Long Term Care
Past, Present, and Future
Daniel Swagerty, MD, MPH, CMD
AMDA Foundation Chair
Themes

Health Care Delivery is changing
 Nursing Facilities are transforming from
sites of custodial care into sites of high
intensity care for sick, complex patients
 Expectations are rising
 Much more is and will be expected of
facilities, attending physicians, and medical
directors
Themes

Long-Term Care Medicine is a legitimate
specialty
 More and more care will be provided by
fewer practitioners
 AMDA is committed to meeting the needs
of LTC practitioners for information,
education, support, advocacy, and
recognition
LTC: Past
 “Rest Homes” The road to the nursing home is
said to be ONE WAY
 Custodial care for patients with severe cognitive
impairment, functional impairment, or both
 Physicians absent or inadequate
 Skilled care absent or low intensity
LTC: Present

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Form follows finance: Increased focus on shorter-term
‘skilled care’ = increased revenue/profit for facilities
Patients discharged from hospital ‘sicker and quicker’ with
greater and more acute needs
Frequent mismatches between patient and family
needs/expectations and available resources
– Rapid access to pain medications, availability of
physicians, information from hospitals, provider skills,
etc.
– The job of nurses and doctors are different from the job
for which they were trained
Increased governmental/payor emphasis on quality
measures, especially for issues/areas of high cost (hospital
readmission rates, antipsychotic drug use)
Common Care Delivery Problems in SNF
Hospital Related Issues

Facility not able to provide necessary, appropriate or
desired care
– Lack of communication/ handoff of care between hospital/LTC
physicians, staff
– Inadequate medication reconciliation in hospital = Prescribing
errors
– Unprofessional practices in hospital

Lying about patient care needs or omitting important facts in order to get SNF
to accept patient
– Failure of hospital to provide medication and treatments on day of
transfer resulting in pain and other acute problems upon arrival to
SNF
Common Care Delivery Problems in SNF
Hospital Related Problems
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Inappropriate and/or unnecessary care in hospital Excessive medication doses, chemical/physical restraints,
PPIs, heparin
Inadequate patient communication
– Lack of accurate explanation of patient diagnoses,
prognosis, hospital course, goals by hospital staff with
unrealistic expectations created
Ignorance of health care delivery, SNF Care, regulatory
environment by hospital staff with unrealistic expectations
created
Failure to provide specialty physician follow-up
Common Care Delivery Problems in SNF
Facility Related Problems

Lack of preparation/planning at facility to begin care
– Necessary equipment, narcotic and other medications
not quickly available in SNF
– Lack of communication with families

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Realistic expectations for care, likely outcomes, timeline,
goals, preferences including advance directives, identification
of decision maker with contact information
Lack of physician availability at SNF
– Assess patient, meet with family, provide orders

Lack of availability of facility staff at peak admit times
– Begin care in timely manner and inspire confidence in patients/
families

Overpromising and underdelivering
Common Care Deliver Problems in SNF
Ongoing Care Concerns

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Gaps in resources, communication, and collaboration of
greatest concern
Movement of sick, complex patients into facility has
proceeded faster than the movement of resources into
facility to provide necessary care
Mismatch between patient needs and available staff /other
resources
– Ability to accurately assess patients with changing
conditions
Common Care Deliver Problems in SNF
Ongoing Care Concerns

Ability to respond quickly to meet changing care needs
– IVs, labs, medications
– Ability to monitor sick or unstable conditions continuously for an
extended time

Skill set of providers often lacking
– Assessment skills, communication skills, geriatric prescribing, and
knowledge of regulations

Inconsistent provision of care due to variable attitudes,
knowledge, and skills of staff
Common Care Delivery Problems in SNF
Ongoing Care Concerns

Poor communication/teamwork between
disciplines
 Poor communication/teamwork between facility
and family
 Poor communication/teamwork between
physicians
 Poor availability of physician services
Common Care Delivery Problems in SNF
Attending Physicians

Often unavailable/busy elsewhere
– Not part of the team
 On-call or covering physicians may be unqualified
and/or unwilling to provide orders, see patient, be
responsive
 May be ignorant of regulatory issues, Medicare
coverage/payment issues
Common Care Delivery Problems in SNF
Attending Physicians

May be ignorant of health care delivery/LTC
processes of care
 Failure of facility staff to plan and/or communicate
may result in emergencies for physicians (e.g.
running out of narcotic pain medication after hours)
 Lack of accountability to facility administration and
medical director
Common Care Delivery Problems in SNF
Medical Directors
Many facilities don’t know what to do with a (good)
medical director
 Many medical directors don’t know what to do with
themselves, other than accept new admissions
 Lack of awareness of medical director responsibilities
 Lack of availability/willingness to fulfill
roles/responsibilities required by regulations

Current Trends
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Facilities want more complex patients, fewer custodial care patients
– Facilities want to offer more services i.e. cardiac monitoring
– More SNFs providing post-acute care only; no long-term care
Need physician services continues to rise as a result
– Increased interest in full-time LTC physicians nationwide among
both facilities and physicians
Greater scrutiny of quality and cost as overall health care costs rise
– Atypical antipsychotic drug use in dementia will be actively
discouraged (> $15 billion /yr vs $4 billion/yr for LTC practitioner
compensation)
– Hospital readmission rates scrutinized
– Rehabilitation outcome measures being introduced
Reduced access for certain patients (Medicaid patients with dementia)
LTC : Future

Facilities, patients, families, regulators, others will expect
more of attending physicians and medical directors
 Quality assurance/Process Improvement (QAPI) a CMS
requirement of SNFs
 Physicians must expect more of themselves
 Physicians involved in LTC need more from facilities
– Teamwork, support, qualified staff, communication, etc
 AMDA must meet the needs of physicians and other LTC
professionals in order to fulfill mission of improving
quality
LTC : Future

Emergence of LTC specialists (a la Hospitalists)
– Fewer physicians overall, providing more care to more
SNF patients
– Full-time practitioners in nursing facilities
– Increasingly will be employees of NH chain or LTC
physician group
– Specific set of competencies required Knowledge/skills/attitudes/behaviors
– Attractive compensation and lifestyle compared to
hospital and office-based primary care practice
LTC : Future

Greater emphasis on patient outcomes
– Reporting of outcomes
 Changing payment structures to incentivize
quality, preferred outcomes, resource utilization
 Greater scrutiny of costs, service utilization (esp.
rehabilitation and medications), and quality
measures
LTC : Future

Labor shortages (especially for lower wage
workers) will create greater challenges for
facilities
 Greater involvement and scrutiny by family
members
– Use of internet
 Role of hospital diminishing- May be bypassed in
future
 Less access for custodial care in NH, especially
Medicaid patients with dementia
AMDA
 Mission

is to promote quality LTC
AMDA uniquely concerned about meeting
needs of patients, families, and practitioners in
LTC
– What do patients/families need?
– What do LTC practitioners need in order to meet
patient/family needs and improve quality of care ?
What Is AMDA doing for you?

Education
– Providing information/education to medical directors,
LTC practitioners to achieve clinical, administrative
excellence, thrive in changing environment
– Articulating Core Competencies and developing
training materials related to those competencies for
attending physicians and NPs
– Clinical Practice Guidelines
– Education materials for nurses and other disciplines,
such as “Know it All Before You Call” cards to
enhance assessment and communication skills
What Is AMDA doing for you?

Education
– Annual Education Symposium : March, 2013
 Gaylord Hotel - Suburban Washington DC
– Core Curriculum in Medical Direction
– Advanced Course on Medical Direction
What is AMDA doing for you?

Development of broader menu of focused
educational offerings
– On line, self paced
– Related to core competencies
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Education to support teamwork
 Education for interdisciplinary team
members
What is AMDA doing for you?

Internal Reorganization:
– New CEO fall 2012
– Complete reassessment of organizational effectiveness
– Strategic planning 2012/2013 to identify member
needs, develop new products, and services to meet
those needs
– Increased support of state chapters
– Needs assessment of members
– Enhancement of products and services to meet those
needs
What Is AMDA Doing for You ?
Advocacy
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Public Policy: Monitoring and influencing external
environment (government, consumers) in a strategic way
to improve care and careers in LTC
Demonstrate value of CMD to Government, Industry, and
public
Demonstrate value of Competence in LTC Medicine to
government, industry, and public
Enhance recognition of CMDs and Competencies in LTC
Medicine
What Is AMDA Doing for You ?
Advocacy
 Strong advocacy for payment to LTC practitioners
 Provide invaluable expertise to CMS and other
others in regulations, standards, quality promotion,
and measurement
 Position ourselves as advocates for patients in
order to improve care and enhance our role
What is AMDA Doing for You:

Mentorship and Career support
 Increased reimbursement for LTC service codes
 Develop LTC workforce
– AMDA Futures program
– Supportive network of LTC professionals
– AMDA Foundation Capital Campaign
 Increased recognition for LTC practitioners and
CMDs
What is AMDA Doing for You:
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Pursue other benefits and opportunities for
members
Health information technologies/ EMR/eprescribing for LTC
Set research agenda for LTC
Evaluate effectiveness of CPGs
Define quality in LTC population/setting
Summary – General

Health care delivery rapidly changing
 Status quo not an option
 Tremendous opportunities and challenges in
LTC
 LTC is considered a solution, not a problem
in health care reform
Summary - AMDA

Professional society for LTC practitioners
 One “Stop Shop” for LTC and Medical
Director education
 Shape long-term care delivery by
emphasizing quality and advocating for
LTC practitioners and consumers
 Providing all of the necessary tools for
excellence and professional satisfaction