in integrated care models (such as ACOs)
  • Why Hospitals Care About You • CMS has implemented a payment penalty to hospitals with high 30 day readmission rates for discharges diagnoses • CHF • Pneumonia • Myocardial infarction • Hospitals participating in ACO or Bundle payment demos can only achieve savings by reducing rehospitalizations • Hospitals are partnering with LTC providers • Referring to low readmission providers
  • Hospital Readmissions: Achieving the Goal • Adopt the INTERACT program • Ensure seamless information exchanges between providers through the use of electronic health records (EHRs) • Engage providers at all points throughout the spectrum of care. Expand the use of nurse practitioners • Use consistent assignment of staff to ensure that staff are familiar with residents’ normal patterns and characteristics so that they detect early changes in resident’s conditions before they lead to a hospitalization • Utilize the tools on the Quality Initiative for Assisted Living website
  • Hospital Readmissions: Resources • • • • • • • Business Case Measurement Summary INTERACT SBAR for Assisted Living Nurses INTERACT SBAR for Assisted Living Caregivers INTERACT Stop & Watch INTERACT Measurement of Hospital Transfer Rates INTERACT Change in Condition Cards *All the above resources are available at qualityinitiative.ncal.org
  • INTERACT for Assisted Living • NCAL Quality Committee nurses and AALNA Board worked together to revise INTERACT tools for AL – approved by developers of INTERACT • These are posted on NCAL’s website (www.NCAL.org ) and recommended for use until the developers of INTERACT release INTERACT for AL
  • Stop & Watch for AL • Purpose: • Guide front-line staff through brief review of early, often subtle, indicators of change in condition • Improve communication between frontline staff and the nurse in charge
  • Tips on Implementing Stop & Watch • Stop & Watch • • • • • Send staff to learn from another facility using tool Pilot test 1 team on 1 unit Let team decide how to use stop & watch Meet with pilot team daily for feedback Make changes based on feedback • Start with CNA – Nurse using • Gradually expand to other staff, then to families 6 months to successfully roll out Stop & Watch
  • Tips on Implementing Stop & Watch • Need to work with staff to remind them to complete stop & watch • Need to work with RN’s to follow-up on submitted stop & watch • Look at stop & watch forms (or lack thereof) • Engage Physicians • Support notification of MDs/NPs on early signs 6 months to successfully roll out Stop & Watch
  • SBAR for Assisted Living Nurses • Structured format to assemble key information physicians need to make a decision • Complete prior to calling MD 4-6 months to successfully roll out SBAR
  • SBAR for AL Nurses • Situation • Background • Assessment (RN) or Appearance (LPN/LVN) • Request
  • Tips on SBAR implementation • Start with 1 nurse/staff • Announce to all staff that your using SBAR but piloting with <insert nurse’s name> • Review each day nurse’s experience with SBAR • Modify SBAR protocol based on each day’s feedback • Engage Physicians • Seek feedback from attending and covering MDs • Try pilot testing for 1 condition on 1 unit • INR calls to physicians • Elevated blood glucose • Falls 4-6 months to successfully roll out SBAR
  • SBAR for AL Caregivers • Structured format to assemble key information physicians need to make a decision • Complete prior to calling MD 4-6 months to successfully roll out SBAR
  • SBAR for AL Caregivers • Situation • Background • Appearance • Ready to call
  • Staff Stability
  • Increase Staff Stability Target: Each year, until March 2015, maintain nursing staff turnover rates below 30 percent.
  • Staff Stability: Measurement Calculation: # of terminations for nursing staff in the calendar year DIVIDED BY: Total # of current nursing staff employees at the end of the year *total includes full-time, part-time, permanent, short-term, seasonal salaried and hourly RN, LPN/LVN, CNA, CMA, personal caregivers and other similar front-line staff directly responsible for the daily care of residents. Employees of temporary agencies and outside contractors are not included. For Minnesota, include home health aides.
  • Staff Stability: The Business Case • The better staff members know a resident, the easier it is to deliver person-centered care. • Staff who are satisfied are more likely to recommend the community as a place to work. Good caregivers recruit good caregivers. • Communities have a positive reputation that spreads in the community leading to greater opportunity for business development. • Training new staff and turnover costs are high.
  • Staff Stability: Achieving the Goal • Focus on staff satisfaction, turnover, and empowerment, as well as consistent assignment. • Regularly measure staff satisfaction, including drill-down to specific factors to inform quality improvement efforts • Measure and track staff turnover to identify patterns, trends and potential root causes of high turnover in order to act on them • Empower staff at all levels to participate in problem-solving and quality improvement • Utilize the tools on the Quality Initiative for Assisted Living website
  • Staff Stability: Resources • Staff Turnover Calculator (Excel Spreadsheet) • Introducing Peer Mentoring in Long-Term Care Settings • Staff Stability toolkit (available in the AHCA/NCAL Bookstore!) *All the above resources are available at qualityinitiative.ncal.org
  • Recognize deserving staff! Noble Caregiver in Assisted Living Award NCAL Assisted Living Nurse of the Year NCAL Administrator of the Year National Assisted Living Week Programming Award Application submission for 2013 is now closed. Visit www.ncal.org for more information.
  • Customer Satisfaction
  • Increase Customer Satisfaction Target: By March 2015, maintain the number of customers who would recommend the community to others at or above 90 percent. Communities with customer satisfaction below 90 percent should improve to 90 percent by March 2015
  • Customer Satisfaction: Measurement Calculation: Current residents/families who would recommend the community # of current residents/families who answer a survey question about “willingness to recommend” a community positively DIVIDED BY: # of current residents/families responding to a survey question on “willingness to recommend”
  • Customer Satisfaction: Measurement Calculation: Residents who have moved out of AL who would recommend community # of residents who moved out and answer a survey question about “willingness to recommend” a community positively DIVIDED BY: # of residents who moved out and respond to a survey question on “willingness to recommend”
  • Customer Satisfaction: The Business Case • Increasing customer satisfaction can have a direct impact on increasing census and generating additional revenue from positive customer referrals. • Achieving customer satisfaction is the root of person-centered care. • High customer satisfaction data can be used to support participation in preferred provider plans, including Accountable Care Organizations medical homes and other organizations that provide health care services in the care continuum. • High customer satisfaction data can help the community differentiate themselves from other providers.
  • Customer Satisfaction: Achieving the Goal • Regularly measuring customer satisfaction, including identifying key factors that are contributing to overall ratings • Utilizing satisfaction data to prioritize quality improvement needs and act on them. • Using consistent assignment of staff to allow positive and continuing relationships to develop that allow staff to successfully provide individualized, person-centered care. • Utilize the tools on the Quality Initiative for Assisted Living website
  • Customer Satisfaction: Resources • Better Serving the Lesbian, Gay, Bisexual, and Transgender Populations in AL • Preparing Residents to Move Out • Assisted Living Staff Checklist for Responding to Complaints • Making Resident and Family Councils Successful in AL • Turning Complaints into Compliments • The Power of Ethical Marketing *All the above resources are available at qualityinitiative.ncal.org
  • Antipsychotic Medications
  • Safely Reduce Off-Label Use of Antipsychotics ​Target: By March 2015, safely reduce off-label use of antipsychotics by 15 percent. Communities that have less than 5 percent of off-label use maintain rates at or below 5 percent. All communities will implement use of at least one tool aimed at reducing off-label use of antipsychotics by March 2015.
  • Antipsychotic Medications • • • • • • • • • • • Conventional (Generic) Haldol (Haloperidol) Loxitane (Loxapine) Navane (Thiothixene) Orap (Pimozide) Compazine (Prochlorperazine) Mellaril (Thioridazine) Moban (Molindone) Prolixin (Fluphenazine) Stelazine (Trifluoperazine) Thorazine (Chlorpromazine) • • • • • • • • • Atypical (Generic) Abilify (Aripiprazole) Saphris (Asenapine) Clozaril Fazaclo (Clozapine) Fanapt (Iloperidon) Zyprexa (Olanzapine) Invega (Paliperidone) Seroquel (Quetiapine) Risperdal (Risperidone) Geodon (Ziprasidone)
  • FDA Approved Diagnoses • Schizophrenia • Bi-polar Disorder • Irritability associated with Autistic Disorder (Aripiprazole & Risperidone) • Treatment Resistant Depression (Olanzapine) • Major Depressive Disorder (Quetiapine) • Tourettes (Orap) When prescribed to a patient without an FDA approved diagnosis; considered off-label use, which is allowed by FDA and Medical Boards
  • Common Off-label uses • Dementia with behavior difficulties • Agitation • Aggression • Wandering • • • • Acute Delirium Depression Obsessive-compulsive disorder Psychotic symptoms (e.g. hallucinations, delusions) with neurological diseases • Parkinson’s disease • Stroke
  • Effectiveness in Dementia • Antipsychotic effect takes 3-7 days • Acute response most likely due to sedating properties, not antipsychotic effect • In RCTs, recipients do a little bit better than placebo but the effect beyond 3 months is unclear and: • Not everyone who receives the meds improves • A large number of people getting the placebo improve • The net effect is that 10 to 20 people out of 100 who receive the medication improve due to the medication
  • Associated with Adverse Outcomes • Off-label use of antipsychotics in nursing facility residents is associated with increase in: • • • • Death (heart failure or pneumonia) 1.6 x greater than placebo Hospitalization (40% increase) Falls & fractures Venothrombotic events • Conventional antipsychotics are worse than atypical antipsychotics
  • Effectiveness with Low Doses • Low dose Risperidone (<1 mg/d): small positive effect but also increased risk of adverse events • Low dose Olanzapine (5 mg/d): no positive effect but does have increase risk of adverse events • Low dose Aripiprazole and Quetiapine: effectiveness unknown, but Quetiapine at normal dose has no evidence of effectiveness Source: Cochrane Review 2012; Meta-analysis 16 RCTs in dementia
  • Evidence for Discontinuing Low Doses • RCTs for withdrawal of medication show • No difference in outcomes between placebo and continued medication • About 75% remain off the drug after the trial • Less than 25% need to be restarted on the medication • Placebo group (drug withdrawal) have fewer adverse events
  • Antipsychotic Measurement: Incidence Calculation: Incidence: % of residents who have an antipsychotic drug initiated for an off-label use within the first 90 days at assisted living community # of residents with antipsychotic drug use indicated on medical records over the first 90 days at the assisted living DIVIDED BY: # of residents who have been at the assisted living for 90 or less days
  • Let’s Practice! # of residents with antipsychotic drug use indicated on medical records over the first 90 days at the assisted living = 2 DIVIDED BY: # of residents who have been at the assisted living for 90 or less days = 10 Incidence: 2/10 = 0.20 or (0.20 x 100) = 20%
  • Antipsychotic Measurement: Prevalence Calculation Prevalence: % of resident with off-label use of an antipsychotic drug # of residents (who have been at the AL over 90 days) with antipsychotic drug use indicated on medical records at the end of the target period DIVIDED BY: # of residents (who have been at the AL over 90 days) at the end of the target period
  • Let’s Practice # of residents (who have been at the AL over 90 days) with antipsychotic drug use indicated on medical records at the end of the target period = 10 DIVIDED BY: # of residents (who have been at the AL over 90 days) at the end of the target period = 100 Prevalence: 10/100 = 0.10 or (0.10 x 100) = 10%
  • Percent Reduction – Let’s Practice! By December 2013 your community now has 8 residents on antipsychotics % reduction = ((Initial value – final value) / (Initial value) ) x 100 % reduction = ((10-8) / 10) x 100 % reduction = (2/ 10) x 100 % reduction = .20 x 100 % reduction = 20%
  • Tracking On a Real-time Basis • Percent of new admissions without approved psychiatric diagnoses admitted to your community on antipsychotic drugs that have those drugs discontinued at 30, 60, 90 days of their stay • Percent of new admissions without FDA approved diagnoses that are admitted without antipsychotic prescriptions and started on these. • Percent of residents in the community for more than 90 days that are taking antipsychotic drugs without psychiatric diagnoses that are on antipsychotic drugs • On an ongoing basis, track the number of days since the last person was started on an antipsychotic medication in the community.
  • Antipsychotics: The Business Case • Decreases the side effects and adverse drug reactions associated with these medications. • Non-pharmacologic interventions help to enhance an individual’s ability to direct their care, which improves their independence, dignity, and quality of life. • Adverse Drug Events (ADEs) may require hospitalization and the community may experience lost revenue for days the resident is not in the community. • A reputation for using innovative, person-centered care approaches will provide a competitive advantage.
  • Antipsychotics: Achieving the Goal • Focus on non-pharmacologic approaches for preventing the frustrations that can lead to challenging behavior and for addressing resident’s behavioral expressions when they do occur • Using a positive physical approach, engaging residents in meaningful activity, and using therapeutic strategies for catastrophic events can make a real difference for residents with dementia. • Environmental changes : reducing noise, improving lighting, and allowing flexible scheduling.
  • SBAR for Antipsychotics
  • Antipsychotics: Resources • • • • • Qualityinitiative.ncal.org CEAL Clearinghouse www.theceal.org Alzheimer’s Association IA-ADAPT https://www.healthcare.uiowa.edu/igec/iaadapt/ The National Dementia Initiative White Paper http://www.ccal.org/national-dementia-initiative/whitepaper.shtml
  • The assisted living portion of the AHCA/NCAL Quality Initiative Recognition Program is designed to recognize NCAL members that demonstrate the attainment and a commitment to one or more of the four NCAL Quality Initiative goals: •Safely reduce hospital readmissions by 15% •Increase staff stability by maintaining nursing staff turnover below 30% •Increase customer satisfaction to 90% •Safely reduce the off-label use of antipsychotics by 15%. All submissions must be received by NCAL no later than 11:59 PM (EDT) September 30, 2013. Those receiving recognition will be notified in November.
  • Get Recognized! Assisted living communities must submit their staff turnover data to NCAL through the Assisted living communities must submit their 2012 customer satisfaction survey results to NCAL through the online Customer Satisfaction survey. Assisted living communities may pledge their intent to join the PSO by submitting their information through NCAL’s online survey. Communities will need to sign-up for the PSO by a specified date once official registration is open
  • Recognition Levels
  • Data Collection in Assisted Living
  • “In God we trust, all others bring data” – Elements of Statistical Learning
  • Why Representative Data Matters
  • Quality of Life Performance Measures • Identified 10 performance measures related to:  Operational performance  Resident quality of life • Completed 3 years of surveys (2010-2012) • Links to survey reports on NCAL Website
  • Quality of Life Performance Measures • Resident & family satisfaction • Employee satisfaction • Staff retention • Census/Occupancy rate • Resident Councils • Family councils • Mission and vision statements • Safety programs • Nurse availability • State criminal background checks
  • Vacancy, Retention, and Turnover • NCAL launched the first national survey for assisted living in January 2010 • Fourth annual survey launched January 2013 • Supported by Leading Age, ALFA, and ASHA • Links to results on NCAL’s Website
  • Next Step: Clinical Performance Measures • Falls • Pain management • Pressure ulcers • Infection control • End-of-life care • Demographics • Medication management • Hospitalizations • Depression • Elopements • Advanced care planning
  • Patient Safety Organizations January 2013 – NCAL Board of Directors voted to collaborate with the New Jersey Hospital Association’s (NJHA) Institute for Quality and Patient Safety Organization (PSO) to collect Tier II Clinical Performance Measure
  • What is a PSO? • PSOs serve as a group of independent, external experts who can collect, analyze, and aggregate Patient Safety Work Products locally, regionally, and nationally to develop insights into the underlying causes of patient safety events. • Communications with PSOs are protected from disclosure to allay fears of increased risk of liability because of collection and analysis of patient safety events • PSOs are certified by the Agency for Healthcare Research & Quality (AHRQ)
  • Benefits of Partnering with a PSO • Improve safety and quality leading to better resident outcomes • Participate in a non-punitive reporting system that is designed to reduce or minimize harm to members • Contribute to national safety initiatives • Move toward a culture of safety and awareness and away from a culture of blame and shame • Reduce liability costs and exposures • Use of de-identified quality data to assist members in quality efforts • Detect and address emerging quality issues as they arise through alerts and other communication methods
  • PSO: Timeline & Cost Timeline • August 2013- Contract between NCAL & NJHA signed and measures finalized • September start signing up pilot communities • October-December Pilot study • Nov-Dec – sign-up NCAL members • January 1, 2014 data collection for all NCAL members Cost • 25 or less beds: $35 per unit with a $250 minimum • 26 or more units: $35 per unit with a maximum annual compensation of $3,500 • Multi-community Entities (with 100+ units): $3,500 for the first 2 communities plus $800 for each additional community *Note that multi-community entities with less than 100 units will pay $35 per unit with a maximum annual compensation of $3,500.
  • NCAL 2014 Spring Conference The Future is Now March 10 -12, 2014 Casers Palace, Las Vegas, NV Registration opens in November! Visit www.NCAL.org for more information
  • Questions? www.ncal.org Dave Kyllo – dkyllo@ncal.org