CORE CURRICULUM ON MEDICAL
DIRECTION IN LONG TERM CARE
July 21-27, 2012
Baltimore, MD
Core Curriculum on Medical Direction in Long Term Care
July 21-27, 2012  Baltimore, MD
SCHEDULE AT A GLANCE: PART I
TOPIC
DATE / TIME
Saturday, July 21, 2012
AGENDA ITEM
FACULTY
LOCATION
Grand Ballroom
Foyer
3:30 PM - 4:30 PM
REGISTRATION
Topic: 01
4:30 PM - 5:00 PM
Course Introduction
Burl
Grand Ballroom
Topic: 02
5:00 PM - 6:00 PM
Overview of Long Term
Care Lecture
Winn
Grand Ballroom
6:00 PM – 6:30 PM
Small Group Breakout
All Faculty
Breakouts
6:30 PM – 7:30 PM
MEET AND GREET
Grand Ballroom
Foyer
7:00 AM - 7:30 AM
BREAKFAST
Grand Ballroom
Foyer
7:30 AM - 9:45 AM
Regulatory Environment
Lecture
9:45 AM - 10:00 AM
BREAK
Sunday, July 22, 2012
Topic: 03
Topic: 03
10:00 AM - 11:00 AM
Topic: 04
11:00 AM - 12:00 PM
12:00 PM - 1:30 PM
Regulatory Environment
Breakouts
Medical Information
Management Lecture
Sponsored Lunch
Symposium:
Practical Considerations
in Stroke Risk Reduction
in Non-Valvular Atrial
Fibrillation
Leible/Baker
Grand Ballroom
Foyer
All Faculty
Breakouts
Kaplan/Baker
Grand Ballroom
Sponsored
University
Ballroom
All Faculty
Breakouts
Kaplan/Baker
Grand Ballroom
Bluestein
Grand Ballroom
Provided by Boehringer
Ingelheim
Topic: 04
1:30 PM - 2:15 PM
Topic: 04
2:15 PM - 2:30 PM
Topic: 05
2:30 PM - 3:30 PM
3:30 PM - 3:45 PM
Speaker: Steven N.
Singh, MD
Medical Information
Management Breakouts
Medical Information
Management (Wrap-Up)
Employee Health and
Safety Lecture
BREAK
Grand Ballroom
Grand Ballroom
Foyer
1
TOPIC
DATE / TIME
AGENDA ITEM
FACULTY
LOCATION
Topic: 06
3:45 PM - 5:15 PM
Infection Control Lecture
Kaplan/ Brechtelsbauer
Grand Ballroom
Monday, July 23, 2012
Grand Ballroom
Foyer
7:15 AM - 7:45 AM
BREAKFAST
Topic: 06
7:45 AM - 8:45 AM
Infection Control
Breakouts
All Faculty
Breakouts
Topic: 07
8:45 AM - 10:15 AM
Residents Rights Lecture
Brubaker/Bluestein
Grand Ballroom
10:15 AM - 10:30 AM
BREAK
Topic: 08
10:30 AM - 11:45 AM
Financial Issues Lecture
Brubaker
Grand Ballroom
Topic: 08
11:45 AM – 12:00 AM
Financial Issues: Coding
Lecture
Baker
Grand Ballroom
12:00 AM - 1:00 PM
Lunch: In-The-Trenches
Topic: 08
1:00 PM - 3:00 PM
3:00 PM - 3:30 PM
Financial Issues: Coding
(Continued)
Focus Session and
Evaluation of Part I
Grand Ballroom
Foyer
University
Ballroom
Baker
Grand Ballroom
Burl
Grand Ballroom
2
Core Curriculum on Medical Direction in Long Term Care
July 21-27  Baltimore, MD
SCHEDULE AT A GLANCE: PART II
TOPIC
DATE / TIME
Tuesday, July 24, 2012
Topic: 09
Topic: 10
Topic: 10
FACULTY
LOCATION
Grand Ballroom
Foyer
7:00 AM - 7:30 AM
BREAKFAST
7:30 AM - 7:35 AM
Introduction and Overview of
Part II
7:35 AM – 7:45 AM
CMD Presentation
7:45 AM - 7:55 AM
Personality Profiles Worksheet
Burl
Grand Ballroom
7:55 AM - 9:50 AM
Introduction to Medical Care
Delivery Systems Lecture
Brechtelsbauer
Grand Ballroom
9:50 AM - 10:05 AM
BREAK
10:05 AM - 11:30 AM
Essential Health Information &
Tools Lecture
11:30 AM - 12:30 PM
LUNCH
12:30 PM - 1:40 PM
Essential Health Information &
Tools Breakouts
1:40 PM - 1:55 PM
BREAK
Topic: 10
1:55 PM - 3:35 PM
Topic: 11
3:35 PM - 5:10 PM
Topic: 12
AGENDA ITEM
Essential Health Information &
Tools Lecture (Continued)
Medical Director’s Contract
Lecture
Burl
Grand Ballroom
Grand Ballroom
Grand Ballroom
Foyer
Leible/Baker
Grand Ballroom
University
Ballroom
All Faculty
Breakouts
Grand Ballroom
Foyer
Leible/Baker
Grand Ballroom
Burl
Grand Ballroom
Grand Ballroom
Foyer
5:10 PM - 5:30 PM
BREAK
5:30 PM - 6:30 PM
Personality Profiles Lecture
Burl
Grand Ballroom
Wednesday, July 25, 2012
Topic: 13
7:45 AM - 9:00 AM
Influencing Empl. Behaviors
Lecture w/ BREAKFAST
Bluestein
Grand Ballroom
Topic: 14
9:00 AM - 10:00 AM
Medical Staff Oversight Lecture
Kaplan
Grand Ballroom
10:00 AM - 10:15 AM
BREAK
Topic: 14
10:15 AM - 11:00 AM
Topic: 14
11:00 AM - 11:30 AM
Medical Staff Oversight
Breakouts
Medical Staff Oversight Lecture
(Wrap-Up)
Grand Ballroom
Foyer
All Faculty
Breakouts
Kaplan
Grand Ballroom
3
TOPIC
DATE / TIME
AGENDA ITEM
FACULTY
LOCATION
11:30 AM - 1:00 PM
Sponsored Lunch Symposium:
MDS 3.0 and Management of
Moderate to Severe
Alzheimer's Disease in LTC
Sponsored
University
Ballroom
Provided by Forest
Pharmaceuticals, Inc.
Speaker: Roger J. Cadieux, MD
Topic: 15
1:00 PM – 2:15 PM
Biomedical Ethics Lecture
Winn
Grand Ballroom
Topic: 15
2:15 PM – 3:00 PM
Biomedical Ethics Breakouts
All Faculty
Breakouts
3:00 PM – 3:15 PM
BREAK
3:15 PM – 5:15 PM
Working with Families Lecture
Topic: 16
Grand Ballroom
Foyer
Brechtelsbauer
Grand Ballroom
Thursday, July 26, 2012
Grand Ballroom
Foyer
7:30 AM – 8:00 AM
BREAKFAST
8:00 AM - 8:05 AM
Opening Remarks
Burl
Grand Ballroom
8:05 AM - 9:05 AM
Quality Management Lecture
Bluestein/Leible
Grand Ballroom
9:05 AM - 9:20 AM
BREAK
Topic: 17
9:20 AM - 10:00 PM
Quality Management Cont.
Bluestein/Leible
Grand Ballroom
Topic: 17
10:00 AM – 12:00 PM
Quality Management
Breakouts
All Faculty
Breakouts
12:00 PM – 1:00 PM
LUNCH
1:00 PM – 2:30 PM
Risk Management Lecture
2:30 PM - 2:45 PM
BREAK
Topic: 19
2:45 AM – 3:45 PM
Systems Theory Lecture
Brechtelsbauer
Grand Ballroom
Topic: 19
3:45 PM - 4:45 PM
Systems Theory Breakouts
All Faculty
Breakouts
Topic: 19
4:45 PM - 5:15 PM
Systems Theory Lecture
(Wrap-Up)
Brechtelsbauer
Grand Ballroom
5:15 PM - 5:30 PM
Focus Session and Evaluation
Burl
Grand Ballroom
5:30 PM - 6:00 PM
Workshop on Action Plan
Burl
Grand Ballroom
Topic: 17
Topic: 18
Grand Ballroom
Foyer
University
Ballroom
Winn/Kaplan
Grand Ballroom
Grand Ballroom
Foyer
Friday, July 27, 2012
Grand Ballroom
Foyer
6:30 AM - 7:00 AM
BREAKFAST
Topic: 20
7:00 AM - 7:45 AM
Governance Lecture
Brubaker
Grand Ballroom
Topic: 21
7:45 AM - 8:30 AM
Committees Lecture
Brubaker
Grand Ballroom
8:30 AM – 8:45 AM
BREAK
Topic: 21
8:45 AM – 9:15 AM
Committees Breakout
All Faculty
Breakouts
Topic: 22
9:15 AM - 11:15 AM
Leadership in the Organization
Lecture
Burl
Grand Ballroom
Grand Ballroom
Foyer
4
TOPIC
DATE / TIME
AGENDA ITEM
FACULTY
LOCATION
11:15 AM – 11:30 AM
Closing Remarks
Burl
Grand Ballroom
5
Core Curriculum on Medical Direction in Long Term Care
DAILY REMINDERS and INFORMATION
Welcome to the AMDA Core Curriculum on Medical Direction in Long Term Care! We are very excited
about the week ahead since we know the course will offer you opportunities for interaction with one
another and faculty, as well as the chance to provide feedback through the audience response system
(the keypads you see on your desks) and several evaluations – allowing us to check in with you to
learn your thoughts as we go along. The information you provide us is vital to us as we attempt to
tailor the Course onsite to your needs and wishes as a group, and later, to shape future courses to
better meet the overall needs of students in medical direction. We know you’ll find our work this week
intensive, challenging and rewarding.
MATERIALS
As far as materials go, you have each received a bag with several items. The bag includes a flash drive
containing the course materials, slide sets, answer keys and JAMDA reference information. You have
also been provided with an attendee folder including the course agenda, CME tracking form,
commitment to change form, MDS 3.0 booklet, two blank Individualized Action Plan forms and course
evaluation. NOTE: If you will only be joining us for Part I you will not have the course
materials for Part II. We hope you enjoy these resources, a small sampling of the products and
tools AMDA has to offer. AMDA staff will have a display set up later in the week with products
available for sale. We encourage you to take a look.
BREAKOUTS
For several modules, we’ll be working in small groups in breakout sessions. For these sessions you
have been given a participant workbook, which is located on your flash drive. Please bring the flash
drive with you to the breakout session.
FORMING GROUPS
If you have not already done so, please complete the Pre-Course Assessment Form and return to the
AMDA staff ASAP. We will use this information to place you in the appropriate small group assignment.
Group assignments are posted on a board near the registration desk.
EVALUATIONS AND ASSESSMENTS
One goal of this course is to measure learning and changes in attitude at various points throughout the
week. In addition to the pre-course assessment, we ask that you complete the evaluation form we’ve
provided. At the course conclusion, you will also be asked to complete 2 Individualized Action Plan
(IAP) forms. In approximately 6-months you will receive a Post-Course Assessment to complete and
return. Please do not forget to include your name on all forms. We need to be able to match
pre and post assessments to collect data. Your names will only be used for culling information and will
not be noted or referenced in any other way.
6
CME TRACKING FORM
The CME Tracking Form located in your Attendee Folder is a 2-part form. Do not lose it. This is your
record and ours of your participation in this conference. Remember that you must attend both
morning and afternoon sessions to make the most of your educational experience. Please keep one
copy to serve as YOUR certificate of attendance and drop off the other at the registration desk at the
end of the week. A separate certificate will NOT be mailed to you after the conference.
SIGNING IN
Please be sure to sign in each morning and afternoon at the registration desk. We will use the sign-in
sheets to verify your attendance. You need to sign in twice a day.
BATHROOMS
Restrooms are located outside of the General Session room and will be directly on your right.
PHONES
We ask that you limit distractions by turning off your cell phones or turning them to vibrate.
LUNCH
If you requested a special meal, please be sure to bring your meal ticket and give it to your server to
ensure the appropriate meal.
Please return the following forms to AMDA staff by the end of the week:
- Evaluation Form
- The CME Tracking Form
- Pre-course Assessment Form (If you have not previously filled it out online)
- White Copy of the Two IAP Forms
- White copy of the Commitment to Change Form
Thank you and we look forward to learning your thoughts on your evaluation forms and to keeping in
touch with you as AMDA follows up with your progress on your Individual Action Plans.
7
Core Curriculum on Medical Direction in Long Term Care
WHAT HAPPENS AT THE END OF THE CORE?
1. At the end of Part II, Core attendees complete 2 Individualized Action Plans
(IAP) based on the Functions and Tasks that have been covered throughout the
Core.
2. These IAPs can only be done after the full completion of the entire Core
Curriculum (parts I and II) as the knowledge from both parts is needed to fully
implement any plan of action.
3. Development of the IAP is considered to be part of the course Part I and Part II
and is required to be completed in order to obtain the 46 credit hours of
CME/CMD for the course.
4. Return a copy of your IAPs to staff and keep a copy as your guide and reminder.
5. Additionally sign your ‘Commitment to Change’ form and return one copy to
AMDA
WHAT HAPPENS AFTERTHE CORE?
1. Once back in your practice setting, take steps to implement your action plans.
2. Over the following 6 months, you will receive a reminder(s) from faculty to be
working on your action plan
3. At 6 months post-Core, AMDA staff will send you a Post-Course Assessment to
complete and return.
4. In order to obtain all of the 20 additional Performance Improvement (PI) credit
hours of CME/CMD, an attendee must complete the course in its’ entirety.
Full completion of the course includes:
 Pre-Course Assessment
 Part I and Part II of the course
 Development of the IAP
 Implementation of the IAP (successfully or not, with reasons)
 Post-Course Assessment.
The 20 additional credits is a separate activity from the 46 hours awarded for
full participation at Part I and Part II of the Core Curriculum. The 20-hour
activity is a performance improvement activity which allows learners to selfassess and implement improvement to their practice over time. There is no
partial credit for the PI portion of the course.
8
CORE CURRICULUM ON MEDICAL DIRECTION
Learning Objectives
Part I
Part I Overall
 Describe the framework and expected outcome of the course work.
 Explain the concept and levels of care in the continuum of long term care.
 Discuss the effects of influencing factors and emerging trends on the continuum of care.
 Identify regulatory requirements and delineate how the medical director can assist the facility in compliance.
 Assess the survey process and the medical director’s role in the process.
 Recognize the components and functions of a comprehensive medical record in long term care and employ
processes to ensure the integrity and usefulness of the medical record.
 Develop and recommend ways to monitor infectious disease and improve infection control within the facility.
 Critique components and processes that provide adequate employee health and safety programs.
 Integrate awareness of residents’ rights into the differing scopes of practice of medical director and attending
physician within an ethical framework.
 Define the medical director’s functions and tasks relative to financial issues in long term care facilities.
Topic
Topic Objectives
01 Course
1. Delineate the content, format and rationale of the Core Curriculum.
Introduction
2. Define roles, functions and tasks as they apply to medical direction.
3. Describe the behavioral expectations for the participants after the course, including the
development of a personalized action plan.
4. Share data about perceptions of participants’ current behavior.
02 Overview
of Long Term
Care
1. Discuss the history and evolution of systems of long term care.
2. Understand the concept of the continuum of care and identify key organizations that provide
that care.
3. Identify the levels of care provided and the differences between delivery sites.
4. Be able to match the needs of long term patients with the appropriate level of care.
5. Describe the influence of other factors in the long-term care environment.
6. Understand the effect of emerging trends and patterns on the roles and responsibilities of
long term care organizations.
03
Regulatory
Environment
1. List the long term care regulatory agencies and describe their process of developing and
enforcing regulations.
2. Describe the survey process, the types of surveys, and responses to deficiencies.
3. Delineate the ways in which the medical director may assist the facility in complying with
local, state and federal regulations.
4. Define medical director’s role in a survey visit.
5. Describe the role of the medical director and the associated investigative protocol.
6. Describe the special emphasis and regulations regarding medication use in long-term care.
04 Medical
Information
Management
1. Recognize the components and describe the functions of a comprehensive medical record in
long term care.
2. Describe the tasks of the medical director that help ensure the integrity and clinical usefulness
of the medical record.
3. Describe and use a process to critique and improve the usefulness of the medical record.
4. Describe legal and regulatory forces that may impact clinical data.
5. Recognize existing computer technologies designed to facilitate medical record keeping and
promote effective use of facility-wide data.
6. Recognize the differences in record-keeping between nursing facility and non-nursing home
settings.
9
CORE CURRICULUM ON MEDICAL DIRECTION
05 Employee
Health &
Safety
Learning Objectives
1. Describe components and processes of an effective employee health program.
2. List important (common and uncommon, but serious) illnesses and injuries seen in the LTC
setting.
3. Assess the adequacy of the employee health and safety program at the participant’s facility.
4. Define the medical director’s tasks that contribute to a successful facility employee health
program, including workman’s compensation.
5. Manage the potential ethical and legal conflicts resulting from establishing a physician-patient
relationship with an employee while having a fiduciary relationship with the facility.
06 Infection
Control
1. Develop or make recommendations for improving the infection control program in the
participant’s facility.
2. Help control and prevent important (common, or uncommon but serious or emerging)
infectious illnesses dealt with in the LTC continuum, including particularly nosocomial
infections.
3. State the regulatory basis for an infection control program.
4. Describe the medical director’s tasks that contribute to the facility’s infection control program
5. Access current regulations and clinical guidelines that impact this area of medical direction.
6. Choose and utilize appropriate techniques and data sources for facility-wide monitoring of
infectious disease.
07 Residents
Rights
1.
2.
3.
4.
5.
08 Financial
Issues
1. Explain the differences between the sources of Long Term Care funding.
2. Communicate effectively with the administrator concerning the expense and revenue aspects
of the facility budget.
3. Define the nature of the Medical Director’s roles and responsibilities relative to financial issues
in long term care facilities.
4. Identify issues related to documentation, coding and physician reimbursement in long term
care.
Enumerate basic categories of Residents Rights.
Discuss factors that influence the ability of residents to exercise their rights.
Describe common situations where Residents Rights are relevant.
Discuss the prevention of and response to abuse and neglect.
Compare and contrast the medical director’s role and the attending physician’s role in
honoring Residents Rights.
10
CORE CURRICULUM ON MEDICAL DIRECTION
Learning Objectives
Part II
Part II Overall
 Relate the training and typical tasks of the members of the multidisciplinary team and realize how each
contributes to total resident care.
 Explain how the collection and use of data supports quality management and initiatives.
 Delineate the medical director’s responsibility in ensuring facility-wide ethical decision making.
 Employ communication strategies to learn the basic concepts of each family system and to address complex
family situations.
 Analyze the content of the medical director’s contract to ensure that all elements are covered, including risk
management and liability insurance.
 Establish policies, procedures, and tools that enhance care, quality management, and reduce facility risks.
 Assimilate the concepts of leadership, organizational culture, and values that enhance management and care
processes.
 Develop an individualized action plan to implement new strategies or problem solutions at the site of
practice.
09 Introduction
to Medical Care
Delivery
Systems
1.
2.
3.
4.
10 Essential
Health
Information
Tools in
Medical
Direction
(MDS, RAI,
Oasis, others)
1.
2.
3.
4.
5.
6.
11 Medical
Director’s
Report and
Contract
1.
2.
3.
4.
Describe the basic elements of systems theory.
Discuss the characteristics of organization.
List the types of care delivery systems to patients in Long Term Care Facilities.
Describe the training and typical roles and functions of the members of the
multidisciplinary team.
5. Value the contributions of the different members of the multidisciplinary care team.
Trace the history and relevance of the MDS.
Explain the process of data collection in creating the MDS.
Utilize the MDS in the Resident Assessment Instrument for care planning.
Describe how the MDS is utilized as a reimbursement tool.
Demonstrate how the MDS is utilized by CMS for monitoring quality.
Evaluate the application of additional data sets (Oasis, UDS-FIM, pharmacy and lab
composite reports).
7. Recognize potential uses of MDS data for outcomes evaluations, research and quality
management.
Define the purpose and content of the Medical Director’s report.
Describe the elements and content of the medical director’s contract.
Ensure that all of the essential elements are in the participant’s contract.
Discuss elements of risk management including liability insurance and anti-kickback
provisions.
12 Personality
Profiles
1. List the four domains of Myers-Briggs.
2. Explain the differences between the four domains and how they help create a personality
profile.
3. Recognize the potential impact of the four domains may have on Medical Director's
functions.
13 Employee
Behavior
1. Describe situations in which employees may not know why and what they should be doing.
2. Explain why no positive consequences for the right thing could negatively influence
employees’ behaviors.
3. Apply concept of Fourniers differential diagnosis to help correct negative behaviors.
11
CORE CURRICULUM ON MEDICAL DIRECTION
14 Medical
Staff Oversight
Learning Objectives
1. Explain rationale and discuss basic Medical Director responsibilities for Medical Staff
oversight.
2. Describe models of Medical Staff organization and oversight, including non-physician staff
members.
3. Define responsibility in credentialing and privileging.
4. Delineate issues and develop strategies to address medical staff issues concerning roles,
functions or tasks, including non-physician staff.
15 Biomedical
Ethics
1.
2.
3.
4.
16 Working
with
Families
1.
2.
3.
4.
5.
6.
17 Quality
Management
1. Describe QA and TQM principles and tools.
2. Use QA and TQM tools to evaluate and enhance health professional and system
performance.
3. Assist facility in developing and/or maintaining compliance program.
18 Risk
Management
1.
2.
3.
4.
19 Systems
Theory and
Problem
Solving
20 Governance
21 Committees
Discuss basic principles (concepts) relevant to biomedical ethics.
Identify key process steps in managing ethical issues.
Apply key ethical principles and processes in various situations.
Delineate Medical Director responsibilities in helping to ensure facility-wide ethical
decision-making.
5. Use appropriate resources for good decision-making.
6. Discuss ethical considerations of research in vulnerable subjects.
Define basic concepts of family systems, including boundary, structure, and culture.
Relate chronic disease to patient and family relationships and interactions.
Identify common patterns of family behavior that arise in the LTC setting.
Discuss effective strategies to enhance physician communication with families.
Employ appropriate strategies to deal with complex family situations.
Delineate the Medical Director’s tasks that address family issues.
Establish policies and procedures for an effective facility risk management program.
Define the core elements contained within an incident report.
Describe the relationship of unions and medical director.
Identify risk management strategies to reduce medical director's liability.
1. Describe the process of problem solving.
2. Apply systems theory and medical direction tools and skills to problem solving in long-term
care settings.
1. Describe relationships between Medical Directors and governing body, boards,
administrators, and staff.
2. Illustrate basic governance arrangements.
1. Define the role and functions of committees and committee members.
2. Develop and define the role and functions and tasks of committees and committee.
members, and the specific role the medical director will play.
12
CORE CURRICULUM ON MEDICAL DIRECTION
Learning Objectives
Define basic leadership and management principles.
Compare and contrast the differences.
List the skills helpful to exert leadership as a medical director in a long term care facility.
Demonstrate two leadership skills which may be helpful in your facility.
Understand the potential power sources in your facility.
Describe how the behavior of leaders and managers create and define an organizational
culture.
7. Apply an understanding of personality types to your leadership role and how it may
influence team process.
22 Leadership
1.
2.
3.
4.
5.
6.
23 Integration
of the Medical
Director’s Role
and
Development of
Individualized
Action Plan
1. Synthesize the functions and tasks of the medical director to fulfill the role of the medical
director.
2. Develop an individualized action plan.
3. Review the content, format and rationale of the Core Curriculum and agree to participate
in the evaluation and follow-up of the course.
13
Core Curriculum on Medical Direction in Long Term Care
Target Audience
Medical directors practicing in any setting or combination of settings across the long term care
continuum, including skilled nursing facilities, assisted living, CCRCs, hospice, and home care
are encouraged to attend.
Geriatric fellows in training who are considering the inclusion medical direction in their practices
are also encouraged to attend.
This course is the foundation for certification as an AMDA CMD. Taking the course does not
make you a CMD. There are other requirements to complete. Contact AMDA at 800-876-2632
for a CMD Brochure outlining the details of certification as an AMDA CMD.
Course Objectives
The goal of this comprehensive course is to create a stronger sense of the leadership role of the
medical director and to provide opportunities to hone skills and interact with peers. Following
the conference, participants should be able to:
 Develop practical skills needed to fulfill the role and responsibilities of the medical director.
 Identify the unique aspects of the long term care environment that impact the medical director’s
job.
 Describe the organizational responsibilities and dynamics of the medical director and the
interdisciplinary team.
 Develop communication skills to deal with responsibilities for the interdisciplinary team, residents,
and their families.
 Explain the resident care responsibilities of the medical director, including emergency care, quality
management, family systems, and ethical considerations.
 Enhance leadership skills and team building towards a stronger role for the medical director with
the interdisciplinary team.
 Develop human resource skills to deal with difficult situations and improve personal effectiveness
in this area.
 Improve the medical director’s ability to learn and practice in the evolving environment of health
care delivery.
 Apply newly acquired knowledge to daily facility and practice activities.
Accreditation
The American Medical Directors Association is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME Credit
AMDA designates this educational activity for a maximum of 46 AMA PRA Category 1
Credit(s)TM. Physicians should only claim credit commensurate with the extent of their
participation in the activity.
14
Certified Medical Director (CMD) Credit
The AMDA Core Curriculum on Medical Direction has been approved for a maximum of 46 credit
hours in medical direction. Credit hours may be applied toward certification as a Certified
Medical Director in Long Term Care (AMDA CMD). The AMDA CMD program is administered by
the American Medical Directors Certification Program (AMDCP). Physicians should only claim
credit commensurate with the extent of their participation in the activity.
AAFP Credit
This program has been reviewed and is acceptable for up to 44.25 prescribed credits by the
American Academy of Family Physicians.
AGS Credit
This program has been endorsed by the American Geriatrics Society. Credits earned from this
activity may be counted toward the AGS Geriatrics Recognition Award.
Tracking and Sign-In Sheets
Attendees should sign in daily (morning and afternoon). All attendees seeking credit should
track their participation on the tracking sheet that AMDA has provided. At the end of the
course, keep the white copy for your records and return the yellow copy to AMDA, as you will
not receive an additional certificate.
AMDA Disclaimer Statement
Participants understand that medical and scientific knowledge are constantly evolving. The
views and treatment modalities of the authors are their own and may reflect innovations
(including off-label or investigational use of medical products) and opinions not universally
shared. Every effort has been made to assure the accuracy of the data presented in the
context of accepted medical practice. Physicians should check specific details such as drug
doses and contraindications, off-label uses, or other details in standard sources prior to clinical
application. The views and treatment modalities of the authors are not those of the American
Medical Directors Association (AMDA), but are presented in this forum to advance scientific and
medical education.
Requirement for Author Disclosure
ACCME and AMDA policy requires everyone in a position to control the content of this
educational activity to provide full disclosure of any affiliation or financial interest that is directly
relevant to speaker’s presentation(s). In addition, speakers are required to disclose when
references to pharmaceuticals, medical devices, or other therapeutic products used in
treatments are “off-label” (not approved by FDA for the use described). Disclosure information
is reviewed in advance to manage and resolve any conflict of interest that may affect the
balance and scientific integrity of an educational presentation.
Faculty Disclosure Information
Faculty are required to provide verbal disclosure prior to each talk. If the learner perceives any
bias toward a commercial product or service, please report this to AMDA staff.
All program planners and faculty have provided full disclosure and report no
relationships relevant to this course.
15
Core Curriculum on Medical Direction in Long Term Care
Faculty Roster and Biographies
Jeffrey B. Burl, MD, CMD (Course Chair)
Sutton, MA
[email protected]
Jeffrey Burl, MD, CMD is Medical Director of the Overlook Masonic Nursing and Rest Home and Clinical Director of
the Fallon Clinic Division of Geriatrics. He is the director of the AMDA Core Curriculum as well as member of the
education, finance and competency committees.
Alva S. Baker, MD, CMD
Sykesville, MD
[email protected]
Alva S. Baker, MD, CMD began caring for frail elderly patients in the long term care setting in 1972. He served as
the Medical Director for Episcopal Ministries to the Aging (EMA) from 1980 until his retirement in June of 2009 as
Vice President for Health and Wellness Services for EMA. He concurrently served as the Executive Director of The
Copper Ridge Institute, wherein his focus of research and teaching has been on the care of persons with
Alzheimer’s disease and other forms of dementia. He serves on the faculty of the Division of Geriatric Psychiatry
and Neuropsychiatry of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University
School of Medicine. He is also serves on the Gerontology faculty at McDaniel College, where he holds the position
of Director of The Center for the Study of Aging. Board certified in Geriatrics and in Hospice and Palliative
Medicine, he serves on the Professional Advisory Committee of Carroll Home Care/Carroll Hospice, as an Associate
Medical Director for Carroll Hospice, and on the Board of Directors of the Partnership for a Healthier Carroll County.
Dr. Baker is an Emeritus member of the Medical Staff of Carroll Hospital Center in the Department of Internal
Medicine. He has taught extensively about medical direction issues and continuous quality improvement to medical
directors and staff at all levels in residential care facilities throughout the long term care continuum. He is a
Certified Medical Director and a member of the American Medical Directors Association, for which he served as
President in 2007-2008.
Daniel Bluestein, MD, MS, CMD
Norfolk, VA
[email protected]
Daniel Bluestein, MD, MS, CMD, AGSF holds the Certificate of Added Qualification in Geriatrics and is Professor of
Family & Community Medicine, Eastern Virginia Medical School. As Director of the Department's Geriatrics Division,
he is responsible for geriatrics training offered to Family Medicine and Family Medicine-Internal Medicine Combined
program trainees. He is also an AMDA-certified Medical Director at multiple long-term care facilities. Dr. Bluestein is
faculty for the AMDA Core Curriculum, has presented at multiple AMDA and other national Geriatrics meetings and
is the holder of two AMDA Foundation/Pfizer Continuous Quality Improvement awards. He is also a past chair of
the ADMA Communications Committee.
16
J. Kenneth Brubaker, MD, CMD
Mount Joy, PA
[email protected]
J. Kenneth Brubaker, MD, CMD completed his geriatric fellowship in 1989 and works fulltime as a geriatrician.
During the past 20 years, Dr. Brubaker has worked as a medical director in several large CCRC in addition to caring
for residents. Presently, he is the medical director of Masonic Village in Elizabethtown, PA and Willow Valley
Retirement Communities in Willow Street, PA. Together the two facilities serve over 500 skilled residents, over 300
personal care residents, and several thousand independent living residents, In addition to running a 35 bed
dementia unit, Dr. Brubaker serves as the PDA/OLTL for the PA Dept. of Aging /Office of Long Term Living and as a
faculty member of the Lancaster General Geriatric Fellowship Program.
David A. Brechtelsbauer, MD, CMD
Sioux Falls, SD
[email protected]
David A. Brechtelsbauer, MD, CMD is an Associate Professor in the Department of Family Medicine at The Sanford
School of Medicine of The University of South Dakota, and an Associate Director at the Sioux Falls Family Medicine
Residency. In addition to being Board Certified in Family Medicine, he holds a Certificate of Added Qualifications in
Geriatric Medicine and is a Certified Medical Director. He was awarded the James Pattee Excellence in Education
Award Presented by the American Medical Directors Association in March 2005. He is a past President of the
American Medical Directors Association.
Robert G. Kaplan, MD, CMD
Longwood, FL
[email protected]
Robert G. Kaplan, MD FACP CMD is Board Certified in Internal Medicine with a CAQ in Geriatrics, and a Certified
Medical Director. He has an extensive background in Long-Term Care, and serves as a Multi-Facility Medical
Director and Attending Physician. He is a Board member of the Florida Medical Directors Association and currently
President elect. Dr. Kaplan is a Fellow of the American College of Physicians, was a practicing Internist for
approximately twenty years, and a former Chairman of the Department of Medicine and Medical Staff President of
South Seminole Hospital in Longwood, Florida. A graduate of New York University and the University of Brussels
School of Medicine, Dr. Kaplan completed his residency at the Genesee Hospital in Rochester, New York.
Karyn Leible, MD, CMD
Rochester, NY
[email protected]
Karyn Leible, MD, CMD is an internist with a Certificate of Added Qualifications (CAQ) in Geriatrics. During her
geriatric fellowship, she concentrated on long term care and palliative care medicine. She has practiced in 3 states,
Colorado, Florida and Georgia. She has spent time doing clinical practice in academic medicine at Emory University
in Atlanta as well as private practice in Colorado and Florida. Currently, she is in Rochester New York where she is
Sr. VP of Medical Services for Jewish Senior Life. She is Immediate Past President for the American Medical
Directors Association.
Peter Winn, MD, CMD
Oklahoma City, OK
[email protected]
Peter Winn, MD, CMD is a Professor at the University of Oklahoma for the Department of Family Medicine and
Adjunct Professor for the Department of Geriatric Medicine. Dr. Winn is Board Certified in Family Medicine in the
United States and Canada and has CAQs in Geriatrics and Hospice. He is a Palliative Medicine Medical Director for
the long term care (LTC) Unit at the Fountains at Canterbury and is the Medical Director for Mercy at Home
Hospice.
17
Core Curriculum on Medical Direction in Long Term Care
Commonly Used Acronyms and Terms in Long Term Care
ACLS
Advanced Cardiac Life Support
ADE
Adverse Drug Event
ADL
Activities of Daily Living
ADR
Adverse Drug Reaction
AIMS
Abnormal Involuntary Movement Scale
AL / ALF / ALC
Assisted Living / Assisted Living Facilities / Assisted Living Center
ATLS
Advanced Trauma Life Support
BBA
Balanced Budget Act
BBRA
Balanced Budget Refinement Act
BLS
Basic Life Support
CCRC
Continuing Care Retirement Community
CF
Conversion Factor
CFR
Code of Federal Regulations
CMD
Certified Medical Director (through AMDA)
CME
Continuing Medical Education
CMN
Certificate of Medical Necessity
CORF
Comprehensive Outpatient Rehabilitation Facility
CPT
Common Procedural Terminology – a system of codes for billing for physician
services.
CQI
Continuous Quality Improvement
CR
Chemical Restraints
DJD
Degenerative Joint Disease
DME
Durable Medical Equipment
DNR
Do Not Resuscitate
DON
Director of Nursing
DRGs
Diagnosis Related Groups
18
ECF
Extended Care Facility
EMR
Electronic Medical Record
FQHMO
Federally Qualified Health Maintenance Organization
FPL
Federal Poverty Level
F-Tags
A designation used by state survey agencies to identify particular tag sets
within the state operation manual’s interpretative guidelines.
HCPCS
HCFA Common Procedural Coding System
HCR
Health Care Reform
HEDIS
Healthplan Employer Data and Information Set – An automated database for
Managed Care; HEDIS is a set of standardized performance measures designed
to ensure that purchasers and consumers have information to compare the
performance of managed health care plans.
H&P
History and Physical
HHC
Home Health Care – Care provided to individuals in their homes. Patients
must need a skilled service (nursing, PT, OT, ST) to qualify for Medicare
home health benefit; also have to be homebound and need help only
intermittently. If patient qualifies, patient can also get assistance from a
home health aide.
Hospice
Program of palliative (comfort) care for persons who are dying. Medicare
covers hospice services, which may be provided at home or in a hospital or
SNF. Individual must be certified by physician as having less than 6 months to
live.
ICF
Intermediate Care Facility
IPO
Insured Product Option
LMRPs
Local Medical Review Policies
LTC
Long Term Care
LTCF
Long Term Care Facility
MCO
Managed Care Organization
MDS
MICU
Minimum Data Set – used for assessment and care, quality assurance and
improvement, reimbursement, and survey process.
Medical Intensive Care Unit
MLP
Midlevel Practitioner
MSS
Medical Social Services
MSW
Master of Social Work or Medical Social Worker
NDC
National Drug Code
NF
Nursing Facility – can be used to denote a nursing home that is not certified
for Medicare (e.g. not a SNF)
NF
National Formulary
19
OASIS
Outcome and Assessment Information Set (for home care patient)
OBQI
Outbound-Based Quality Improvement (used by Medicare certified home
health care agencies to measure patient outcomes)
OBRA
Omnibus Budget Reconciliation Act
OSCAR
Online Survey Certification and Reporting
PA
Physician Assistant
PASARR
Preadmission Screening and Annual Record Review
PDP
Prescription Drug Plan (with Medicare Part D)
PHO
Physician-Hospital Organization
POS
Point of Service
Post-acute care
Services patients receive after an acute illness (usually entailing a hospital
stay.) Can refer to SNF/NF and home health services, as well as other
rehabilitation services.
PPO
Preferred Provider Organization
PRIT
Physicians Regulatory Issues Team
PPS
Prospective Payment System
PSO
Provider-Sponsored Organization
PSRO
Professional Standards Review Organization
QA
Quality Assurance
QAAC
Quality Assessment and Assurance Committee
QI
Quality Improvement, Quality Indicator, based on MDS data, or Qualified
Individual (Medicare)
QIO
Quality Improvement Organization
QM
Quality Management or Quality Measure, based on MDS data
QMB
Qualified Medicare Beneficiary
RAI
Resident Assessment Instrument
RAP
Residential Assessment Protocol – used for decision making, care planning
and implementation, and evaluation.
RBRVS
Resource Based Relative Value System
RNAC
Registered Nurse Assessment Coordinator
RUGs
Resource Utilization Groups
RVUs
Relative Value Units – components (e.g., physician work, practice expense,
malpractice expense, etc.) used in calculating Medicare physician fee
schedule.
S&C
Survey and Certification
20
SCU
Specialized Care Unit
SLMB
Specified Low-Income Medicare Beneficiary
SNF
Skilled Nursing Facility – A nursing facility (or specially certified part of one)
that participates in Medicare.
SOAP
Subjective Objective Assessment and Plan for progress notes
SOM
State Operations Manual (published by CMS)
TQM
Total Quality Management
UM
Utilization Management
UR
Utilization Review
21
Commonly Used Acronyms for Medical Organizations
AAAHC
Accreditation Association for Ambulatory Health Care
AAFP
American Academy of Family Physicians
AAHCP
American Academy of Home Care Physicians
AAHPM
American Academy of Hospice and Palliative Care
AAHSA
American Association for Homes and Services for the Aging – represents nonprofit providers of nursing facilities, home health agencies, assisted living
communities, and continuing care retirement communities.
ACHCA
American College of Health Care Administrators
ACP – ASIM
American College of Physicians – American Society of Internal Medicine
ADA
American Dietetic Association
ADC
Alzheimer’s Disease Center
ADEAR
Alzheimer’s Disease Education and Referral Center
AHCA
American Health Care Association – represents for-profit owners of nursing
facilities and assisted living facilities.
AHRQ
Agency for Healthcare Research and Quality
AIR
American Institute of Research
ALFA
Assisted Living Federation of America
ALZ ASSN
Alzheimer’s Association
AMDCP
American Medical Directors Certification Program
APIC
Association for Professionals in Infection Control and Epidemiology
ASCP
American Society of Consultant Pharmacists
BQC, BQA
Bureau of Quality Compliance or Assurance
CDC
Centers for Disease Control
CERTs
Centers for Education & Research on Therapeutics
CMS
Centers for Medicare and Medicaid Services (formerly HCFA)
DEA
Drug Enforcement Authority
DHHS
DSS
Department of Health and Human Services
Department of Social Services
FDA
Food and Drug Administration
FEHBP
Federal Employees Health Benefit Program
22
GSA
Gerontological Society of America
HCFA
Health Care Financing Administration (now CMS) – agency that administers
Medicare and Medicaid.
HHS
Health and Human Services
JCAHO
Joint Commission on Accreditation of Healthcare Organizations
MedPAC
Medicare Payment Advisory Commission
MSO
Management Services Organization
NADONA
National Association of Directors of Nursing Administration
NAGNA
National Association for Geriatric Nurse Aides
NAIC
National Association of Insurance Commissioners
NANDA
North American Nursing Diagnosis Association
NCCNHR
National Citizens Coalition for Nursing Home Reform
NCI
National Cancer Institute
NCQA
Managed Care Association
NCQA
National Committee for Quality Assurance
NFCA
National Family Caregivers Association
NIH
National Institutes of Health
NIMH
National Institutes of Mental Health
NLN
National League for Nursing
NPDB
National Practitioner Data Bank
NQF
National Quality Forum
OCI
Office of the Commissioner of Insurance
OIG
Office of the Inspector General
OMB
Office of Management and Budget
OPHC
Office of Prepaid Health Care
OSHA
Occupational Health and Safety Administration
OTA
Office of Technology Assessment
PRO
Peer Review Organization (also known as QIO)
QIO
Quality Improvement Organization
SHEA
Society for Healthcare Epidemiology of America
USP
United States Pharmacopeia
USPHS
United States Public Health Service
23
ORIGINAL STUDIES
Impact of Medical Director Certification
on Nursing Home Quality of Care
Frederick N. Rowland, PhD, MD, CMD, Mick Cowles, BA, MS, Craig Dickstein, BA, MS, and Paul R. Katz, MD, CMD
Objective: This study tests the research hypothesis
that certified medical directors are able to use their
training, education, and knowledge to positively
influence quality of care in US nursing homes.
Design: F-tag numbers were identified within the
State Operations Manual that reflect dimensions of
quality thought to be impacted by the medical
director. A weighting system was developed based
on the ‘‘scope and severity’’ level at which the nursing
homes were cited for these specific tag numbers.
Then homes led by certified medical directors were
compared with homes led by medical directors not
known to be certified.
Data/participants: Data were obtained from the
Centers for Medicare & Medicaid Services’ Online Survey Certification and Reporting database for nursing
homes. Homes with a certified medical director (547)
were identified from the database of the American
Medical Directors Association.
Measurements: The national survey database was
used to compute a ‘‘standardized quality score’’ (zero
representing best possible score and 1.0 representing
Since the introduction of the concept of nursing home
medical directors in the 1970s there have been multiple
papers, guidelines, and books published on the role of the
medical director and how this should affect the quality of
care in the nursing home.
Section of Geriatric Medicine, Saint Francis Hospital and Medical Center,
Hartford, CT (F.N.R.); Mercy Community Health, West Hartford, CT (F.N.R.);
Cowles Research Group, McMinnville, OR (M.C.); Tamarack Professional Services, LLC, Caratunk, ME (C.D.); Division of Geriatrics/Aging, University of
Rochester School of Medicine and Dentistry, Rochester, NY (P.R.K.)
The authors have no conflicts of interest regarding this article.
Address correspondence to Frederick N. Rowland, PhD, MD, CMD,
Department of Medicine, Section of Geriatric Medicine, Saint Francis
Hospital and Medical Center, 114 Woodland Street, Hartford, CT
06105–1299. E-mail: [email protected]
Copyright Ó2009 American Medical Directors Association
DOI:10.1016/j.jamda.2009.05.012
ORIGINAL STUDIES
average score) for each home, and the homes with
certified medical directors compared with the other
homes in the database. Regression analysis was then
used to attempt to identify the most important
contributors to measured quality score differences
between the homes.
Results: The standardized quality score of facilities
with certified medical directors (n 5 547) was 0.8958
versus 1.0037 for facilities without certified medical
directors (n 5 15,230) (lower number represents
higher quality). When nursing facility characteristics
were added to the regression equation, the presence
of a certified medical director accounted for up to
15% improvement in quality.
Conclusions: The presence of certified medical
directors is an independent predictor of quality
in US nursing homes. (J Am Med Dir Assoc 2009; 10:
431–435)
Keywords: Certified medical director; quality of care;
medical director; nursing facility; skilled nursing
facility
There has, however, been no clear quantification of the
impact that a well-trained medical director can have on the
quality of care within a facility.
The official mission statement of the American Medical Directors Certification Program (AMDCP) is to ‘‘.advance physician leadership.thereby enhancing quality of care.’’1 Since
its inception in 1991, the AMDCP has certified more than
2500 medical directors. The certification process follows an ‘‘experiential’’ model that incorporates existing mechanisms such
as fellowship programs, board certification, continuing medical
education programs (offered by major provider organizations),
courses in medical direction (approved by AMDCP), and other
continuing education programs. Familiarity with the medical
director certification process leads to the expectation that medical director certification is positively correlated with quality of
care. Although such a correlation is commonly and reasonably
asserted, we have found nothing in the literature empirically
demonstrating such a relationship.
Rowland et al 431
24
This study tests the hypothesis that certified medical directors
are able to use their training, education, and knowledge to positively influence quality of care in US nursing homes. The alternate hypothesis (or null hypothesis) is that certification makes
no appreciable difference to nursing home quality of care.
This project was granted institutional review board (IRB)exempt status by the IRB of Wright State University via the
American Medical Directors Research Foundation. The
project was sponsored by generous grants from the American
Medical Directors Certification Program and AMDA state
chapter contributions.
METHODOLOGY
FINDINGS
F tags from the State Operations Manual2 (N 5 27) were
identified that appear to reflect dimensions of quality potentially directly impacted by the medical director. These were
chosen by consensus of the research team including the authors, AMDCP staff, and the AMDCP Executive Committee
on the premise that these were areas of quality potentially
influenced by medical director activity. A weighting scheme
based on the ‘‘scope and severity’’ level at which the nursing
homes were cited for these specific tag numbers was also developed. This was constructed to emphasize serious, widespread, or patterns of deficiencies. It was thought that
a better prepared medical director would be able to reduce
the incidence of deficiency citations for these 27 specific F
tags, or, at a minimum, reduce the scope and severity level
at which they were cited. A listing of the 27 F tags and our
scope and severity–based weighting scheme is listed in
Appendix 1. The weighting scheme is similar, though not
identical, to that used by the Nursing Home Compare
Five-Star Rating guide.3
Using the Centers for Medicare & Medicaid Services’ Online Survey Certification and Reporting (OSCAR) database
as of March 2008, a ‘‘raw quality score’’ was computed, and
a ‘‘standardized quality score’’ for all 15,777 certified nursing
homes that were in operation in the United States in March
2008.4 The raw quality score was computed by summing the
weights of the relevant deficiency citations. We then divided
the raw quality score by the state average raw quality score to
yield a standardized quality score. Standardization of the quality score is necessitated by wide state-to-state variation in the
survey process. For example, New Jersey nursing home surveys
result in an average of 4 total deficiencies per survey, whereas
in neighboring Delaware the comparable average is 13.5
Dividing the raw quality score by the state average ‘‘standardizes’’ the score, creating a measure that is comparable across
states. Note that lower adjusted quality scores denote better
quality, and an adjusted quality score of unity denotes average
quality.
Records of the American Medical Directors Association
(AMDA) were then used to identify 547 nursing homes
that had certified medical directors during the year immediately preceding and during the survey contained in our data
capture. The first step was to compare the average standardized quality score in facilities with certified medical directors
to those without certified medical directors. A ‘‘t test’’ was
then computed to evaluate the degree to which the difference
between the averages was statistically significant. Finally,
other variables were considered that could also affect quality,
and multiple regression analysis was used to better understand
the relationship between medical director certification and
quality of care.
432 Rowland et al
As shown in Table 1, the average standardized quality score
(SQS) in facilities with certified medical directors was 0.8958
compared with 1.0037 for facilities without certified medical
directors. Recall that lower numbers represent better quality,
with zero representing the best possible score. The difference
of 0.1079 represents a 12% improvement in quality associated
with the presence of a certified medical director, and the t test
indicated that the difference is statistically significant at the
98% level.
It was suspected, however, that other nursing home characteristics are correlated with quality, such as facility size, class of
ownership, case mix, staffing, and urban/rural status. Smaller
facilities should tend to have fewer deficiencies because of
fewer opportunities for errors, and not-for-profit facilities are
known to have better surveys than for-profit facilities.5 The
higher case mix associated with more medically complex cases
might result in more deficiencies, higher staffing would be
expected to result in fewer deficiencies, and rural facilities
might have better surveys than urban facilities. The urban/rural impact on quality, if there is one, might more accurately be
associated with size or staffing differences between urban and
rural nursing homes.
There appears to be significant potential for the statistical
relationships hypothesized in the preceding paragraph to confound the initial findings reported in Table 1. For example,
what if facilities with certified medical directors are more
likely to be small, or more likely to be not-for-profit? If that
were the case, then the variation in quality of care that is
attributed to medical director certification in Table 1 might
in fact be attributable to these other factors. Stepwise multiple regression analysis was used to help determine if this
might be the case and to better understand the relationship
between quality and medical director certification. Data
from the best specified equation are reported in Table 2. It
was found that the strongest predictors of adjusted quality
were whether or not the nursing home had a certified medical
director, whether or not the total number of beds in the facility was greater than 99, whether or not it was a proprietary
(for-profit) facility, and the number of registered nurse
(RN) staffing hours per patient day.
Recall that the average adjusted quality score is 1.0000
and that lower numbers reflect better quality. Thus, the
Table 1. Average Standardized Quality Score With and Without
a Certified Medical Director (CMD)
With CMD (n5547)
Without CMD (n515,230)
Difference #
Difference %
0.8958
1.0037
0.1079
12.05
JAMDA – July 2009
25
Table 2.
Regression Equation Predicting Standardized Quality Score
Dependent Variable: Adjusted Quality Score
Number of observations read
Number of observations used
Number of observations with missing values
15777
15618
159
Analysis of Variance
Source
Model
Error
Corrected total
DF
Sum of Squares
4
15613
15617
562.03592
37431
37993
Root MSE
Dependent mean
Coefficient of variation
Mean Square
140.50898
2.39739
1.54835
1.00559
153.97489
F Value
Pr.F
58.61
\.0001
R-Square
Adj R-Square
0.0148
0.0145
Parameter Estimates
Variable
DF
Intercept
Certified medial director present
Beds .99
For profit
Registered nurse hours per patient day
1
1
1
1
1
Parameter Estimate
0.98780
0.14705
0.22309
0.08987
0.24987
estimated regression coefficient of –0.14705 for the certified
medical director variable indicates that, holding other predictors constant, the presence of a certified medical director
will improve quality by about 15%. Other results from the
regression equation were consistent with stated preconceptions, ie, larger facilities, proprietary facilities, and facilities
that staff fewer RN hours per patient day tend to have
poorer quality. Urban/rural status and case mix are not
included in the equation as they did not improve equation
specification.
DISCUSSION
For the first time, this study demonstrates that the certified
medical director has a measurable positive effect on the
quality of care provided in facilities in which they serve.
In 1975, regulations were promulgated that required skilled
nursing facilities to have a medical director. In response to
this, AMDA was formed in 1977 to organize the medical
directors and provide a venue for education of the medical
directors in their role and responsibilities. Numerous articles
(representative articles in references) have been written since
that time about the role of the medical director.6–10 Articles
have been written on specific problems in which the medical
director can and should make a difference.11–13 Textbooks
on the role of the medical director14,15 and long-term care
medicine16,17 have been published. To the best of our knowledge, only one has made an attempt to show via survey of
medical directors and administrators in Maryland that requiring medical director training makes a positive difference in
the quality of medical directorship provided.18 In that study,
which reports on a survey of medical directors and administrators following the institution of mandatory medical director education, there was consensus that the relationship
between the medical director and other administrators in
ORIGINAL STUDIES
Standard Error
0.03461
0.06783
0.02546
0.02744
0.02918
T Value
28.54
2.17
8.76
3.7
8.56
Pr./t/
\.0001
.0302
\.0001
.0011
\.0001
the nursing home was improved, that the medical director
spent more time in the facility working on system issues,
and that the medical director spent more time with the administrator reviewing the care provided. In contrast, the present study uses a comparison of actual survey data from the
facilities.
The current study was initiated in an attempt to demonstrate whether the presence of a certified medical director
made a measurable difference in the quality of care provided
within long-term care facilities. The results support the
conclusion that the presence of a certified medical director
makes an appreciable and positive difference on the quality
of care provided within long-term care facilities. The data
also support the premise that there are other important
factors determining the quality of care provided.
OTHER FACTORS AFFECTING RESULTS
There is great confidence that all 547 nursing homes that
were flagged as having certified medical directors during the
study period actually did have certified medical directors
because all certified medical directors identified their facility
as where they worked in their medical director role for
AMDA records in the time frame immediately before this
study. The comparison group of 15,230 facilities that are
treated as not having a certified medical director may actually
contain facilities that may have had a certified medical
director during all or part of the study period. This is likely,
because of the 2500 certifications awarded, it is estimated
via AMDA records that approximately 1500 of these individuals are still working. If the truth is that certified medical
directors are associated with higher quality, then including
facilities in the control group that actually had certified medical directors would tend to reduce the difference between the
2 comparison groups. Thus, if there were inadvertently
Rowland et al 433
26
included facilities in the comparison group that had certified
medical directors, then the true difference between the
certified and noncertified groups was larger than what is
reported, ie, the research results are even more robust than
what is reported.
The probability values reported in Table 2 are for a 2-tailed
t test. We could argue on theoretical grounds that the 1-tailed
test is more appropriate. Interpreting our t ratios using
a 1-tailed test would also make our results more robust,
ie, double the level of statistical significance for each
predictor variable.
Of note on the statistical analysis of the linear regression
model is that the multiple correlation coefficient (R squared)
is relatively low (0.0148); however, it needs to be placed in
the context that the goal of this study was to test whether
the presence of a certified medical director made a positive
impact on the quality of care in that nursing home, not to
explain the total variation in the quality measured. Thus,
the magnitude of the partial correlation coefficient associated
with the certified medical director variable (–0.14705) and its
associated level of statistical significance (.0302) are of much
greater importance than the absolute value of the multiple
correlation coefficient.
Other factors that theoretically could bias the outcome are
that 2 of the authors are currently certified medical directors
and medical directors of facilities included in the database,
however it is doubtful that 2 individual homes would bias
the overall results in comparison with either the 547 identified facilities with a certified medical director or the 15,230
other facilities. A potentially more important variable is
that many AMDA members have trained in geriatric fellowship programs and have certification in geriatric medicine. Of
the certified medical director–led facilities in this study, 18%
(101 of the 547) are led by medical directors with geriatric
fellowship training. We did not attempt to separate out the
contribution of this training in the current project, but
a recent survey study examined barriers to care and visit
time expectations, which revealed that geriatric-trained physicians may have a higher level of expectation in their care of
long-term care patients.19
Currently, all long-term care facilities are required to
have a physician identified as medical director. The data
now reported suggest that there is a clear and measurable
positive effect on quality if that medical director is a certified
medical director. This may have policy implications in all of
long-term care. Because the certified medical director designation indicates a minimum level of experience and education in medical director management and clinical geriatric
medicine, it suggests that every long-term facility and program should have a certified medical director or the equivalent. An alternate explanation is that certified medical
directors are a self-identified group of dedicated, experienced
individuals who are willing to be held accountable as longterm care providers and leaders, and that they would be so
whether or not they had attained recognition as a certified
medical director. Whatever the reason, our patients deserve
the best of all of us.
434 Rowland et al
CONCLUSION
This research demonstrates that the presence of a certified
medical director in a facility makes an appreciable positive difference in the quality of care provided in that facility. The data
also identify other factors—small facility size, not-for-profit
status, and higher RN hours per patient day—as important determinants of higher quality offered by a facility. It is hoped
that this will lead to further recognition of the knowledge
and skills of trained medical directors, and encourage all medical directors to work to attain and improve these skills.
REFERENCES
1. AMDA. Certified Medical Director in Long Term Care (AMDA CMD).
Available at: http://www.amda.com/certification/overview.cfm. Accessed June 17, 2009.
2. Interpretive Guidelines for Long-Term Care Facilities. Available at:
http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.
pdf. Accessed June 17, 2009.
3. NursingHome Compare. Design for Nursing Home Compare Five-Star
Quality Rating System: Technical Users Guide. January 2009. Available
at: http://www.cms.hhs.gov/CertificationandComplianc/13_FSQRS.asp.
Accessed June 17, 2009.
4. Obtained from the files of Cowles Research Group. Available at: http://
www.longermcareinfo.com/about_oscar.html. Accessed June 17, 2009.
5. Cowles CM. Nursing Home Statistical Yearbook: 2007. McMinnville,
OR: Cowles Research Group; 2008. pp.70, 72–73.
6. American Medical Directors Association. Roles and responsibilities of
the medical director in the nursing home: position statement A03.
J Am Med Dir Assoc 2005;6:411–412.
7. Schnelle JF. Total quality management and the medical director. Clin
Geriatr Med 1995;11:433–448.
8. Schnelle JF, Ouslander JG. CMS guidelines and improving continence
care in nursing homes: The role of the medical director. J Am Med Dir
Assoc 2006;7:131–132.
9. Zimmer JG, Watson NM, Levenson SA. Nursing home medical
directors: Ideals and realities. J Am Geriatr Soc 1993;41:127–130.
10. Smith RL, Osterweil D. The medical director in hospital-based
transitional care units. Clin Geriatr Med 1995;11:373–389.
11. Colon-Emeric CS, Casebeer L, Saag K, et al. Barriers to providing
osteoporosis care in skilled nursing facilities: perceptions of medical
directors and directors of nursing. J Am Med Dir Assoc 2005;6:S61–S66.
12. Richards CL Jr.. Preventing antimicrobial-resistant bacterial infections
among older adults in long-term care facilities. J Am Med Dir Assoc
2005;6:144–151.
13. Munir J, Wright RJ, Carr DB. A quality improvement study on calcium
and vitamin D supplementation in long-term care. J Am Med Dir Assoc
2006;7:305–309.
14. Pattee JJ, Otteson OJ. Medical Direction in the Nursing Home: Principles and Concepts for Physician Administrators. Minneapolis, MN:
North Ridge Press; 1991.
15. Levenson SA, editor. Medical Direction in Long-Term Care: A Guidebook
for the Future. 2nd ed. Durham, NC: Carolina Academic Press; 1993.
16. Katz PR, Calkins E, editors. Principles and Practice of Nursing Home
Care. New York: Springer Publishing; 1989.
17. Ouslander JG, Osterweil D, Morley J. Medical Care in the Nursing
Home. 2nd ed. New York: McGraw-Hill; 1997.
18. Boyce BF, Bob H, Levenson SA. The preliminary impact of Maryland’s
medical director and attending physician regulations. J Am Med Dir
Assoc 2003;4:157–163.
19. Caprio TV, Karuza J, Katz PR. Profile of physicians in the nursing home:
Time perception and barriers to optimal medical practice. J Am Med Dir
Assoc 2009;10:93–97.
JAMDA – July 2009
27
Appendix 1
F-tags Included in Standard Quality Scores
The following list of F-tags was determined by consensus to be those most likely to be directly influenced by the medical
director.
F-Tag
Area of Medical Direction
202
221–222
223
280
281–282
309
314
319–320
323–324
325
329
385, 386, 387, 388, 390
441, 442, 443, 444
492
Identify appropriate ways to minimize avoidable transfers
Restraints: Policies and procedures; alternatives to use
Freedom from abuse
Train attending physicians to help staff develop resident care plan
Medical direction—additional duties
QA relative to MDS
Pressure ulcers
Access to mental health treatment
Minimizing and reporting accidents
Weight loss and nutrition
Unnecessary drugs
Quality assurance issues around physician performance
Infection control
Compliance with federal, state, and local laws and regulations; physician oversight;
additional duties (see also 281–282)
Medical direction
Establish and implement a relevant facility-wide quality assurance program,
including a QA committee
501
520
At the same time, the following weighting scale based on scope and severity was approved:
Scope and Severity Designation
Weight
A – isolated event, no actual harm
B – possible pattern, no actual harm
C – widespread, no actual harm
D – isolated, no actual .minimal harm, no immediate jeopardy
E – possible pattern, no actual .minimal harm, no immediate jeopardy
F – widespread, no actual .minimal harm, no immediate jeopardy
G – isolated, actual harm, no immediate jeopardy
H – pattern, actual harm, no immediate jeopardy, substandard care
I – widespread, actual harm, no immediate jeopardy, substandard care
J – isolated, immediate jeopardy, substandard care
K – pattern, immediate jeopardy, substandard care
L – widespread, immediate jeopardy, substandard care
deleted, not significant to our study
0
1
1
2
2
3
10
10
15
20
20
ORIGINAL STUDIES
Rowland et al 435
28
29
01 Introduction
01 Course Introduction
Welcome
Core Curriculum on
Medical Direction
2
1
Learning Objectives




Delineate the content, format and rationale of
the Core Curriculum.
Define roles, functions and tasks as they apply
to Medical Direction.
Describe the behavioral expectations for the
participants after the course, including the
development of a personalized action plan.
Share data about perceptions of participants’
current behavior.
The Core
Curriculum
3
4
Rationale for Curriculum

Curriculum Design
Physicians need to master a basic core of facts
needed to work effectively in long term care as
administrators.

Two parts

Part I – 2 days



Experiential learning of attitudes and skills
needed to function effectively as a medical
director will optimize the performance of the
physician serving in that capacity and improve
the quality of care for the residents in the facility
that s/he serves.
5

Didactic sessions covering basic factual information.
Introduction of small group session as learning tool.
Part II – 4 days



Extensive use of experiential interactive small group
sessions.
Systems theory, leadership and management
Developing behavioral models of effective medical
direction.
6
30
01 Introduction
Background of AMDA
History of Core Curriculum

AMDA was formalized as an organization in
1977, grown from a handful to over 6000.

Basic Mission: Improve the quality of care of
residents in the long term care continuum.


Providing training in administrative medicine for
medical directors in long term care.
Certified Medical Director Program (AMDCP)

In mid-1980’s, Dr. James Pattee at the University
of Minnesota created the role and functions for
Medical Directors.

Dr. Pattee provided programs to teach these
concepts (3 weekends, 60 hours).

Core curriculum conference by AMDA in early
1990’s restructured this information into 36 hours
of education in three sessions (Modules A, B, C).
7
History of Core Revision

Faculty Disclosures
AMDA embarked on project to re-evaluate the
educational programs which taught the
Curriculum.



8

All faculty have stated there are no
disclosures to be made that are
pertinent to this course.
October, 2001 – initial workgroup meeting
Additional work by experienced medical
directors and Core faculty, with AMDA staff and
educational consultant assistance
Result: Redesign of education model,
sequencing of topics, coordination of content,
increase in contact hours to 46.
9
Participant Outcome

10
Resources

The goal of this curriculum and this educational
model is that at the end of this week, the
participant will…

Understand and utilize the knowledge,
skills and attitudes needed to effectively
fulfill the roles, functions and tasks of the
Medical Director.
11

Course syllabus – slide sets
Exercise workbook – ‘handouts’ you will
need for class work in this room and in
small groups
Resources – additional resources in
Adobe Acrobat document (.pdf) format.
12
31
01 Introduction
Roles, Functions, and Tasks
Role

Definition


The set of behaviors an organizational
member is expected to perform and that
he/she feels obligated to perform.
Role of the Medical Director varies.


Situation specific.
Dependent on individual’s knowledge and
skills and facility culture and needs.
13
14
Role





Key Roles
Medical Director is involved at all levels of
patient care.
Serves as the clinician who oversees and
guides care.
Leader to help define a vision of quality
improvement.
Direct supervisor of the medical practitioners.
Operations consultant for day to day issues.

Physician Leadership: Responsible
overall care and clinical practice in the
facility.

Clinical Leadership: Applies clinical and
administrative skills to help guide facility
in providing care.
15
Key Roles

16
Function
Quality of care: Helps the facility
develop and manage both quality and
safety initiatives.




Education, information and
communication: Provides information
that helps others understand and
provide care.
Definition
Functions of the Medical Director.

17
Major domains of activity within the role.
Statements of responsibilities of the
Medical Director.
18
32
01 Introduction
Functions –
Pattee JJ, Otteson OJ. Medical Direction in
the Nursing Home - Principles and Concepts
for Physician Administrators. 1991.
Minneapolis, Minnesota: North Ridge Press
Functions –
The Medical Director . . .
The Medical Director…
1. Participates in administrative decision making
and recommends and approves policies and
procedures.
2. Organizes and coordinates physician
services and services provided by other
professionals as they relate to patient care.
3. Participates in the process to ensure the
appropriateness and quality of medical care
and medically related care.
4. Participates in the development and
conduct of educational programs.
5. Participates in the surveillance and
promotion in the health, safety, and
welfare of employees.
6. Helps articulate the long term care
facility’s mission to the community.
19
20
Functions –
Tasks
The Medical Director . . .
7. Participates in establishing policies and
procedures for assuring that the rights of
individuals (resident, staff members, and
community members) are respected.
8. Acquires, maintains, and applies
knowledge of social, regulatory, political,
and economic factors that relate to
patient care services.
9. Person directed care.
21

Definition


Specific activities used to carry out a
function.
Tasks

Specific activities performed by the medical
director to fulfill functions.
22
Tasks



Function and situation specific.
Timely and accurate completion of tasks
ensures fulfillment of related function.
Handout: Reference listing of common
Medical Director tasks.
23
24
33
01 Introduction
A System of Care

A system is a unity of interrelationships
and interactions.

Events in one part of the system impact
other parts of the system.
25
26
You Are Part of a System of
Care!

You Are Part of a System of
Care!
You have great influence and power in
these environments by your presence
that is derived from:
Your influence and power extend as far
as you wish to exert it! For example:

Nutritional practices
Admission standards
 Skin care protocols
 Quality assurance plan and emphasis
 Team building
 Pharmacy practices

Professional expertise
 Personality (leadership ability)
 Demonstrated interest
 Title
 Ethical behavior (or lack of it)


27
28
Introduction to Medical Care
Delivery Systems

Introduction to Medical Care
Delivery Systems
There will be an explicit and deliberate
effort to incorporate the principles of
systems theory and systems thinking
throughout the course.
29

Systems theory will be utilized to:

Examine typical care delivery processes in
LTC.

Understand the roles, functions, and tasks of
the Medical Director, as well as other
members of the LTC interdisciplinary team.
30
34
01 Introduction
Becoming a Leader
Becoming a Leader

Medical Directors by their position are
de-facto leaders.

We are unique in our facilities.

We need to start to become leaders in
our facilities.

Curious and risk takers

Concentrate at work

Learn from adversity
31
Becoming a Leader

Credibility

Knowledge

Ego Strength

Have a sense of humor
32
Becoming a Leader

Actions that exemplify desired values
between individual and organizational
values.

Actions that communicate the presence
of predictability, honesty, and concern.
33
Becoming a Leader


34
Resource Disk
Actions that indicate a concern in
followers’ interests as they relate to
work, career, family, and extramural
activities.
Actions that indicate that leader’s
interest in self-knowledge and selfdevelopment.

Roles and Responsibilities of the
Medical Director in the Nursing Home

AMDA position statement

35
JAMDA articles: Relevant to the sessions
presented through the week.
36
36
35
01 Introduction
Behavioral Outcomes

Individualized Action Plan
Expectations




Be an ‘active learner’ in the ongoing process
of developing the knowledge, skills and
attitudes needed in order to be an effective
medical director.
Develop a personalized ‘action plan’ of
behavior changes and commitment for
implementation upon return to work setting.
Commitment to participate in ‘outcomes’
evaluation six months after completion of the
course.
37
Individualized Action Plan

From what you will learn in this course
and using the worksheet:


38
Individualized Action Plan
For each task, list the steps you will
need to follow in order to implement the
task.



Create two separate IAP’s by the end of the
course.
For each chosen IAP you will choose one
function and specify at least two tasks that
you are presently not doing and that you will
do upon your return.
For each step, list the challenges or
perceived barriers to implementation and
what methods you will use to overcome
them.

As you proceed through the week think
about your strengths and opportunities
at your facility.
Then choose two that you feel would be
doable given your time and
commitment.
Feel free to ask the faculty for advice on
a function\tasks.
39
Outcomes Evaluation

Individualized Action Plan
Six months from course completion, AMDA
will send you a survey.

40
We are looking for you to respond to the
survey concerning:
 Ability to implement plan.
 Usefulness of information learned.
 Behavioral changes experienced and
projected.
41

When you complete and mail back the 6
month course survey, you will receive
an additional 20 CME’s that may be
used toward CMD requirement.

Your IAP need not have been
completed or successful to be eligible
for the CME’s.
42
36
01 Introduction
Outcomes Evaluation

Distance view of course content:
 What was irrelevant?
 What was overdone?
 What could be added to course
content?
1.1 – 1.12
43
44
37
02 Overview
Session Objectives
02 Overview of Long Term
Care: Past, Present and Future
Core Curriculum on
Medical Direction

Review the demographics of aging in the USA.

Discuss the evolution of long term care (LTC).

Describe the LTC continuum of care and the
key programs and organizations that provide
that care.

Review emerging challenges to LTC.

Use your CMD skills to diagnose and treat your
nursing facility!
2
Overview of Long Term Care
Part I
Demographics of Older Persons
Part II
Why Long Term Care
Part III
Payors for Long Term Care
Part IV
Industry Trends in Long Term Care
Part V
Using Your CMD Skills
2.1 – 2.6
4
Demographics – Number of Older Americans
Age and Gender of the Medicare
Population
The proportion of women increases among those 85 and older.
17.9 million
Enrollees (millions)
20
Females
18
Males
16
54%
14
12.6 million
12
10
8
59%
5.5 million
6
4
2
44%
4.7 million
46%
41%
56%
Under 65
5
71%
29%
0
65-74
75-84
85+
Note: Fifty-six percent (23 million) of all Medicare beneficiaries are female; 44% (18 million) are
males. Data reflect Medicare beneficiaries ever enrolled in the program during the year.
Source: CMS, Office of Research, Development, and Information: Data from the Medicare
Current Beneficiary Survey (MCBS) 2000 Access to Care File.
6
38
02 Overview
Indicator 37 – Residential Services
Where Medicare Beneficiaries Live
For the six percent of beneficiaries living in long-term care facilities, most live in
nursing homes but some live in assisted living/retirement homes or other facilities.
Community
with
Skilled Nursing
Facility
2.2%
Community
91.4%
LongTerm
Care
Facilities
Other
0.5%
Assisted Living
/ Retirement
Homes
1.5%
Nursing
Homes
4.4%
Note: Assisted Living/Retirement Home also includes Domiciliary Care Homes, Board and Care Homes, and Independent Living Units.
All of these arrangements offer some level of assistance to the beneficiary. “Other” includes mental health facilities, mentally
retarded/mentally disabled facilities and other unclassified facilities.
Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS) 2000
Cost and Use File.
7
Nursing Facility Population
By Age
8
Transitions of Care: Revisited
3/10
3/10
Home
1/10
1st NH
Admission
3/10
3/10
8/10
Acute
Hospital
Repeat
NH
Admission
6/10
1/10
4/10
9
Death
4/10
Kane RL, Ouslander JG, and Abrass IB: Essentials of Clinical Geriatrics, 2nd ed. New York, McGraw-Hill, 1989, Data
source: Lewis MA, Cretin S, and Kane RL: The natural history of nursing home patients. Gerontologist 25:38210
388, 1985
The “Language” of Geriatrics
Part II: Why Long Term Care?
ADLs
(Activities of daily living)
The Issue: Progressive Loss of
Abilities in the Last Years of Life
11
Ambulation
Bathing
Dressing
Grooming
Transferring
Toileting
Eating
IADLs
(Instrumental activities of daily)
Transportation
Phone use
Shopping
Preparing Meals
Housework
Taking Medications
Personal Finances
12
39
02 Overview
Percentage of People By Age and Sex
Needing Assistance with Everyday
Activities:
Long Term Care

Developed to meet these chronic
needs.

Definition:
Health, social and personal services
provided to the chronically ill and
disabled of any age over an extended
period of time in a variety of settings.
Percentage Needing Assistance
Source, CMS
13
14
Long Term Care Continuum
Long Term Care




Evolved from welfare system, not health
system.
1965, Medicaid and Medicare legislation
enacted- health care requirements were first
introduced.
Today, in nursing homes
 Medicaid pays 50 - 66% of costs
 Medicare pays 10% of costs
Originally, care given by non professionals with
little training- we have come a long way!!
15
Chronic Disease Hospitals







Institutional Services
 Chronic Disease
Hospitals
 Inpatient Rehab Units
 Nursing Facilities
 Skilled Nursing Facilities
 Subacute Care Units
 Respite Care

Community Based Services
 Home Health Care
 Senior Centers
 Adult Day Care
 PACE

Hybrid Services
 Assisted Living
 Hospice
 Case Management
 Assessment Programs
16
Inpatient Rehab Units
Require more intensive medical &
nursing care than NF or SNF, less than
acute hospital.
Ventilator
Multiple complex wounds
ESRD
Multiple IVs
Typical LOS around 30 days
17

Stay of many weeks.

Must be able to do 3 hours of
rehabilitation a day.

Goal is to go “home.”
18
40
02 Overview
Nursing Facilities (NF)

Meet eligibility requirements for
Medicaid reimbursement.

Custodial Care

Skilled Nursing Facilities (SNF)
Formerly known as:
Intermediate Care Facilities (ICFs)

Definition:
Treatment and continuing observation
and assessment of the medically stable
and unstable chronically ill.

Must meet criteria for Medicare
reimbursement.
19
20
Skilled Nursing Facilities (SNF)

Skilled Nursing Facilities (SNF)
Free standing or part of a NF as a wing
or beds on a regular unit.
Medicare Covered Stay (10%)

Max. 100 days
 20 days no copay, 80 copay

Payor Medicare Part A / Managed Care

Requires 3 day hospital stay (within 30 days for
the same diagnosis)

Requires skilled treatment.

PPS Effective July 1, 1998
 Per diem based on resource utilization
 Covers room, medications, diet, nursing
services, medical supplies, DME, meds
21
Qualifying Needs for SNF

PT/OT/Speech at least one hour a day

Wound care
Subacute Care Units

Hospital Based



PEG feedings

Chronic oxygen therapy

Dialysis Patients

Diabetes monitoring
22



Non- Hospital Based (in NF or free standing)

23
Usually <20 day length of stay
Same rules and regs as NFs
Previously reimbursed significantly more than non
hospital subacute units in SNFs when cost based
systems was the norm.
Physicians use NF CPT codes

Same rules and regs as NFs
Physicians use NF CPT codes
24
41
02 Overview
Respite Care

Designed to aid the caregivers.

Short stays

Often assisted living or nursing home
facilities.

Predominantly private pay (as well as
hospice.)
Nursing Facility Residents
All Nursing Facility Residents
"Short Stayers"
(1 - 6 Months)





Terminally Ill
Cognitively Impaired
Short Term Rehab
Cognitively & Physically Impaired
Subacute
Physically Impaired
(After Kane RL, Ouslander JG, and Abrass IB: Essentials of Clinical
Geriatrics, 2d ed. New York, McGraw-Hill, 1994)
25
Nursing Facilities
"Long Stayers"
(6 Months - Years)
26
Ownership of Nursing Facilities
Over 15,000 freestanding nursing home
facilities in 2012.
1.7 million licensed beds.
85.0% average occupancy (93% 1994)
26.6% of NH beds are in large nursing
home chains.
50 - 66% of nursing home revenue is
from Medicaid
27
.
28
Adapted from Kaiser State Health Facts, 2007
Resident ADL Limitations in
Nursing Facilities
100%
95%
87%
80%
79%
74%
60%
50%
40%
20%
0%
Bathing
29
Dressing
Toileting
Transferring
Eating
Adapted from Cowles, CM, Nursing Home Statistical Yearbook, 2001, Cowles Research Group, Montgomery MD
30
42
02 Overview
Nursing Facility Residents
Dependency Status
Home Health Care

3 ADLs
5%
2 ADLs
8%
1 ADLs
7%
Medicare Covered Services

0 ADLs
5%


4 ADLs
23%


5 ADLs
52%
Adapted from Cowles, CM, Nursing Home Statistical Yearbook, 2001, Cowles Research Group, Montgomery MD
31
32
Adult Day Care/Adult Day
Health Care
Home Health Care:
Payer Mix
Private
Insurance
18.3%
Part time skilled nursing, PT,OT, HH aides
80% of DME.
Must be home bound (“out to physician’s
office only.”)
Physician determines need & sets up plan of
care.
Agency accepts Medicare payment as
payment in full.

Both licensed community based programs that
provide health, social, and supportive services.

Both programs typically provide meals, activities,
and supervision by professionals.

Adult Day Care
 Attendees have a personal care plan.
Medicaid
24.8%
Medicare
32.3%

Patient (Self-pay)
16.5%
Other Public
5.5%
Source: CMS, Office of the Actuary, National Health Statistics Group


Physical and cognitive impairment
Socially isolated
Persons needing assistance with personal care
Provides a safe and caring setting for adults
who cannot be left at home alone.
34
PACE
Adult Day Health Care



33
Adult Day Care/Adult Day
Health Care


In addition to features of adult day care,
Offers medical services, like rehabilitation,
therapy, nursing care and special nutrition in
addition to social and support services.
PACE (Program for All Inclusive Care of the
Elderly)
Eligibility Criteria
 55 years of age or older
 Able to live safely in the community at the
time of enrollment
 Live in a PACE service area
 Certified as requiring nursing home level of
care
 Dependent in ADLs
 Medical needs (DM, CHF, Dementia)
35
43
02 Overview
PACE
PACE Services Include
Funding (unique arrangement with the federal
and state governments)
 Medicare
 Medicaid and
 Private pay options







Coverage includes:
 All of the Medicare (Acute care, Subacute
care, SNF, skilled home care) as well as
Medicaid ( NF, medical and social respite)
Typically includes:







Most Assisted Living Care is
Privately Financed
Assisted Living


Adult day health care
Transportation
Home health and personal care services
PT, OT, ST
SNF & NF services
Inpatient and outpatient services
All Medicaid and Medicare covered services provided
DME, laboratory services, medical supplies, all
prescription medications
Medical care provided by physician and IDT of healthcare
professionals familiar with history, needs and preferences
of each participant.
3 meals a day
24 hour security
help with ADLs
reminders about medicines
assistance with appointments/transportation
“Non medical environment”, but what about
the medical stuff?
39
Care is self directed.

Facilities are not responsible for
coordinating medical care.

No requirement for a medical director,
but individual facilities are
experimenting.
40
Hospice:
Growth in 2009 to 1.2M!
Assisted Living

Source: 2006 Overview of Assisted Living
41
Source: National Hospice and Palliative Care Organization at
www.nhpco.org/public/articles/provider graph
42
44
02 Overview
Hospice: Qualifying Diagnoses
Hospice: Ownership

Non-For-Profit
49%

For-Profit
47%

Government
1992
2007

All Cancers
75.6%
41.3%

All Non-cancers*
24.4%
58.7%
*Major non-cancer diagnoses included CHF,
COPD, stroke, Alzheimer’s Disease
4%
NHPCO Facts & Figures, Oct. 2008
43
Hospice: OIG Report 2011



44
Hospice: OIG Report
31% of hospice beneficiaries lived in
nursing facilities.
Over 50% had at least 25% of their
beneficiaries in nursing facilities and
19% had more than half.
Close to 8% of all hospices had twothirds or more of their beneficiaries
residing in nursing facilities (high
percentage), total of 263 hospices.
Of h
2%
f
fi
d



Medicare paid $3,182 more per
beneficiary served by the high
percentage hospices than hospices in
general.
Medium number of days for the high
percentage hospices was 3 weeks
longer than medium days for a typical
hospice beneficiary, 52 days vs. 31.
28% of beneficiaries in high percentage
hospices received more than 6 months
The Nation’s Health Dollar, CY 2009
Part III:
Payors for Long Term Care
Medicare, Medicaid, and SCHIP account for one-third of national health spending.
1
Social Security
 Medicare
 Medicaid
 Patients/Families

Medicaid and
SCHIP
15%
Other Public
12%
2
Other Private
6%
CMS
Programs
33%
Private Insurance
34%
Medicare
17%
Out-of-pocket
15%
Total National Health Spending = $2.5 Trillion
1 Other public includes programs such as workers’ compensation, public health activity, Department of Defense, Department of
Veterans Affairs, Indian Health Service, and State and local hospital subsidies and school health.
2 Other private includes industrial in-plant, privately funded construction, and non-patient revenues, including philanthropy.
47
Note: Numbers shown may not sum due to rounding.
Source: CMS, Office of the Actuary, National Health Statistics Group.
48
45
02 Overview
The Nation’s Health Dollar, CY 2009
It All Began Here in 1935!
Hospital and physician spending accounts
or more than half of all health spending.
Other Spending
24%
Hospital
Care
32%
Program
Administration
and
Net Cost
6%
Prescription
Drugs
9%
Nursing Home
Care
7%
Physician and
Clinical Services
22%
Total Health Spending = $2.5 Trillion
Source: CMS, Office of the Actuary, National Health Statistics Group.
49
50
SSA Amendments of 1965, enacted
Title XVIII, Medicare Act
Social Security Act (SSA)

New Deal Program of 1935.
Eliminating poor houses.
Social Security for retired workers.
 Old Age Assistance for aged poor.
 Linked to prior earning and length of work
history.



Beginning of the Welfare State.

Medicare Part B premiums are now deducted
from social security checks.
51
52
Medicare: Title XVIII
Medicare

Health insurance program for all people 65 or
older who are eligible for Social Security.

The culmination of thirty years of national
discussion and debate on national health
care. Compromise bill preferred over a
national health care plan.

Part A Provides a defined amount of hospital
care for everyone.



Part B provides physician and other medical
services for those who pay a monthly fee.


President Johnson signing the legislation in
1965. “Social Security Amendments of 1965”.

Optional program
Part D provides prescription drug coverage.

53
Includes limited long term care benefits.
Funded by payroll taxes with a trust fund.
Optional program
54
46
02 Overview
Medicare Spending
Overall Medicare spending grew from $3.3 billion in 1967 to nearly
$294 billion in 2004 and $502 billion in 2009.
$350
294
$300
$241
$250
Dollars in Billions
$211
$200
$132
$150
$81
$100
$50
$50
$3
$9
1967
1972
$23
$0
1977
1982
1987
1992
1997
2004
Fiscal Year
Note: Overall spending includes benefit dollars, administrative costs, and program integrity costs. Represents Federal spending only.
Source: CMS, Office of the Actuary.
55
56
Medicaid: Title XIX


Medicaid
Also passed in 1965 as an amendment
to the Social Security Act.
Social assistance program of health
insurance for the Aged, Blind, and
Disabled poor (the “ABD” population).
57
Jointly funded by the federal and state
governments.

Federal share is 50-83%
 Balance is state and local
 Based on per capita income
Three types of critical health protection:



Health insurance for low-income families and
people with disability.
Long term care for older Americans and
individuals with disabilities.
Supplemental coverage for low-income
Medicare beneficiaries for services not
covered by Medicare (medications) and
Medicare premiums, deductibles, and cost
sharing.
58
Part IV:
Healthcare Industry Trends
Medicaid


Increasing:
 Stakeholder involvement
 Financial Stressors / Controlling Costs
 Survey and Regulatory Reform
 Workforce Shortage
59
60
47
02 Overview
Involvement of Stakeholders
Stakeholders

Payors
 Patients and Families
 Medicare, Medicaid
 Insurance Companies
 Managed Care

Regulatory Agencies
 Determines direction of revenue flow
 Determines standards
Customers
 Varies
 Expectations
Access to Information
Quality Indicators
Who are the stakeholders?

61
Financial Stressors
Advocate Organizations






62
American Medical Directors Association (AMDA)
American Healthcare Association (AHCA)
American Association of Homes and Services
for the Aging (AAHSA)
National Association of Directors of Nursing
Administration (NADONA)
American Society of Consultant Pharmacists
(ASCP)
National Citizens’ Coalition for Nursing Home
Reform (NCCNHR)
63
Occupancy Trends
 Occupancy Rates Down
 Reimbursement Changes
 Liability Costs Up
 Competition from Assisted Living
Number of Nursing Facilities
Median Occupancy Rate
17,500
96%
94%
93%
17,250
92%
92%
91% 91%
17,259
17,121
17,000
90%
90%
17,083
16,886
16,750
16,706
87% 87%
88%
86%
16,675
16,500
86% 86%
85%
16,389
16,250
84%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
16,000
1995
1996
1997
1998
1999
2000
2001
Source: HCFA-OSCAR Form 1539 and Form 672:F78
OSCAR = Online Survey, Certification, and Responding
65
Adapted from Cowles, CM, Nursing Home Statistical Yearbook, 2001, Cowles Research Group, Montgomery MD
66
48
02 Overview
Average Deficiencies Going Up!
Now 8 in 2009
Increasing Liability Costs
Annual Number of Claims per 1,000 Beds
Average Deficiencies
5.50
5.1
5.00
5.00
5.5
5.3
4.50
4.00
4.00
4.00
3.50
3.00
3.00
3.00
2.50
2.00
1997
Office of the CMS Actuary, 2003
67
1998
2002
1999
2003
1999
2000
2001
2002
2003
2004
Source: HCFA-OSCAR
Percent Deficiency-Free Down!
1997
2001
1998
68
Regulatory Reform
Not Whether, But How!
2000
2004
Attitude Shift: From Punitive to Collaborative
25.00
22.30
Focused on Quality Improvement
20.50
20.00
17.70
15.00
Fair, Fast, Final Dispute Resolution Process (IDR)
15.00
13.50
Revise Policies Related to Mandatory Termination
12.1
10.5
10.00
1997
1998
1999
2000
2001
Source: HCFA-OSCAR
2002
2003
10
2004
Redirect Poor Performing Chains Policy
“The beatings will stop when attitudes improve”.
69
Workforce Issues
70
Long Term Care: Future

 Caregiver Supply

 Salary Competition
 Job Demands

 Regulatory Climate

71
More older patients, not enough beds.
More older patients, not enough
caregivers.
More older patients, not enough
resources to pay for care.
Less working persons per beneficiary to
pay for Medicare, Social Security of the
elderly.
72
49
02 Overview
Part V:
Using Your CMD Skills
Long Term Care: Future







Affordable Care Act of 2010
Accountable Care Organizations
Bundling of Services
Value Based Purchasing
Electronic Medical Records
E-prescribing
Medical Homes
Diagnosing and Treating Your
Nursing Facility!
74
Diagnosing Your Nursing
Facility (NF)
Diagnosing Your NF

Patient


Complaints
Practitioner
vs.
Nursing Home



Facility concerns
Medical Director



Core Skills / Knowledge






Regulations
Financial Issues
Medical Care Delivery Systems
Medical Director Contract
Healthcare Ethics
Governance
Core Skills
History
Evaluation
Diagnosis
Intervention
History




Sources of Information
 Board
 ED
 Administrator
 Nurse Practitioner/CNS/Physician Assistant
 DON
 Unit Manager
 Nursing
 Nursing Assistants
Make it a routine.
Weekly/Monthly attendance at QA, Medicare A, QOL,
Falls, Wound Rounds (Committees)
Follow up builds your power base and influence.
50
02 Overview
Evaluation









Evaluation
OSCAR Data
MDS Data
QI/QM reports
Incident Reports
In House QA data- Falls, Wounds, Wt Loss
Infections
Lab
Radiology
Pharmacy







Diagnosis



PROCESS
Sequence of tasks aimed at
accomplishing a goal.
Produce data which can be analyzed.
Diagnosis

First: Your current processes are perfectly
designed to get the results they are already
getting and designed to get,

With it's corollary:
 Insanity is doing things the way you have
always done them while expecting different
results.
Diagnosis- PDCA
85/15 Process Rule

Individuals have direct control over
only 15% of their work problems.

The other 85% are controlled by the
process in their work environment.
Review Current Policies / Procedures
Employee Health
Infection Control
Resident Rights
Medical Record
Coordination of Medical Care
Risk Management
Plan
START
Act

Do
Deming 4% - 96%
Check
51
02 Overview
Complete
MDS
Admission
Nursing
Assessment
Does Falls
RAP Trigger?
Yes
No
Is there any
other reason to
believe patient is at
high risk
for falls?
Identify modifiable
intrinsic or extrinsic
risk factors
Yes
No
Establish
Care Plan
Routine
Precautions
Fishbone Diagram
CNA assistance with meals
Inadequate
training
Hospice
Ortho
Rehab
Example Facility
Weight Loss > 5 lbs and Below IBW
Short staffed
Type of Patient
Obese patient
on diet
High toileting needs
Holiday call-offs
Lack of
interest
Wages not competitive
30%
Don’t understand
importance
Weight Loss
New
Dietician
Mean
22%
UCL
18%
LCL
10%
Ju
n96
Au
g9
O 6
ct
-9
6
D
ec
-9
6
Fe
b97
A
pr
-9
7
Ju
n97
A
ug
-9
O 7
ct97
De
c97
Fe
b98
Poor presentation
Wrong Temperature
Monotonous Menu
Dietary Staffing
26%
14%
Wages not competitive
Holiday call-offs
34%
Food Not Appetizing
Control Chart
87
Weight Loss > 5lbs and Resident Outside Ideal Weight
Intervention
Changed timing
0.40
Cycle 1
0.35

0.30
Process Improvement
Cycle 2
0.25
Cycle 3
0.20
0.15
2 oz with meds
0.10
Phase 1 – Stabilization
 Phase 2 – Active improvement
 Phase 3 - Monitoring

Cycle 4
Other supps
Flavor variety
0.05
UCL= 0.304
D ec-0 3
Ju n - 0 3
D ec-0 2
Ju n - 0 2
D ec-0 1
Mean= 0.197
Ju n - 0 1
D ec-0 0
Ju n - 0 0
D ec-9 9
Ju n - 9 9
D ec-9 8
Ju n - 9 8
D ec-9 7
Ju n - 9 7
D ec-9 6
Ju n - 9 6
D ec-9 5
Ju n - 9 5
D ec-9 4
Ju n - 9 4
D ec-9 3
Ju n - 9 3
D ec-9 2
Ju n - 9 2
D ec-9 1
Ju n - 9 1
D ec-9 0
Rate
89
LCL= 0.090
90
52
02 Overview
Intervention





The Big Picture
Systems Theory/Problem Solving
Leadership
Personality Profiles
Influencing Employee Behaviors
Working with Families
System
Process
People
• Group of related interdependent
processes working together to achieve
a common goal
• Made up of a culture, structure and
boundary
• Sequence of tasks aimed at
accomplishing a goal
• Produce data which can be
analyzed
• Have beliefs, values,
interests, needs
• Have roles which are
made up of functions
and tasks
Solutions Will Be Needed!





Leadership
 Know what the right thing is
 And do it!
Changing the paradigm of long term care.
AMDA is here to do this!
You are here to do this!
Welcome to the CMD course!
93
53
03 Regulatory Environment
Learning Objectives

03 Regulatory Environment

Core Curriculum on
Medical Direction

List the long term care regulatory agencies
and describe their process of developing
and enforcing regulations
Describe the survey process, the types of
surveys, and responses to deficiencies
Delineate the ways in which the medical
director may assist the facility in complying
with local, state, and federal regulations
2
1
Learning Objectives



Outline for This Session:

Define the medical director’s tasks in a
survey visit
Describe the role of the medical director
and the associated investigative
protocol for F501.
Describe the special emphasis and
regulations regarding medication use in
long-term care





3
History of regulation.
The regulation-making process.
Types of surveys and the survey process.
Response to deficiencies.
Medical director’s tasks in the survey process.
Regulations regarding the F-501 tag, Medical Director
Requirement in Nursing Homes.

Breakout session- Survey deficiency case
analyses.

Regulations regarding medication use and monitoring.
Case studies in medication monitoring.
4

History: Why the Federal
Government is Involved in LTC

History: Why the Federal
Government is Involved in LTC

“Old Folks Homes”: prior to 1965
Institute of Medicine



1965: Medicare and Medicaid
study – begun in 1983
report – issued in1986

Recommended


SNF regulations – 1974

ICF regulations - 1976


OBRA ‘87 - 1987

implementation began in 1990
enforcement expanded in 1995

revised State Operations Manual (SOM) – 1999

5
re-design of the survey process
use of a data driven approach
6
54
03 Regulatory Environment
Purpose and Intent of
NH Regulations
History: Why the Federal
Government is Involved in LTC
Senate Committee on Aging hearings




July 1998
Quality of care issues
Survey process questioned

Ensure that facilities meet minimum
requirements for participation in payment
programs -Medicare/Medicaid

Thereby, hopefully, to ensure that residents
reach the
Clinton initiatives in response to above



Off-hour surveys, remove predictability
Focus on dehydration, malnutrition, pressure
sores

Highest practicable physical

Mental

Psychosocial well-being
7
8
Health Care of the Elderly is a
Team Effort
Purpose and Intent of NH
Regulations


Promote a coordinated interdisciplinary approach to:

Optimize function

Minimize preventable negative outcomes such as serious
injury due to correctable causes of falling

Manage complex problems such as impaired behavior
appropriately and with regard for risks associated with
interventions such as psychoactive medications and
restraints
The Goal: To Achieve:
Synergy
The action of two or more that achieves an
effect which each is individually incapable
of doing.
Collaboration
To work together in a joint effort
in a spirit of cooperation.
In other words, promote the applications of effective
geriatrics approaches to care
9
10
Underlying Realities
Related to Regulations
Reference Sources for
Regulations


Many negative things happen to frail, elderly individuals.

Many negative outcomes are unavoidable, while others
result at least partially from process failures.

Medicare and Medicaid beneficiaries receive many
treatments, including medications.


These treatments do varying degrees of good and harm.


It is reasonable to ask for evidence that efforts were
made to minimize the known risks and maximize the
benefits.
Federal publication


State publication

Similar to Federal, splitting proposed and final
Commercial/trade publications

11
Federal Register: proposed regulations
Code of Federal Regulations (CFR): final
regulations
For example, AHCA

Administrator

AMDA Web Site Links
12
55
03 Regulatory Environment
Process: How Are Regulations
Born?
State Regulations

Vary from state to state.

May be stricter, but not more lenient that
Federal regulations.

All states conduct the OBRA survey on
behalf of the Federal Government.

Separate Federal surveys, including “lookbehind.”

Statutory authorization

Development

Implementation
13
14
Process: Evolution of OBRA
Statutory Authorization
Process: Development
CMS
DHHS
Cycle:
Fed
Reg.
OMB

Omnibus Budget Reconciliation Act
(OBRA) of 1987, Public Law 100-203,
included The Nursing Home Reform
Amendments.

Signed into law by Ronald Reagan.
1. Preamble and Rule
2. Final Rule
Public
Comment
15
16
Process: Evolution of OBRA
Implementation
Process: Evolution of OBRA
Development
CMS
DHHS

October 1990 - Federal and State surveyors start
using interpretive guidelines for survey process.

July 1995 - New enforcement procedures.

July 1999 - Revised State Operations Manual
(SOM), containing procedures for conducting the
survey, enforcement, and other related
processes.
Cycle:
Fed
Reg.
OMB
1
2
1. Preamble and Rule
2. Final Rule
3. Final Final Rule
3
Public
Comment
17
18
56
03 Regulatory Environment
Jargon





DHHS
OMB
Federal Register
Medicare - Title 18
 Part A
 Part B
Medicaid - Title 19
Jargon







CMS
IOM
MDS
Triggers
RAPS
OBRA ’87
OSCAR

Key Players






CMS
NCCNHR
AHCA
AAHSA
AARP
AMDA
19
20
Jargon

Survey Types
Enforcement




Scope (wide spread)
Severity
Remedies
 plan of correction
 civil money penalties
 denial of payment
 management
 termination
Dispute mediation; appeal


Standard
Extended survey


If significant issues in the following areas
 Quality of life
 Quality of care
 Resident behaviors
Must be done within 14 days of end of
standard survey.
21
22
Survey Types
Standard Survey

Abbreviated standard
 Complaint
 Change in management

Partial extended
 Done if substandard care is found in
abbreviated survey.

Post-survey revisit
 Monitor implementation of plan of correction.

23
All nursing facilities and skilled nursing
facilities that are certified to participate in
the Federal Medicare Program and/or the
State Medicaid Program must be
surveyed at least annually to determine
whether the facilities are in compliance
with the Requirements of Participation.
24
57
03 Regulatory Environment
Standard Survey
Standard Survey
Requirements of Participation
Requirements of Participation
483.12 Requirements for Admission,
Transfer and Discharge
483.13 Resident Behaviors
483.15 Quality of Life
483.20 Resident Assessment
483.25 Quality of Care





483.30
483.35
483.40
483.55
483.60
483.65
483.70
483.75








Nursing services
Dietary services
Physician services
Dental services
Pharmacy services
Infection control
Physical environment
Administration
25
26
Standard Survey
Standard Survey
Requirements of Participation
Requirements of Participation

Each of these requirements have one or more
associated “F-tags.”

Lack of compliance with a
requirement of participation.
483.40 Physician Services
 483.40(c)(1): F Tag 387


Deficiency:

The Resident must be seen by a physician at least
once every 30 days for the first 90 days after admission,
and at least once every 60 days thereafter.
483.20 Resident Assessment
 483.20(k)(3)(I): F Tag 281

The services provided or arranged by the facility must
meet professional standards of quality.
27
The Survey Process
Overview
OBRA - Enforcement

Possibly: To identify “poor performers.”

28

Timing of survey

Notification
 Must be unannounced
 Usually annual

Timing- generally 8:00AM - 6:00PM
 CMS requires that at least 10% of
surveys must begin on the weekend or
in the evening or early morning hours.
But essentially:

Looking for substantial compliance.

Remedies for deficiencies based on the
scope and severity of what is found.
29
30
58
03 Regulatory Environment
The Survey Process
Overview
The Survey Process
Overview

Surveyors are required to conduct the survey in
accordance with the regulations and interpretive
guidance set forth in the State Operations
Manual (SOM).

The facility must prepare a Plan of Correction
(POC) for each violation and notify the State
Survey Agency of a date by which the facility
will be in compliance.

If deficiencies are found, the survey team will
issue a Statement of Deficiencies:

The State Survey Agency or CMS may conduct
a post-survey revisit to assure adherence to the
POC.
 For minor deficiencies, only a letter from the
facility confirming compliance is necessary.



Summarizes findings.
Identifies failure to comply with regulatory provisions.
Categorizes the seriousness of the violations based
31
on a matrix created by the CMS.
32
The Traditional Survey Process

The QIS Survey Process
Elements of the Traditional Standard Survey
 Pre-visit survey (Task 1)
 Entrance Conference & On-Site Preparation
(Task 2)
 Initial Tour (Task 3)
 Sample Selection (Task 4)
 Information Gathering (Task 5)
 Determination of Compliance (Task 6)
 Exit Conference (Task 7)
QIS Survey



Development began 1994
University of Colorado
States involved





2005 CT, OH, FL, LA, KS
2006 CA
2008 NM, MN, NC
2009 WV, MD, WA
33
34
The QIS Survey Process


The QIS Survey Process
Automated
During Stage 1 residents are randomly
selected.




QIS survey designed to:


Interviews with Residents (83% are
interviewable) that a proscribed.
Interview with staff, families.
Observations of those non interviewable
residents.

35
Improve consistency and accuracy of QOC
and QOL problem identification.
Enable timely and effective feedback on the
survey process.
Systematically review requirements and
objectively investigate all triggered regulatory
areas.
36
59
03 Regulatory Environment
The QIS Survey Process

The QIS Survey Process

QIS survey designed to:



Elements of the QIS Survey

Provides tools for continuous quality
improvement.
Enhance documentation.
Focus survey resources.







37

Differences Between Traditional
and QIS Survey Process


Information requested:
 QI/QM report
 Roster sample matrix
Tour
 Gather information about
concerns that have been
preselected, new concerns,
and other candidates for the
phase 1 sample.
 Are preselected residents still
present.

Information requested:
 Alphabetical list of all
residents and their room
numbers.
 List of new admissions and
discharges over the last 30
days.
Tour
 Initial review to gain
information about the
resident population, staff and
facility layout. Not
information gathering.




Traditional
Sample selection
Residents selected offsite
based on facility’s QI’s of
concern.
Determine whether any preselected concerns should be
substituted based on review of
Roster/Sample Matrix and
findings from the tour.
Determine Phase 1 sample
residents who are
interviewable.
39
Differences Between Traditional
and QIS Process
Traditional

Survey Structure
 Phase I involves both
comprehensive and
focused reviews.
 Phase II focused and
closed reviews.

QIS
Survey Structure
 Stage I involves a
preliminary investigation of
all regulatory areas in
Admissions, Census, and
Surveyor-initiated samples.
 Stage II involves further
investigation of triggered
Care areas in Stage II
sample chosen based on
Stage I findings.
41
38
Differences Between Traditional
and QIS Survey Process
QIS
Traditional

Task 1: Off site preparation
Task 2: Onsite preparatory activities and entrance
conference
Task 3: Initial tour
Task 4: Stage 1 survey tasks
Task 5: Non-staged survey tasks
Task 6: Transition from stage 1 to stage 2
Task 7: Stage II survey tasks
Task 8: Analysis and decision making
Task 9: Exit conference

QIS
Sample selection
4 samples selected by QIS DCT:
 MDS offsite sample-residents with
an MDS within 180 days.
 Random Admission sample-30
residents admitted more than 30
days prior to survey.
 Random Census sample-40
residents currently in facility
selected through offsite and onsite
activities.
 Surveyor-initiated sample-resident’s
selected at surveyor’s discretion.
40
The QIS Survey Process

www.Nursinghomequality.com
42
60
03 Regulatory Environment
The Traditional Survey Process
Pre-visit Preparation (Task 1)
The Survey Process
Contact ombudsman
Review 2567, previous level A citations
Review OSCAR Report 3 (Hx facility profile)
Review OSCAR Report 4 (Full facility profile)
Review results of interim complaint investigations
Any outstanding complaints
PASSAR reports on MI/MR
Review waivers/variances
MDS assessments
Quality Monitor/Indicators Report











Quality Indicator/Quality Measure
Reports





Facility characteristics
Facility level summary
Resident level summary
Resident census and conditions
Resident roster/sample matrix
43
44
Quality Measures/Indicators
13 Domains/31 Indicators + 3 Post
Acute Indicators

For example, the Accidents “domain” has two
“indicators”
 Accidents
 1) Incidence of new fractures
 2) Prevalence of falls

This will report for any time frame selected the
number of residents with new fractures (facility
acquired) and with falls, calculate the % rate,
compare that rate with state and national rates, and
provide a percentile rank relative to all facilities in
your state.
45
46
The QIS Survey Process
Pre-visit Preparation (Task 1)

Similar to Traditional process tasks but:



Surveyors do not review QI/QM data and
OSCAR 4 reports or preselect residents for
review.
MDS is loaded offsite into surveyors
computers and are used to calculate QCI’s
and randomly select residents for Stage I.
QCI=Quality of Care Indicators
47
3.1 – 3.5
48
61
03 Regulatory Environment
The Survey Process
The Survey Process
Entrance Conference and On-Site
Preparation (Task 2)
Entrance Conference and On-Site
Preparation (Task 2)

Team coordinator informs administrator
of survey and introduces team.
Team members proceed to initial tour.

Survey team





Team coordinator


Has at least a nurse and dietician.
A pharmacist may be involved.
Depending on facility size and issues, more
nurses or other disciplines.

Requests copy of working schedules for
licensed staff and registered nursing staff by
the end of the tour.
Informs facility team will communicate with
them and give facility the opportunity to
clarify issues brought to facility’s attention.
Give administrator OSCAR reports 3 and 4.
49

50
The Survey Process
The Survey Process
Entrance Conference and On-Site
Preparation (Task 2)
Entrance Conference and On-Site
Preparation (Task 2)
Team coordinator




Asks administrator about any special
features of the facility.
Requests time to meet with
residents/families without the facility staff
present.
Request additional documents within 24
hours of Entrance Conference.
Within 1 hour of conclusion of Entrance
Conference the facility must provide:





List of key personnel.
Copy of written information given out regarding
Resident Rights.
Meal times, dining locations, copies of all
menus to be used during the survey.
Medication pass times.
Copy of the facility layout, AND….
51

52
The Survey Process
The Survey Process
Entrance Conference and On-Site
Preparation (Task 2)
Entrance Conference and On-Site
Preparation (Task 2)
Within 1 hour of conclusion of Entrance
Conference the facility must provide:




Copy of the facility admission contracts for all
residents.
Copy of policies and procedures to prohibit
and investigate allegations of abuse.
Evidence that facility routinely monitors
accidents and other incidents, and its system
to minimize them.
53
Within 1 hour of conclusion of Entrance
Conference the facility must provide:



Current resident activity calendar.
Names and ages of residents 55 and
under.
Names of residents who communicate with
non-oral devices, sign language, or speak
language other than dominant language in
the facility.
54
62
03 Regulatory Environment
The Survey Process
The Survey Process
Sample Selection (Task 4)
Initial Tour (Task 3)

Brief visit to the kitchen early on Day 1.

Confirm or invalidate “pre-selected
concerns.”
Procedures dictate sample selection
based on the resident census. Types of
reviews include:






Comprehensive reviews
Focused reviews
Closed record review
Resident family interview
W.H.P. group (unintended weight loss,
hydration, or pressure sores)
55
56
The Survey Process
The Survey Process
Sample Selection (Task 4)

Approximately 60% of the sample was preselected prior to entry.

Statutory requirement for sample to be casemix stratified.


Current (2009) “hot button” issues are


F 329 Medication Management
F 309 Pain Management
If any resident flags under W.H.P. Quality
Indicators, at least 50% of sample must
include residents with these conditions.
57
58
Investigative Protocols
Resident
Sample
Selection

For selected conditions spells out specific
criteria and protocol:






Note, W, H, P

Adverse Drug Reactions (ADR) and
Inappropriate Medications (2006)
Pressure Sore/Ulcer (2004)
Hydration (2004)
Unintentional Weight Loss (2007)
Medical Director (2005)
Urinary Incontinence and foley catheters (2005)
Pain Management (2009)
60
63
03 Regulatory Environment
The Survey Process
The Survey Process
Information Gathering (Task 5)
Determination of Compliance: Task 6
5A General observations
5B Kitchen/Food Service
5C Resident Review
5D Quality of Life Assessment
5E Medication Pass Observation
5F Quality Assessment and Assurance
Program
5G Abuse Prohibition Review








Assesses problems based on
 Scope - How wide spread is it


Severity - Degree of harm
And derives a grid score by letter (A through L)
for each deficiency.
 Higher letters generally indicate more
trouble for the facility.
61
62
OBRA – Enforcement
OBRA – Enforcement
Deficiency Scope Levels
Deficiency Severity Levels

Scope can be:



LEVEL
Isolated
Pattern
Widespread
EXAMPLE
No actual harm with potential
for minimal harm
No actual harm with potential
for more than minimal harm,
no immediate jeopardy
Actual harm, no immediate
jeopardy
salt on NAS tray; failing to
follow a physician order for a
routine lab test
poor sanitation; omitted dose
of important, but not critical,
medication
puree not smooth, resident
chokes; failure to turn &
position, then pressure ulcer
poor refrigeration of food;
toxic item in food; no program
to prevent/heal ulcers
Immediate jeopardy to
reident’s health or safety
63
64
G: puree not smooth,
resident chokes
OBRA - Enforcement
OBRA - Enforcement
Severity
IMMEDIATE
JEOPARDY
POC
REQ: CAT 3
OPT: CAT 1
OPT CAT 2
POC
POC
J
Sub. REQ: CAT 3
CAT 1
QOC OPT:
OPT CAT 2
POC
Act Harm;
REQ: CAT 2
no immediate OPT: CAT 1
G
jeopardy
No Act Harm; POC
REQ: CAT 1
>Minimal harmOPT: CAT 2
D
no imm jeop
POC
No Act Harm; No
COMMITMENT TO
< Min Harm CORRECT
POC
REQ: CAT 2
OPT: CAT 1
POC
REQ: CAT 1
OPT: CAT 2
A
Subst. Compl.
Isolated
POC
K
Sub. REQ: CAT 3
CAT 1
QOC OPT:
OPT CAT 2
H
Sub. REQ: CAT 2
CAT 1
QOC OPT:
OPT: TEMP
L
POC
MGMNT
POC
REQ: CAT 2
OPT: CAT 1
E
B
Subst. Compl.
Pattern
POC
I
F
Sub.
QOC
Sub.
QOC
Sub.
QOC
C
IMMEDIATE
JEOPARDY
POC
REQ: CAT 3
OPT: CAT 1
OPT CAT 2
Actual Harm;
no immediate
jeopardy
No Act Harm;
>Min harm
no imm jeop
No Act Harm;
< Min Harm
POC
REQ: CAT 2
OPT: CAT 1
POC
REQ: CAT 1
OPT: CAT 2
Sub. REQ: CAT 3
CAT 1
QOC OPT:
OPT CAT 2
POC
REQ: CAT 2
OPT: CAT 1
G
POC
REQ: CAT 1
OPT: CAT 2
D
No POC
COMMITMENT TO
CORRECT
Subst. Compl.
A
Subst. Compl.
Widespread
D: poor sanitation;
soft-cooked egg
Scope of the problem
65
POC
POC
J
Isolated
K
Sub. REQ: CAT 3
CAT 1
QOC OPT:
OPT CAT 2
H
Sub. REQ: CAT 2
CAT 1
QOC OPT:
OPT: TEMP
L
POC
MGMNT
POC
REQ: CAT 2
OPT: CAT 1
E
POC
B
Subst. Compl.
Pattern
POC
I
F
Sub.
QOC
Sub.
QOC
Sub.
QOC
C
Subst. Compl.
Widespread
66
64
03 Regulatory Environment
National Deficiency Data
National Deficiency Data
Trends in Deficiencies, 2005-2007
2008 “Trends in Nursing Home
Deficiencies and Complaints”
Reported by the CMS

2005
2006
2007
Percentage
change
2005-2007
% of NF with
deficiencies
91.5%
91.8%
91.9%
0.9%
Avg # of
deficiencies per
NF
6.4
6.9
7.0
10.7%
Total #
deficiencies
95,624
102,487
104,665
9.5%
Total #NF
15,046
14,954
14,872
-1.2%
67
68
Total Deficiencies by Class of
Ownership 2007
National Deficiency Data 2007
Immediate
Jeopardy J
G
1.3%
K
1.2%
L
0.4%
14.1%
H
1.1%
I
0.1%
D
82.4%
E
62.8%
F
21.2%
No harm A
0.0%
B
27.6%
C
22.2%
Isolated
Patterned

For Profit
7.6

Non-Profit
5.7

Government
6.3
Widespread
69
70
National Deficiency Data 2007

National Deficiency Data 2007
Percentage of NF receiving at least one
deficiency by category
Quality of care
 Resident assessment
 Quality of life

73.6
58.2
43.3

Summary




71
91% of NF were cited for deficiencies.
 Variation by state total number per facility.
Greater number of for profit than not for profit
are cited.
17% surveyed in 2007 cited for actual harm or
immediate jeopardy.
3.6% were cited for substandard quality of
care.
72
65
03 Regulatory Environment
OBRA – Enforcement
Substandard Care

OBRA – Enforcement
Substandard Care
Substandard quality of care: Any survey
deficiency in:

That constitutes immediate jeopardy to
resident health or safety; OR •

483.13
Resident Behavior and Facility
Practices

A pattern of or widespread actual harm that is
not immediate jeopardy; OR

483.15
Quality of Life


483.24
Quality of Care
Widespread potential for more than minimal
harm that is not immediate jeopardy, with no
actual harm
73
74
OBRA - Enforcement
Immediate Jeopardy
Severity
IMMEDIATE
JEOPARDY
Act Harm;
no immediate
jeopardy
No Act Harm;
>Minimal harm
no imm jeop
No Act Harm;
< Min Harm
J
Sub.
QOC
K
G
H
D
E
Sub.
QOC
L
Sub.
QOC
I
F
Sub.
QOC

The Guidelines also clarify that actual harm, as well
as the potential for harm, to one or to more than
one individual may constitute Immediate Jeopardy.
Sub.
QOC
A
B
C
Subst. Compl.
Subst. Compl.
Pattern
Immediate Jeopardy: “A situation in which the
provider’s noncompliance with one or more
requirements of participation has caused, or is
likely to cause, serious injury, harm, impairment, or
death to a resident.” (See 42 CFR Part 489.3.)
Sub.
QOC
Subst. Compl.
Isolated

Widespread

Scope of the problem
Ref: SOM: Appendix Q: Guidelines for determining Immediate
Jeopardy (292 pages)
76
OBRA – Enforcement
Substandard Care

OBRA - Enforcement
Severity
If substandard care is cited, the State
must notify:

The state NHA licensing board.

Attending physicians of residents.
IMMEDIATE
JEOPARDY
POC
REQ: CAT 3
OPT: CAT 1
OPT CAT 2
POC
REQ: CAT 3
OPT: CAT 1
OPT CAT 2
POC
REQ: CAT 3
OPT: CAT 1
OPT CAT 2
Act Harm;
no immediate
jeopardy
No Act Harm;
>Minimal harm
no imm jeop
No Act Harm;
< Min Harm
POC
REQ: CAT 2
OPT: CAT 1
POC
REQ: CAT 2
OPT: CAT 1
POC
REQ: CAT 1
OPT: CAT 2
POC
REQ: CAT 1
OPT: CAT 2
POC
REQ: CAT 2
OPT: CAT 1
OPT: TEMP
MGMNT
POC
REQ: CAT 2
OPT: CAT 1
No POC
COMMITMENT TO
CORRECT
POC
POC
Subst. Compl.
Subst. Compl.
Isolated
Pattern
Subst. Compl.
Widespread
Scope of the problem
77
78
66
03 Regulatory Environment
OBRA – Enforcement
Categories of Remedies

OBRA – Enforcement
Categories of Remedies
Category 1
 Directed plan of correction.


State monitoring and/or directed
in-service training.
Category 2
 Denial of payment for new admissions.
 Denial of payment for ALL residents
(imposed by CMS).
 And/or civil money penalties ($50 $3,000 per day; may be retroactive).
79
The Survey Process
Exit Conference: Task 7
OBRA – Enforcement
Categories of Remedies

80
Category 3
 Temporary management
 Termination
 Optional civil money penalties
($3,050 - $10,000 per day;
may be retroactive)
81
Deficiency and Plan of Correction
OBRA – Enforcement
Plan of Correction

Defines the problem found in the survey
deficiency.

States how problem will be resolved.
 Methods
 Time frame

States how facility will ensure that the
deficiency does not/will not affect other
residents.
82
Deficiency
and
reference
regulation
F- tag
Justification
for citation
83
Plan of
Correction
84
67
03 Regulatory Environment
OBRA – Enforcement
“Informal Dispute Resolution”
and Appeals

“Informal Dispute Resolution” has
relatively informal process; NO
DELAY in enforcement.

may have ONE hearing for appeal,
using Federal or State process •
Survey Reports
Available on the Internet

In an attempt to help customers select nursing
homes based on quality, annual survey results
and quality monitor/indicator data are available
on line at:
www.medicare.gov
Look for:
nursing home compare
85
86
Home Care and Hospice
Quality Monitoring
3.6 – 3.11
87
Home Care and Hospice

Home Care and Hospice
Initiatives similar to those covering the nursing
home industry are being carried over into other
domains where Federal funds are involved:
home care and hospice






MDS, Minimal Data Set (NH) =
UDS, Uniform Data Set (Home Care and Hospice)

OSCAR (NH) = OASIS (Home Care/Hospice)
89
Outcome
Assessment
Information
Set
(Outcome and Assessment Information Set)
“OASIS”

Reported on-line
O
AS
I
S
Full name is Medicare Home Health Care Quality
Assurance and Improvement Demonstration Outcome
and Assessment Information Set
90
68
03 Regulatory Environment
Home Health Agency
Quality Indicators
Home Care and Hospice

Outcome-based quality improvement.

Modeled after the nursing home
industry.

Derived from a 5 year national research
program to develop outcome measures
for home care.

Tested nationally and revised.
91
92
Home Health Compare
Quality Indicators





% who improve in
walking or moving
around
% who improve in
medication
administration
% who improve at
getting in and out of bed
% who improve getting
to and from the toilet
% who have less pain
when moving






% who improve in bathing
% who get better at getting
dressed
% who stay the same at
bathing
% who had to be admitted
to the hospital
% who need urgent,
unplanned care
% whose confusion
improves
Improvement in Bathing
Oasis
Report
Improvement in Toileting
Improvement in Ambulation
93
94
The Medical Director’s Role
F 501 Tag
3.12 – 3.14
95
69
03 Regulatory Environment
Medical Directors &
Federal Regulations
Importance of the Medical
Director

Medicare regulations have required medical
directors in SNFs since 1974.

OBRA ’87 extended the requirement to
nursing facilities (NFs).

Federal regulations specify only two duties.





Implementation of resident care policies.
Coordination of medical care in the facility.
97
Importance of the Medical
Director



Medical directors accountable for the quality of
care in LTC, but have little authority within
facilities and over attending physician.
Recommended vesting greater authority &
responsibility in medical directors for medical
services and require attending physicians and
nurse practitioners to follow facility medical
policies and procedures.
98
Revised Investigative Protocol for
F-501 Tag (2005)
“An Insider’s View: The Role of the Nursing
Home Medical Director”
(OIG Report, Feb 2003)

Improving the Quality of Long-Term Care
(Institute of Medicine report, 2001)

Medical Directors are committed.
Medical Directors value role more than
administrators do.
Inadequately defined regulatory role results in
underutilization.
No fundamental change in expectations or
requirements but:
 Better defined the medical director’s importance.
 Clarifies the meaning of the original
requirements.
 More details of essential functions and tasks.
 Standardized expectations for providers.
 Consistent with the core roles/functions
identified by medical directors themselves.
99
100
Medical Directors &
Interpretive Guidance

Interpretive Guidance




Medical Director’s Tasks
Clarify meaning and implementations of
basic federal regulations.
Subject to periodic revision.
Stakeholders can provide input.
Original CMS Interpretive Guidelines
defined seven functions for Medical
Directors.
101

(1) Assuring that the facility is providing
appropriate care as required.

(2) Monitoring and ensuring implementation of
resident care policies.

(3) Providing oversight and supervision of
physician services and medical care of the
residents.
102
70
03 Regulatory Environment
Medical Director’s Tasks
Medical Director’s Tasks

(4) Overseeing overall clinical care of residents
to ensure to the extent possible that care is
adequate.

(5) Evaluating possibly inadequate medical
care - including drug irregularities- identified or
reported, evaluate and try to correct the
problem.

(6) If necessary, consult with resident and
resident’s physician about care and treatment.

(7) Assure the support of essential medical
consultants as needed.
103






104
Medical Director’s Tasks
Medical Director’s Tasks
OBRA: Resident Care Policies (1 of 2)
OBRA: Resident Care Policies (2 of 2)
Admissions
Treatment
Discharge
Infection control
Use of restraints
MD privileges &
practices

Non-MD staff





Ancillary services

Nursing
Rehab services
Dietary in res. care
Emergency care
Res. assessment &
care planning



Lab
Radiology
Pharmacy



Use of medications
Use and release of
clinical information
Overall quality of care
“The Medical Director is responsible for ensuring
that these care policies are implemented.”
105
106
Medical Director’s Tasks
Medical Director’s Tasks

The medical regimen must be part of an
interdisciplinary care plan designed to:

Try to achieve highest practicable physical,
mental and social well-being.

Preserve function

Minimize injury/falls

Minimize psychoactive meds/restraints

Restraint use requires rigorous
individualized clinical assessment,
should be appropriate, and implemented
only after considering other less risky
alternatives.


107
Additional functional decline may be caused
by inappropriate restraint use.
Type, duration, indications, review, revision
108
71
03 Regulatory Environment
Medical Director’s Tasks
Proactive Measures to Ensure
Year-Round Compliance
Medical Director’s Tasks

The resident’s drug regimen must be
justifiable.





Necessary, appropriate indications.
Appropriate dose, duration and monitoring.
Not duplicated unnecessarily.
Monitoring of adverse affects.
Attempts at drug/dose reduction, when
indicated.

Re-evaluate hiring and credentialing.

Ensure that attending physicians provide
a thorough, relevant, well-documented
initial examination.

Help physicians address consent-totreatment issues.
109

110
Medical Director’s Tasks
Medical Director’s Tasks
Proactive Measures to Ensure
Year-Round Compliance
Proactive Measures to Ensure
Year-Round Compliance
Ensure that physicians address the
broad range of patient conditions, overall
functional status, and quality-of-life
issues in the proper context.




Ensure that physicians develop
documentation skills that reflect OBRA
awareness – not OBRA obsession.

Develop medical policies and procedures
geared to effective geriatrics and compatible
with OBRA guidelines.
Help physicians in their relationships with
residents and families.
Actively help develop and implement an
aggressive quality-assurance program.
Participate in the survey process and in
challenging questionable deficiencies.
111
112
Medical Director’s Tasks
Survey Participation

Pre-Survey


Surveyor Investigative Protocol
Medical Director (2005)

Follow proactive measures listed above
During the Survey




Objective: “To ascertain whether the medical director, in
collaboration with the facility, coordinates medical care and
the implementation of resident care policies.”

Introduce yourself if possible to surveyors in the
building- business card?
Be available to administration and to surveyors
Show your presence and interaction with the staff
and administration, at least some time during the
survey
Participate in exit conference if possible
113
Use this protocol when:
 The facility does not employ a licensed medical
director, or the medical director is not currently
licensed by the State.
 Concerns with the provision of resident care or
medical care or
 Concerns with quality assurance related to the
provision of medical or resident care.
114
72
03 Regulatory Environment
Surveyor Investigative Protocol
Medical Director
Surveyor Investigative Protocol
Medical Director
During the survey process, the surveyor should attempt to
communicate with the medical director about concerns
related to:








“When concerns are identified regarding the quality of
care, quality of life, or protection and promotion of
resident rights, the surveyor should evaluate the
possibility of isolated or systemic failure of the provision
of medical care in the facility.”
Admission of residents whose care needs cannot be readily met by
the facility.
Access to or provision of physician or consultant services.
Identification, assessment, or provision of services to meet resident
needs.
Capabilities and credentials of staff or other providers/contractors.
Facilities success in honoring residents rights and enhancing
personal dignity.
Implementing and maintaining current standards of practice for
resident care and quality of life.
Effectiveness of the various committees responsible for overseeing
resident care and quality of life.
115
“If the survey process identifies the facility’s lack of a
functioning medical director or the lack of medical
director involvement in implementing resident care
policies and coordinating care, use the Medical Director
Investigative Protocol.”
116
Surveyor Investigative Protocol
Medical Director
Surveyor Investigative Protocol
Medical Director

Facility/Medical Director responsibility for resident care
policies.

If the survey team identifies concerns related to the
provision of resident care, investigate how the medical
director, in coordination with the facility, provides input
into the new development, review, revision, and oversight
of the implementation of resident care policies.
 How was it determined that the policy reflected current
standards of practice.
 If not available, interview the Medical Director about
his/her involvement in implementing resident policies.
117
Surveyor Investigative Protocol
Medical Director

Coordination of medical care/physician leadership.





Ensuring that provisions are in place for physician
services 24 hours a day and in case of emergency.
Ensuring that visits and orders are provided as required.
Ensure that rules and procedures are established for
ongoing coverage for physician services.
Ensuring that practitioners, who are used to perform
physician delegated tasks, act within the regulatory
requirements and within their scope of practice as defined
by State law; and ensure that they are under a physician’s
supervision.
Whether the facility identified problems related to care
that needed her/his consultation, i.e. notification of a
physician about resident changes.
119

Coordination of medical care/physician leadership.

If the survey team discovers issues or concerns with
resident care/medical care, determine how the facility
obtains the medical director’s input in developing policies
related to these issues and involvement in the coordination
of medical care.

Determine how the facility has involved the medical director in
establishing and maintaining policies and procedures for
credentialing physicians, nurse practitioners, physician assistants
and other licensed or certified health care practitioners.

Determine how the facility has involved the medical director in
monitoring the provision of physician services.
118
Surveyor Investigative Protocol
Medical Director

Once the survey team has determined
that non-compliance exists, the team
will select the appropriate level of
severity

AND they must find a deficient practice
at another tag .
120
73
03 Regulatory Environment
Surveyor Investigative Protocol
Medical Director


Surveyor Investigative Protocol
Medical Director Citation Examples
The citation of a deficiency at F501, Medical
Director, is a deficiency regarding the facility’s
failure to comply with this regulation.

The facility is in compliance if the medical director
has assured that the facility has adopted and
implemented relevant policies and procedures
based on current standards and if the medical
director has coordinated the provision of medical
care and services in the facility.
121
Surveyor Investigative Protocol
Medical Director Citation Examples


Severity level 4
Must have a related care tag with actual harm and the
Medical Director had knowledge of the issue.
Timely antibiotic/medication delivery problem
(widespread and known to the medical director) in a patient
with pneumonia.

Severity level 3
The surveyor must identify the relationship between the
failed practices cited at other regulatory tags and the failure
of the medical director to perform his/her functions.
Stage 2 pressure sores in a facility with no pressure
sore treatment protocols reviewed by the Medical Director.
122
Survey and F-Tags:
Another “Hot Topic”
Severity level 2

Must have a related care tag with no actual harm and the
potential for more than minimal harm and the medical
director had knowledge of the issue.
Repeat lack of reporting of INR levels with the result
that a patient’s anticoagulation profile is very high, but not
bleeding. This is a facility wide problem and the medical
director was aware.


Severity level 1
There is a deficient facility practice but no negative resident
outcome.
The facility is searching for a new Medical Director. 123
Revision of the investigative protocol for F501 created anxiety for many medical
directors.
As it’s played out to date, this has not
appeared to add additional work or legal
liability (but the legal impact is perhaps not
yet evident.)
But there is always some issue rising to the
top.
124
Medications in Long Term Care
Special Concern and Additional Scrutiny
3.15 – 3.18
125
126
74
03 Regulatory Environment
Medication Benefits and Risks



Prevalence of Medications
Medications can stabilize or improve
outcome, quality of life, and function.
Any medication can have adverse
consequences.
Potential to increase risk of adverse
consequences.





Study of 33,301 nursing facility residents
in 2000.
Average of 6.7 medications per individual.
Twenty-seven (27) percent of residents on
nine or more medications.


Without adequate indications.
Excessive dose
Excessive duration
Without adequate monitoring.

Currently greater than 55% of all
residents in long term care are receiving
1 or more mood altering drugs.
127
128
Medication Costs in the US:
U.S. Total
Drug
Expenditures
Total
Drug
Therapy
Costs
=
Product Cost
+
Distribution Cost
X
Utilization
U.S. Cost of
Medication-Related
Problems
+
Medication-Related
Errors
&
Adverse Consequences
$ 288
Billion

Source: Parade Magazine, March 12, 2006
129
$ 111 Billion
Medication
(Ref: Ernst and Grizzle. J AM
Pharm. Assoc., 2001)
Management
ADRs Increase With Number of
Medications
130
Adverse Consequences:
Evidence




131
$ 177 Billion
1.6 million US residents in nursing homes.
Drug related injuries estimated to occur at
a rate of 350,000 events per year.
Thought that at least half may be
preventable.
20,000 of these events may be fatal or life
threatening and 80% of these may be
preventable.

Gurwitz JH et al. Arch Intern Med. 2002;162:1670-2
132
75
03 Regulatory Environment
Adverse Consequences:
Evidence










History of Inappropriate
Medication Regulation
Review of 2 large academic LTC facilities
1229 beds in total
9 month record review
815 ADE which caused injury
188 deemed ‘Serious’
33 ‘Life Threatening’
4 ‘Fatal’
Most errors were in the prescribing and monitoring
10 ADE/month per 100 NH beds
60% of serious, life threatening and fatal were felt to
be preventable

Gurwitz JH et al. Am J Med. 2005;118:251-8

OBRA Regulations 1987 regulated the use of
psychoactive medications in nursing homes.

Beer’s Criteria




HCFA (CMS) modified its regulations for nursing
home residents in nursing homes in 1999.

Revision of F Tag 329 (2006)
133
134
483.25 (I) - Unnecessary Drugs
General
Unnecessary Drugs: F329
Overview and Interpretive Guidelines

Each resident’s drug regimen must be free from
unnecessary drugs. An unnecessary drug is any
drug when used:






135
483.25 (I) - Unnecessary Drugs
Antipsychotics

1991 Nursing home residents over age 65
1997 Include all elderly regardless of setting
2003 Updated
Based on a comprehensive assessment of
a resident, the facility must ensure that:

Residents who have not used antipsychotic drugs are
not given these drugs unless antipsychotic drug
therapy is necessary to treat a specific condition as
diagnosed and documented in the clinical record; and

Residents who use antipsychotic drugs receive gradual
dose reductions, and behavioral interventions, unless
clinically contraindicated, in an effort to discontinue
these drugs.
137
In excessive doses (including duplicate therapy); or
For excessive duration; or
Without adequate monitoring; or
Without adequate indications for its use; or
In the presence of adverse consequences which
indicate the dose should be reduced or
discontinued; or
Any combinations of the reasons above.
136
INTENT: (F329) 42 CFR
483.25(l)

Each resident’s entire drug/medication
regimen is managed and monitored to
achieve certain goals
138
76
03 Regulatory Environment
INTENT: (F329) 42 CFR
483.25(l)

An individual receives only medications
clinically necessary to treat assessed
condition(s).

Non-pharmacologic interventions
considered and used instead of, or in
addition to, medication when indicated.


INTENT: (F329) 42 CFR
483.25(l)

Medication or combination helps promote
or maintain highest practicable physical,
functional, and psychosocial well-being.

Risks for adverse consequences or
negative outcome(s) due to medication(s)
are minimized.
Appropriate doses for appropriate duration.
For example, behavioral interventions for
dementia-related behavioral symptoms.
139
140
INTENT: (F329) 42 CFR
483.25(l)

If an individual experiences decline or
newly emerging or worsening symptoms



Change is recognized promptly.
Medication regimen evaluated as potential
contributing or causative factor.
Changes made as appropriate.
“Any symptom in an elderly
patient should be considered a
drug side effect until proved
otherwise”
Gurwitz, 1995
141
142
Purpose of F329 Surveyor
Guidance
Medication Management

143
Help surveyor determine whether the
facility has a system for medication
management that promotes key
objectives regarding medications.
144
77
03 Regulatory Environment
Guidance To Surveyors


Key Considerations
Guidance applies to all categories of
medications including antipsychotic
medications.
Surveyor’s review of medication use not
intended to constitute practice of
medicine.

Indications for use
Dosage
Duration
Monitoring for effectiveness and
adverse consequences
Tapering / gradual dose reduction
Preventing, identifying, and responding
to adverse consequences.





However, surveyors are expected to
investigate basis for decisions and
interventions.

145
146
What Can the Physician Do?




Step One
Proper assessment
Make the right choices
Monitor for efficacy
Monitor for continued need
Proper assessment




Analyze the problem, do not treat the
symptom.
Avoid the prescribing cascade.
History, physical exam and problem
focused work up.
147
148
The “Cascade Effect”
Step Two

Right Drug




Right Dose


149
Appropriate for the diagnosis.
Appropriate for the older adult.
Evaluate side effect profile and potential to
cause drug drug interactions.
Consider age related metabolism changes.
Right Time

Consistent with goals of care.
150
78
03 Regulatory Environment
Step Three

Monitor




For effectiveness
For continued need
For side effects
For drug drug interactions
151
152
Adverse Drug Withdrawal Events




GDR: Antipsychotics
Retrospective review of 175 VA NH
residents.
94 ADWEs in 62 residents (35.4%)
Cardiovascular and Psychoactive
medications most common.
Increased risk with number of diagnoses,
number of medications and hospitalization
during NH stay.

Gerety M et al. J Am Geriatric Soc. 1993;41:1326-1332

Within the first year in which a resident is admitted on an antipsychotic
medication or after the facility has initiated an antipsychotic medication,
the facility must attempt a GDR in two separate quarters (with at least
one month between the attempts), unless clinically contraindicated.
After the first year, a GDR must be attempted annually, unless clinically
contraindicated.

For any individual who is receiving an antipsychotic medication to treat
behavioral symptoms related to dementia, the GDR may be considered
clinically contraindicated if:

The resident’s target symptoms returned or worsened after the most
recent attempt at a GDR within the facility; AND

The physician has documented the clinical rationale for why any
additional attempted dose reduction at that time would be likely to impair
the resident’s function or increase distressed behavior.
153
154
GDR: Psychopharmacological
Medications
GDR: Antipsychotics

For any individual who is receiving an antipsychotic medication to treat
a psychiatric disorder other than behavioral symptoms related to
dementia, the GDR may be considered clinically contraindicated if:

The continued use is in accordance with relevant current standards of
practice and the physician has documented the clinical rational for why
an attempted dose reduction would be likely to impair the resident’s
function or cause psychiatric instability by exacerbating an underlying
psychiatric disorder; OR

The resident’s target symptoms returned or worsened after the most
recent attempt at a GDR within the facility AND the physician has
documented the clinical rationale for why any additional attempted
dose reduction at that time would be likely to impair the resident’s
function or cause psychiatric instability by exacerbating an underlying
medical or psychiatric disorder.
155

During the first year in which a resident is admitted on a psychopharmacological
medication (other than an antipsychotic or a sedative/hypnotic), or after the facility
has initiated such medication, the facility should attempt to taper the medication
during at least two separate quarters (with at least one month between the
attempts), unless clinically contraindicated. After the first year, a tapering should
be attempted annually, unless clinically contraindicated. The tapering may be
considered clinically contraindicated, if:


The continued use is in accordance with relevant current standards of practice AND the
physician has documented the clinical rationale for why any attempted dose reduction
would be likely to impair the resident’s function or cause psychiatric instability by
exacerbating an underlying medical or psychiatric disorder; OR
The resident’s target symptoms returned or worsened after the most recent attempt at
tapering the dose within the facility AND the physician has documented the clinical
rationale for why any additional attempted dose reduction at that time would be likely to
impair the resident’s function or cause psychiatric instability by exacerbating an
underlying medical or psychiatric disorder.
156
79
03 Regulatory Environment
Dementia Related Behaviors






No FDA approved drug therapy for agitation.
Impaired memory and processing can be mistaken for
psychosis.
Not all delusions are psychosis.
Non-pharmacologic interventions are always first and
second line choices.
Pharmacotherapy should only be considered if nonpharmacologic interventions have failed and the symptoms
are impairing function or causing danger to self or others.
Pharmacotherapy in this setting is associated with an
increase risk of falls, cognitive decline and functional
157
decline.
Caring for the Ages, Nov 2007
Surveyor Expectations





Monitoring for efficacy and ADR.
Recognize change in condition as possible ADR.


Performs Monthly Regimen Review
Reports irregularities to MD and facility
Facility and MD act on recommendation.
159
160
Implementation Of Resident Care
Policies
F Tag 501 and F Tag 329



Observation and record review.
Interview resident, family, staff,
clinicians, pharmacist.
Review Medication regimen reviews.
Pharmacist



Non pharmacologic measure first if possible.
Attempts at tapering if indicated and appropriate.
Facility in collaboration with prescriber are


Sources of Information
Medications should have a clinical indication.

158
For thirty years, Medicare regulations have
required medical directors in SNFs.

OBRA ’87 extended the requirement to
nursing facilities.



Federal regulations specified two duties.



Implementation of resident care policies.
Coordination of medical care in the facility.
161
Medications have an indication clearly documented.
Written physician orders for medications must include
indication in order.
Nursing will request indication if taking a verbal order.
Significant resident change of condition such as
weight loss, falls, functional decline and cognitive
decline will be conveyed to consultant pharmacist on
monthly basis.
Facility has policy for appropriate follow up of
medication regimen reviews generated by consultant
pharmacist.
162
80
03 Regulatory Environment
Coordination of Medical Care in
the Facility




Education of medical staff regarding
principles of medication management and
requirements of F329.
Education of nursing home staff regarding
monitoring for drug efficacy and potential
side effects.
Collaborating with consultant pharmacist
regarding approach to MRR.
Review MRR with nursing staff.
OBRA and Medical Practice

The practice of medicine is not regulated by CMS
and OBRA…


But the facility (and the Medical Director) are at risk if
the attending physicians do not follow guidelines AND
cannot justify significant deviations.
Clinical judgment and practice must be based on
medical standards and principles
The literature contains ample evidence about
medication-related problems in the elderly.


ADRs are probably more common than recognized.
163
164
Case 1

OBRA and Medical Practice
The answer to justification of disparities
or discrepancies between guidelines and
actual practice (translated into survey
deficiencies) is clear, clinically
relevant….
Mrs. B is an 88 year old female long term resident
who you are visiting for your 60 day regulatory visit.
Her major complaint is constipation. Staff reports 3
falls over the past 90 days. You note she has lost
20 pounds over the past 4 months. BP is 96/50, HR
of 64. Her diagnoses include CAD, HTN, CHF, H/O
PUD, Osteoporosis, and Overactive Bladder. Her
medications include Metoprolol XL 100mg qd,
Lisinopril 40mg qd, Digoxin 0.25mg qd, Furosemide
40mg qd, Diltiazem CD 240mg qd, Calcium
Carbonate 500mg bid, Alendronate 70mg qweek,
Omeprazole 40mg qd, Oxybutynin ER 10mg qd.

What would you like to do next?
165
Case 2

Mr. C is a 78 year old male being treated for
dementia related behaviors. He was started on
Risperidone 0.5mg bid 4 months ago with
moderate improvement in his symptoms. His
family is grateful that he has improved. Your
consultant pharmacist is asking for a GDR.




What is your next step?
What if this medication was being used to treat
delusions and mania related to bipolar
disorder?
What if the medication was Sertraline and being
used to treat depression?
What if the medication was Galantamine? 167
166
Case 3

You are the new Medical Director of a 130 bed facility who has
hired you to help improve care. Your review reveals that the
facility is flagging in weight loss, late loss decline in ADLs and
residents receiving 9 or more meds. Review of the consultant
pharmacist report shows that 83% of the residents receive an
antidepressant and 51% of the residents receive an
antipsychotic medication. You are told that every admission
receives a psychiatry consult. The psychiatrist is well regarded
by the staff and all assessments and interventions are carefully
documented. This physician has been overheard stating that it
is difficult to be admitted to the nursing home and his
medications help the resident to adjust. The MDS coordinator
confides in you that there are frequent discrepancies between
psychiatrist documentation and nursing home staff observation.

What now?
168
81
03 Regulatory Environment
Case 4

Case 5
Your consultant pharmacist reports that Dr.
D is often ignoring his MRR, and when he
does respond he always checks “Disagree”
without offering any documentation or
justification for his decision. Dr. D has been
overheard by staff complaining about the
over regulation of medicine and his distaste
for others questioning his decisions.

What now?

Your DON and Administrator ask to meet with you
because they are concerned about the new
medication and pharmacy tags. It is there
understanding that all new admissions need a
MRR and anytime someone has a fall, loses weight
or develops a pressure ulcer they need one as
well. They are faxing over incident reports and
notifications to the pharmacy but are being told the
pharmacist cannot assess the resident every time
they receive a fax.

Your thoughts?
169
170
Case 6

You are reviewing prescribing habits with one of
your attending physicians, who happens to have
the highest number of medications per resident in
the facility. When questioned, the physician states
being frustrated about MRR recommendations for
lipid and osteoporosis screenings and
recommendations for starting cognitive enhancers
in residents who have a diagnosis of dementia.
“Once these recommendations are in the chart, I
am concerned that if I do not agree with them, it will
open me up for a law suit”.

3.19 – 3.22
Your thoughts?
171
172
82
04 Medical Information Management
Learning Objectives
Recognize the components and functions of a
comprehensive medical record in long term
care.
Outline the tasks of the Medical Director that
help ensure the integrity and clinical usefulness
of the medical record.
Discuss implementation of EMR in LTC setting.
Describe legal and regulatory requirements,
including HIPAA, that impact clinical
documentation.

04 Medical Information
Management

Core Curriculum on
Medical Direction


2
1
The Medical Record System has
Multiple Functions and Users





Chart organization
Component location(s)
Availability
User friendliness
Confidentiality
4.1 – 4.6
3
4
How Easy is it to Enter Clinical
Data?
How Good your System is
Depends on Inputs and Outputs



inputs
outputs

5
Physician, nurse, therapist notes
Nurse assistant ADL data
MD orders
Clinical monitoring, ie BS, BP’s
6
83
04 Medical Information Management
How Easy is it to get the Data Out
When and Where you Need it?




LTC Records are more Comprehensive
Than Those at any Other Site

Advance directives/code status
Labs/Xray reports
Consultant reports
Hospital records



More regulations
Longer length of stay
More disciplines
MDS and care plan
7
8
Medical Director’s Role is to
Ensure Record….




The “Survey-Friendly” Medical
Record
Meets acceptable care standards.
Is “physician-friendly.”
Is timely, accessible, accurate.
Fulfills regulatory requirements.





Data is logically organized and
consistent.
Facility policies are followed.
Entries are clear and legible.
Addresses commonly posed questions
by surveyors.
Demonstrates effective communication
with physician, resident and family.
9
10
Medico-legal/Regulatory
Compliant Documentation Tips

Medico-legal/Regulatory
Compliant Documentation Tips
Pressure Ulcers






Identify risk factors (modifiable?)
Implement preventive strategies
Early recognition/Staging
Interventions (consult?)
Progress and prognosis
Falls





11
Identify risk factors (modifiable?)
Preventive strategies (?? restraint use)
Realistic goals: e.g. reduce risk of injury
Interventions—risk sharing
Progress and prognosis
12
84
04 Medical Information Management
Medico-legal/Regulatory
Compliant Documentation Tips

Medico-legal/Regulatory
Compliant Documentation Tips
Unintentional Weight Loss





Antipsychotic Use
Identify risk factors—avoidable or not?
Implement preventive strategies
Monitor progress
Document discussion regarding alternate
feeding method (i.e. tube feeding)


Clear justification and evidence of
reductions for:
 Use in geriatrics
 Use in dementia
 Two Antipsychotics
Address informed consent, long term side
effects, black box warning.
13
14
Medico-legal/Regulatory
Compliant Documentation Tips

Medico-legal/Regulatory
Compliant Documentation Tips
Family Conflict/Futility
 Describe dilemma and thought
process.
 Be sensitive in reference to family
members.
 Get second opinion. (? ethics consult)



Interdisciplinary consistency in
documentation is crucial.
Medical Director can be second
opinion/consult for clinically complex
cases.
Ensure appropriate documentation for
sentinel events (dehydration, fecal
impaction, low risk pressure ulcer).
15
16
The Medical Director has the
Opportunity to:


Provider Documentation:
Medical Director Role
Improve care and reduce litigation with
simple improvements in the medical
record.

Participate with IDT in projects to
improve usefulness of clinical record.



17
Staff education
Oversight
Supervision
Role model
18
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04 Medical Information Management
Comprehensive SNF Resident
Assessment Includes:





After Initial Evaluation…
Functional assessment
Decision-making capacity
At risk for: weight loss, falls, pressure
ulcer, decline in status, etc.
Goals for care/expectations
Informed consent for psychotropics




Regulatory visits
Acute visits
Annual evaluation
Consider including: Functional status,
problem list, current medications, social
issues, family communication,
intercurrent problems, prognosis
19
20
Regulatory Visits






Regulatory Visits
Everything that happened since last
regulatory visit.
Record should tell story.
Subjective/objective findings.
Summary
Interim plan
Long range plans, if changing.

The more you do during the visit, the
higher reimbursement( assuming
medical necessity)





21

The Physician Annual Review is a
Chance to Summarize and Update



What has happened since last visit
(nurse’s notes)
Vitals, glucose, labs, consults
Problem list
Current medications, side effects
Address ROS and SH (daily routine)
Check skin
22
A Good Annual Exam:

Review and update active problem list.
Summarize current medications—
appropriate monitoring/opportunities for
discontinuation?
Current functional status.


23
Summarizes overall goals for care.
Lists specific plans related to findings
from the entire review.
Documents discussion of review,
assessment and plan with resident or
authorized representative.
24
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04 Medical Information Management
Might Want to Try:



Might Want to Try:
Medical Director consultation notes:
Can bill if there is face to face contact
with the patient, medical necessity and
(preferred) request from attending.
“At your service notes” high quality
notes you write and send to the primary
doctor, ideally to have them review and
sign on key topics.
Note templates for high risk situations
25
(eg Falls Pressure Ulcers Wt loss )


26
Electronic Medical Record
(EMR)
What do you do If…



Quality-council generated notes on inhouse pressure ulcers, antipsychotics,
non-adherence.
Templates for physicians (e.g. no-touch
exam note, psychotropic justification,
diabetic orders.)
Physician is not visiting the facility for
more than regulatory allowed intervals.
Notes are illegible.
Large in-house pressure ulcer and no
documentation by the MD.
27
28
SNFs will be Following Along
Very Soon

The EMR in LTC—Beginning,
not Quite Mature
The Tide is Turning Toward
EMR
29

Goal: Computerized record containing
all data elements, accessible at all times
to anyone with access privilege,
integrates between systems.

Reality: LTC facilities beginning cautious
implementation of some components.
30
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04 Medical Information Management
AARA Offers Incentives for
“Meaningful Use”
There is no Turning Back




In 2007, Minnesota mandated EMR in
LTC.
Standards being developed for LTC,
studies show benefit.
Federal and state mandates are likely
coming to you soon.
American Recovery and Reinvestment
Act of 2009 invests millions of dollars in
Medicare and Medicaid for meaningful
use of certified IT products.
31
32
Meaningful Use Means…



Last Point is Scary
Use in a meaningful manner for
selected functions.
Allow electronic exchange of Health
information (HIE) to improve quality.
Use technology to submit to the
Secretary real time clinical information
on quality.



Now the Secretary can analyze charts
electronically to find the smallest errors.
Surveyors may not just look at a
sample, but can access all records,
remotely, anytime.
Many fear felony convictions for nursing
home leadership related to quality of
care.
33
34
Some are Moving Ahead, But
Meaningful Use in SNF


Carrot: Perhaps eligible for incentive
payments from CMS. (Right now paying
10-30% of hospital implementation
costs.)
Stick: May keep from penalties.
(Hospitals have to have meaningful use
of certified EMR by 2014 or lose
reimbursement.)
35



There is no certification yet for long term
care and post acute facilities.
Existing software choices are limited—
especially in interfaces.
No carrots and no sticks.
36
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04 Medical Information Management
Health Information Exchange
(HIE)
Who will Certify?
Certification Commission for Healthcare
Information Technology (CCHIT)

Evaluates EMR Systems in 3 primary areas:
functionality/security/interoperability

Certification required to qualify eligible
providers and hospitals for meaningful use
stimulus program under ARRA.

The idea is that everything can be
integrated and accessible at your
fingertips--hospitals, labs, X-ray,
medical offices, pharmacy.

National HIE is network of local and
regional HIEs.
37
38
There are Challenges we are all
Familiar With





Staff turnover, skills, training.
Money: high Medicaid population
IT support—staffing, programs in short
supply.
Integration with providers inside and
outside.
Complex, highly regulated care.
Return on Investment




39
Payback can come in as little as a year
after implementing EMR.
Saving staff time in documenting returns
clinical time for resident care.
Reducing waste and inefficiency and
improving staff work life translates to
lower turnover and higher satisfaction.
Better documentation can mean more
reimbursement.
40
Successful Adopters in LTC
Said….






Care was better.
Data was available, consistent and
accurate.
Reports helped track outcomes.
Employees satisfied.
Benefits outweighed costs.
No-one wants to go back to paper.
So let’s do it!
41
42
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04 Medical Information Management
Savage Gutkind EMR
Implementation Model
Most SNFs do not have a Full EMR,
but have some Electronic Functions




Financial and billing
Staffing and timekeeping
Generating face sheets and care plans
MDS




0=manual
1=ADT and MDS
2=C.N.A. documentation
3= Order management
Source: Savage-Gutkind EMR adoption model for LTC.
43
44
Savage Gutkind EMR
Implementation Model







4=E-MAR and E-TAR
5= assessments
6=care planning
7=Clinical documentation
8=Ancillary integration
9=Decision support
10=Interoperable EMR
Chief Information Officer Consortium EMR
Cost Study for Long Term Care estimated
EMR implementation costs at
more than $250,000 per facility.
45
46
Resources

Electronic Medical Records Cost Study
http://www.leadingage.org/uploadedFiles/Co
ntent/About/CAST/Resources/CIO_Consortiu
m_EMR_CostStudy.pdf
Agency of Health Care Research
LTC EMR implementation study
highlighted the challenges of EMR in
long term care.
As well as the significant benefits.
47
48
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04 Medical Information Management
Medical Information: EMR

Medical Information: EMR
Study: Cost, Staffing, Quality Impact of
EMR in Nursing Homes.
Example of EMR in LTC


Facilities with EMR
 Higher Total/Nursing costs
 Similar Staffing ratios/retention
 Improved QIs/QM
JAMDA 2010; 11: 485-493


49
50
EMR Difficulties




Change in work
processes.
Attachment to paper.
How well do you
type?
Staff acceptance





VA (SNF) Orlando
Using CPRS (Computerized Patient Record
System).
Fully integrated with VA Hospital, outpatient,
lab, pharmacy, radiology, and other regional
VA systems.
Physician orientation – 2 formal half day
sessions…plus on the job learning.
To Overcome Barriers
Multiple providers/
facilities
Time – data entry
Financial
Maintenance of
systems.
Integration with
other health care
delivery systems.




Hire a professional/product with SNF
experience.
Dedicate a project manager.
Expect major change in work processes
and culture shift.
Time for training, money for incentives.
51
52
Successful Implementation
Involves…




For Staff Engagement
Emphasize…

Staff engagement and preparation.
Working with partners and vendors.
Adapting software to LTC environment.
Managing the implementation.




53
Benefits to patient care.
Eventual time savings.
Reducing wasteful workflows.
New skills.
Need to do workflow analysis, identify
champions, and start small with
motivated people.
54
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04 Medical Information Management
For Partners and Vendors…



Adapting to your Environment
Take the time to review products with
real life examples and exceptions.
Go to places that have the system you
are using and talk to users.
Collaborate in teams to make vendors
change.

Means integrating software into clinician
and physician workflow, both on and off
site.
 Where and when do you enter and
need information?
 How can you review it best?
55
56
Training




Online Resources Available
Has to be personalized, often one to
one.
Consider bringing the training to the
physician’s office.
Classroom training makes people leave
thinking they know it, but they need
hands on.
Arrange ongoing support by someone
who knows exceptions, even at night. 57

www.nursinghome.org/pro/HIT/hit.html

HIS: Understanding the costs and
benefits of health information
technology in nursing homes and home
health agencies 2009 includes many
tool kits, articles from early adopters,
basic facts about technologies and
grants you can get.
Medical Director Role in EMR
E-Prescribing in LTC



58

No exception, but no certified systems.
Increasing number of non-office/nonhospital based Physicians are using eprescribing, but
Barrier – Facilities unlikely to allow
physician to bypass nursing staff and
communicate directly with dispensing
pharmacy.

Obtain reports for quality assurance.
Advocate for MD use of EMR.




59
How will the doctors input?
What data do doctors need to get from the
record and is it easy?
How does the record fit with the regular
routine/work processes? (in person and
off-site)
Shows value as Medical Director.
60
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04 Medical Information Management
Change is coming, move with it.


Best of Times – Stakeholders see great
potential.
HIPAA
Worst of Times – So far away from a
fully integrated EMR system.
Health Insurance Portability and Accountability Act
61
62
HIPAA: What It Is

HIPAA Goals
Health Insurance Portability and
Accountability Act
 Signed into law by President Clinton
08/21/96.
 Several Titles and Subtitles, etc.
 We are primarily concerned with parts
of Title 2: the Privacy Rule and the
Security Rule.

HIPAA has many goals.

The principle goal in which we are
interested is
 Protect the privacy and security of
patient information stored and
exchanged electronically.
63
64
HIPAA: Privacy
Privacy and Security Rules

Privacy governs how patient-identifiable
health information is used and disclosed

Security governs how electronically
stored or transmitted patient-identifiable
health information is kept confidential by
assuring the security and integrity of
electronic health data.
65

The Privacy Rule addresses an
individual’s rights to control access to and
disclosure of his/her Individually
Identifiable Healthcare Information (IIHI).

IIHI is also more commonly referred to as
Protected Health Information (PHI).
PHI includes oral, written and electronic
health data, past, present and future.

66
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04 Medical Information Management
Privacy Rule – IIHI is PHI:
HIPAA: Use and Disclosure

“Any information, whether written, stored in a
computer or verbal . . . .
Use


that relates to the past, present or future health
or condition of an individual, any healthcare
services that individual has received, is
receiving or will receive . . .

TPO (Treatment, Payment, Operations)
As permitted or required by the Rule
Disclosure


and which identifies the individual or there is
reasonable basis to believe that the information
can be used to identify the individual.”
As permitted or required by the Rule
As authorized by the person; standardized
information required
67
68
ePHI
HIPAA: Security


Concerns only electronically stored or
transmitted PHI, which is becoming
more commonly referred to as ePHI.




This is increasingly important because
of the burgeoning use of EMRs and,
with the current status of software, the
risk of unauthorized disclosure of PHI.


69
Computer programs
E-mail
Billing information to insurers,
Medicare, Medicaid
Faxes
Portable Communication
Devices (phones, Blackberrys)
Communication /
Documentation tools such as
Accunurse
HITECH Act (2009)

HITECH
Health Information Technology for
Economic and Clinical Health Act.

Health
Information
Technology for
Economic and
Clinical
Health Act


71
Part of the American Recovery and
Reinvestment Act of 2009 (ARRA).
Incentives related to health care
information technology in general.
Specific incentives aimed at increasing the
use of electronic health record (EHR)
systems among providers.
72
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04 Medical Information Management
HITECH Act – Important Items
HITECH Act and HIPAA



Widens the scope of privacy and
security protections available under
HIPAA.
Increases the potential legal liability for
non-compliance.
Provides for more enforcement.




Right to access to and copy of ePHI.
Business Associates required to comply
with the safeguards in the Security Rule.
Imposes data breach notification
requirements for unauthorized uses and
disclosures of “unsecured [currently,
unencrypted] PHI”.
Increased enforcement provisions.
73
74
HIPAA and HITECH: Enforcement
HIPAA and HITECH: Penalties
Health Plans/Healthcare Clearinghouses
/Healthcare Providers/Business Associates

Enforcement is under
the aegis of the Office
of Civil Rights (OCR).
New: 4 tiers of fault and penalties
Violation category
[42 USC 1320d-5(a)(1)]
Minimum Penalty,
each occurrence
(A)
Did not know and would
not have known
$100 - $50,000
(B)
Reasonable cause and not
willful neglect*
$1,000- $50,000
(C) (i)
Willful neglect* –corrected
within 30 days of discovery
$10,000 - $50,000
(C) (ii)
Willful neglect* – not
corrected
$50,000
Willful neglect:
“the conscious,
intentional
failure or
reckless
indifference to
the obligation
to comply"
The maximum penalty for all violations of any category in a
calendar year is $1.5M ($1,500,000).
75
76
HIPAA and HITECH: Penalties
Health Plans/Healthcare Clearinghouses
/Healthcare Providers/Business Associates

New: 4 tiers of fault and penalties
Violation category
[42 USC 1320d5(a)(1)]
(A)
(B)
HITECH: Criminal penalties
Did not know and
would not have
known
Reasonable cause
and not willful neglect
Minimum Penalty, each
occurrence
$100 - $50,000
$1,000- $50,000
(C) (i)
Willful neglect –
corrected within 30
days of discovery
$10,000 - $50,000
(C) (ii)
Willful neglect – not
corrected
$50,000
Before: if did not know and
would not have known,
penalty could be set aside;
Now: Only defense against
monetary penalties is for
violations not due to willful
neglect [Categories (A) and (B)] if
the violations are corrected
within 30 days of discovery.
77

Criminal penalties can now be enforced
against individuals (including employees
of a covered entity.) The scope of
activities subject to criminal prosecution
is broadened to include individuals who
obtain or disclose individual PHI
"without authorization."
78
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04 Medical Information Management
HIPAA Violation Slideshow

Participants: Watch the following movie
and make a list of HIPAA violations
which are apparent in the movie.
 A series of photos are presented for
15 seconds each.
 Look at the photo and jot down the
violations.
79
80
81
82
HIPAA Violation Movie

Participants: Watch the movie and
observe the clues to the HIPAA
violations.
Violations Discussion

Critical Points
Thinking about these scenarios, what are
 The Medical Director’s responsibility,
and
 Corrective action the Medical Director
might take to ensure that the violation(s)
cease and do not recur.
83

Address HIPAA complaints promptly
and aggressively. (Especially if you receive
complaints from the Office of Civil Rights.)

The potential civil penalties for violating
HIPAA have been increased
substantially via the HITECH act, and
that these higher penalties can be
applied to HIPAA violations of any kind.
84
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04 Medical Information Management
Critical points


Medical Director Tasks
Both covered entities and
business associates: reevaluate all of
HIPAA compliance practices, even for
the parts of HIPAA that were not
changed by HITECH.
Provide or arrange for HIPAA education
on an annual basis for medical staff.
Maintain observatory vigilance about
privacy protection.
 Report violations
 Insist on corrective action
Always: advocate for our residents.


More changes in enforcement will be
forthcoming.

85
86
Small Group
Exercises
4.6 – 4.8
87
Medical Information Management
Review
Wrap Up
Breakout





Example of system issue within a facility.

Lack of compliance with policy and
procedures.
Physician oversight
Quality assurance
Solution multifaceted


88
Medical Record
 Components
 Systems
 Medical Director tasks
 The “survey friendly” medical record
 Regulatory compliant
Facility staff
Medical staff
89
90
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04 Medical Information Management
Medical Information Management
Review


Electronic data handling
 Current status
 Barriers to implementation
 Benefits

HIPAA


Role of the Medical Director

Medical Information Management
Review
Tasks of the Medical Director

Use of data to facilitate carrying out of
Medical Director functions and tasks.
91
PHI (Protected Health Information) and IHII
(Individually Identifiable Health Care
Information)

Engender a culture of protecting PHI.
Ensure HIPAA education for the medical
staff.
92
98
05 Employee Health and Safety
Objectives

05 Employee Health and
Safety

Core Curriculum on
Medical Direction

Manage the potential ethical and legal conflicts
resulting from establishing a physician-patient
relationship with an employee while having a
fiduciary relationship with the facility.
List important occupational illnesses and injuries
seen in the LTC setting.
Describe components and processes of an
effective employee health program.
2
1
Why Should You Know About
Employee Health?
Objectives


Define the medical director’s responsibilities in
developing a successful facility employee
health program.
Assess the adequacy of the employee health
and safety program at the participant’s facility.
Leadership
Quality and Risk
Management
Federal and State
Regulations
Infection control
3
4
More Why?
The NH is a Dangerous Place
Why, Continued. You Have Much to
Offer in the Employee Health Domain

Medical Expertise
Enhanced Moral
Authority
Medical
Director

1.5 million NH employees
Nursing homes among top 10 industries for
musculoskeletal problems =>

Increased
Employee
Moral


Nursing home workers (132 injuries per 1,000
workers

Reduced
Employee
Turnover

Worsening
Workforce
Issues
Absenteeism & consequences of staff turnover,
workers’ compensation claims,
Comparable to airline baggage handlers, meat-packers
Health-care frame of reference:


5
Hospital-based workers: 46 injuries per 1,000 workers.
Home-care: 52 injuries per 100 workers but more severe
Meyer et al. Am J Ind Med 1999; 35(3):295-301.
Department of Labor, Bureau of Labor Statistics. May 2007
6
99
05 Employee Health and Safety
A Case of Acute Shoulder Strain

You are asked by
the nurse to see
Sarah, a CNA who
has just “strained
her shoulder” while
lifting a resident.
5.1
7
8
A Case of an Acute Strain



Liability Concern

Can you see the
employee in your
facility?
What if the
employee is your
office patient?
What resources,
practically speaking,
are available to you
in your setting?
Medical Care of Employees is NOT an
administrative duty,
 Therefore needs medical malpractice
coverage.
 Document-Document-Document

However, lawsuits related to treatment of
an employee in the nursing home are
extremely rare.
9
10
Another Liability Consideration


Manage the Ethical Conflict …

Female employees,
keep pregnancy in mind
as you order x-rays or
prescribe.
 May not be at the
forefront in a geriatric
venue.
You may want the
facility to purchase a
pregnancy test kit.
The American College of Occupational and
Environmental Medicine (ACOEM) Code of
Ethical Conduct offers useful guidelines.
MDs should:


11
Keep confidential all individual medical information.
Release information only if required by:
 Law
 Overriding public health considerations.
 Other physicians according to accepted medical
practice.
 At the request of the individual.
12
100
05 Employee Health and Safety
Further ACOEM suggestions
Manage the Ethical Conflict…
The ACOEM Code states physicians
should recognize that employers may be
entitled to counsel about an individual’s
medical work fitness, but not to
diagnoses or specific details, except in
compliance with laws and regulations.





www.acoem.org/code
13
Workers should understand that their private
disclosures will be treated in as confidential a
manner as possible.
 Try to obtain consent before disclosing
sensitive information, e.g.
STDS such as hepatitis or HIV.
Treatment for mental illness or substance abuse.
If disclosure is legally required or consent is not
legally required, the employee should be notified
of the impending disclosure before the
encounter.
14
A Workplace Clinic?


Location
Staffing







Mid-level providers?
Equipment
Liability coverage
Scope of practice
What issues addressed
What issues referred to PCP or for consultation
Records





Need written policy for the treatment of medical records:
where and how the records are stored;
Who has access?
Mechanism of consent?
What happens if employee leaves or facility closes?
15
Important Occupational
Illnesses and Injuries
Occupational Illnesses
 Primarily infectious diseases
“Important” implies

Common-ex. Low back pain




 The employee may contact at work or
bring into the facility.
 Could cause serious morbidity or
mortality for:
Medically minor
Impact by weight of numbers
Uncommon-ex. Pulmonary TB, but potentially
consequences for:

Employee
Facility and it’s residents

Both

Emerging-ex. SARS, H1N1
16
 Employee
 Other employees
 Residents of facility
17
18
101
05 Employee Health and Safety
Important Occupational Illness




A Case of MRSA
Blood Borne Pathogens: Hepatitis B and C,
HIV
GI: food and nonfood-related illness,
Hepatitis A, Salmonella, Norovirus
Respiratory: Influenza, TB
Skin: Scabies, Zoster

Two residents have been admitted with
MRSA infections and active drainage.
Staff has been reminded about the
importance of hand washing, but now are
hesitant to care for these two residents.

The Director of Nursing asks you to assist
in resolving the employee fears.
 How might you proceed?
Note: covered in ID topic
19
20
Vaccination Case

Your facility has a very
low employee
acceptance of influenza
vaccination
 What would you do?
5.2
21
22
Flu Vaccination for Employees:
Immunization Program Elements




5.3
23
A written facility policy and plan on
immunization.
An implementation manual.
Training for staff members, including
physicians, on the immunization plan.
Evaluate by collecting and recording
employee vaccination rates.
24
102
05 Employee Health and Safety
Improving Vaccination Rates






Barriers - Examples
Engage leadership
Standing orders
Offer vaccine in workplace
 Free
 Consider incentives (door prizes, etc)
Declination forms
Evaluate progress
 Identify organizational & personal barriers
Use QI process to test interventions


Organizational barriers to better immunization performance:
 Inadequate vaccine supplies.
 General vaccine inaccessibility.
 Lack of positive incentives for immunization.
 Requirement of written consent.
 Limited record keeping.
 Lack of any feedback or shared learning.
Individual barriers to better immunization performance:
 Limited leadership knowledge and support.
 Poor staff knowledge about influenza.
 Negative staff attitudes about the vaccine and injections.
25
26
Importance of Employee
Vaccination



Nace et al. JAMDA 2007;
8(2):128-33
Reduce transmission to vulnerable
residents
Reduce disruption to staffing
Reduce mortality



Improving employee vaccine rates to 50%60% => reduced flu mortality 40%
Intervention used needs assessment to
target address of these barriers =>
sustained 90% employee immunization
rates
Details:
http://download.journals.elsevierhealth.co
m/pdfs/journals/15258610/PIIS1525861006004919.pdf
27
28
Fig 1
QI Process
Important Occupational Injury





Source: JAMDA 2007; 8:128-133 (DOI:10.1016/j.jamda.2006.09.014 )
Copyright © 2007 American Medical Directors Association Terms and Conditions
Musculoskeletal diseases
“Stress”
Latex Sensitivity
Toxic exposures
Workplace Violence
30
103
05 Employee Health and Safety
Occupational Injuries
Workman’s Compensation
Assistive
Equipment
Employee Health
and Safety
5.4
Ergonomic Guidelines
31
32
Back Injury - Epidemiology



Back Injury Risk factors
The most common musculoskeletal problem &
cause of work-related disability in under 45 years
of age.
The most expensive cause of work-related
disability due to workers' compensation and
medical expenses.
Most low back pain (97%) is mechanical and the
majority of that is benign---especially in the age
group of most employees.
Deyo et al. NEMJ 2001; 344 (5):363-70
33


NH work is physically demanding which contributes to a high
number of injuries.
Injury is usually associated with manual lifting, transferring
and repositioning of residents (particularly back injury).
 Awkward postures (e.g., working in confined areas)
 Large amounts of weight
 Unexpected shifting of weight
 Unexpected loading
 Employee factors
 Obesity
 Deconditioning
 Under-estimating the job
34
Prognosis



30-60% recover in 1 week,
60-90% recover in 6 weeks,
95% recover in 12 weeks.



A Case of Back Injury

However, relapses and recurrences are common.
Good evidence that acetaminophen, nonsteroidal
anti-inflammatory drugs, skeletal muscle
relaxants, heat therapy, physical therapy, and
advice to stay active are all effective.
But…95% of back pain gets better regardless or
in spite of interventions offered.
AFP 2007; 8(7):1181-92
35
After the CNA Sarah was treated and
quickly returned to work, the administrator
mentions to you that low back pain is
keeping employees off work for an
average of 23 days and wonders if that
period of disability can be safely reduced.

What are some explanations?
36
104
05 Employee Health and Safety
Reasons for Protracted Recovery







Is the Problem Real?
Disputed compensation claims.
Fear avoidance (exaggerated pain or fear that
activity will cause permanent damage.)
Job dissatisfaction.
Pending or past litigation related to the back
pain.
Psychological distress and depression.
Reliance on passive treatments rather than
active patient participation.
Somatization
AFP 2007; 8(7):1181-92
OR

Is the data valid?

Could this be a system
problem?
38
Assistive Equipment and
Prevention of Back Injury
Not surprisingly, volume of back &
musculoskeletal injuries increase WC
costs.

Assistive Equipment



Does this figure sound
reasonable?
37
Workman's Comp



Can be ameliorated.
Insurance and OSHA information have
shown that Mechanical lifts work.
Corsets and education are not effective.
Recurrence reduced by


Exercise programs of the back and legs
that have aerobic conditioning and
strengthening .
Ergonomic redesign of strenuous job tasks.
39
40
Process for Addressing
Ergonomic Issues
OSHA Ergonomic Guidelines
 Provide management
support.
 Involve employees.
 Identify problems.
 Implement solutions.
 Address reports of
injuries.
 Provide training.
 Evaluate ergonomic
efforts.
 Recommendations:
 Manual lifting of residents be minimized, and
eliminated when feasible.
 Employers develop a process for
systematically addressing ergonomic issues.
http://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html
41
Weber. Nursing Management 2008; 39(7):28–31
42
105
05 Employee Health and Safety
OSHA’s Occupational Hazards in
LTC Nursing Home e-Tool

http://www.osha.gov/SLTC/etools/nursin
ghome/index.html

Need Screen Shot - Thank You
Click on the area for more specific
information. Common safety and health
topics:
•Ergonomics
•Patient Handling Program
•Patient Handling Controls
•Trips/Slips/Falls
43
•Awkward Postures
•Other Ergonomic Hazards
•Recordkeeping
44
In Sum-selected Injury
Prevention Strategies from OSA



Use mechanical lifts & other assistive
devices.
Raise bed
Proper positioning of storage shelves &
appliances-no reach or stoop.


Esp. non-clinical staff, dietary, janitorial,
laundry workers
5.5 – 5.7
Nursing stations:


Ergonomically correct computer stations.
Proper light to reduce glare, eyestrain.
45
46
Stress
Stress on the Job

On the job and brought
from outside is important
because:



Compassion for employee.
Distraction, inattentiveness
can be related to errors
and accidents.
Probably a factor in staff to
resident “abuse.”
47




Cognitively impaired
residents.
Family caregivers’
“advocacy.”
Inadequate orientation,
training, feedback.
Violence/injury
sustained at the hands
of residents.
48
106
05 Employee Health and Safety
Stress Brought From Outside
Stress Reduction
 Psycho-social realities
 Family Responsibilities
 Domestic Violence

Facility management possibilities:
 Job
 Supervisor
 Description & Training
 Job placement
 Action Plan
 Incentives
 Pay/Other positive reinforces
 NH social work role?
 Employee Assistance Plan (EAP)
 Financial issues
 Cultural issues
 Ethnic Diversity
 Language Barriers
49
50
51
52
Stress Reduction

Societal responses:
 ADA (1991)
 Family Medical
Leave Act (1993)
ada.gov, www.dol.gov/esa
Environmental Risks
53

Latex

Cleaning and
other Chemicals
54
107
05 Employee Health and Safety
Latex Allergy:
Allergic Contact Dermatitis
Latex Allergy

Irritant contact dermatitis (Nonimmune)



Gradual onset, over days, caused by hand
washing, occlusion, antiseptics and glove
chemicals
Symptoms - redness, cracks, fissures, scaling


Type IV, delayed hypersensitivity
Onset six to 48 hours after contact, caused by
chemicals
Symptoms - erythema, vesicles, papules,
pruritus, blisters, crusting
Am Fam Phys 2009
Am Fam Phys 2009;
80(12):1413-20.
55
56
Latex Allergy:
Immediate hypersensitivity (type I)


Case of the Chemical Spill
Onset within minutes, very rarely longer
than two hours, caused by latex
Symptoms - urticaria, angioedema, nausea,
vomiting, abdominal cramps,
rhinoconjunctivitis, bronchospasm,
anaphylactic shock
Am Fam Phys 1998, 57

How will you respond?
58
MSDS Sheet
Advise Bruce to remove clothing.
Advise Bruce to wash with water.
Ask the nurse to obtain for you the Material
Safety Data Sheet (MSDS) for Envirocide.



General first aid


You are at the facility when a nurse runs
you down. Bruce, a maintenance
employee, just spilled “Envirocide” all over
his pants. He is tearful & screaming for
help. The nurse wants to know what to do.
57
How Did You Respond?


Where are they kept in your facility?
Be, or at least appear, calm and caring.
59
60
108
05 Employee Health and Safety
MSDS Sheets
MSDS Sheet - Envirocide
1. Identification
2. Composition information
3. Physical and chemical properties
4. Fire and explosion hazard data
5. Reactivity data
6. Health hazard data
7. Emergency first aid procedures
8. Precautions for safe handling & use
9. Control measures
10.Transportation information
11.Special information
6. Health hazard data
 Skin: Moderate irritation
 Eye: Contact with eyes can cause
reversible damage
 Inhalation: Low or mild irritation
7.
Emergency first aid procedures

Skin: Wash skin with soap and water.
61
62
Employee Health Program:
Components
The Case of the Chemical Spill

What about Prevention?

Would this elicit an
incident report in your
facility?
Would the report be
reviewed in a thoughtful
and meaningful manner?
Who would do the
review?








Policies and Procedures
Employee Health Nurse - “n of two”
Committee
Personnel Department
Safety Committee
Infection Control Committee
Quality of Work Life (QWL) Committee
64
63
Employee Health & Safety

Employee Health Program

Components 


Employee Health Program: Tasks

What role do you currently have in
these areas?
Hiring and Placement
Monitoring & Surveillance of employee
 General Health Promotion
 Risk Management
 Prevention

Do you have policies, personnel, or
committees in place to address these
issues?
Are you, as medical director involved in
any of these activities?
Should you be?

65
66
109
05 Employee Health and Safety
Employee Health Program:
The Medical Director Role
Employee Health Program: Tasks
Educational Resource
Hiring and
Placement
General Health
Promotion
Prevention
Employee Health
Program
Risk Management
Direct Care Provider
Risk Manager
Consultant To
Administration
Leader
Monitoring &
Surveillance
Data Manager
67
68
Employee Health Resources,
Summarized

Medical Director Resources
for an Employee Health Program
Information Sources






 Communicable Disease Manual:
Control of Communicable Diseases Manual
Medical Texts and Journals
Traditional texts and journals
Dr. Pattee’s and Dr. Levenson’s textbooks
JAMDA and Caring for the Ages
Course Resource Disk


An official report of the American Public
Health Association
18th Edition 2006
Web pages





www.acoem
www.osha.gov
www.cdc.gov
www.ada.goc
www.dol.gov

69
70
Medical Director Resources
for an Employee Health Program
A Parting “Meta-message”

Scientific background
Insider-outsider
Knowledge
Sources of Power
Creditability
Insurance Company Risk Management
materials and consultants.
Factual Expert
71
“Perhaps the most difficult shift for
medical directors is making the shift from
helping people directly and one-on-one to
helping people indirectly through the
creation and implementation of facility
systems, policies and procedures, or
educational ventures that help employees
as a group.”
Brechtelsbauer D. Caring for the Ages 2005; January 2005
72
110
05 Employee Health and Safety
Employee Health & Safety

Thank you for helping assure the health
and safety of workers in America’s long
term care facilities.
73
111
06 Infection Control
Infection Control Module
Objectives
You will develop the knowledge and skills to:
06 Infection Control


Core Curriculum on
Medical Direction

Develop or make recommendations for improving
the infection control program in your facility.
Help control and prevent important infectious
illnesses dealt with in the LTC continuum,
particularly nosocomial infections.
State the regulatory basis for an infection control
program.
2
Infection Control Module
Objectives



Infection Control
Describe the medical director’s tasks that
contribute to the facility’s infection control
program.
Access current regulations and clinical
guidelines that impact this area of medical
direction.
Choose and utilize appropriate techniques and
data sources to assist your facility in the
monitoring of infectious illnesses.

Why infection control?

You are a part time medical director in a 100
bed facility. While busy in your office, with a
full schedule of patients, you are handed a
message from the facility ICP (infection
control professional---in this case, as is true
in most facilities, the ICP is a nurse who has
many other duties in the facility).
3
4
Infection Control

The note reads:
“There was a needle stick incident at the
nursing home. They need you to call the
lab and let them know what labs are
needed.”
6.1
5
6
112
06 Infection Control
Where to Find Current, Authoritative,
Regulatory Compliant Guidelines

Textbooks or journal articles might be a
good source, but most infectious disease
recommendations ultimately come from
the Center of Disease Control (CDC) and
most regulatory issues, relative to
employees, from the Occupational Safety
and Health Administration (OSHA).
Where to Find Current, Authoritative,
Regulatory Compliant Guidelines

Going to the appropriate web sites would
produce precise, current, and authoritative
recommendation regarding care of residents or
employees potentially exposed, as in this case,
to bloodborne pathogens.




http://www.cdc.gov
http://www.osha.gov
http://www.shea-online.org
http://www.apic.org//AM/Template.cfm?Section
=Home1
7
8
Where to Find Current, Authoritative,
Regulatory Compliant Guidelines

A few clicks from either the CDC or OSHA
website and you will find:
Bloodborne Infectious Diseases: HIV/AIDS,
Hepatitis B, Hepatitis C
Emergency Needlestick Information
http://www.cdc.gov/niosh/topics/bbp/emergnedl.html
9
Needle Stick at Nursing Facility

What you find here is very likely to be
current, credible, and helpful.

As a short term solution can you refer
the ICP to this resource and have
him/her follow the stated guidelines?
12
113
06 Infection Control
What do the Current
Guidelines Say?
What do the Current
Guidelines Say?
Factors to consider in assessing...




Evaluation of occupational exposure
sources

Type of exposure
Type and amount of fluid/tissue
Infectious status of source
Susceptibility of exposed person
 Susceptibility of the exposed person





Hep B vaccine history, vaccine response status
HBV, HCV, HIV immune status
Test known sources for HBsAg, anti-HCV,
and HIV antibody.
Do not test discarded needles for bloodborne
pathogens.
For unknown sources, evaluate the likelihood
of exposure to a source at high risk for
infection.
13
14
Immunization of
Health-Care Workers:
Healthcare Professional
Immunization
Recommendations Strongly
recommended by the CDC:





6.2-6.4

15
Hepatitis B
Influenza
MMR
Varicella
Tetnus, diptheria, pertussis
Menigococcal
www.immunize.org/catg.d/p2017.pdf
(verified 4-2010)
16
Infection Control

Next time you are in
the facility, ask your
ICP to bring you the
Policy Manual
regarding needle stick
injuries and review it
with him/her.
6.5
17
18
114
06 Infection Control
483.75 Administration
483.75 Administration
F-Tag 501 (R) Medical Director


The medical director is responsible for
implementation of resident care policies.
 (IG) Admission, Discharge,Transfer
 Physician privileges and practices
 Non-physician health care workers
 Ancillary services
 Policies and procedures related to
accidents and incidents [infection
surveillance]
F-Tag 501 (R) Medical Director responsible
for coordination of resident’s care:





(IG) Providing appropriate resident care.
Monitoring and insuring implementation of
resident care policies.
Provide oversight and supervision of
physician services and medical care.
Oversee clinical care.
Assuring support of essential consultants
as needed.
Regulatory Mandate:

483.65 Infection Control
Infection Control Program
F-Tag 441 (R) - Facility must:
Must:



Establish and maintain an Infection Control
Program.
Provide a safe, sanitary, comfortable
environment.
Help prevent development and transmission
of disease and infection.



Investigate, control, and prevent infections in
the facility;
Decide what procedures, such as isolation,
should be applied to an individual resident;
and
Maintain a record of incidents and corrective
actions related to infections.
21
Components of an Infection
Control Program




Program development
and oversight
Policies and procedures
Documentation
Infection control
practitioner




483.65 Infection Control
Infection Control Program (IG)
Communicable
disease reporting
Education
Antibiotic review
Surveillance


22



Monitoring
Data analysis
23
Defined in writing and include scope and
application of infection surveillance,
prevention and control program
Program reviewed periodically
Based on current standards of practice.
24
115
06 Infection Control
Surveillance
Infection Surveillance Program

Facility should maintain a separate
record on infection that identifies:





25
F-Tag 441 (IG)
Infection Surveillance Program
Must enable facility to timely analyze:
 Clusters
 Changes in prevalent organisms, or
 Increases in the rate of infection

Pay attention to residents at high risk of infection:
 Pressure ulcers
Nutrition compromised
 Invasive devices
Immobile
 Recent GACH DC Incontinent

27


Surveillance data should be routinely
reviewed and recommendations made
for prevention and control of additional
cases.
F-Tag 441 (IG)
28
Infection Control
Epidemiological Definitions
Infection Control
Surveillance Program

26
Infection Surveillance Program

F-Tag 441 (IG)
Each resident with an infection
Date of infection (onset)
Causative agent
Site (of infection)
Precautions taken to prevent
spread
It is important and useful to have
precise definitions.
Be sure you know what definitions the
ICP is utilizing.
Be sure the ICP is compulsive in
adhering to definitions.
29

General rules:
A. Only new symptoms or acute changes in chronic
symptoms should be considered.
B. Potential noninfectious causes of the symptoms
and signs should always be considered before
diagnosing infection.
C. Infection should be diagnosed based on several
supporting data and not on a single finding.
Microbiological and radiological findings should
be used only to confirm clinical evidence of
infection.
30
116
06 Infection Control
Infection Control
Surveillance Program

MDS 3.0
Infections present on the resident’s admission or
readmission, or that develop within 72 hours
after admission, are NOT considered Health
Care associated infection (HAI).
 Aka nosocomial
 New guidance in 2009; previously 48 hours
31
Infection Control

Diarrhea Outbreak
Rates of infection:






Calculation of rates.
Review and trend monthly.
Watch for patterns, outbreaks.
Add your clinical knowledge to apparent
statistical truth.
Review of antibiotic usage is often an easily
obtained and useful adjunct to ICP generated
statistical data.
Your facility has a significant diarrhea
outbreak:

Your Infection Control program is working (the
medical director is supposed to be notified of
possible outbreaks). The ICP calls to inform
you that the facility has had 16 cases of
diarrhea in the last two days. (No surprise,
staff absenteeism is up too).

Are there any recommendations to prevent
spread you would like to make?
33
34
Preventing the Spread of
Infection

(R) The facility must require staff to wash
their hands after each direct resident
contact for which handwashing is indicated
by accepted professional practice.

(IG) Procedures must be followed to prevent
cross contamination, including handwashing or
changing gloves after providing personal care,
or….
(IG) Facilities for hand washing must be available.
6.6

35
36
117
06 Infection Control
Preventing the Spread of
Infection


Case 2: Diarrhea Outbreak
When the infection control program determines
that a resident needs isolation to prevent the
spread of infection, the facility must isolate the
resident.
The facility must prohibit employees with a
communicable disease or infected skin lesions
from direct contact with residents or their food, if
that direct contact will transmit the disease.
You recommend isolation (remain in
room, meals in room) for residents with
diarrhea.
This is of course in addition to your
ongoing “standard precautions” policy.
Your social worker says you can’t do that,
it violates residents’ rights.



37
38
F-Tag 441
Preventing the Spread of Infection


F-Tag 441
Preventing the Spread of Infection
(R) When the infection control program
determines that a resident needs
isolation to prevent the spread of
infection, the facility must isolate the
resident.

(IG) Isolate residents only to the degree
needed to isolate the infecting organism.

(IG) Method should be the least
restrictive possible while maintaining the
integrity of the process.
(IG) Isolate appropriately to reduce the
risk of transmission.
39
40
Diarrhea Outbreak

Diarrhea Outbreak
This example is “real.”
In a South Dakota town between
October 2, 2002 and January 8, 2003,
14% of 6093 residents became ill with
acute gastrointestinal symptoms.
 In the facility, 56% of residents had
gastrointestinal symptoms within a 9 day
period at the end of December 2002.

Investigation by the state health
department strongly suggested that the
majority of these cases were related to
Norovirus infection.

This is the same virus implicated in
diarrhea outbreaks on cruise ships.

41
42
118
06 Infection Control








Norovirus
F-Tag 441 Handwashing
High attack rates (68% in one study)
Can shed up to two weeks after sx’s resolve
Low infectious dose (< 100 virons)
High persistence of agent in the environment
Potential for multiple modes of transmission
Percentage cases with vomiting > 50%
Absence of long-lasting immunity
Outbreaks can involve multiple strains

www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-fact sheet-htm
Your policy (and the SOM) says that
the facility should follow the
guidance for surveyors in F tag 441
for handwashing.
43
44
Infection Control

There is a Guideline for Hand
Hygiene in Health-Care
Settings, dated October 25, 2002
from the CDC.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
Useful resource site:
http://www.cdc.gov/handhygiene/Basics.html
6.7-6.12
45
46
Handwashing:
Effects on Bacterial Load
5
4.5
4
3.5
Log
reduction of 3
2.5
bacterial
2
counts
1.5
1
0.5
0
Clostridium Difficile

2010 – Clinical Practice Guidelines for
Clostriduim Difficile Infection in Adults

Soap and Water
Alcohol-gels
15
30
60
Handwashing Time
(seconds)
47
2010 Update by the Society for Healthcare
Epidemiology in America and Infectious
Disease society of America (Infection Control
and Hospital Epidemiology May 2010, Vol 31(5) pp
431-455 )
http://azdhs.gov/phs/oids/epi/disease/cdif/documents/Clinical
%20Practice%20Guidelines%20for%20C%20Diff%20Infection
%20%202010%20update%20by%20SHEA-IDSA.pdf
(accessed 4/30/11)
48
119
06 Infection Control

Clostridium Difficile
Clostridium Difficile
Diagnostic Criteria
Diagnostic Tests


Diarrhea
Evidence of CDAD by any of the following:
 Positive assay
 Pseudomembranous colitis
 Positive stool culture

Cell Culture Cytotoxin Assay


Combined with stool culture is “gold standard.”
Long turnaround time.

Stool Culture

EIA

PCR testing


Sensitive but not specific.
Rapid but less sensitive than cytotoxic assay.
49
C. difficile-associated Diarrhea
Risk Factors in LTC
Clostridium Difficile

50
Facts
 Leading cause of nosocomial enteric
infection.
 3 million new cases/year in U.S.
 20 thousand new cases/year in U.S.
outside hospital setting.
 2003 nearly 2% of patients transferred
from acute care to LTC had dx.
51





Low albumin
Age
Antibiotics
Proton pump inhibitors
More recent admission to the facility
JAMDA 2005; 6:105-108
C. DIFF.
52
C. DIFF.
6.13
C. DIFF.
53
54
120
06 Infection Control
Clostridium Difficile
Clostridium Difficile
Primary Prevention
Primary Prevention
Hand washing and gloves.




What to wash with?
Study – liquid soap vs 4% chlorhexidine

Simple tasks but compliance low.



Both proven to lower Clostridium
difficile rates.

Increasing pace of patient care (plight of
the HCW).
Responsibility (Epidemiology is your
mother – “wash your hands”).

Without gloves – no difference.
With gloves – liquid soap
out-performed 4% chlorhexidine.
Wash with soap (Mom says: “Did you
use soap?”).
55
56
Clostridium Difficile

Room contamination rates (McFarland,
1989).



C. diff. (-) patient = 8%
C. diff. Asymptomatic carrier = 29%
CDAD patient = 49%
6.14
57
58
Clostridium Difficile
Primary Prevention

Antibiotic Control


59
Avoid antibiotic use.
Limit duration.
60
121
06 Infection Control
Clostridium Difficile
Clostridium Difficile
Secondary Prevention

Instruct visitors to hand wash with soap
and water.

Thorough cleaning of all contaminated
and potentially contaminated surfaces.


Private room with contact precautions.

Hand washing/gloves.



1:10 bleach solution
Maintain contact precautions for
duration of diarrhea.
Routine identification of asymptomatic
carriers is not recommended.

61
If single room not available cohort
providing commode for each resident.
Treatment of these asymptomatic residents
is not recommended.
62
Infection Control
Influenza

The ICP calls you at the office. Three residents
in your facility have malaise, headache, cough,
and fever of 101.2 or higher. Influenza, at least
according to the local TV station, is prevalent in
the community. Your facility succeeded in
administering influenza vaccine 8 weeks earlier
to 97% of residents and 68% of employees and
volunteers.
63
64
Things to Consider about
Instituting Chemoprophylaxis:




6.15 – 6.18

65
Amantadine and rimantadine no longer
recommended due to high resistance rates .
Neuraminidase inhibitors
 oseltamivir or zenamivir?
Are some folks already on treatment from
their attending physicians?
If there’s an outbreak---are drugs in the
quantity you need available?
Do some folks need liquid formulations?
66
122
06 Infection Control
Things to Consider about
Instituting Chemoprophylaxis:




Things to Consider about
Instituting Chemoprophylaxis:
Do you need to know, or does the pharmacy
insist on being informed of the serum creatinine
(ozseltamivir or adamantanes)?
Do you have a problem list that will identify
COPD or Asthma (zenamivir)?
Do you need to notify the POA for any or all
residents?
Will you do any active monitoring for ADRs
related to the prophylactic medication?




How much will all this cost?
Who will pay?
(Patient? Part D carrier? Facility?)
How long do you need to continue
prophylaxis once started?
Are there any drug / disease interactions
that would preclude use of the first choice
drug?
67
68
483.25(n) Influenza and
Pneumococcal Vaccinations

www.cdc.gov/flu/ (accessed 4/30/11)
69
70
Vaccinations

Influenza Vaccine





October 7, 2005 Federal Register /
Vol. 70, No. 194 / Friday, October 7,
2005 / Rules and Regulations. Pp
58834-58852
 Pneumococcal Polylsaccharide
Vaccine (PPV23)
 Influenza Vaccine
Recommended annually for, among others,
those living and working in LTC facilities.
As of October 2002 CMS permits a standing
order program for PPV and influenza vaccines.
Revaccinate annually.
Detailed recommendations published annually
by CDC.
Quality Measure (Short and Long Stay
residents)
71
Vaccinations

Pneumococcal Polysaccharide Vaccine
(PPV)




Recommended for, among others, those living
in LTC facilities.
As of October 2002 CMS permits a standing
order program for PPV and influenza vaccines.
Revaccinate once, five years after the first
dose, if first dose was given before age 65.
Quality Measure (Short and Long Stay
residents)
72
123
06 Infection Control
Vaccinations

Herpes Zoster Vaccine


Approved (FDA) for individuals over age 50
(ACIP recommendation not yet extended
below age 60)
Not reimbursed by Medicare




Infection Control – Part II
Some part D carriers will cover
Not used for the treatment of Zoster
Not used for the treatment of post herpetic
neuralgia
Tetanus
75
76
Burden of Infections Among U.S. Nursing Home
Residents
Resistant Organisms
* wound infections, respiratory infections, urinary tract
infections, or pneumonia
Centers for Medicare and Medicaid Services, Long Term Care
Minimum Data Set, Resident Profile Table as of 05/02/2005.
Baltimore, MD
77
78
124
06 Infection Control
Prevalence of Resistant Organisms
Upon Admit to Hospital from NFs

By site





Resistant Organisms
Urine
Blood
Wound
Sputum

Gram positive
Gram negative
MRSA (24%)
ESBL-producing K. Pneumoniae (18%)
ESBL-producing E. coli (15%)
VRE (3.5%).




Only 6% of patients with resistant organisms were on
infection control precautions at the time of the survey
cultures
High ADL dependence was a predictor of MRSA and
ESBL-producing Klebsiella.
Prior Abx was predictive of MRSA and VRE.

By organism class

Trick et al have reported from a point-prevalence survey
(using rectal, nasal, GI-tube site, wound, and axillary
cultures) in a skilled nursing facility that 43% or residents
had one or more of:

17%
7%
52%
40%
19% (almost all MRSA)
3%


Am J Infect Control 2001; 29(3):139-44
79
80
JAGS 2001 Mar; 49(3):270-6.
Resistant Organisms

The admissions coordinator wants to
admit a patient whose labs indicate
MRSA is growing in the sputum. The
ICP calls to see if this is ok and to ask
what precautions, if any, will be
necessary.
6.19-6.23

81
82
Staphylococcus aureus Colonization
in Nursing Home Residents
Staphylococcus aureus Colonization
in Nursing Home Residents
213 residents of MI NF’s in a prevalence study
(nares, oropharynx, groin, perianal, wound, and
enteral feeding tube site cultures).
 62% were colonized with MRSA.
 75% colonized among those with indwelling
devices.
 49% colonized among those without indwelling
devices.
 Nares cx’s were positive in only 65% of those
with MRSA colonization.
Clin Infect Dis 2008 May 1; 46(9):1368-73
83

Colonization is often transient.

Persistence may be associated with density on
semi-quantitative cx’s.


(Infect Control Hosp Epidemiol 2008; 29(2):143-8)
MRSA less likely to be persistent than MSSA.

(Am J Infect Control 1997;25(4):312-21)
84
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06 Infection Control
Preventing Transmission of
MRSA in LTC

2008 Cochrane review:



6.24-6.25
85
There is no evidence in LTC that screening potential
admissions for MRSA or decolonizing those who are
positive reduce LTC colonization or infection rates.
 Yashikowa and Strausbaugh, 2007
MRSA in LTC
Looking for nosocomial spread





Drinka looked at Staph aureus isolates from a
VA Nursing Home in WI.
A shift in abx use from TMP-sulfa to quinolones
was associated with an increase in MRSA
isolates.

(22%51% between 1997 and 2002).

MSSA and MRSA usually sensitive to TMPSx.
MSSA usually sensitive to quinolones.
MRSA usually resistant to quinolones.


87
88
MRSA in Wounds

86
Antimicrobial Use and MRSA
Lee et al demonstrated in a NF that antibiograms
alone or genotyping alone were each associated
with a poor discriminatory ability.
 Many organisms with same genotype had
variable antibiotic sensitivity patterns. Many
organisms with same antibiogram had
different genotypes.
 The two techniques are likely to be
complimentary in investigation of potential
epidemic spread.
Infect Control Hosp Epidemiol 2000;21(3):218-21
No studies met the review criteria.
Much of the evidence for recently-issued United Kingdom
guidelines for control and prevention of MRSA in health
care facilities was generated in acute care settings. It
may not be possible to transfer such strategies directly to
the nursing home environment.
 Cochrane Database Syst Rev 2008 Jan
23;(1):CD006:354
MRSA in Urine
Attempt to cohort with other MRSA residents
Avoid non-MRSA roommates who have
unhealed wounds, indwelling catheters, or are
immunosuppressed
If drainage can be contained in a dressing,
resident may go out of room unless exhibiting
behaviors likely to increase chance of
transmission (e.g., picking at wound dressing,
picking nose)
89

MRSA in urine
Cohort with other MRSA patients.
 Avoid high risk roommates.
 If continent, may leave room.
 If incontinent, ICP and Medical Director
should analyze whether isolation to room
is necessary (usually not).

90
126
06 Infection Control
Respiratory MRSA

Active pneumonia or bronchitis



MRSA

Private room
Standard surgical masks for all entering room.
Respiratory tract colonization without signs
of infection.




Private room not necessary.
Cohort
Avoid high risk roommates.
At first sign of acute exacerbation, re-evaluate
need for respiratory (droplet) isolation.
91

Housekeeping: standard practices
appropriate
Barriers:




Gloves should be used, wash hands after
removing gloves.
Gown use if care activity likely to result in
soiled clothing. (i.e., gown not needed to take a
temperature or give medication.)
Masks needed only if aerosolization likely.
Isolation carts likely to be helpful.
92
Evolution of Drug Resistance in S. aureus
MRSA in LTC

In LTC



S. aureus
Infection rates
 colonized=10%/yr
 Non colonized =2-4%/yr
Colonization not clearly related to MRSAinduced morbidity.
Non-MRSA mortality in colonized residents is
2-3 times higher than in non-colonized
(probably reflecting functional status and
underlying disease).
93
[1997]
Vancomycin
[1990s]
Vancomycin-
resistant
S. aureus
[ 2002 ]
Vancomycin
intermediateresistant
S. aureus
(VISA)
Vancomycin-resistant
enterococci (VRE)
94
What We Think We Know About
VRE
Resistant Organisms

Penicillin
Methicillin
MethicillinPenicillin-resistant
resistant
[1950s]
[1970s]
S. aureus
S. aureus (MRSA)
What if the potential resident had a
urine culture showing VRE? Would you
approve admission?
Enterococci,
(E. faecalis & E. faecium)




95
Normal inhabitants of the bowel.
Often resistant to aminoglycosides.
When high resistance occurs to gentamycin
and streptomycin, there is usually no reliably
bactericidal regimen.
96
127
06 Infection Control
What We Think We Know About
VRE



Multiple genetic mechanisms for
vancomycin resistance.
Vancomycin resistance has been
demonstrated to transfer between VRE
and Staph aureus, Listeria, and Strep
pyogenes.
Death rates from VRE bacteremia may
exceed 30%.
What We Think We Know About
VRE

Risk factors for colonization




Recent treatment with oral or parenteral
Vancomycin or cephalosporins.
Recent treatment with anti-anaerobic drugs
(metronidazole, clindamycin, imipenem).
Prolonged hospitalization.
Proximity to patient colonized by VRE (not
clearly demonstrated in LTC).
97
98
What We Think We Know About
VRE

Risk factors for colonization





What We Think We Know About
VRE

Care by nurse who cares for another VRE
patient (documented in Acute Care).
Longer ICU stay.
Care in hospital with high VRE prevalence.
Contamination from inanimate objects.
Factors increasing environmental or skin
contamination (e.g., diarrhea).
Colonization
 Fecal VRE an important source of
infection as well as nosocomial
spread.
 Skin colonization (even above the
waist) is common.
 Duration of colonization variable (up
to years).
99
What We Think We Know About
VRE

NF residents colonized with VRE are at increased
risk of colonization/infection with other resistant
organisms.
 Rectal colonization with MDR Gm neg
 17 % vs 4%
 6 month rate of subsequent CDAD
 26% vs 2%
 6 month rate of subsequent MRSA infection
 17% vs 4%
Infect Control Hosp Epidemiol 2003; 24(4):242-45
101
100
Control Efforts for VRE





Limit use of vancomycin.
Limit use of other antibiotics, especially
cephalosporins.
Vigorous environmental cleaning.
Isolation
Rarely eliminate VRE entirely from
institution.
102
128
06 Infection Control
What We Think We Know About
VRE

Inappropriate Uses of Vancomycin
Control Efforts



Consider Medical Director chart review of
residents with orders for vancomycin,
fosfomycin, quinupristin-dalfopristin and
linezolid to ensure drug is truly indicated.




Eradication of MRSA colonization.
Primary treatment of C. difficile colitis.
Prophylaxis for indwelling catheters.
Topical use for irrigation.
When cultures are negative for B-lactam
resistant organisms.
When only 1 of multiple blood cx’s “+” for
coagulase negative staphylococci.
103
104
Appropriate Uses of Vancomycin



Treatment of serious infections caused
by beta-lactam resistant gram positive
organisms.
Treatment of infections caused by gram
positive organisms in patients with true
beta-lactam allergy.
C. difficile colitis which is both severe
and unresponsive to metronidazole.
VRE Control Efforts



All enterococcus isolates should be tested for
sensitivity to vancomycin (check to determine
that your lab does).
Surveillance cultures for VRE are NOT
indicated unless in epidemic situation, or high
risk unit (vent unit, dialysis unit).
Do stool or rectal swab culture on roommates of
newly diagnosed VRE residents.
http://www.cdc.gov/ncidod/dhqp/ar_multidrugFAQ.html#5
105
106
VRE Control Efforts

Dedicated equipment




VRE Control Efforts: Isolation

Blood pressure cuff, thermometer, steth
Notify ambulance staff and receiving
hospitals/clinics when VRE resident is
being transferred.
Educate staff about VRE and facility’s
VRE policies.
Monitor rates of VRE infection and
compliance with policies.


107
Private room or cohort with another VRE
patient .
Wear gloves when entering room of VRE
resident.
Wear gown if substantial contact with
resident or environmental surfaces is
anticipated, if resident is incontinent, or
resident has ostomy, diarrhea, or wound
drainage.
108
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06 Infection Control
Preventing Transmission of
Resistant Organisms in LTCFs

Trick et al compared 2 strategies:



Preventing Transmission of
Resistant Organisms in LTCFs

Routine glove use without contact isolation
Contact isolation
No difference in baseline prevalence of
resistant organisms [MRSA 21%; ESBL
Klebsiella 14-17%; VRE 14-19% with
prevalence slightly higher in glove use
unit]; ESBL E coli was more prevalent on
glove use unit (25 vs 12%).
J Am Geriatr Soc 2004; 52:2003-2009


109
J Am Geriatr Soc 2004; 52:2003-2009
VRE Control Efforts: Isolation



Devoted equipment in room.
Remove gloves immediately upon exiting
room AND wash hands with soap and
water.
Ensure clothing and hands don’t contact
environmental surfaces after removal of
gloves and gown and handwashing.

Stopping VRE Isolation
 No proven recommendations for LTC.
 Consider:
Primary site culture is negative x1 if site is
normally sterile.
 Primary site culture is negative x2 (at least 72
hours apart) if site not normally sterile (e.g.,
skin, bowel,).
 Stool VRE cultures negative x3 (at least 72
hours apart).

112
VRE Control Efforts: Isolation
Emerging Resistance
SHEA Isolation Recommendations




Limit resident transport to situations required for
medical care; transport with precautions.
Residents may travel out of room, assuming they
are coherent (able to understand instructions about
basic hygiene), continent of stool (or diapered to
contain stool), and wearing clean clothing.
Room restrictions probably appropriate for residents
with wound drainage not contained by a dressing,
or those incontinent or having diarrhea.
Infection Control and Hospital Epidemiol Vol. 19, No. 7, Jul., 1998
110
VRE Control Efforts: Isolation
111

No significant difference in rates of acquisition
of resistant organisms occurred: Rate/1000
patient days =
 1.5 for Routine Glove Use
 1.6 for Contact Precautions
Hand hygiene occurred more frequently in the
Glove group 57% vs 36% of observations (p =
0.02).
Costs of Contact Precautions were 40% higher.
113


Multi drug resistance Acinetobacter
ESBL gram negatives
Carbipenem-resistant Enterobacteriaceae
114
130
06 Infection Control
Emerging Resistance
Emerging Resistance
Multi-Resistant Gram Negatives


Resistant to all of:
 Ceftriaxone
 Cefapime
 Piperacillin
 Gentamycin
 Tobramycin
OR
 They have documented ESBL (extended broad
spectrum beta-lactamase production) [note: this is
only possible at this time with E. coli and Klebsiella.

More likely to emerge on anti-anaerobic Abx regimens
(Infect Control Hosp Epidemiol 2003;24(9):644-9)
Multi drug resistant
Acinetobacter baumannii

Resistant to all antimicrobial agents or all
except imipenem.

Risk factors (Am J Infect Control 2002;30(7):386-90)
 Prior Abx
 Prior hospitalization
 Prior NF residency
 Use of a vent or trach
 Foley
115
116
Resistant Organisms in NonHospital Settings: CDC Guidance
XDR Acinetobacter

Acenitobacter baumanii





Gram negative
Most commonly encountered as a health-care
acquired infection.
As with most other organisms, treatment
should only be given for infections (Not for
colonization).
Isolation: Enhanced contact precautions
(appropriate hand washing, gloving, and
gowning).
117
Standard and Contact precautions; and
consider:


Patient placement - Private room, if possible.
(when not available, cohort). Another option is to
place an infected patient with a patient who does
not have risk factors for infection.
Group activities – Maintaining socialization and
access to rehab is important. Infected or colonized
patients should be permitted to participate in group
meals and activities if draining wounds are covered,
bodily fluids are contained, and the patients observe
good hygienic practices.
http://www.cdc.gov/ncidod/dhqp/ar_multidrugFAQ.html#5
Accessed 5/1/11
118
Tuberculosis in LTC

Guidelines for Preventing the
Transmission of Mycobacterium
tuberculosis in Health-Care Settings,
2005 (MMWR)


Facility risk assessment determines facility
program.
Criteria for the Frequency of TB screening
for HCWs and residents has been changed.
119
131
06 Infection Control
TB Control Measures



Administrative
Environmental
Respiratory protection
2005 Updated Guidelines
on TB Prevention in Health Care Settings
MMWR December 30, 2005 / Vol. 54 / No. RR-17
TB Control
Administrative Measures





Assign responsibility for TB infection control in the nursing
home.
Conduct TB risk assessment.
Develop / institute written TB infection-control plan to
ensure
 prompt detection.
 airborne precautions.
 treatment of persons who have suspected or confirmed
TB disease.
Ensure timely availability of recommended laboratory
processing, testing, and reporting of results to the ordering
physician.
Implement effective work practices for the management of
patients with suspected or confirmed TB disease.
125
124
TB Control
Administrative Measures






Ensure proper cleaning and sterilization or disinfection of
potentially contaminated equipment (e.g., bronchoscopes,
endoscopes); (not usually an issue for LTC).
Train and educate health-care workers (HCWs) regarding
TB, with specific focus on prevention, transmission, and
symptoms.
Screen / evaluate HCWs who are at risk for TB disease or
who might be exposed to M. tuberculosis (TST).
Apply epidemiologic-based prevention principles, including
the use of setting-related infection-control data.
Use appropriate signage advising respiratory hygiene and
cough etiquette.
Coordinate efforts with the local or state health department.
126
132
06 Infection Control
TB Control
Environmental Measures



Facility Risk Assessment
Use of environmental controls to prevent the spread and
reduce the concentration of infectious droplet nuclei in
ambient air.
Primary environmental controls control the source of
infection by using local exhaust ventilation (hoods, tents,
or booths) and dilute and remove contaminated air by
using general ventilation.
Secondary environmental controls control the airflow to
prevent contamination of air in areas adjacent to the
source (airborne infection isolation [AII] rooms) and clean
the air by using high efficiency particulate air (HEPA)
filtration, or ultraviolet germicidal irradiation.
127
Considers


Classifies facilities



Assesses screening (TST / BAMT) and conversion rates.
Assesses the presence and performance of the infection
control program and the presence of a person identified
as responsible for the program.
Looks at Environmental Controls and Respiratory
Protection Program.



http://www.cdc.gov/tb/publications/guidelines/AppendixB_092706.pdf
accessed 5/1/11


Baseline two-step TST testing required.
Periodic repeat TST testing interval now varies,
based on the facility’s risk assessment (though
states may require greater frequency than the
feds).

HCWs refer to all paid and unpaid persons
working in healthcare settings who have the
potential for exposure to M. tuberculosis.
HCWs who have duties that involve face-to-face
contact with patients with suspected or
confirmed TB disease (including transport staff)
should be included in a TB screening program.
129
130
Reading the Tuberculin Skin Test




128
TB Screening Program
Health Care Workers
Employee Health - TST Baseline Testing
and Periodic Retesting

Low risk
Intermediate risk
Ongoing Transmission

Infection Control

TB incidence in facility, community, and state.
Whether facility treats patients with TB.

Read reaction 48-72 hours
after injection.
Measure only induration.
Measure the greatest
length of induration
perpendicular to the long
axis of induration.
Record reaction (induration;
not redness) in millimeters.
Infection Control TB

You are asked to look at what the ICP feels
is an equivocal TB skin test


131
Having instructed and observed the ICP
administer PPD testing, you are confident
there were no technique problems.
You feel the test has 11 mm induration (and 17
mm erythema, but that doesn’t count).
132
133
06 Infection Control
Negative TST

Anergy

If there is <5 mm of induration or no
reaction at all, the test is considered
negative.

Do not rule out diagnosis based on negative skin
test result.
Consider anergy in persons with no reaction if:



Always record the test results in
millimeters (mm) and not as “negative”.





133
Boosting



HIV infected
Overwhelming TB disease
Severe or febrile illness
Viral infections
Live-virus vaccinations
Immunosuppressive therapy
Anergy skin testing no longer routinely
recommended.
Two-Step Testing
Some people with LTBI may have
negative skin test reaction when tested
years after infection.
Initial skin test may stimulate (boost)
ability to react to tuberculin.
Positive reactions to subsequent tests
may be misinterpreted as a new infection.

Use two-step testing for initial skin testing of
adults who will be retested periodically




If first test positive, consider the person infected.
If first test negative, give second test 1-3 weeks
later.
If second test positive, consider person infected.
If second test negative, consider person
uninfected.
135
136
Positive TST > 5mm





134
Positive TST > 10mm
HIV infection
Close contact with an infectious
tuberculosis case in past year.
Chest x-rays with fibrotic lesions likely to
represent healed TB.
Organ transplant / immunosuppressed (>
15 mg Prednisone/day for > 1 month).
Receiving Tx with TNF-alpha antogonists.
137

>10 mm is classified as a positive reaction in all
other persons who do not meet the above criteria
but who have other risk factors for TB, including:



Recent immigrants (i.e., w/in the past 5 years) from
countries with a high prevalence of TB such as Africa,
Asia, Eastern Europe, Russia, and Latin America.
Injection Drug Users
Residents / employees of high-risk congregate settings:
 Nursing homes and other LTC facilities for the elderly.
 Hospitals and other health-care facilities, and
homeless shelters.
138
134
06 Infection Control
Infection Control


Infection Control TB
You confirm that there is 11 mm of induration;
therefore you would likely recommend further
evaluation and treatment for this new employee.

You are asked to look at what the ICP
feels is an equivocal TB skin test.

The test was on an newly employed CNA, a
refugee from Bosnia. She had BCG when she
was in school about 11 years ago.
 Is BGG a contraindication for TST?

She has had no weight loss, cough, chills or
sweats, and had not knowingly been exposed
to anyone with TB.
If evaluation is reassuring (i.e., no active TB), the
recommended treatment is 9 months of INH (for
INH-resistant, see appendix).
139
140
BCG Vaccination and
Tuberculin Skin Testing
Infection Control

Tuberculin skin testing not contraindicated for BCGvaccinated persons.

LTBI diagnosis and treatment for LTBI considered for
any BCG-vaccinated person whose skin test reaction
is > 10 mm, if any of these circumstances are present:
 Was contact of another person with infectious TB.
 Was born or has resided in a high TB prevalence
country.
 Is continually exposed to populations where TB
prevalence is high.

Your DON approaches you frantically indicating
that she needs to fill a nursing vacancy, and has
a nurse from the Philippines who has a green
card and comes with good references, but the
nurse states she previously had BCG refuses to
have a TST despite sharing the info discussed
above. Are there any other options?
141
142
2005 Updated Guidelines
on TB Prevention

TB Screening Program
Blood Assays for M. tuberculosis
The whole-blood interferon gamma release assay
(IGRA), QuantiFERON®-TB Gold test (QFT-G)
 FDA approved in vitro cytokine-based assay for
cell-mediated immune reactivity to M.
tuberculosis.
 Might be used instead of TST in TB screening
programs for health care workers.
 An example of a blood assay for M. tuberculosis
(BAMT).
MMWR December 30, 2005 / Vol. 54 / No. RR-17
143

The QFT-G measures cell-mediated immune
responses to peptides from two M. tuberculosis
proteins that are not present in any Bacille
Calmette-Guérin (BCG) vaccine strain and that
are absent from the majority of nontuberculous
mycobacteria (NTM), also known as
mycobacteria other than TB (MOTT).

http://www.cdc.gov/nchstp/tb/pubs/mmwrhtml/Maj
_guide/Diagnosis.htm
144
135
06 Infection Control
Summary

Facility must maintain an active infection
control program.



6.26
Surveillance-systematic data collection to
identify infections in residents.
Outbreak control-system for detection,
investigation, and control of epidemics.
Isolation-an isolation and precautions system
to reduce the risk of transmission of infectious
agents.
145
146
Establishing / Updating Infection
Control Program
Summary





Set Deadlines
Policies and procedures-relevant to infection
control.
Education-continuing education in infection
prevention and control.
Antibiotic stewardship-a system for antibiotic
review and control.
Employee health program
Performance improvement/resident safety
(QA&A)





Deadline #1: Complete / Review and Revise
manual
Deadline #2: Establish permanent Committee
and IC Coordinator
Deadline #3: Train Committee and Coordinator
Deadline #4: Inservice Everyone
Deadline #5: Implement program
147
Establishing / Updating Infection
Control Program: No Surprises

Communicate with stakeholders






Infection Control
Administration ($)
Director of Nursing
Infection Control Coordinator
Medical Staff
Board of Trustees
Werner’s rule: “If someone would be
surprised to hear from anyone but you,
talk to that one first.”

Infection Control - Parting Thoughts

Get to know the facility ICP very well. Be
sure this person is well-trained and
trustworthy.

Policies may seem boring, but they can
really help people keep their wits and do
the correct thing in a time of urgency or
crisis
*
150
136
06 Infection Control
Infection Control

Infection Control
Infection Control - Parting Thoughts


Guidelines may seem set in stone, but they
change frequently. Develop a method to
keep up with changes. Distinguish
between proposed changes (which the
administrator hears about and panics) and
actual finalized changes (which, if enforced
by regulation, must be accommodated).
Infection Control - Parting Thoughts

Recognize not all guidelines are written with
the realities of LTC in mind.
 Sometimes the guidelines are enforced by
regulation and you must make them work.
 Sometimes logical thinking is permissible
and adaptation is appropriate and
acceptable.
151
Infection Control

152
Breakout Session
Infection Control - Useful References



www.cdc.gov…consider subscribing to MMWR
www.osha.gov
Control of Communicable Diseases Manual,
an official report of the American Public Health
Association, 19th edition, 2008 David L
Heymann, editor
153
154
137
07 Resident Rights
Learning Objectives

07 Resident Rights


Core Curriculum on
Medical Direction


1
Enumerate basic categories of resident’s rights.
Discuss factors that influence the ability of
residents to exercise their rights.
Describe common situations where Resident
Rights are relevant.
Discuss the prevention of and response to abuse
and neglect.
Compare and contrast the Medical Director’s
role and the Attending Physician’s role in
honoring Resident Rights.
2
Resident Rights
RIGHT
F Tag
Fed Regulation
F150, 241, 242
483.10
483.15a and b
Telephone & Mail
F183,184,187
483.10 (i) (k)
Protection of Funds
F159,160,172
483.10(c)
Complaints/Grievances
F177,178
483.10(f)(l)
Physician Services
F385-390
483.10(d)(1)
483.25(l)(1)
483.40
Medication Usage
F155,329,428,429
483.10(b)(4)
483.25(l)(2)
483.60(c)(1)(2)
Basic Resident Rights
Case 1:
Rules for Admission and Notification
3
4
Admissions May not be Denied
Based on….
Race
Constitutional
Rights
Political
Beliefs

Sexual
Orientation


Religion*
Admission
Marital
Status


Age
National
Origin
Admission May Not be Based
Upon . . .
Payment guarantee by another.
Gifts or donations.
Medicaid or Medicare benefits.

Disability
5
Ineligibility
Refusing to apply.
Waiving benefit rights.
6
138
07 Resident Rights
Facility Must Notify the Resident
of These Rights:
Reasons for Admission Denial




No bed available.
Cannot meet resident’s needs.
No Medicaid bed available or facility is
not Medicaid certified.
Private religious/fraternal organization.


Medical treatment
 Resident has the right to refuse any
or all treatment.
Advance directive
 Resident has right to choose or
refuse to have an advance directive.
 Resident has right to choose personal
representative.
7
Notification Responsibilities, Cont.
Notification Responsibilities, Cont.




8
Written notice of
services and their
charges.
Copy of all his/her bills.
Any room or roommate
change, or decision to
transfer or discharge.
Recent survey within
last 5 years and the
last plan of correction.




Physician information
The PASRR
Termination of Medicare benefit
Medicaid Rights:



Determination of eligibility.
Receive information on how to apply for
coverage.
Right to appeal decisions.
9
Notification Responsibilities,
Process



Immediate Notification
How?


Orally and in writing and signed by
resident/responsible party.
In a language the resident understands
(e.g. sign language).


When?

10
Accident results in injury.
Significant change in physical, mental,
or social status occurs.
There is a need to significantly alter
treatment/ care plan.
Upon admission, change of regulations or
resident request.
11
12
139
07 Resident Rights
Case 2
Re-admission, Transfer and Discharge
Rights
Readmission



Resident still requires
nursing care.
Appropriate bed is
available.
If hospital stay is >3
over nights and
resident qualifies for
Medicare, resident
must use Medicare
benefit.
13
Involuntary
Discharge or Transfer
Transfer and Discharge
Medical
Reason
NF Loses
Medicaid

Danger

Involuntary
Move
NF Closes
14

Bills not paid
Advance notice of room or roommate
changes.
Refuse transfer if for Medicare
reimbursement.
Discharge self at any time unless a
guardian has been appointed.
NF No Longer
Required
15
16
17
18
Complaints




May complain/appeal
decision of transfer or
discharge.
Without fear of retaliation,
harassment, or eviction.
NF’s complaint procedure.
May complain to anyone.
140
07 Resident Rights
Complaints

The Care Plan
All names, addresses, and phone
numbers of pertinent state client
advocacy groups should be posted:




Resident participation


State survey and certification agency
State licensure office
State ombudsman program
Medicaid fraud and control unit
Language the resident understands.
Right to access the care plan and other
records.
Notification


Information in advance about proposed care
or changes to care.
Immediate notification of change.
19

The Care Plan
Privacy Rights
Servicing residents so that they reach and
maintain the highest practicable.





20
Physical
Mental
Social well-being




Preventing decline when possible.

A private room only if medically
necessary
Medical treatment
Written communications
Phone conversations
Visitation
Mail
21
Civil and Constitutional Rights




22
Representation
Right to vote.
Right to make informed
decisions before
consent.
Freedom from
discrimination.
Right to meet privately
to discuss issues.

23
Right to Identify Representative to Act
on One’s Behalf
24
141
07 Resident Rights
Case 3
Person Centered Care
Right to Work Regulations
Right to refuse to work.
Must be permitted by Care Plan.
Paid or voluntary.



26
25
Person-Directed Care


Person-Directed Care
9th function
6 associated tasks





CQI to ensure quality of care in persondirected care initiatives.
Encourage active participation of residents in
their plan of care.
Development of policies and procedures that
ensure that residents are provided with
choice.

Collaborates with IDT, family and allied
services to ensure person-directed care.
Educates medical professionals on
individualized care.
Collaborates with nursing home
leadership to create an empowered
person-directed care environment.
27
28
Quality of Life
Resident Rights include…
Person-Directed Care

F 241 Dignity
“No signs posted that include confidential or
personal information.”

Self-determination
F 242 Self-Determination and Participation

Dignity

Participation in activities

Accommodation of needs



“Residents must have choices over their daily
routine including –”




Waking/Sleeping
Bathing
Eating
Association
29
30
142
07 Resident Rights
Quality of Life
Resident Rights include …




Quality of Medical Care
Visiting hours
Personal
possessions
Clean and
“homelike living
space.”
Access to stamps
and writing
materials.

Physician Services (F385-F390)
 Right to choose physician.
 Right to know credentials of physician.
 Right to change physicians.
 Right to expect standard of care.
31
32
Quality of Medical Care:
Medications
Quality of Medical Care

Physician Services (F385-F390)
 To be seen q 30 days for 1st 3
months, then q 60 days, and as
medical needs dictate.
 Physician responsible for initial
comprehensive visit.

Right to self-administer medications.
 May not apply to residents of private
nursing facilities.
33
34
Quality of Medical Care:
Unnecessary Drugs (F329)




Right to Refuse Treatment
Excess doses.
Excessive periods of time.
Without adequate monitoring.
Producing adverse effects that indicate
the drug needs.


Reduced
Stopped



35
Resident has right to refuse, by
informed consent, if there is
decision-making capacity.
If refusal prevents proper care
according to professional standards,
discharge may occur after
appropriate notice.
Right to refuse to take part in any
clinical research procedures,
without jeopardizing resident’s care
or stay in the facility.
36
143
07 Resident Rights
Case 4:
Bill & Effie
Rights of Elders

Constitutional guarantees:




Constitutional rights are not changed
because of a change of living situation.

Resident Rights vs. Facility Responsibilities
Involving Sexual Behavior
Three components required for consent:
 Comprehension
 Consequences
 Choice
 Communicate
 Consistent
Facility/community responsibility:



To protect vulnerable elders from harm.
To prevent abuse or assault.
To monitor elders in declining health,
especially those with cognitive impairment.
Suggested Clinical Queries

Patient’s awareness of the relationship:



Is the patient aware of who is initiating
sexual contact?
Does the patient believe that the other
person is a spouse and, thus, acquiesces
out of a delusional belief,?
Can the patient state what level of sexual
intimacy [he/she] would be comfortable with?
Limits: Diminished mental capacity and
cannot consent.
Most Widely Accepted
Criteria for Consent
Conflict

Freedom of expression
Freedom of association
Pursuit of happiness
Suggested Clinical Queries

Patient’s ability to avoid exploitation:
 Is the behavior consistent with formerly held
beliefs/values?
 Does the patient have the capacity to say no?

Patient’s awareness of potential risks:
 Does the patient realize that relationship may
be time limited?
 Can the patient describe how [he/she] will
react when the relationship ends?”
Lichtenberg, Strzepek. The Gerontologist 1990; 30:117-20.
144
07 Resident Rights
Case 5
Abuse & Neglect
Abuse and Neglect




Neglect
Mental, physical,
sexual, and verbal
abuse
Punishment
Misuse of property
43
Barriers to Reporting Abuse:
Attending Physician





Abuse and Neglect:
Medical Director’s Responsibilities
Concerns about alienating.

44

Family
Facility personnel

Easy to ignore/dismiss.
Lack of knowledge of how to report.
Difficult to identify abuse.


Implement strategies to identify and
monitor abusive individuals.
Acknowledge responsibility of the facility
to report an incident.
Maintain a high level of sensitivity.
Aggressively investigate any suspected
abuse or neglect.
45
Restraints



Restraints
Must be in writing and for medical
symptoms.
May not be used for discipline or staff
convenience.
In emergency, nurse may apply
restraints temporarily to protect resident
or others.


Documented
Physician informed promptly
46

47
What is a restraint?

Physical

Chemical
48
145
07 Resident Rights
Barriers to Resident Rights
Observation

Barriers to Resident Rights
Observation
Residents
 Lack awareness of rights violation.
 Unable to exert control.
 Fear assertiveness.
 Disease processes.
 Tolerate rights violation.

Staff
 Lack of training and supervision.
 Cultural differences.

Facility
 Staff training and supervision.
 Physical plant.
 Toleration of rights violation.
49
Common Situations Where
Resident Rights are Relevant
Most Common Violations



50
Confidentiality: 483.10(e)
Privacy: 483.10(e)
Independence: 483.15




Conflicts between individual and facility.
Advance directives and refusal of
medical care.
Conflicting rights.
Balance between protection and risk
situations.
51
How Facilities Can Promote
Resident Rights



52
Promotion of Resident Rights
Knowledge of resident rights.
Advocacy for residents.
Promote resident rights to the staff.




Aging Simulation
Speaker series to residents, families, staff
Posters
Resident Rights Bingo (Available from Colorado
State Ombudsman Program (303) 722-0300 )




53
Awards
Staff fantasy exercise
Staff questionnaire
Vignettes for staff
54
146
07 Resident Rights
Attending Physician’s Tasks





Attending Physician’s Tasks
Providing the best possible care.
Monitoring drug regimens.
Eliminating restraints.
Ensuring privacy.
Resident advocacy.





Ethical decision making.
Decision making capacity.
Advance directives.
Resident’s right to refuse treatment.
Communication
56
55
Medical Director’s Tasks
Medical Director’s Tasks

Overseeing





Ensuring

Quality of care
Quality of life
Quality improvement
Policies




Evaluation of decision
making capacity.
Determination of substitute
decision makers.
Access to quality care.
Advance directives.
Ethical decision making.
57
58
Medical Director’s Tasks

Conclusion
Advocating for resident rights.







Ability of resident to voice concerns.
Privacy
Right to refuse treatment.
Choice
Respect
Dignity



59
OBRA ’87 changed nursing home expectations by
emphasizing determining and meeting the needs of
nursing home residents.
The Federal Resident Bill of Rights created by OBRA
’87 was aimed at improving residents quality of life.
There are many barriers that interfere with residents
rights in the nursing home.
As attending physicians and medical directors we can
help facilities ensure that residents rights are honored.
60
147
08a Financial Issues
Learning Objectives

08a Financial Issues
Long Term Care Financing Medical Directors Tasks in
Organizational Budgeting Physician Billing, Coding, and
Documentation


Core Curriculum on
Medical Direction

2
1
Financial Issues

Explain the differences between the sources of
long term care funding.
Communicate effectively with the administrator
concerning the expense and revenue aspects of
the facility budget.
Define the nature of the Medical Director’s
functions and tasks relative to financial issues in
long term care facilities.
Identify issues related to documentation, coding,
and physician reimbursement in long term care.
Financial Overview and Long
Term Care Funding
Three main components to this module.
1. Financial Overview and Long Term Care Funding
 National Funding Data
 Nursing Home Payment Systems
 Accountable Care Organizations
The Big Picture
2. Basic Accounting, the Nursing Home Budget, and the
Medical Directors Tasks in Organizational Budgeting.
3. Physician Documentation, Coding and Billing in Long
Term Care.
4
3
Distribution of Personal Health Care Expenditures
by Source of Payment, 1999 and 2009
1999
Public 42.6% Private 57.4%
2009
Public 47.4% Private 52.6%
Projected National Health Expenditures in the
United States, by Source of Payment, 2010
Private Health
Insurance
Other Private
Spending
Medicare
Out-of-Pocket
Payments
$1.1 Trillion
$2.1 Trillion
Notes: Personal health care expenditures are spending for health care services, excluding administration and net cost of insurance, public health activity, research,
and structures and equipment. Out-of-pocket health insurance premiums paid by individuals are not included in Consumer Out-of-Pocket; they are counted as part
of Private Health Insurance. Medicaid spending for the State Children's Health Insurance Program (which began in 1998) is included in Other Government
Programs, not in Medicaid.
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics
Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2009;
file nhe2009.zip).
Other Public
Spending
Medicaid and
CHIP1
Total National Health Expenditures, 2010 = $2.6 Trillion
NOTES: 1Includes Children’s Health Insurance Program (CHIP) and Children’s Health Insurance Program expansion (Title XIX). Percentages do not sum to 100% due
to rounding.
SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, Updated National Health Expenditure Projections 2009-2019, January 2011.
148
08a Financial Issues
Medicare Spending as a % of Total
Federal Spending, Fiscal Year 2010
Medicare Enrollment, 1966-2010
Nonelderly Disabled (Under Age 65)
Elderly (Age 65 and Older)
Number in millions:
37.6
28.5
25.0
4.4
5.4
7.3
7.0
6.7
45.4 46.1 47.0
7.5
20%
8.0
7.6
20%
3.3
15%
2.9
3.0
2.2
19.1 20.5
19.1
34.2
31.1
39.6
44.0
42.5 43.3
22.8
20.5
25.5
31.0
28.2
33.2
34.3
35.8
37.0
36.3
37.9
38.5
19%
39.0
8%
6%
Total Federal Spending, FY2010 = $3.5 Trillion
1966 1970 1975 1980 1985 1990 1995 2000 2005 2006 2007 2008 2009 2010
NOTES: Numbers may not sum to total due to rounding. People with disabilities under age 65 were not eligible for Medicare prior to 1972.
SOURCE: Centers for Medicare & Medicaid Services, Medicare Enrollment: Hospital Insurance and/or Supplemental Medical Insurance Programs for Total,
Fee-for-Service and Managed Care Enrollees as of July 1, 2008: Selected Calendar Years 1966-2008; 2009-2010, HHS Budget in Brief, FY2011.
NOTES: FY is fiscal year. 1Amount for Medicare includes offsetting premium receipts. 2Other category includes disaster costs and negative outlays for
Troubled Asset Relief Program.
SOURCE: Office of Management and Budget, FY2011 Budget, Summary Tables; February 2010.
Medicare Benefit Payments, by Type of
Service, 2010 and 2020
Part A
Parts A and B
Outpatient
Prescription
Drugs
Hospital
Inpatient
Services
11%
Hospital
Outpatient
6%
Services
Part B
Medicare’s Share of National Personal Health
Expenditures, by Type of Service, 2010
Part D
Outpatient
Prescription
Drugs
19%
27%
27%
8%
Physician 13%
Payments
6%
5% Skilled
Other
Services
12%
Nursing
Facilities
10%
4%
23%
Home
Health
12%
11%
Medicare
Advantage
(Part C)
Medicare Benefit Payments
2010 = $509 Billion
12%
5%
Medicare Benefit Payments
2020 = $914 Billion
NOTES: Totals do not include administrative expenses and are net of recoveries. Other Services include hospice services; durable medical equipment;
ambulance services; independent, physician in-office, and hospital outpatient department laboratory services; hospital outpatient services that are not paid for
using the prospective payment system (PPS); Part B prescription drugs; rural health clinic services; outpatient dialysis; and benefit payments not allocated to
specific services, including adjustments to reflect year-to-date spending (2010), and savings from the Independent Payment Advisory Board (2020).
SOURCE: Congressional Budget Office, Medicare Baseline, August 2010.
Estimated Sources of Medicare Revenue, 2010
Expenditures in Billions
Medicare
Total
$489
$31
$235
$62
$105
$29
$2,142
$77
$789
$260
$536
$149
NOTES: Total also includes dental care, durable medical equipment, other professional services, and other personal health care/products.
SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Expenditure Projections 2009-2019, February 2010.
Medicare
Funding of Benefits
Mandatory Enrollment
Optional
25%
25%
2.9% divided
between workers
and employers
TOTAL
$499 billion
PART A
$218 billion
PART B
$219 billion
PART D
$63 billion
SOURCE: 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
12
149
08a Financial Issues
Historical and Projected Number of Medicare
Beneficiaries and Number of Workers Per Beneficiary
Number of Beneficiaries (in millions)
Components of Average Health Care
Spending by Medicare Households, 2009
Share of Total Spending
Number of Workers Per Beneficiary
9.8%
($3,038)
Other
Household
Spending
85.1%
Health
Care
14.9%
2.6%
($804)
Medical Services (17.4%)
2.1%
($654)
Prescription Drugs
(14.2%)
0.4% ($125)
Average Total Spending = $30,966
Health Insurance
(65.7% of Health Care
Spending)
Medical Supplies (2.7%)
Average Health Care Spending = $4,620
SOURCE: 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
NOTES: Numbers may not sum to total due to rounding.
SOURCE: Kaiser Family Foundation analysis of the Bureau of Labor Statistics Consumer Expenditure Survey Interview and Expense Files, 2009.
Characteristics of the Medicare Population
Projected Medicare Outlays, 2010-2020
Percent of total Medicare population:
Total Outlays in billions:*
Income <200% FPL
($21,660 in 2010)
3+ Chronic Conditions
Cognitive/Mental
Impairment
Fair/Poor Health
Under-65 Disabled
2+ ADL Limitations
Age 85+
Long-term Care Facility
Resident
NOTE: ADL is activity of daily living.
SOURCE: Income data for 2009 from U.S. Census Bureau, Current Population Survey, 2009 Annual Social and Economic Supplement. All other
data from Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2008 Access to Care file.
NOTE: Outlays have been rounded to the nearest whole number and exclude offsetting receipts
SOURCE: Kaiser Family Foundation based on data from Congressional Budget Office, August 2010.
Net Effect of Major Legislation on Medicare Spending
Net Spending/Savings as a Share of Projected Medicare Spending Over 10 Years
(1999)
(2000)
(2003)
DRA
MIPPA
(2005)
(2008)
-$394
$25
$82
$391
-$23
-$2
-$424
$3.4
$3.2
$3.2
$3.9
$5.6
$6.8
$7.1
BBA
10-yr Medicare
spending/savings
(in $ billions):
BBRA
BIPA
MMA
Net
savings
(in $ trillions):
Overall Medicare spending grew from $3.3 billion in 1967
to nearly $414 Billion in 2009.
(2010)
Net
spending
10-yr Medicare
baseline amounts
Medicare Spending
PPACA
Dollars in Billions
(1997)
Source: Kaiser Family Foundation analysis of Congressional Budget Office (CBO) estimates.
Notes: Shares are rounded to the nearest whole number. Net spending as a percent of baseline for MIPPA is rounded up from -0.02%; estimate for DRA is
rounded from -0.47%. Baseline amounts are based on CBO projections of 10-year Medicare baseline spending prior to enactment of legislation.
Note: Overall spending includes benefit dollars, administrative costs, and program integrity costs. Represents
Federal spending only.
Source: CMS, Office of the Actuary.
18
150
08a Financial Issues
Growth in Medicare Skilled Nursing Facility
Program Payments
PAYMENT IN MILLIONS
After rising rapidly during the 1990s, payments to skilled nursing
facilities fell for the first time in 1999, then continued their rise.
Implementation of
Medicare Catastrophic
Coverage Act of 1988
Medicaid Financials
Transition
To SNF PPS
MCCA Repealed
$9,617
$11,199
CALENDAR YEAR
20
19
Medicaid Has Many Vital Roles In Our
Health Care System
Assistance to
Medicare
Beneficiaries
Health Insurance
Coverage
29 million children & 15 million
adults in low-income families; 15
million elderly and persons with
disabilities
Long-Term Care
Assistance
8.9 million aged and disabled —
21% of Medicare beneficiaries
Medicaid in the Health System, 2009
Medicaid as a share of national
health care spending:
1 million nursing home
residents; 2.8 million
community-based residents
MEDICAID
Support for Health Care
System and Safety-net
State Capacity for Health
Coverage
16% of national health spending;
40% of long-term care services
Federal share can range from 50 - 83%;
For FFY 2012, ranges from 50 - 74.2%
Total
National
Spending
(billions)
$2,330
$759
$675
$137
$250
Note: Does not include spending on CHIP.
SOURCE: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health
Statistics Group, National Health Expenditure Accounts, January 2011.
SOURCE: Kaiser Commission on Medicaid and the Uninsured, 2011.
Growth in Medicaid Long-Term Care
Services Expenditures, FFY 1990-2009
Projected Spending on Health Care as a
Percentage of Gross Domestic Product
25%
Institutional Care
Home and Community-Based Services
20%
In Billions
$92
$75
$54
$32
13%
87%
1990
32%
$100
37%
41%
42%
70%
68%
63%
59%
58%
19.3%
$122
15%
43%
30%
20%
80%
$109
$115
10%
Total National
Health Spending
5%
Medicare Spending
57%
3.4%
Medicaid Spending
0%
2009
7.6%
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
$3,025
$3,225
$3,442
$3,684
$3,936
$4,204
$4,483
Total NHE:
(in billions)
1995
2000
2002
2004
2006
2008
2009
Note: Home and community-based care includes home health, personal care services and home and community-based service waivers.
Institutional care includes intermediate care facilities for the mentally retarded, nursing facilities, and mental health facilities.
SOURCE: KCMU and Urban Institute analysis of HCFA/CMS-64 data.
$2,472
$2,570
$2,703
$2,850
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at
http://www.cms.hhs.gov/NationalHealthExpendData/03_NationalHealthAccountsProjected.asp#TopOfPage (see
Projected; NHE Historical and projections, 1965-2019, file nhe65-19.zip).
151
08a Financial Issues
Since The Start Of The Recession More
Than 7 Million More Enrolled in Medicaid
Medicaid-To-Medicare Provider Fee Ratios
for All Services
NH
VT
WA
MT
Monthly Enrollment in Millions
44.8
43.6
42.7
42.3
MN
OR
WI
RI
MI
WY
NE
NV
UT
CO
MO
OK
AZ
NM
OH
IN
ILIL
KS
CT
NJ
PA
IA
CA
MA
NY
SD
ID
50.3
48.7
46.9
ME
ND
WV
AL
DC
SC
AR
MS
MD
NC
TN
TX
DE
VA
KY
GA
LA
AK
FL
HI
Jun-07
Dec-07
Jun-08
Dec-08
Jun-09
Dec-09
Jun-10
U.S. Average = 72% of Medicare fees
NOTE: Tennessee does not have a fee-for-service component in its Medicaid program
SOURCE: S. Zuckerman, AF Williams, and KE Stockley, “Trends in Medicaid Physician
Fees, 2003-2008,” Health Affairs, 28 April 2009.
SOURCE: Analysis for KCMU by Health Management Associates, using compiled state Medicaid enrollment reports
Statutory Federal Medical Assistance
Percentages (FMAP), FY 2012
WA
VT
MT
MN
SD
ID
NV
WI
WY
UT
CO
CA
AZ
NM
PA
IL
KS
OK
TX
MO
IN
WV
KY
MS
AL
VA
CT
NJ
DE
MD
28.7%
ARRA Enhanced FMAP
(2009-2011)
12.9%
12.7%
DC
10.4%
9.9%
8.7%
8.4%
SC
8.5%
5.5%
GA
FL
10.8%
10.1%
7.7%
7.6%
6.4%
4.9%
3.0% 3.8%
1.3%
5.8%5.7%
4.0%
50 percent (15 states)
51 – 59 percent (11 states)
60 – 66 percent (13 states)
67 – 74 percent (12 states including DC)
6.6%
7.3%
2.2%
Enhanced FMAP /
Federal Fiscal Relief
(2003-2005)
AK
HI
State
RI
NC
TN
AR
LA
OH
Total
NH
MA
NY
MI
IA
NE
Total and State Medicaid Spending Growth
FY 2000 – FY 2012
ME
ND
OR
< 70% (11 states including DC)
70-84% (7 states)
85-99% (21 states)
100%+ (11 states)
-4.9%
-10.9%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Adopted
NOTE: State Fiscal Years.
NOTE: Rates are rounded to nearest percent. These rates will be in effect Oct. 1, 2011 – Sept. 30, 2012.
SOURCE: Federal Register,, Nov, 10, 2010 (Vol. 75, No. 217), pp. 69082-69083.
http://edocket.access.gpo.gov/2010/pdf/2010-28319.pdf
SOURCE: Historic Medicaid Growth Rates, KCMU Analysis of CMS Form 64 Data; FY 2008, 2009 and
2010, KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management
Associates, 2011 .
Growth in Medicaid Expenditures
and Enrollment
Estimated Medicaid Enrollment in 2021
Under the House Budget Plan
Enrollment in Millions
ACA Repeal: -17M
Total Cut: 36M
Block Grant: -19M
75.9 M
(48% Enrollment
Cut)
39.5 M
Current Law, Including ACA
29
House Budget Plan*
*Assumes current enrollee spending growth and a reduction across all eligibility groups. Please see full report at http://www.kff.org/medicaid/8185.cfm.
Source: Urban Institute estimates prepared for the Kaiser Commission on Medicaid and the Uninsured, May 2011.
152
08a Financial Issues
Distribution of National Prescription Drug
Expenditures by Source of Payment, 1999-2009
Medicaid Expenditures by Service, 2009
Home Health and
Personal Care
14.4%
Private Insurance
DSH Payments
Inpatient
4.8%
13.9%
Physician/ Lab/ X-ray
3.7%
Mental Health
1.2%
Public Funds
Long-Term
Care
33.3%
Outpatient/Clinic
7.1%
ICF/MR
3.8%
Drugs
4.3%
Nursing
Facilities
13.9%
Consumer Out-ofPocket Payments
Payments to Medicare
3.3%
Acute
Care
61.9%
Other Acute
8.2%
Payments to MCOs
21.4%
Total = $366.5 billion
Notes: Percentages may not total 100% due to rounding.
NOTE: Total may not add to 100% due to rounding. Excludes administrative spending, adjustments
and payments to the territories.
SOURCE: Urban Institute estimates based on data from CMS (Form 64), prepared for the Kaiser
Commission on Medicaid and the Uninsured.
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary,
National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by
type of service and source of funds, CY 1960-2009; file nhe2009.zip).
Nursing Homes Total Funding CY 2009
Medicaid remains the largest single payer of nursing home care.
Other Public Funds, 3%
Out-of-pocket, 27%
Medicaid, 42%
Private Health
Ins, 7%
Medicare, 18%
Private
Funding
37%
Other Private Funds,
3%
Average Hospital, SNF, Hospice and
Home Health Medicare Charges
(FY 2006)

Hospital charges/day
$5,036

SNF charges/day
$535

Hospice charges/day
$144

Home health charges/visit
$137
Annual Statistical Supplement, to the Social Security Bulletin, October 2008
Source: AAHSA, Health Advocacy Department
33
34
Long Term Care Funding
Nursing Home Payment Systems
Medicaid
Historical Perspective
1960’s
 Federal law silent on how to set rates.
Medicaid, Medicare, and Prospective
Payment System

There was no information available on
costs to the nature of the “industry.”

Very low unrealistic flat per diem rates
set.
“How Did We Get To This Place?”
35
36
153
08a Financial Issues
Medicaid
Boren Amendment
Historical Perspective
1981
1972



Congress required payments to be related
to costs.
To meet legislative mandate and lack of
data, - States Used Medicare Rates.
“Reasonable and Adequate”
Payments to facilities for efficiently and
economically operated facilities included
costs of complying with OBRA.
1980

Required states to make
“Medicare cost based payments are
inherently inflationary.”

Development of the “cost plus” system.
37
38
Boren Amendment

BBA 97 Repealed Boren
Tremendous Litigation from Providers
Against States
1990
 Supreme court gave nursing homes the
right to challenge state rates on:
 Substantive Issues
 Procedural Matters

Replaced with existing “equal access” provision.

Requires state Medicaid payment to be
“consistent with efficient, economic, and
quality care to enlist enough providers to
have appropriate care available.”

Less precise wording on quality - No OBRA.

Changed procedures and providers rights.
39
Balanced Budget Act 1997
Medicare
Influence on Medicare and Medicaid

40
Savings over 5 years:
Medicare
SNF
$115 B
$ 9.2B
Medicaid
$ 16B
Evolution
Past to Present
41
42
154
08a Financial Issues
Benefits
Benefits
Part A - Coverage

Part B - Coverage

Inpatient Hospital
 Postacute Care in Nursing Home
Physician Services
 Outpatient


In-Pt 3 Days Within 30 Days of Admission
Days 1 to 20 - No Deductible or Co-pay
 Days 21 to 100 - Co-pay
 Days > 100 - No Coverage

Diagnostics
PT, OT, Speech
 Audiology
 Some Ambulance
 Some Home Health




Hospice
43
2012 Medicare


Monthly Premium
Hospital inpatient




Days 1-60
Days 61-90
$1,156.00 deductible
$289.00/day deductible
First 20 days
Days 21-100

Retrospective- “Cost Plus”

Routine cost limits for overhead.
no charge
$144.50/ day deductible

Part B



$451
NH


Medicare in NH:
Old System Pre PPS
Part A

44

Deductible
Monthly premium
$140.00
$110.50

Nursing
Room and Board
No limits on ancillary services.
Part D

Monthly Premium
$ 30.00 (Approximate Basic)
45
46
Medicare in NH:
Old System Pre PPS - Costs

Changes to NH Industry
Retrospective- “cost plus”

Routine



Hospital Prospective Payment System
(DRG) 1983

Major change in financing mechanism.

Introduced the concept of capitated
rates on a large scale to the health care
system.
- Paid in Full
Therapy, Drugs, Lab
Capital

- Cost Limits
Room, board, nursing, minor medical supplies,
medical and psychologic social services
Ancillary


- Paid in Full
Land, Building, Equipment, Interest
47
48
155
08a Financial Issues
Prospective Payment System for
Nursing Homes
PPS
Recent Evolution of PPS

OBRA 93 – Provision in Conference Report for
HCFA to develop PPS by 10/1/95.

FY96 – Republican Conference Bill- Vetoed by
President Clinton, had provision for SNF PPS
with bipartisan support.

BBA 97 - Balanced Budget Act
“BUBBA 97”
49
Medicare SNF
Changes with BBA 97

50
Prospective Payment System
(PPS)
Prospective Payment System (PPS)
Two important features:
 Consolidated Billing
 Case Mix

Per Diem:
Not Episodic

Resource Based:
Not By Diagnosis
51
Federal Rate Calculation

52
Consolidated Billing
Based on FY 1995 Costs
(implemented 1997)
Basics, Promises, and Problems
a. Hospital and freestanding facilities
b. Gradual reduction to one rate locally
phased in over a 4 year period.

Adjustments
a. Urban/rural
b. Geographic – wage index
c. Case-Mix from MDS / RUGS III
53
54
156
08a Financial Issues
Basics
Consolidated Billing
Excluded Services


Skilled nursing facilities must submit all
Medicare claims for all of the services
that its residents receive.





Excluded services



Physician Services
PA / NP
Qualified Psychologists
Nurse Anesthetists
Home Dialysis Supplies
Erythropoeitin for Dialysis
Hospice
Ambulance Trip to SNF for Initial Admission
55
56
SNF Responsibility to Bill
Ends When:





Consolidated Billing
Promises
Admission to the hospital.
Admission to another SNF.
Receives services from home health.
Outpatient services from Medicare that
that are not pursuant to plan of care.
Discharged

Provides an essential foundation for
PPS by bundling into a single facility
rate virtually all of the services that the
PPS payment is intended to capture.

Eliminates potential for duplicative
billing.
57
Consolidated Billing
Promises

Spares beneficiaries from incurring
out-of-pocket expenses.

Requires and enhances SNF’S
capacity to meet responsibility to
oversee and coordinate care.
58
Significance of Consolidated
Billing to Facility
59

SNF is no longer able to unbundle
services to outside suppliers.

Increased accounting costs.

Increase in responsibility of facility to
control costs.
 Therapy
 Supplies
60
157
08a Financial Issues
Consolidated Billing
Problems
Prior System Versus PPS

Prior System
 Retrospective
Cost Reimbursement


New System
P.P.S.




Ancillaries- not
capitated
Incentive to shift costs
to ancillary areas.
More ancillary costmore shift.




Grossly under- funded long term care.

Rate based on RUGs.
Ancillaries capitated
Incentive to reduce
costs and streamline.
Less ancillary costmore profit.

Average 18% cut in funding.
Profit margins were no where near this
level leading to wide spread bankruptcies
in the industry.


CMS response - “bad management”
Congressional response FY 2000 (too
late) - more money.
61
62
Case Mix Adjustments


Hospice Financing
Resource Utilization Groups (RUGs)
Version III (RUGsIII)

44 (53) Group Classification
 Adjusts for resources used.
 Based on staff time measures.

Classified from MDS
Each group has different payment.
63
Home Health Prospective
Payment

Medicare “capped” hospice payment per patient
to approximately $23,000 in 2009.

A 2008 report by National Hospice and Palliative
Care Organization showed that 84.3% of hospice
care was paid for by Medicare.

Hospice reduced Medicare costs by an average
of $2,309 per hospice patient in 2008.

In fiscal year 2008 - 09, 2% of hospice funding
came from charitable contributions..
64
Long Term Care Continuum
Home Health Care: Payer Mix FY 2006
Medicaid-Federal
only 19%
Medicare 37%
Other Public
3%
Out-of-pocket
10%
* State/Local
Governments
19.9 %
Private Insurance 12%
Source: CMS, Office of the Actuary, National Health Statistics Group
65
Includes Home Health Care and Hospice
*State/local government funding includes Medicaid matching funds
66
158
08a Financial Issues
Home Health Care before and after
PPS Implementation in October ‘02
Home Health Care before and after
PPS Implementation in October ‘02
1997 2000 2008
Home Health Payments (billions) $17.7 $8.5 $16.9
Users (millions)
3.6
2.5
3.2
Number of Visits (millions)
258.2 90.6 177.8

Average home health outlays

Average payment/client


Visit Type (percent of total)
Skilled Nursing
Home Health Aid
Therapy
Social Services

41
48
10
1
49
31
19
1
55
18
26
1

$2,914 (1999)
$3,803 (2002)
$5,337 (2008)
Average number of visits



97/client (1999)
37/client (2002)
38/client (2008)
67
Home Health Funding
PPS began October 2002
68
The Impact of Prospective Payment
Home Health

80 different payment levels.

Varies by geographic area and county.

Case-mix weighted reimbursement.

Modeled after the PPS for skilled
nursing.
69
Boling, PA. Using Home Care to Improve Outcomes and Lower Costs. Clinical Geriatrics:12;30-35, 2004
70
Basis Accounting and the Medical
Directors Tasks in Organizational
Budgeting
As It Applies To The Nursing Home and
Other Long Term Care Organizations
8.1 – 8.2
71
72
159
08a Financial Issues
Basic Accounting
Objectives
Basic Accounting
Concepts

To understand basic accounting concepts.


To be familiar with budgeting and the medical
director’s tasks in the budgeting process.
Revenue versus expense
Asset versus liability
Net worth
Balance sheet
Income statement
Budget




To be able to delineate the sources of revenue
and the major expense items in long term care.



To understand cost accounting and the role of
cost containment.
73
74
Budgeting

Budgeting
Revenue

Purpose - An attempt to predict
revenue and expense for a specific
period of time (usually one year).



Need to consider:



Expense

Current financial status (balance sheet)
Current financial performance (budget,
income statement, and variances)
Goals of organization (profit vs. service)


75
Basic Accounting




Operational (supplies, insurance, payroll,
food, utilities, etc.)
Capital (depreciable items, such as
machines, buildings, expensive computer
76
hard/software)
Basic Accounting
Asset - What you have that is to your
financial benefit.

Patient care (third party, private pay, long
term care insurance)
Investment

Property
Cash, securities
Accounts receivable
Net Worth - The equity you have
in the business.
Net Worth = Assets - Liabilities
Liability - What you have that is to your
financial detriment.



Mortgage
Accounts payable
Depreciation
77
78
160
08a Financial Issues
Basic Accounting
Basic Accounting

Income Statement - Measures the financial
performance of the organization at a point in time,
measuring assets, liabilities, and net worth.

Budget - A prediction of future financial
performance; it essentially predicts a future
income statement.


Capital Expense - One above an arbitrary
defined cost, usually is non recurring and can be
depreciated over a defined time period.
 Examples:

Budget Variances - How the actual income
statement compares with the budgeted
(predicted) one; variances may be favorable or
unfavorable.
79


Cash Versus Accrual

Cost - Accounting
Accounting Methods

Cash - Exact amounts in and out.

Accrual - Takes into consideration:
 “Accounts Receivable” (AR)
 “Accounts Payable” (AP)
 More accurate picture of status.
A new rehabilitation section to the nursing home
qualifies (non recurring, high cost, eligible for
depreciation).
A new employee does not count (recurring
expense).
A new coffee pot does not count (cost threshold
not met).
80

Defining the cost of providing a given product
or service (material, time, admin).
 An hour of nursing care.
 Continence care
 Providing ADA vs. “no concentrated sweets”
diabetic diets.

Critical information for surviving in capitated or
prospective payment system as opposed to
cost-plus reimbursements.
81
82
Cost Containment
Cost Containment

“Reduce overhead”

Reducing expense to:

Advantages




Increase profit (or excess of revenue over
expense)
Decrease loss (or excess of expense over
revenue)
Unless system is poorly managed and full
of “fat”, may lead to reduced quantity and
quality of care.
83


Trim waste.
Increase revenue for profit or services.
Disadvantages



Interfere with/reduce quality of care.
Alienate staff by increasing workload.
Alienate medical staff by care issues or by
making milieu less “user-friendly.”
84
161
08a Financial Issues
Dashboard for
Revenues/Operations
Resident Revenue Minus Resident
Expense Divided by Resident Revenue
85
Total Operating Expenses Divided
by Total Operating Revenues
86
Cash on Hand Required by
Bond Covenant
87
Ability to Pay the Annual Debt Service
89
88
Occupancy History of a CCRC
90
162
08a Financial Issues
History of Staffing Patterns
Budgeting

Steps for Medical Director for medical staff
budget:




Prepare medical staff objectives and goals.
Consider prior years’ revenue and expense.
Consider coming year’s revenue and expense.
Justify budget requests.


Focus on new items/programs/services.
If budgeted expense is in excess of budgeted
revenue, indicate how the shortfall will be made up.
91
92
Budget
Medical Director’s Tasks

Departmental budget

Provide input on medical care issues.



New treatments such as skin/wound care.
Human resource needs.
CQI data
8.3 – 8.6
93
Accountable Care Organizations
94
Challenges With Our Present
System of Care
1. Lack of integration of our health care system.
2. System of reimbursement is based upon
productivity.
3. Quality of care, cost of care, and patient
satisfaction plays a minor role in providers’
salaries.
4. Increase cost of care for our dually eligible
residents (Medicare and Medicaid).
ACO
95
96
163
08a Financial Issues
Why is There Such a Variation in
Cost of Care in Our Country?
Review the article, “The Cost
Conundrum” written by Dr. Atul
Gawande and published in the New
Republic in June of 2009.

How Will Quality of Future Health
Care be Measured?



Successfully meeting the preestablished Quality Measures.
Delivering cost effective care.
Demonstrating good patient satisfaction
of their care.
97
98
Potential Financial Benefits of an
ACO
Key Components of an ACO






Participate in a legal structure.
Accurate reporting of Quality Measures.
Requires a three year contract.
Requires a minimum of 5000 patients.
Requires an integrated clinical and
administrative system.
Patient centered care .
99
Examples of Cost Savings in a
AMDA Medical Director’s Nursing
Home



Providers will share with the government
savings depending on the level of risk.
Savings are based on the expected cost of
care in a geographic area verses the actual
costs of care.
The percentage of shared cost savings
depends on the level of risk assumed in the
ACO.
100
Readmission Rates During First
30 Days of Nursing Home Stay
180
160
140
120
100
Evercare
Non-Evercare
80
60
40
20
0
2007
2008
2009
2010
2011
5 year history of admission rates/1000 residents/year
(800 admissions/1000 residents/year is consider the average
throughout the USA)
101
102
164
08a Financial Issues
Preparing to Participate in an
ACO
Preparing to Participate in an
ACO

Establish a team charged with
monitoring regulations and analysis of
the impact on your organization.

Review existing relationships with local
hospitals and request a seat at the ACO
table with the hospital(s).
103
Start collecting and sharing your nursing
home data with hospitals and/or large
physician groups.
1. Admissions and re-admissions to
hospitals.
2. Number of ER visits per 1000 resident
days.
3. Costs for common rehab care such joint
replacements, CHF, strokes, etc.
104
Preparing to Participate in an
ACO
Develop a strategic or enhanced plans to
handle post acute care patients such as:
1. Open or closed staff.
2. Staff rounding daily.
3. Limited number of providers.
4. Regular staff meetings.
5. JACHO approval.
105
165
08b Financial Issues - Coding
Physician Payment Systems
08 Financial Issues

Physician Billing, Coding, and
Documentation


Evaluation and Management
Codes
E/M
Core Curriculum on
Medical Direction
2
1
Historical Perspective

Historical Perspective
1980’s – early 1990’s - Medicare
Payment Policy for LTC



Only one visit paid for q 30 days.

Lower reimbursement if >1 patient seen on
the same trip (but no reimbursement for
travel to facility!)

The net result of these short-sighted policies:



Lower reimbursement in general- average
$15.
Large scale abandonment of LTC patients because of
low reimbursement, “punishment” for seeing more than
one patient, and only allowed to see patient once a
month.
When physician informed of a problem - “send to the
ED.”
No physician visits to the nursing home.
Physicians abandon this practice site from their practice
plans. They still went to the hospital, but not the nursing
home across the street.
3
4
Medicare
8.7 – 8.14
5
6
166
08b Financial Issues - Coding
Medicare Carriers

Local insurance companies that
contract with CMS to do Part B billing
(some also do Part A)

Physician Billing – Part B
Medicare Carriers

National Policy
 Broad guidelines, may be modified by
LMRP (Local Medical Review Policy).
7
8
Medicare Carriers

Medicare Carrier Manual
LMRP – Local Medical Review Policy
 Individualized guidelines specific to
each carrier.
 Generally follow AMA CPT
descriptions.
 Generally follow CMS guidelines.
9
10
Medicare Claims Processing Manual,
Pub.100-04
Goals for Session
Chapter 12 –
Physicians/Nonphysician Practitioners
1. Know what the rules are.
2. Know where the rules come from.

3. Know how to use the rules.
4. So that you can:
30.6 - Evaluation and Management Service
Codes

Get paid for what you do.

30.6.13 - Nursing Facility Services

11
General - Codes 99201 - 99499
Codes 99304 - 99318
12
167
08b Financial Issues - Coding
Medicare Claims Processing Manual, Pub.100-04

SEC. 30.6.1 - Selection of Level of
Evaluation and Management Service

A. Use of CPT Codes
Medicare Claims Processing Manual

Manual
http://new.cms.hhs.gov/manuals/downloads/clm104c12.pdf


CMS Transmittal 808 (January 6, 2006)
http://new.cms.hhs.gov/Transmittals/Downloads/R808CP.pdf


Medlearn Matter Article
http://new.cms.hhs.gov/MedlearnMattersArticles/downloads/M
M4246.pdf

Or go to cms.hhs.gov and look for Regulations and
Guidance, Manuals
13
Medicare Claims Processing Manual, Pub.100-04,

“Medical necessity of a service is the overarching
criterion for payment in addition to the individual
requirements of a CPT code.”
“The volume of documentation should not be the
primary influence upon which a specific level of
service is billed. Documentation should support
the level of service reported.”
14
Medicare Claims Processing Manual, Pub.100-04,

30.6.13 - Nursing Facility Services
A. Visits to Perform the Initial Comprehensive
Assessment and Annual Assessments
B. Visits to Comply With Federal Regulations
(42 CFR 483.40 (c) (1)) in the SNF and NF
C. Visits by Qualified Nonphysician
Practitioners
30.6.13 - Nursing Facility Services
E. Incident to Services
F. Use of the Prolonged Services Codes and
Other Time-Related Services
G. Gang Visits
H. Split/Shared E/M Visit
D. Medically Complex Care
I.
SNF/NF Discharge Day Management
Service
15
16
Medicare Claims Processing Manual, Pub.100-04,

Documentation Guidelines







Do not Underdocument

30.6.13 - Nursing Facility Services
B. Visits to Comply With Federal Regulations (42 CFR 483.40)
Overall status of the patient
Multiple diagnoses
Co-morbidities
Other complicating issues
Family issues
Facility issues


17
“Payment is made under the physician fee schedule by
Medicare Part B for federally mandated visits. Following the
initial visit by the physician, payment shall be made for federally
mandated visits that monitor and evaluate residents at least
once every 30 days for the first 90 days after admission and at
least once every 60 days thereafter.”
“Medicare Part B payment policy does not pay for additional E/M
visits that may be required by State law for a facility admission
or for other additional visits to satisfy facility or other
administrative purposes.”
“E/M visits, prior to and after the initial physician visit, that are
reasonable and medically necessary to meet the medical needs
of the individual patient (unrelated to any State requirement or
administrative purpose) are payable under Medicare Part B.”
18
168
08b Financial Issues - Coding
30.6.13 C
Medicare Claims Processing Manual, Pub.100-04,

Visits by Qualified Nonphysician
Practitioners
30.6.13 - Nursing Facility Services

Medically Necessary Visits
“Medically necessary E/M visits for the diagnosis or
treatment of an illness or injury or to improve the
functioning of a malformed body member are
payable under the physician fee schedule under
Medicare Part B. CPT codes, Subsequent Nursing
Facility Care, per day (99307 - 99310), shall be
reported for these E/M visits even if the visits are
provided prior to the initial visit by the physician.”
State Regulations, State Scope of
Practice

All E/M visits shall be within the State scope of
practice and licensure requirements where the visit
is performed and all the requirements for physician
collaboration and physician supervision shall be met
when performed and reported by qualified NPPs.

General physician supervision and employer billing
requirements shall be met for PA services in
addition to the PA meeting the State scope of
practice and licensure requirements where the E/M
visit is performed.
19

20
30.6.13 C
30.6.13 C
Visits by Qualified Nonphysician
Practitioners
Visits by Qualified Nonphysician
Practitioners
Federally Mandated Visits
 SNF


Federally Mandated Visits
 NF
Following the initial visit by the physician,
the physician may delegate alternate
federally mandated physician visits to a
qualified NPP who meets collaboration and
physician supervision requirements and is
licensed as such by the State and
performing within the scope of practice in
that State.
21

Per the regulations at 42 CFR 483.40 (f), a
qualified NPP, who meets the collaboration and
physician supervision requirements, the State
scope of practice and licensure requirements, and
who is not employed by the NF, may at the option
of the State, perform the initial visit in a NF, and
may perform any other federally mandated
physician visit in a NF in addition to performing
other medically necessary E/M visits.
22
30.6.13 I
SNF/NF Discharge Day Management

Requires a face-to-face visit.

Reported for the date of the actual visit by the
physician or qualified NPP even if the patient is
discharged from the facility on a different calendar
date.

99315-99316

Death

may be reported using CPT code 99315 or 99316,
depending on the code requirement, for a patient
who has expired, but only if the physician or
qualified NPP personally performed the death
pronouncement.
23
Timing of Visits

OBRA - NH Code / Regulation
 Every 30 days for first 90, then at
least every 60 days.

Medicare
 Will only pay for medically necessary
and reasonable visits.
24
169
08b Financial Issues - Coding
Timing of Visits

Timing of Visits
Medicare
Acute care program.
 Does not recognize subacute care.
 Recent inclusions for some preventive
type care.

Medicare - Does not pay for routine or
preventive care unless it is considered
necessary and reasonable.

No definition of medical necessity or
what is considered reasonable.

Influenza
Pneumococcal vaccine
 “Initial / welcome” physical


25
26
Medical Necessity
AMDA Definition

“Evaluation and management services,
diagnostic tests and procedures, treatments,
medical/surgical procedures, equipment or
supplies that in the judgment of the attending
physician….are required to professionally
assess, plan, manage and monitor the health
care of a resident or patient in the facility
within the parameters of generally accepted
principles of medical practice.”
AMDA White Paper, October 1999
8.15 – 8.20
27
28
CPT Codes For Long Term Care
CPT Codes For Long Term Care
Physician Reimbursement


Relative Value System (RVU)

Coding

Documentation Guidelines
Codes, Codes, and More Codes
29
30
170
08b Financial Issues - Coding
CPT 2000-2003
2000
376,448
99301
539,609
99302
893,521
99303
99311 7,018,933
99312 7,766,568
99313 1,926,461
190,232
99315
65,497
99316
Total 18,777,349
Relative Value System

Formula
[(Work RVU x Work adjuster x Work GPCI) +
(Practice Cost RVU x Practice Cost GPCI) +
(Malpractice RVU x Malpractice GPCI)]
x Conversion factor = PAYMENT
2002
2003
318,696
301,285
583,401
577,594
1,056,020
1,162,273
6,405,300
5,971,971
8,766,676
9,305,483
2,567,224
3,021,191
255,388
282,136
104,905
127,402
20,059,612 20,751,338
31
32
Resource Disk
Documentation Guidelines

Multiple Versions, 1995, 1997,
proposed 2001 guidelines that were
withdrawn.

CPT Codes: The Evolution and Current State



Continuing to be revised as we speak.

Common sense
CPT Coding for Hospice in Long Term Care


JAMDA 2001
JAMDA 2004
Psychiatry Billing for Nursing Home Services

JAMDA 2005
33
34
Evaluation and Management
Codes (E/M)

Evaluation and Management
Codes (E/M)
There are seven components to level of care, six
of which are used in defining the level of service:
 History
 Examination
 Medical decision making
 Counseling
 Coordination of care
 Nature of the presenting illness
 Time
35


All evaluation and management codes have
performance and documentation requirements.
Your billing codes should reflect what
evaluation and management was performed
and documented. There are standards for each
code in regard to:




History taking
Examination completeness
Medical decision making
Your notes should reflect the level of care you
have performed.
36
171
08b Financial Issues - Coding
NH CPT Codes – 1999-2006 AMA

Documentation Guidelines


1999 - OLD
Comprehensive

Do not underdocument


Overall status of the patient







Multiple diagnoses
Co-morbidities
Other complicating issues
Family issues
Facility issues




2006 - NEW
Initial









99315
99316
99307
99308
99309
99310
Discharge Services

99315
99316

99318


99304
99305
99306
Subsequent Care
99311
99312
99313
Discharge Services


99301
99302
99303
Subsequent Care


Annual
37
Level Of E/M Service

38
Level of E/M Service
How To Choose Level Of Service?

History

Examination

Medical decision making
39
40
4 Types of History
Level of E/M Service



History



Examination
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
3 Defined Components To Each Level

Medical decision making
 History of Present Illness
 Review of Systems
 Past Family, Social History
41
42
172
08b Financial Issues - Coding
Extent/Level of History Subsequent
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
Brief
Prob. Pert.
N/A
Extended
Extended
Extended
Com plete
Extent/Level of History Initial
HPI
ROS
PFSH
TYPE
99307
Brief
N/A
N/A
PROB. FOC
EXP. P F
99308
Brief
Prob. Pert.
N/A
EXP. P F
Pertinent
DET AILED
99309
Extended
Extended
Pertinent
DET AILED
99304
Com plete
COMP.
99310
Extended
Com plete
Com plete
COMP.
99304-6
43
44
Extent/Level of History Subsequent
History
History Of Present
Illness – 2 Types


1. Brief

1 to 3 Elements
2. Extended

4 Elements
-OR
Status of at least 3 chronic or
inactive conditions.
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
99307
Brief
Prob. Pert.
N/A
EXP. P F
99308
Extended
Extended
Pertinent
DETAILED
99309
Extended
Complete
Complete
COMP.
99310
45
46
Extent/Level of History
Initial
History
Review of Systems –
3 Types
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
Brief
Prob. Pert.
N/A
EXP. P F
Extended
Extended
Pertinent
DETAILED
99304
Extended
Complete
Complete
COMP.
99304-6
47

1. Problem Pertinent
 One system

2. Extended

2 to 9 systems

3. Complete

At least 10 systems
48
173
08b Financial Issues - Coding
Extent/Level of History Subsequent
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
Brief
Prob. Pert.
N/A
Extended
Extended
Extended
Complete
Extent/Level of History
Initial
HPI
ROS
PFSH
TYPE
99307
Brief
N/A
N/A
PROB. FOC
EXP. P F
99308
Brief
Prob. Pert.
N/A
EXP. P F
Pertinent
DETAILED
99309
Extended
Extended
Pertinent
DET AILED
99304
Complete
COMP.
99310
Extended
Com plete
Com plete
COMP.
99304-6
49
50
History
Past, Family, and/or Social
History – 2 Types



Extent/Level of History
Initial
1. Pertinent - 99304
2. Complete – 99304-6
Not required for subsequent
nursing facility care.
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
Brief
Prob. Pert.
N/A
EXP. P F
Extended
Extended
Pertinent
DET AILED
99304
Extended
Com plete
Com plete
COMP.
99304-6
51
Level of E/M Service
52
Extent of Examination

History

Problem focused

Examination

Expanded problem focused

Medical decision making

Detailed

Comprehensive
53
54
174
08b Financial Issues - Coding
Extent of Examination




Level of E/M Service
Initial Codes
Detailed
 99304 (Or comprehensive)
Comprehensive (full) exam
 99305-99306
Subsequent Codes



2 of 3 key components
Appropriate exam
Geriatric exam

History

Examination

Medical decision making
55
56
Medical Decision Making
Not Well Defined Components
Except For Risk
Medical Decision Making

4 Levels of Complexity
Straightforward
Low
 Moderate
 High

Number of diagnoses / management
options

Amount / complexity of data

Risk of complications, morbidity,
mortality


57
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99307
Lim ite d
Multiple
Ex te nsive
Lim ite d
Mode ra te
Ex te nsive
Low
Mode ra te
High
LOW
MODER ATE
HIGH
58
Complexity Of Medical Decision Making –
Initial (3 of Three)
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99304
Lim ite d
Lim ite d
Low
LOW
99304
Multiple
Mode ra te
Mode ra te
MODER ATE
99305
Ex te nsive
Ex te nsive
High
HIGH
99308
99309
99310
59
9930660
175
08b Financial Issues - Coding
Medical Decision Making
Medical Decision Making
Number Of Diagnoses / Management
Options – 4 Types
Amount / Complexity Of
Data – 4 Types

1. Minimal

1. Minimal or none

2. Limited

2. Limited

3. Multiple

3. Moderate
4. Extensive


4. Extensive
61
Medical Decision Making
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
Risk Of Complications, Morbidity,
Mortality - 4 Types

# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99307
Lim ite d
Lim ite d
Low
LOW
99308
Multiple
Mode ra te
Mode ra te
MODER ATE
99309
Ex te nsive
Ex te nsive
High
HIGH
99310
1. Minimal


62
1 self limited / minor problem
 No meds, minimal lab
2. Low



2 or more self limited or minor problems
One stable chronic illness
Acute uncomplicated illness
 OTC Meds, PT, OT
63
Complexity Of Medical Decision Making –
Initial (3 of Three)
# DIAG
AMT DATA
RISK
TYPE
64
Medical Decision Making
Risk Of Complications, Morbidity,
Mortality
CODE

Minim a l
Minim a l
Minim a l
STR AIGHT.
99304
Lim ite d
Lim ite d
Low
LOW
99304
Multiple
Mode ra te
Mode ra te
MODER ATE
99305
Ex te nsive
Ex te nsive
High
HIGH
3. Moderate




9930665
1 or more chronic illness w/ mild
exacerbation.
2 or more stable chronic prob.
Acute illness with systemic symp.
Undiagnosed new problem with uncertain
prognosis.
 Prescription meds
66
176
08b Financial Issues - Coding
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99307
Lim ite d
Lim ite d
Multiple
Mode ra te
Ex te nsive
Ex te nsive
Low
Mode ra te
High
LOW
MODER ATE
HIGH
Complexity Of Medical Decision Making –
Initial (3 of Three)
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99304
Lim ite d
Lim ite d
Low
LOW
99304
Multiple
Mode ra te
Mode ra te
MODER ATE
99305
Ex te nsive
Ex te nsive
High
HIGH
99308
99309
99310
67
Medical Decision Making
9930668
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
Risk Of Complications, Morbidity,
Mortality

# DIAG
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99307
Lim ite d
Lim ite d
Low
LOW
99308
Multiple
Mode ra te
Mode ra te
MODER ATE
99309
Ex te nsive
Ex te nsive
High
HIGH
99310
4. High



1 or more chronic illnesses w/ severe
exacerbation.
Acute or chronic illnesses that pose a
threat to life.
Abrupt change in neuro status.
 Surgery, parenteral meds, DNR
69
Complexity Of Medical Decision Making –
Initial (3 of Three)
70
NH CPT Codes – 1999-2006 AMA


# DIAG
AMT DATA
RISK
TYPE
CODE
1999 - OLD
Comprehensive



Minim a l
Minim a l
Minim a l
STR AIGHT.
99304


Lim ite d
Lim ite d
Low
LOW
99304


Multiple
Mode ra te
Mode ra te
MODER ATE
99305









99315
99316
Ex te nsive
High
HIGH
9930671
99304
99305
99306
Subsequent Care

99307
99308
99309
99310
Discharge Services

99315
99316

99318


Ex te nsive
2006 - NEW
Initial
99311
99312
99313
Discharge Services


99301
99302
99303
Subsequent Care


Annual
72
177
08b Financial Issues - Coding
Extent/Level Of History
Initial
Initial Nursing Facility Care

99304 (3 of three)




HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
Brief
Prob. Pert.
N/A
EXP. P F
Extended
Extended
Pertinent
DET AILED
99304
Extended
Com plete
Com plete
COMP.
99304-6
Detailed or comprehensive HX
Detailed or comprehensive exam
Medical decision making:
 Straightforward / low
Used for:


Initial admission / readmission
Usually, the problem(s) requiring admission
are of low severity.
73
74
Complexity Of Medical Decision Making –
Initial (3 Of Three)
Initial Nursing Facility Care
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99304
Lim ite d
Lim ite d
Low
LOW
99304
Multiple
Mode ra te
Mode ra te
MODER ATE
99305

99305 (3 of three)
 Comprehensive HX
 Comprehensive exam
 Medical decision making:


Used for


Ex te nsive
Ex te nsive
High
HIGH
9930675
Moderate
Initial admission / readmission
Usually, the problem(s) requiring admission
are of moderate severity.
76
Complexity Of Medical Decision Making –
Initial (3 of Three)
Extent/Level Of History
Initial
# DIAG
AMT DATA
RISK
TYPE
CODE
PROB. FOC
Minim a l
Minim a l
Minim a l
STR AIGHT.
99304
N/A
EXP. P F
Lim ite d
Lim ite d
Low
LOW
99304
Extended
Pertinent
DET AILED
99304
Multiple
Mode ra te
Mode ra te
MODER ATE
99305
Com plete
Com plete
COMP.
99304-6
Ex te nsive
Ex te nsive
High
HIGH
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
Brief
Prob. Pert.
Extended
Extended
77
9930678
178
08b Financial Issues - Coding
Extent/Level Of History
Initial
Initial Nursing Facility Care

99306 (3 of Three)
 Comprehensive HX
 Comprehensive exam
 Medical decision making:


High
Used for:
 Initial admission / readmission
 Usually, the problem(s) requiring
admission are of high severity.
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
Brief
Prob. Pert.
N/A
EXP. P F
Extended
Extended
Pertinent
DET AILED
99304
Extended
Com plete
Com plete
COMP.
99304-6
79
80
Complexity Of Medical Decision Making –
Initial (3 of Three)
Subsequent Care
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99304
Lim ite d
Lim ite d
Low
LOW
99304
Multiple
Mode ra te
Mode ra te
MODER ATE
99305
Ex te nsive
Ex te nsive
High
HIGH


9930681
Extent/Level Of History Subsequent
99307 (2 of three)
 Problem focused HX
 Problem focused exam
 Medical decision making:
 Straightforward
Used for
 Patient stable, recovering, or improving
 “Routine / regulatory” visit
82
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99307
Lim ite d
Lim ite d
Low
LOW
99308
99309
Multiple
Mode ra te
Mode ra te
MODER ATE
99309
99310
Ex te nsive
Ex te nsive
High
HIGH
99310
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
99307
Brief
Prob. Pert.
N/A
EXP. P F
99308
Extended
Extended
Pertinent
DET AILED
Extended
Com plete
Com plete
COMP.
83
84
179
08b Financial Issues - Coding
Extent/Level Of History Subsequent
Subsequent Care


99308 (2 of Three)
 Expanded problem focused HX
 Expanded problem focused exam
 Medical decision making:
 Low
Used for:
 Patient responding inadequately to RX
or developed minor complication
85
 “Routine / regulatory” visit
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
99307
Brief
Prob. Pert.
N/A
EXP. P F
99308
Extended
Extended
Pertinent
DET AILED
99309
Extended
Com plete
Com plete
COMP.
99310
86
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
# DIAG
AMT DATA
RISK
TYPE
Subsequent Care
CODE

Minim a l
Minim a l
Minim a l
STR AIGHT.
99307
Lim ite d
Lim ite d
Low
LOW
99308
Multiple
Mode ra te
Mode ra te
MODER ATE
99309
Ex te nsive
Ex te nsive
High
HIGH
99310

87
Extent/Level Of History Subsequent
99309 (2 of three)
 Detailed HX
 Detailed exam
 Medical decision making:
 Moderate
Used for
 Patient developed significant
complication or significant new problem
 “Routine / regulatory” visit
88
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
99307
Lim ite d
Lim ite d
Low
LOW
99308
99309
Multiple
Mode ra te
Mode ra te
MODER ATE
99309
99310
Ex te nsive
Ex te nsive
High
HIGH
99310
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
99307
Brief
Prob. Pert.
N/A
EXP. P F
99308
Extended
Extended
Pertinent
DET AILED
Extended
Com plete
Com plete
COMP.
89
90
180
08b Financial Issues - Coding
Extent/Level Of History Subsequent
Subsequent Care


99310 (two of three)
 Comprehensive HX
 Comprehensive exam
 Medical decision making:
 High
Used for

The patient may be unstable or may have
developed a significant new problem
requiring immediate physician attention.
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
99307
Brief
Prob. Pert.
N/A
EXP. P F
99308
Extended
Extended
Pertinent
DET AILED
99309
Extended
Com plete
Com plete
COMP.
99310
91
92
Complexity Of Medical Decision Making –
Subsequent (2 of Three)
Discharge Services
# DIAG
AMT DATA
RISK
TYPE
CODE


Minim a l
Minim a l
Minim a l
STR AIGHT.
99315 - 30 minutes or less
99316 - More than 30 minutes
99307

Lim ite d
Lim ite d
Low
LOW
99308

Used for:


Multiple
Mode ra te
Mode ra te
MODER ATE
99309


Ex te nsive
Ex te nsive
High
HIGH
99310
93
Total Duration Of Time

Final exam
Instructions for continuing care
Preparation of discharge records
Prescriptions
Referral forms
94
Extent/Level Of History –
Annual
Annual Visit


99318 (3 of three)
 Detailed interval HX
 Comprehensive exam
 Medical decision making:
 Low to moderate
Used for
 Annual exam
 Usually, the patient is stable,
recovering, or improving.
95
HPI
ROS
PFSH
TYPE
Brief
N/A
N/A
PROB. FOC
Brief
Prob. Pert.
N/A
EXP. P F
Extended
Extended
Pertinent
DET AILED
Extended
Com plete
Com plete
COMP.
99318
96
181
08b Financial Issues - Coding
Complexity Of Medical Decision Making –
Annual
# DIAG
AMT DATA
RISK
TYPE
CODE
Minim a l
Minim a l
Minim a l
STR AIGHT.
Lim ite d
Lim ite d
Low
LOW
99318
Multiple
Mode ra te
Mode ra te
MODER ATE
99318
8.21 – 8.49
Ex te nsive
Ex te nsive
High
HIGH
97
98
Financial Issues



Long Term Care Financing
Medical Directors Tasks in Organizational
Budgeting
Physician Billing, Coding, and Documentation
99
182
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Part I Handouts - American Medical Directors Association

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