March 2019 • VOLUME 20, NO. 2 www.caringfortheages.com

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an Official Publication of

In an innovative senior living commu-nity in Columbia, MO, called Tiger-

Place, sensor technology that continually monitors the residents and sends alerts when patterns change is helping nurses and other providers prevent falls and de-tect early signs of illnesses and changes in health status, allowing them to intervene days or weeks earlier than they otherwise might.

The facility — a state-sponsored aging-in-place site that is jointly oper-ated by the University of Missouri (MU) Sinclair School of Nursing and Americare Systems, Inc. — is one of the oldest living laboratories in the coun-try for passive monitoring technology, which aims to slow and prevent func-tional and cognitive decline and keep people out of nursing homes and hospi-tals. Today TigerPlace has growing com-pany; experts who are developing and/or tracking the development of elder care technology say that interest in pas-sive monitoring systems is gaining steam both inside and outside academia and across the care continuum.

“It’s the biggest push that we’re seeing [in technology innovation for seniors],”

said Justin Smith, innovation and tech-nology manager for Direct Supply, Inc., in Milwaukee, WI. “Facilities tradition-ally have had an episodic data-gathering approach. But now we’re seeing a move toward more continuous, round-the-clock data — data that can be turned

[into alerts] that tell the clinician ‘Here’s a trend we’re seeing for this resident . . . maybe you need to check in with them.’”

The commercial marketplace for pas-sive sensor systems is still in its infancy.

See TECHNOLOGY • page 10

From Detection to Prevention and Beyond: The Future of Sensor Technology in Senior Livingchristine Kilgore

a Person-centered approach to Fall PreventionBarbara resnick, PhD, crNP

Fall prevention is a major concern for every community in which older

adults live. Approximately 15% to 50% of older adults living in assisted living communities experience a fall over a 6- to 24-month period, and 4% to 22% of nursing home residents fall annually. Only a small percentage of falls result in major adverse outcomes such as a fracture or head trauma, but bruising can still cause pain, and skin tears can result in a

slow healing process that requires signifi-cant nursing time. Falls also can have a psychological impact — such as instilling a fear of falling with a subsequent decline in physical activity. The staff may begin to fear a resident’s falling as well and wish to keep that resident immobilized.

The factors that influence falls are many, encompassing issues with both individuals and the environment. The resident-level factors include age, muscle

strength, gait and balance, cognitive function, visual and hearing impair-ment, depression, and the use of certain medications (antidepressants, anxio-lytics, antipsychotics, diuretics, or any medication that can cause orthostatic hypotension). The environmental factors that contribute to falls include tortuosity of paths, cluttered areas, slippery areas,

See FALL PREVENTION • page 18

Marilyn rantz, PhD, rN, leads research aiming at measuring function with sensors to help residents live healthier lives.

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IN THIS ISSUE

Paradise LostNatural disasters that drive seniors out of their communities remind us again of glaring gaps in the senior care system. 8

When the Cookie Jar Fills UpGood transitions required clear, concise and tailored instructions. 14

Medical Director of the Year FinalistsThe most innovative and committed PaLTc leaders compete for the Medical Director of the Year title. 15

Medical Cannabis is No Pota New York nursing home leads the way in legal medical cannabis use. 16

Caregivers in CrisisOverloaded with responsibility, family caregivers increasingly engage in risky health-related behaviors to cope with stress. 17

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2 carING FOr ThE aGES March 2019

Professional negligence lawsuits against skilled nursing facilities and

other senior living communities — and to a lesser extent, against the physicians and other practitioners who provide care in them — continue to increase in num-ber and average value.

The increase in lawsuits can prob-ably be attributed to multiple factors. One has been the trend toward more medically frail, complex, and seriously ill residents. These residents are likely to experience “bad outcomes,” such as death or pressure ulcer development, that are often unrelated to any negli-gence but rather to progressive illness and poor prognosis.

Some plaintiffs’ attorneys capitalize on family members’ guilt about plac-ing their parent or spouse in a nursing home by placing billboards near skilled nursing facilities (SNFs) or by otherwise soliciting new cases. This creates a win-win situation for the potential plaintiffs: They can assuage their own guilt by blaming someone else for what may just be disease progression while potentially getting significant financial compensa-tion in the process.

Employees of nursing homes may make offhand remarks about perceived understaffing, sometimes as an excuse for a delay in answering a call light or responding to a resident’s request. Such lapses can be turned into allegations of widespread, deliberate understaffing that places “profits above patient care.” And despite significant improvement in the average competencies of nurses who work in U.S. SNFs, there are still substantial turnover issues and a lack of consistent assignment in some areas. Workforce shortages, particularly of certified nurs-ing assistants, certainly don’t help this perception, and they are looming larger all the time. At the same time, advo-cacy groups are clamoring for higher and higher minimum staffing requirements. And the lay public serving on juries is unlikely to be sympathetic to nursing homes, making them easy targets.

The Role of InformationIncreased access to medical informa-tion — both patient-specific and the more general disease-related subject matter available on the internet — can be a double-edged sword. It may create unrealistic expectations and further serve to undermine some of the care being provided in nursing homes. But it also may improve care and accountability.

Also, with respect to transparency, the relatively new mandates requiring global facility assessments — including areas iden-tified as in need of improvement — that

are made available to state survey agen-cies represent a perfect invitation for a plaintiff’s attorney to cherry-pick cases that show how a facility was already on notice — for example, for a pressure ulcer problem. It’s unclear whether these documents, which will be a matter of public record, can be protected under the rubric of quality improvement. It’s probable that they will make their way into evidence in some jurisdictions. A SNF’s performance on a variety of qual-ity measures (and its Five Star rating) and the results of the surveys, includ-ing any deficiencies, can also easily be obtained by family members and plain-tiffs’ attorneys. And this information can be admissible in court in some instances.

Electronic health records (EHR) promised improved documentation, but they have not turned out to be a godsend in actual practice. On a positive note, their legibility is excellent (compared with the illegible scrawl many physicians display), but the platforms being used in this care setting can create myriad additional problems when a nursing home must defend itself from allegations of negligence — or, worse yet, accu-sations of fraudulent documentation. Copying and pasting, and rote docu-mentation of meaningless entries (such as “call light within reach” for a resi-dent with advanced dementia), can give the appearance of sloppiness. A single skilled Medicare nursing note, created with numerous drop-down menus and with carried-over data from the previous shift’s or day’s entry, can run 15 pages long. Not only are such items tedious to work through, they can perpetuate erroneous data as “chart lore.”

More worrisome still, sometimes there appears to be a disconnect among the various disciplines, or even between the

charge nurse and the treatment nurse. For example, if the charge nurse checks the box for “no skin issues” but the treatment nurse documents the care of several stage 3 or 4 pressure ulcers, it suggests that the charge nurse and the nursing staff in general are not inter-ested in what can be a serious medical problem. Similarly, sometimes a physi-cal therapist may document that the resident vomited or was incontinent, with a large, malodorous loose bowel movement during therapy — but the nursing notes may make no mention of a potential change of condition. These types of miscommunication or docu-mentation lapses can create significant exposure to liability. More importantly, they may compromise the quality of resident care.

In these times of increasing transpar-ency and access to information, it is critically important for nursing homes to provide and document appropriate care, and to continue to strive to improve their care processes. Even though no chart is ever perfect, and consistently charting every detail of care is impos-sible, it is important for nursing homes to document care appropriately and accurately. When residents refuse treat-ments or medications, these episodes should be documented every time they occur. Nonadherence should be care planned — and the attending physician should be made aware of these events.

The Medical Director’s RoleThe Quality Assurance/Performance Improvement (QAPI) paradigm is a great data-driven tool to improve a vari-ety of care-related parameters. The care facility’s medical director should be an active participant in QAPI programs and in the overall care provided in the facility.

The medical director also should assist whenever other practitioners are not making safe, prudent, or evidence-based orders. This should include assertively educating clinicians and firmly request-ing changes in ordering habits when appropriate. For example, outdated and potentially harmful practices — such as using sliding-scale insulin or as-needed antipsychotic treatments, or sending resi-dents to the hospital inappropriately, or ordering urine studies for vague symp-toms such as confusion or a fall in the absence of actual urinary tract symp-toms — should be actively discouraged.

Nurses can assist in changing these behaviors, but often it will require a peer-to-peer conversation — sometimes with transmission of actual data, such as the references in the Choosing Wisely guidelines (“Ten Things Physicians and Patients Should Question,” http://bit.ly/2DLlf3z) propounded by AMDA — The Society for Post-Acute and Long-Term Care Medicine.

As Caring’s readers undoubtedly know, there is a certification process for medical directors, and there is evidence that the Certified Medical Director (CMD) cer-tificate, available through the American Board of Post-Acute and Long-Term Care Medicine (www.abplm.org), is associated with a statistically significant improvement in a nursing home’s publicly reported qual-ity measures. Some nursing home chains require or encourage their medical direc-tors to take the coursework and obtain the CMD certificate as part of their contract or other explicit expectations, allowing such professional development hours to count toward their contracted hours. Other companies pay an increased differential salary for CMD-certified medical direc-tors. And some corporations that under-stand the importance of well-informed medical directors will underwrite the costs of attending the Society’s annual meeting or its state chapter meetings.

It is clear that an engaged, knowledge-able medical director can help improve quality and reduce liability. Medical directors should also regularly perform chart reviews and ensure that the nurs-ing facility’s policies are up to date and clinically and ethically sound, and they should assist when state survey agency teams are in their buildings.

The Society has a liability workgroup through our Public Policy Committee, and readers with an interest in par-ticipating should get in contact with Alex Bardakh, our public policy direc-tor (abardakh@paltc.org). Our House of Delegates has created Society policy

Medical Directors Should helpImprove Quality and reduce Liability

ON MY MINDKarl Steinberg, MD, cMD, hMDc

Miscommunication or documentation lapses can expose SNFs to liability.

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Serendipitous Leadership LessonsKathleen rathke, MSN, MBa, aGNP-c, SPhr

One of the most delightful aspects of reading is serendipity — the hap-

py discovery of insights in unexpected places. After a long workday, sometimes I’d rather curl up with a good book than a professional journal, but important lessons can be found everywhere, even when we’re reading for pleasure.

Patenting the Sun: Polio and the Salk Vaccine (1990) by Jane S. Smith, PhD, is a fascinating account of the effort to conquer the dreaded disease once known as infantile paralysis. Dr. Jonas Salk clearly made an enormous contribution to world health, but he did not do that alone. The eventual number, breadth, and devotion of the contributors to the polio vaccine were impressive, including Salk’s laboratory colleagues, the other researchers, and the National Foundation for Infantile Paralysis (NFIP).

What leadership lessons or remind-ers for post-acute and long-term care (PALTC) might lie within this gripping story? For me, the importance of engage-ment and collaboration, driven by a clear vision and audience-specific communi-cation, jumped off the pages. For them-selves the researchers expected scientific papers, but the lay public responded best to emotional appeals — how they could personally contribute to defeating polio. The NFIP campaigns, which built strong engagement and trust, produced large donations for research and patient care. And parents willingly — and often eagerly — enrolled their children in the vaccine trials.

As Patenting the Sun also reminds us, diversity enriches our lives and brings enormous benefits to individu-als, patients, teams, and organizations. The book recounts appalling examples of anti-Semitism and racism. Yet Salk, who was Jewish, the African American par-ents and their children in Montgomery in the 1954 field trial, and countless oth-ers worked through prejudice and barri-ers to contribute to the vaccine’s success, inspiring us today with their courage and commitment. It’s a strong reminder to us as leaders that we must continue our

vigilance against discrimination, and we must work to promote diversity, inclu-sion, and cultural competency.

In yet another instance of serendipity, I happened also to be reading an article on “The Secrets of Great Teamwork” by Martine Haas, PhD, and Mark Mortensen, PhD, who describe the conditions conducive to the success of 4-D teams (dispersed, digital, diverse, and dynamic), which share similarities with work groups in PALTC (Harv Bus Rev 2016;6:70–76). In both 4-D and PALTC teams, people who have differ-ing functions, backgrounds, and roles collaborate across work sites/shifts, use technology in their work, and experi-ence hectic environments with frequent staffing changes. And the conditions that enable their success are compelling direction, strong structure, supportive context, and a shared mindset.

Given all these similarities, I won-dered if more connections might be made between the polio eradication effort described in Patenting the Sun and PALTC teams, using Drs. Haas and Mortensen’s framework.

Compelling DirectionOne might imagine no more noble cause than fighting the scourge of polio, and in fact it attracted recruits far and wide. However, as Dr. Smith points out, some individuals “had not joined the polio crusade because it gripped their hearts above all others. They were profession-als . . . who peddled polio the same way they could have sold cars or corsets or annuities.” Yet, significantly, many of these people would also become pas-sionate about the work and spend years supporting the battle against polio.

In a similar fashion, although some individuals may have limited interest in PALTC initially, leaders can engage them through a powerful vision, ambitious goals, and a reward system, just as Drs. Haas and Mortensen suggest. How many of us stumbled into PALTC accidently only to become hooked thanks to strong mentors who modeled a vision of posi-tive social impact, quality, innovation, and fascinating work?

So strategic outreach, mentoring, and development programs are important. A great example of this is the Futures Program of AMDA — The Society for Post-Acute and Long-Term Care Medicine.

Strong StructureA strong structure involves both people and processes. Drs. Haas and Mortensen point out that a team that is diverse and has a mix of skills can provide broad perspectives, minimize groupthink, and increase innovation. According to Vivian Hunt, DBE, and her coworkers, research has shown that a diverse workforce favorably impacts organizational health, including its financial performance

and growth. Michelle L. Odlum, BSN, MPH, EdD, would agree: “A diverse,

culturally competent healthcare work-force is essential to health equity,” and it can potentially overcome health dispari-ties and improve health outcomes (“How to Advance Minority Health?” Apr. 29, 2014; https://rwjf.ws/2HvZOaU).

Leaders play a critical role in attract-ing, developing, and retaining diverse talent across all levels and roles and ensuring a welcoming, inclusive envi-ronment. Formal cultural competency training is important, and self-study resources are available as well. For instance, the Society’s excellent AMDA On-the-Go podcast, hosted by Wayne Saltsman, MD, PhD, includes a dis-cussion with Tim Johnston, PhD, from SAGE, Services and Advocacy for GLBT Elders (http://bit.ly/2TeBnjp).

PALTC roles certainly represent a mix of skills, of which certified nurs-ing assistants, housekeeping staff, nurses, pharmacists, providers, and therapists are just a few. There are different functions, perspectives, and even organizations (e.g., direct staff, hospice, geropsych) all working under one nursing home roof. Thus, as Drs. Haas and Mortensen point out in their article, well-designed pro-cesses, clear principles, and good com-munication are even more necessary to foster a collaborative environment and deter negative behaviors. The rivalries and misunderstandings may make for exciting reading in Patenting the Sun, but these are more painful than thrilling for leaders in real life — and they require a proactive approach.

Supportive ContextFoundational resources are another responsibility of leaders, reminiscent of Abraham Maslow’s hierarchy of needs. If your basic needs haven’t been met, it’s going to be difficult to arrive at self-actualization. As Drs. Haas and Mortensen explain, in a professional setting those basic needs include a per-formance-based rewards system, access to necessary data, opportunities for

training and development, and mate-rial resources.

PALTC is an admittedly challenging environment whose foundation costs must be managed carefully. Drs. Haas and Mortenson noted that rewards can be extrinsic (such as compensation and recognition) but also can be intrinsic (pride and a feeling of purpose). One individual may leap at the chance to lead a polypharmacy project while another may prefer to be assigned a mentee. Both assignments reward and recognize the value of the individual. For the virus researchers, as Dr. Smith wrote, “A grand gesture was to bring a flask of whiskey when you went to meet a colleague at the airport . . . glamour was being sent on an urgent assign-ment to an epidemic area.” To ensure the foundation in your own workplace, know your team members and provide the rewards and recognition that align with their preferences — though per-haps it’s best to leave the whiskey at home.

Shared MindsetDrs. Haas and Mortensen noted that the leader has a vital role in creating a shared mindset through information sharing, common experiences, and other techniques. The 1954 field trial for the Salk vaccine involved nearly 2 million schoolchildren and at least 150,000 vol-unteers. Dr. Smith wrote that leaders in that endeavor worked tirelessly to create and distribute procedure manuals and bulletins across 44 states and small parts of Canada and Finland. Imagine the manual effort required! Despite the challenges presented by electronic medi-cal records, we do have more options for sharing information and helping cre-ate a shared mindset, such as mobile apps, web-based training, and other technologies.

During polio eradication, the NFIP leveraged common experiences to engage people in their fundraising efforts:

See LEADERSHIP • page 8

“In PALTC, different functions, perspectives, and organizations all work under one roof. Well-designed processes, clear principles, and good communication are even more necessary to foster a collaborative environment and deter negative behaviors.”

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Dear Dr. Jeff: More of my time is being spent with fami-lies of residents distressed because of my refusal to order tests, medications, consul-tations, emergency room visits, and even hospitalizations, which they insist should be done. Although occasionally these are reasoned discussions regarding optimal care, frequently they are angry confronta-tions accompanied by threats of lawsuits. I understand and support the rights of patients or their proxies to make choices among alternate treatment regimens or to refuse unwanted care or lifestyle limita-tions. Is there a corresponding right to access any treatment they choose as well?

Dr. Jeff responds: The changing structures of medical care, the ready availability of internet searches with plentiful information and misinfor-mation, the dramatic overselling of the potential of modern medicine to treat end-stage disease, and the movement from a doctor–patient relationship to the paradigm of a health care consumer and a “provider” are all driving encounters such as those you describe. The practitio-ner at the bedside is often caught among competing pressures from demanding families and insurance plans and health care systems to improve consumer satis-faction scores (sometimes increased by pay-for performance measures that treat these scores as metrics of performance). Pressure also may come from antibiotic stewardship programs, which discour-age treating viral syndromes and “foul-smelling urine” inappropriately with antibiotics, and from agencies that fol-low the published metrics of emergency department (ED) referrals and 30-day rehospitalization rates — which may by inappropriately used as proxies for qual-ity care. Practitioners can be pressured by their own judgment and conscience as well.

The various demands can escalate to appeals to the medical director or administrator to intervene — and the stressed practitioners themselves are fre-quently happy to punt these decisions to administration. In addition to the patients’ families, ombudsmen and risk managers may encourage appeals to the medical director as well. Sometimes the unit staff, including the floor nurses and social workers, may refer a family’s issues to a mediator or higher authority, if only to reassure them that their concerns are being heard and addressed.

Medical practitioners have an absolute obligation to provide the best possible care to their patients. Of course, “best possible care” is determined, in part, by the values of the patient and the goals

of care as defined by the patient. The job of the health care professional is to advise patients on the best means to achieve those goals. Primum no nocere (first, to do no harm) is embedded in the Hippocratic Oath and the ethical principle of non-maleficence to remind us that we have a professional obligation to protect our patients from injury.

The corner drug pusher sells what the consumer wants and can pay for. A physician or nurse practitioner is not a prescription-dispensing machine, a glorified Pez dispenser in a white coat who produces a pill whenever desired. If patients had a right to any medication or study, the whole notion of prescription medications or a requirement for prac-titioners’ orders to perform laboratory and radiology procedures would make no sense.

There are days when it feels as though we are the last ones at the barricades while the ignorant hordes — sadly, sometimes led by medical subspecialists with extremely limited knowledge of the care needs of frail seniors — struggle to overwhelm our residents with use-less tests, with ineffective, unnecessary, or frankly toxic medications, and with unnecessary hospitalizations that can return the resident to the facility in worse overall condition than before they left. However, the professional response to all these pressures should not be a policy of “Just Say No.” We should rec-ognize that most families are advocating for what they genuinely believe are the best interests of their loved ones, and often they want treatments that their relatives have experienced in the past. Our response should be based on our knowledge of best practices in the care of frail seniors, their differential responses to medications, and whenever possible the medical literature.

For example, many older patients with severe venous insufficiency experience stasis dermatitis. Some undergo multiple hospitalizations where — despite their lack of fever or elevated white blood cell counts — the condition is treated as “bilateral cellulitis” with bedrest and intravenous antibiotics. These patients typically improve with such care, not because of the antibiotics but despite them: the bedrest with leg elevation can relieve the elevated venous pressure that had, in turn, produced the skin changes. In this type of situation, the nursing home practitioner’s reluctance to follow a previously “successful” antibiotic treat-ment may seem misguided, obstinate, or even ageist.

If we make vague references to our ability to treat a problem in our care

community — or, worse, refer to the federal policy to reduce hospitalizations — we may sound to the patients and families as though we’re placing the interests of our institution — and its desire to keep beds full and maximize insurance reimbursements — over the interests of our residents.

Even worse can be the reaction of resi-dents and families to the suggestion that a proposed treatment or test is a waste of money. Although practitioners do have some responsibility to the medical sys-tem to minimize waste and fight against insurance fraud, our opposition to an expensive, unnecessary test or medica-tion should be based on the exposure of the patient to risk or discomfort with-out any compensating benefits, not the expense per se.

Practitioners and medical directors should be familiar with a number of classic articles related to overused or unnecessary, even risky medications and procedures. Start with the Choosing Wisely materials from AMDA — The Society for Post-Acute and Long-Term Medicine and the American Geriatrics Society. The words “Black Box Warning” should come tripping off your tongue whenever the use of antipsychotics is proposed for the behaviors of dementia.

The article by David Dosa, MD, and the review by Thomas Yoshikawa, MD, and Joseph Mylotte, MD, reinforce that hemodynamically stable nursing home residents with nursing home pneumo-nia have as good or better survival rates when managed in the nursing home (J Am Med Dir Assoc 2005;6:327–333; Clin

Infect Dis2002;35:1205–1210). The concerns raised by Morton C. Creditor, MD, in “Hazards of Hospitalization of the Elderly” remain as relevant now as when he wrote it 25 years ago (Ann Intern Med 1993;118:219–223). That same year Sharon K. Inouye, MD, MPH, and colleagues of Yale University demonstrated a 50% risk of functional decline in the elderly, of which a quarter occurred after hospital admission (J Gen Intern Med 1993;8:665–672); the risk was 2.8 times greater for those admitted from nursing homes. Nursing assistants who have a relationship with the family can confirm from their own experience that residents typically return from hos-pitalizations weaker, less able to partici-pate in care, more confused, and with skin breakdowns.

Many of the bitter struggles between families and practitioners center on patients with dementia, particularly those in their last months of life. Unlike cognitively intact residents who can participate in their care decisions, cog-nitively frail individuals are inevitably subject to care decisions made by prox-ies. As many articles in Caring and other publications have discussed, these legally authorized decision-makers experience conflicting emotions because they have limited ability to predict what their loved one or friend would wish under these circumstances.

What is known is these residents have an increased risk of behavioral distur-bances, agitation, confusion, depression — and a consequent increased risk of feeding tube placement and sedative

DEar Dr JEFFJeffrey Nichols, MD, cMD

Professional or Patsy?

a physician or nurse practitioner is not a Pez dispenser in a white coat who produces a pill whenever desired. If patients had a right to any medication, the whole notion of prescription medications would make no sense.

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use — when they are subjected to the stress of transfers away from a familiar environment and known care staff. This is especially true when they are shuttled from site to site — to the hospital, obser-vation unit, ED, outside consultant’s office, imaging center, or ambulatory surgery suite — during their extended dying process. This phenomenon is known variously as relocation crisis, transfer trauma, or dislocation delirium, and it contributes to their accelerated decline and shortened life expectancy, in addition to its obvious immediate nega-tive effect on their quality of life.

Calmly asserting that we know what is best for our residents and that we are providing evidence-based medicine — superior to a Google search or to the hospital house staff who told them that 15 white blood cells in a urinalysis “proved” that their relative had a urinary tract infection — is not a winning strat-egy. The answer is not a return to the paternalism of the past, even if “father does indeed know best.” Just because we have the power of our licenses does not mean that the wishes of the residents and families can simply be ignored.

We do need to partner with our resi-dents and their families to create care plans that meet our residents’ needs and also alleviate their families’ worries and concerns. This partnership should

emphasize what we can do, the interven-tions we intend to implement, and the close monitoring of resident comfort we can provide.

Patients and families should be informed of the limited efficacy and sig-nificant possible side effects of many commonly used medications and treat-ments, particularly anticoagulants, antiepileptic medications in patients with no recent history of repeated sei-zures, statins, cholinesterase inhibitors, antihistamines, or prolonged or mini-mally indicated courses of antibiotics. The patient with fever and cough will not benefit from an ambulance ride to the ED — but certainly does need a physical examination and may require a chest X-ray, a complete blood count, possibly a blood culture, and perhaps the early initiation of antibiotics if indicated by the examination. Most of this care can occur more quickly in the

nursing home — contrasted with the time required to arrange an ED transfer followed by the likely wait time in your local hospital for a low-priority ED visit.

The lethargic resident with cloudy, foul-smelling urine and no other symp-toms does not require an antibiotic (which is likely to decrease the resident’s oral intake and potentially risk diarrhea and antibiotic resistance). The resident does need increased fluids (preferably orally, but possibly intravenously when the signs and symptoms of intravascular

depletion are present). It might be better not to do a requested urinalysis and cul-ture, but it might be wise to do a meta-bolic profile to assess hydration status.

We should not expect families to have a sophisticated understanding of the best available care for frail seniors — and doing the right thing should not be expressed as doing nothing. Once again, communication is of the essence here. If families in stressful circumstances under-stand that their needs and concerns are being heard and respected — if they are

given the courtesy of the practitioner’s time to explain the decision process — in most situations hostile encounters can be defused.

Dr. Nichols is past president` of the New York Medical Directors association and a member of the Caring for the Ages Editorial advisory Board. read this and other columns at www.caringfortheages.com under “columns.”

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Calmly asserting that we know what is best for our residents is not a winning strategy. We need to partner with our residents and their families to create care plans that meet our residents’ needs and also alleviate their families’ worries and concerns.

6 carING FOr ThE aGES March 2019

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PTSD and Trauma-Informed care in the Long-Term care SettingWhitney Fishburn

Trauma-informed care figures promi-nently in Phase 3 of the revised

federal Requirements of Participation that goes into effect in November of this year, which stipulates that long-term care facilities must provide behavioral health services for residents with a his-tory of trauma or a post-traumatic stress disorder (PTSD) diagnosis.

Treatment of PTSD typically entails a combination of medication and psychotherapy. But in the elderly, in whom PTSD is less understood than in other patient populations, special attention must be paid to age-related comorbidities and changes in drug metabolism, according to Rebekah J. Jakel, MD, PhD, an assistant profes-sor of psychiatry and behavioral sciences at Duke University School of Medicine in Durham, NC. “Certain medications may confer increased risk in the elderly and should be avoided or used with caution,” wrote Dr. Jakel in her review article on what is currently known about PTSD in the elderly (Psychiatr Clin N Am 2018;41:165–175; https://bit.ly/2WmXPZK).

PTSD is defined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as recur-rent, distressing memories, nightmares, flashbacks, avoidance of trauma-asso-ciated reminders, negative cognitions, and moods associated with the traumatic event, and hyperarousal symptoms that persist beyond 1 month and have no other known cause. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitor (SNRIs) are the most commonly used medications for treating trauma-based symptoms such as those in PTSD.

In lower doses — with slower titra-tion and possible dose adjustments for concurrent hepatic or renal impair-ment — antidepressants are generally fine for treating PTSD in the elderly, Dr. Jakel wrote. However, older anti-depressants such as the tricyclics, which are anticholinergic, should be avoided because of their potential for adverse cardiac events. Prazosin, an alpha-agonist that crosses the blood-brain barrier, has shown efficacy in targeting nightmares; however, Dr. Jakel warned that although the drug is sometimes prescribed for hypertension, when it is used at typical doses to target nightmares it is often poorly tolerated by patients because of the potential for hypotension, especially postural hypotension.

The data reviewed by Dr. Jakel indi-cate that older patients with PTSD and dementia have more than twice the odds of being prescribed second-gen-eration antipsychotics compared with patients who have PTSD alone. Whether the therapeutic target was the PTSD

symptoms, the dementia, or a combina-tion of the two was unclear, she wrote. Although the exact nature of the reci-procity between dementia and PTSD is still unknown, studies have consistently shown a significant association between the two. For this reason — and because antipsychotics carry a boxed warning for all-cause mortality in the elderly with dementia — Dr. Jakel urged careful con-sideration before deciding to use antipsy-chotics for PTSD in the elderly.

Benzodiazepines also are thought to have limited utility in this patient popu-lation, according to Dr. Jakel. “They can worsen dissociation, reduce ability to engage in psychotherapy, and worsen mood and substance use,” she wrote, adding that they also confer “signifi-cant risks of falls, delirium, dependence, increased confusion, and respiratory depression, and [they] may prolong PTSD symptoms.”

Although cognitive behavioral thera-pies might be less feasible in this pop-ulation because of cognitive concerns or lack of access, these therapies have been shown effective in younger cohorts, Dr. Jakel said, so they should be made available to the elderly when indicated, in accordance with the revised federal rule. In an email, Timothy Gieseke, MD, a general internist and associate clinical professor at the University of California–San Francisco’s Department of Family and Community Medicine, noted that “Clinical psychology ser-vices have become more available in my community.”

Dr. Gieseke, who has served as a medi-cal director to five skilled nursing facili-ties and two subacute care units in his career, recounted how when three of his facilities experienced rapid evacuations due to wildfires, many of his patients suffered trauma, which led to new diag-noses of PTSD. In some cases, he said, these conditions had “likely been quies-cent,” and access to clinical psychologists was a great help in identifying and treat-ing these patients.

PTSD in the elderly who require hos-pitalization is cause for special attention, according to Dr. Jakel. Medical con-ditions that alter oxygenation, such as chronic obstructive pulmonary disease, may be associated with psychological dis-tress. Beta-agonists and atrial fibrillation also can be associated with autonomic changes that can approximate anxiety, according to Dr. Jakel. Although there are few data on interactions between delirium and PTSD in the intensive care unit, according to anecdotal accounts combat veterans with PTSD have tended to incorporate flashbacks into their delir-ium, which manifested as paranoia and agitation.

According to Dr. Gieseke, having access to cognitive behavioral therapies

carINGFOrThEaGES.cOM carING FOr ThE aGES 7

when determining which symptoms are medical and which are PTSD-related can be useful in such situations. “They have been of great help identifying psycho-pathology that I have missed, and have helped me be more precise in my medi-cal interventions based on more precise diagnoses,” he said.

The DSM-5 sets the lifetime PTSD prevalence rate by age 75 at 8.7%, but data on the disorder are derived largely from studies of cohorts in early adult-hood who were mostly white, male combat veterans or Holocaust victims. Meanwhile, the exact nature of acute trauma’s impact on the elderly, much of which occurs outside the realm of combat, remains a mystery, according to Dr. Jakel. “It is unclear whether age confers a vulnerability or protective fac-tor for trauma sustained in the elderly.” And it may be impossible to ever know definitively due to the inherent chal-lenges of designing studies that can assess pretraumatic baseline functioning and trauma severity as well as effectively con-trol for the multitudinous conditions and processes that correlate with age, including cumulative trauma, according to Dr. Jakel.

Although the effects of trauma can persist across the life span, their exact trajectory is hard to predict. For some individuals, age may be associated with resilience and less vulnerability to devel-oping PTSD. But for others, accord-ing to Dr. Jakel, “It is theorized that trauma-based symptoms may emerge or worsen in the context of aging-related challenges. Some of these stressors could include changes in roles, retirement, loss of family members and friends, loss of autonomy, and physical and cognitive decline.”

Beyond the symptomology of PTSD, the disorder has been associated with a higher risk of suicide, dementia, and other changes in health and functional performance, although PTSD’s exact mechanism is still unknown and the causal links for these associations are

unclear. In the case of suicide, screen-ing for depressive symptoms could help lower the risk — one study reviewed by Dr. Jakel showed that suicidal ide-ation and PTSD were associated with depression.

Other studies reviewed by Dr. Jakel indicated PTSD was correlated with an elevated risk of cardiovascular dis-ease in a male veteran population. Studies also have found positive asso-ciations between PTSD and type 2 diabetes mellitus and gastrointestinal disease. PTSD was also associated with reduced physical performance, accord-ing to self-reports by older male vet-erans in a study that was controlled for demographics and other psychiatric disorders.

Dr. Jakel’s review offers a reminder to clinicians to look deeper into the possible causes of impaired cognition, according to Dr. Gieseke. “[Physicians] commonly miss cognitive impairment due to serious mental illness, and likely miss it in those with PTSD,” he said. “In the latter case, recogni-tion and appropriate management may improve cognition and problem behaviors associated with PTSD.” Dr. Gieseke said this is especially impor-tant in skilled nursing facilities where “there is a tendency to view agitation in a generic way and miss antecedent life events that may be contributing to the agitation.”

Both Dr. Jakel and Dr. Gieseke believe more research into the causes, trajec-tory, and cumulative effects of trauma across the life span could improve care for this patient population. “It would be valuable to better define the impact of PTSD in seniors on life expectancy and quality of life,” said Dr. Gieseke. “Confirming a quantifiable serious adverse effect could free up funding for intervention studies.”

Whitney Fishburn is a Washington, Dc-area freelance health sciences writer.

The Society has updated its Guide to Post-Acute and Long-Term Care Coding, Reimbursement, and Documentation. This popular publication contains documentation requirements and Society-developed coding vignettes for each of the nursing home family of codes as well as Chronic Care Management (CCM), Advance Care Planning (ACP), and Behavioral Health Integrated (BHI) services. It also features frequently asked questions on a variety of related topics and an exclusive link to documentation examples.

GUIDE TO POST-ACUTE AND LONG-TERM CODING,

REIMBURSEMENT, AND DOCUMENTATION

UPDATE

For more information or to order your copy, please visit

paltc.org.

supporting tort reform, particularly caps on noneconomic damages. Also, because most lawsuits require medical expert testimony to help the jury or judge determine the standard of care and any damages from negligence, our readers who are experienced clinicians and medi-cal directors should consider offering their services as expert witnesses. Many of the so-called experts who testify in nursing home cases do not even cur-rently work in nursing homes, so there is always a need for qualified, truthful experts.

There is clearly no way to avoid all lawsuits, and SNFs are an easy target for

these causes of action. But paying close attention to the care processes, commu-nication, and oversight of medical care in your nursing facility — in addition to creating realistic expectations among residents and family — can go a long way toward mitigating that risk.

Dr. Steinberg is chief medical officer for Mariner health central in califor-nia and a longtime nursing home and hospice medical director. he is editor in chief of Caring and chairs the Public Policy committee for the Society. The views he expresses are his own and not necessarily those of the Society or any other entity. he may be reached at karlsteinberg@MaIL.com and he can be followed on Twitter @karlsteinberg.

On My MIndfrom page 2

8 carING FOr ThE aGES March 2019

They have been driven out now, the ones who managed to survive Para-

dise. The inferno burned them from their tiny homes, their trailers, their RVs, their tranquil plots along the ridges and valleys among the pines.

It was there in a forested place where the long-married, the widow, or the widower could afford to live, meagerly, and at least semiautonomously with their canes and walkers and wheelchairs, leaning into each other when needed, always ready with a neighborly hand. A village of elders, the greatest generation, many in assisted living, or care homes, or rehabilitation facilities. Their chil-dren and grandchildren dispersed, they were struggling in their own lives.

In Paradise, CA, where 25% of the population was over 65, while hell bore down, a garbageman scooped a nonage-narian off her porch and, with the help of others, hauled her up into the cab of his truck. There are so many stories like this, and let’s face it: when the fires roar down the canyons, the floodwaters rage through the river valleys, the hurricanes batter the shores, all we will have is each other, if we are lucky.

According to the New York Times, “many of the thousands of structures in Paradise and surrounding parts of Butte County that were lost in the fire were nursing homes, assisted living facilities, other geriatric care centers or mobile home parks catering to retirees. Roughly 2,300 residents of the fire zone had relied on in-home health aides, according to Shelby Boston, the county director of employment and social services” (“After a Wildfire, Rebuilding Life Can Be Hardest for the Oldest,” Nov. 25, 1918; https://nyti.ms/2FJ0A2o).

The secular gods have decreed this to be our New Normal: disasters building over a long period of time due to global envi-ronmental forces “out of our control,” exurbanization and limited affordable housing, too much fuel on the ground, inadequate funding priorities, poor prepa-ration, and overly stretched first respond-ers. “Who could have known? Who could have predicted this?” they say.

Haven’t we been paying attention? It is always our most vulnerable who suffer, who are left behind in the flames. They lie submerged in their bedrooms. They are swept from their front stoops. They drown in their long-term care facilities. They are too cold or too hot, dying of hypothermia or heat stroke in derelict apartments. They are, as they have been: our old-old and oldest-old.

In the Paradise fire, at least 46 of the 88 dead were our geriatric patients, who

died at more than twice the rate as the under-65 population of the area. When Hurricane Irma knocked out the power of a rehabilitation center in Florida in September 2017, no evacuations took place, even though a fully functioning hospital was just across the street. Twelve elderly residents died of heat stroke. The home’s license was suspended, but as of January 2019 no charges have been filed.

Our elderly — our patients — are the detritus, the human fuel accumulat-ing in all the forgotten corners of our nation, waiting for the next spectacular conflagration to bring their plight onto our screens. For a moment we hear their stories, then they are lost in the smoke of other concerns, the next terrorist bomb-ing or school massacre.

Americans rouse themselves and march in the streets to ban guns, but who is marching in defense of our aging population? As Time magazine points out, “from senior living centers to hospice, the country is struggling to adapt a rickety system to handle the demographic wave that is crash-ing over it. At stake are the health, wealth and dignity of a generation” (“Dignity, Death and America’s Crisis in Elder Care,” Nov. 16, 1917; http://bit.ly/2SaBIGy).

Are we marching yet?Most of us are just waiting, aging in place, quietly suffering loneliness and loss, gathering frailty and waning facul-ties. In our increasing irrelevance, by 2050 there will be 80 million of us. Of octogenarians, only 20% are fully

mobile, and 50% have some degree of dementia, recognized or not. The safety nets woven in the last century to cush-ion our inevitable fall, back when life expectancy was 60, are woefully inad-equate now that we hang on through eight decades.

One in three Americans has no sav-ings at all — fixed pensions are gone. Where are the families, you ask? They are scattered and struggling. Our daughters are scrambling: 40% are try-ing to raise their own children alone. And our sons, albeit with exceptions, tend to exempt themselves from care-giving. Yet grandma and grandpa still help when they can: in 2014, they were raising close to 3 million of our nation’s grandchildren.

But demography is destiny.Eventually we will all need care. And unless we are very poor or very wealthy, that care is unaffordable and thus unob-tainable. You, with some resources, think you will float above the fray? Try to find — today, right now — a qualified geriatrician, an honest advocate, a 24/7 live-in caregiver, a “good” long-term care facility. It is a difficult task at present, and it will be much harder in 10 to 20 years. Our nation does not reward those who do this work.

Driven out of Paradise, our elderly — living in shelters or tents, or in cars or vans, perhaps even with relatives or empathic strangers — are on full display. They are now the “new abnormal.” As the fires still rage, pandemonium reigns, and too many have been turned to ash. America is not innocent in this disaster.

We have been warned again and again. We are waiting for a savior who will not come. Our destiny, it seems — in the richest democracy in the history of the world — is in our own frail and trem-bling hands.

Dr. Winakur is a grandfather and a geriatrician. his latest book is Human Voices Wake Us (Kent State University Press, 2017).

MEDITaTIONS ON GErIaTrIc MEDIcINEJerald Winakur, MD, MacP

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“Everyone knew someone whose child had been stricken.” The children in the 1954 field trial were called Polio Pioneers, and they retained that lifetime identity from “a moment of personal glory achieved by being part of a crowd.” In PALTC there are great examples of creating a similar shared mindset through common experiences — from interdis-ciplinary rounds to shared metrics for key result areas. Professional member-ships also can resonate with our inter-ests and values to provide a common identity. The first time I attended the annual conferences of the Society and the Gerontological Advanced Practice Nurses Association (GAPNA), I imme-diately felt a strong sense of kinship and belonging.

Ensuring the enabling conditions — compelling direction, strong structure, supportive context, and shared mind-set — while exciting, may also seem daunting, especially for a new leader. Professional development plans are vital so that leaders can build on exist-ing capabilities, acquire new skills, and engage their teams and other stakehold-ers effectively and with confidence. As Maya Angelou said, “People will forget what you said, people will forget what you did, but people will never forget how you made them feel”. The goal is a positive culture where individuals feel respected, challenged, and central to the success of the vision.

Ms. rathke is principal at KMr consulting and specializes in talent management and organizational effectiveness solutions. She is an adult/gerontological nurse practitioner with senior leadership experience in global human resources. Ms. rathke is active in both aMDa and IMDa (Indiana).

Leadershipfrom page 3

carINGFOrThEaGES.cOM carING FOr ThE aGES 9

Our Foundation’s Unique annual FundBy Matthew Wayne, MD, cMD

To the best of my knowledge, just about every college and university

alumni association has an annual fund campaign to raise money for scholar-ships, facilities, and other higher educa-tion purposes. At some schools, classes compete to determine which is giving the most funds.

The Foundation for Post-Acute and Long-Term Medicine (PALTC), which we refer to as “Our Foundation,” also has an annual fund and I accepted the

invitation to take on the role of campaign chair. I agreed because I strongly believe that AMDA – The Society for Post-Acute and Long-Term Care Medicine needs a robust foun-dation, a body dedicated to rais-

ing money for special programs and pur-poses not covered by our membership dues. It is like a college that raises money for programs not covered by tuition.

Our Foundation focuses on three key areas: workforce development, PALTC quality measures, and recognition of excellence and innovation. Each year, the Foundation board reviews and evaluates the programs it is funding and the board continues to see great success in our Futures program, our efforts to develop and fund quality measures, and the excellence recognition awards we pres-ent at the annual conference each year.

Yet, there is at least one significant difference between a college annual fund and our own annual campaign. The difference is largely math. For an undergraduate college, there is close to a 100% turnover in students every four years. Over time, this creates a very large pool of alumni. But within our Society, many people are members for as long as they are in practice—one, two, three, or more decades. While some give to the Foundation even after they are no longer members, most are donors at the same time they are members. So, the pool of funders for Our Foundation is much smaller.

To me, that means we must accom-plish a much higher percentage of contributions in order to fund Our Foundation. But there is a way that math can work in our favor. I may be setting the bar very low—or very high—but if AMDA members contributed an average of $100 each, Our Foundation would be able to fund programs with roughly $500,000—and that would mostly be new money.

When I say “an average of $100 each,” I know I’m not speaking of a pittance. But I do want to point out that Our Foundation is unique. It is the only charity created by and that works for the purposes of our

PALTC profession. Our Foundation is the only nonprofit dedicated to workforce development, quality care, and recogni-tion of caregiving excellence. Your con-tribution to Our Foundation makes an important difference.

I am asking you as a reader of Caring for the Ages or an AMDA member to please join me and many others in

contributing at the level you can afford to our annual fund. All you need to do is go online at www.paltcfoundation.org and find “Donate” or write a check to the Foundation for Post-Acute and Long-Term Care Medicine. We won’t hound you with phone calls, so it is important that you act now and make what is a very important contribution to

what we can together uniquely call Our Foundation.

Thank you.

Dr. Wayne is chair of the Foundation’s annual appeal campaign and a past president of aMDa – The Society for PaLTc Medicine.

Matthew Wayne, MD, cMD

10 carING FOr ThE aGES March 2019

Even so, some independent assisted liv-ing facilities and full-spectrum corpora-tions are investing and signing on as early adopters, said Mr. Smith and Liz Jensen, RN, MSN, RN-BC, the compa-ny’s clinical director. Technology compa-nies, in the meantime, seem more willing to invest in the research “that’s necessary

to prove the [clinical value and efficacy] of these new ways of providing care and services,” said Ms. Jensen.

Passive monitoring technology is not “ready for prime time . . . but the tech-nology is moving in the right direction,” said geriatrician Jay Luxenberg, MD, a clinical professor at the University of California at San Francisco and medical director of On Lok, Inc., which oper-ates a PACE program (Programs of All-Inclusive Care for the Elderly). On Lok

has been collaborating with researchers at Stanford University’s artificial visual intelligence laboratory on piloting the use of depth and thermal sensors that monitor daily activity patterns and pro-duce corresponding analytics that cli-nicians can use to identity potentially troubling patterns of activity.

“We tell [the researchers] at Stanford, this person got dehydrated, this person fell, this person needed to be hospital-ized with a [urinary tract infection],” Dr. Luxenberg said. Over time, the sys-tem learns which changes can precipitate — and predict — a significant change in function and health. “This,” he told Caring, “is the future.”

Inside TigerPlaceTigerPlace was built as a state-of-the-art independent living facility in which resi-dents could live through the end of life with the support of both care coordina-tion led by registered nurses (RNs) and new technologies to help them improve and maintain their physical and cogni-tive functions. It was built to nursing home standards but was licensed as an intermediate-care facility with waivers to operate as an aging-in-place facility. Essentially, the 54-apartment facility is run as independent housing, with the facility and service operations managed by Americare and the care component managed by a federally certified home health agency created as a department within the MU Sinclair School of Nursing.

The wireless sensor system, developed at the MU College of Engineering’s Center for Eldercare and Rehabilitation Technology (CERT) in consulta-tion with nursing staff and with input from resident focus groups, has several main components. Hydraulic bed sen-sors measure pulse, respiration, and restlessness. Depth sensors produce three-dimensional silhouettes and col-lect information on movement and gait (such as stride length, gait symmetry, and speed). And simple passive infra-red motion sensors produce data that are processed to convey activity levels and patterns (known at TigerPlace as “motion density” patterns). With the use of Microsoft Kinect, a motion-sensing

device originally designed for gaming consoles, each resident can be accurately differentiated from other residents, fam-ily, and caregivers.

From the start, “we set out to find new ways to detect changes in function because we thought that, as health care providers, if we could measure func-tion better, we could help people stay healthier longer,” said Marilyn Rantz, PhD, RN, curators’ professor emeritus in the MU Sinclair School of Nursing and executive director of the Aging In Place project and Sinclair Home Care.

Iterations of the sensor systems were installed in the apartments of consenting residents starting in 2005. Over time, longitudinal collection of sensor data and analysis of significant health events enabled the researchers to develop and test various health alert algorithms. “We went through a lot of sensors over the years, and we also experimented with various clinical parameters so that we got a handle on what [sensors and data] give us the most bang for your buck — the most clinically relevant information,” said Marjorie Skubic, PhD, professor of electrical engineering and computer science and director of CERT.

For instance, “over the years we’ve learned how to map their average in-home walking speed to a standardized fall risk assessment instrument, the TUG [Timed Up & Go] score,” she noted. “So we can tell from our data analysis system whether someone has a low fall risk or a high fall risk.” One of the most recently published studies on falls showed that a decline in walking speed of 5.1 centime-ters per second over a week is associated with an 86% probability of falling. The CERT clinical teams continue to work on streamlining their intervention pro-cess for fall prevention, Dr. Skubic said.

The sensor technology has also alerted providers to early signs of urinary tract infections, pneumonia, upper respiratory infections, pain, delirium, hypoglycemia, and other problems, Dr. Rantz said. She and her colleagues have described the health alerts and what they call a new paradigm of technology-enabled “vital signs” in several published articles.

In an interview with Caring, Dr. Rantz vividly recalled the first time, early in

Technologyfrom page 1

CHICAGO ILLINOIS 2020ANNUAL CONFERENCE • APRIL 2-5

SAVE THE DATEAbstract Submission Opens

April 29, 2019

KEY TECHNOLOGY TRENDS

• The commercial marketplace for passive sensor systems is still in its infancy.• Continuous, around-the-clock data that can translate into alerts or pre-

dict changes in health is the biggest trend in technology innovation for seniors.

• The use of monitoring technology — both biometric remote patient monitoring (as in chronic disease management) and activity monitoring — is on the rise.

• User interface and modes of delivery of usable information to residents and families are becoming increasingly important.

• Most facilities willing to invest in technology are drawn to its fall preven-tion capability while considering its illness-predicting capability too far fetched.

• Technology that helps skilled nursing facility (SNF) providers follow patients home after discharge will emerge in the future.

• As the use of sensors increases, issues related to data security and resident privacy will demand more attention.

“We [clinicians] tell [the technology developers], this person got dehydrated, this person fell, this person needed to be hospitalized. Over time, the system learns which changes can precipitate — and predict — a significant change in function and health. This is the future.”— Jay Luxenberg, MD

carINGFOrThEaGES.cOM carING FOr ThE aGES 11

the research process, that sensor data prompted a valuable intervention. “I was looking over [nighttime bed sensor] data and graphs during a routine morning meeting and knew right away what was going on — that the patient’s [conges-tive heart failure] was accelerating. We caught it early, and we prevented an [intensive care unit] stay,” she said. “This was the first case of a pattern recognition for us . . . before we’d even gotten to the point of sending out automated alerts” to clinicians.

Not all residents at TigerPlace have lived with sensor technology. On aver-age, about half of the facility’s apart-ments have had active systems and half haven’t — a breakdown that has enabled the researchers to tease apart the effects of automated alerts versus the effects of RN coordination, the latter of which is the standard at the facility. A study of length of stay over a span of almost 5 years found that residents using the sensor technology lived at TigerPlace for 1.7 years longer than those without the sensors (Nurs Outlook 2015;63:650-655). (RN coordination alone added an average of 0.8 years to length of stay compared with the national median of 1.8 years in residential senior housing.)

CERT’s current research on sensor technology aims to further improve the alert algorithms and “back-end pro-cessing,” but increasingly it focuses on the user interface — on how best to deliver information to the clinicians who are caring for patients in assisted living or other senior living communi-ties. At TigerPlace, for instance, a clini-cian might now receive an alert of an “increase in bed restlessness” or “greater use of the bathroom,” with a link to graphs and other data for their interpre-tation. But the goal is to capture even more in words. With funding from the National Library of Medicine, CERT is trying to achieve “linguistic summariza-tions” of clinically relevant trends and changes.

And under another 4-year grant from the National Institutes of Health, Dr. Skubic and her team are developing prototype systems for communicating sensor data to seniors who are younger than the population at TigerPlace and to their family members. “Right now we’re asking, What’s the best platform? How should the information be orga-nized so they and their families can use it? What will they use the information for? Could family members get text messages?” she said. Dr. Skubic noted that focus group sessions with seniors and their families have helped shape the prototypes. Later this year, the sensor systems will be deployed in two set-tings — an upscale senior living com-munity and a government-subsidized senior housing community — to test them out.

Outside TigerPlaceA more robust, commercialized version of the sensor system used at TigerPlace has been installed in hundreds of rooms in multiple assisted living communities and memory care units in Missouri and other states by Foresite Healthcare, a company formed in 2013 by former MU doctoral student George Chronis, which partnered in 2017 with Stanley Healthcare as a distributor. (Drs. Rantz

and Skubic are involved in Foresite as advisors and researchers.) Thus far, Dr. Chronis said, the main draw for facili-ties has been the “fall detection and prevention feature of the system.” For many clients, early illness detection still often “sounds like magic,” he said, even though ultimately it has much greater value.

Majd Alwan, PhD, senior vice presi-dent of technology and executive direc-tor of the LeadingAge Center for Aging Services Technology (CAST), has been tracking technology adoption and devel-oping toolkits for technology selection. He said there has been a recent jump in using monitoring technology — both biometric remote patient monitoring (as in chronic disease management) and activity monitoring (passive or active).

Approximately 17% of 200 large, nonprofit, multisite senior living orga-nizations that participated in an annual survey conducted by LeadingAge and Ziegler, an underwriter of financing in this sector, had adopted technology for activity monitoring by the end of 2016. Dr. Alwan said, “Within that 17%, almost all of them include some level of [passive] monitoring of activi-ties . . . and some are incorporating

Explore the � eld of post-acute and long-term care, with expert interviews, journal article reviews,

innovations news, and more.

Visit paltc.org/podcast or search for “AMDA On The Go” on:

Introducing the Society’s Podcast:

AMDA-On-The-GoHosted by: Dr. Wayne Saltsman

AMDAOn-The-Go

WHAT ABOUT WEARABLES?Researchers at the University of Missouri (UM) made a deliberate decision not

to use wearable devices — and to focus solely on passive sensor monitoring — when they developed their technology for TigerPlace in the early 2000s. “As nurses with experience in long-term care and older adults, we knew they would not wear stuff when they’re not feeling well,” said Marilyn Rantz, PhD, RN, curators’ professor emeritus in the MU Sinclair School of Nursing and executive director of the Aging in Place project and Sinclair Home Care. “It’s just when they need it most that they wouldn’t have it on.”

By now, TigerPlace and other communities have proven that valuable clinical information can be gleaned from the environment without requiring the elderly to wear anything or handle any buttons or plugs. Still, wearable devices are one of the three main categories of technology — along with passive monitoring and interactive technology — that have a role in addressing and preventing functional decline, experts say.

Certainly, “any technology that can track individuals and encourage them to engage in physical activity (including physical therapy) is the best preventive use of technology,” noted Majd Alwan, PhD, senior vice president of technology and executive director of the LeadingAge Center for Aging Services Technology (CAST).

Today’s wearables aim to do more than track step counts and pulse, however. Some are being marketed for the collection of data on behavior, activity, and movement in seniors with the goal of predicting illnesses early. The challenge, said Marjorie Skubic, PhD, the director of MU’s Center for Eldercare and Rehabilitation Technology, is that “many aren’t carefully validated against clini-cal outcomes.”

And the question remains of whether these devices can be used reliably in the geriatric population. Dr. Skubic is planning to integrate wearable devices into her upcoming studies of senior living communities outside of TigerPlace. In addition to tracking levels of activity outside the home (where passive monitor-ing will not be possible), one of the things she wants to know is whether seniors will use them consistently.

Research will tell, but tomorrow’s seniors will be much more comfortable with devices overall. “It makes sense for whomever is looking at solutions for [the aging] to think comprehensively about solutions that support today’s residents with passive technologies as well as tomorrow’s residents who will be moving in with their Fitbits and Apple watches,” Dr. Alwan said.

Continued to next page

Marylin rantz talks to a TigerPlace resident.

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12 carING FOr ThE aGES March 2019

more comprehensive and advanced functionalities.”

Thus far, most of the use of activity monitoring has been in retirement and assisted living/senior housing communi-ties “where the provider is making the investment and folding it into the rent of the unit or the overall [price] being charged,” Dr. Alwan said. “The value proposition is keeping people as inde-pendent as possible for as long as possi-ble . . . delaying a transition into assisted living, for instance, or when they’re in assisted living, delaying a transition to skilled nursing.”

Dr. Alwan said his belief in the power of passive health status monitoring was bolstered years ago when he and his then-colleagues at the University of Virginia’s Medical Automation Research Center conducted a controlled study of their passive monitoring system in assisted living, the same technology that would serve as a basis for the first-generation system used at TigerPlace. Over a 3-month period, they dem-onstrated a 75% reduction in billable interventions — including hospitaliza-tions, physician visits, and antibiotic prescriptions — in a monitored cohort

in two communities, compared with an unmonitored cohort in a third, similar community in the same region (Telemed J E Health 2007;13:279–285).

The technology won’t deliver, how-ever, unless staff have the training and resources to understand the predic-tive data and to “turn it into preven-tive action that improves function,” Dr. Alwan said. And at the most basic level, the current payment models and a lack of reimbursement streams are hamper-ing its adoption, Dr. Alwan and other sources said. There are competing pri-orities, moreover; some facilities are still trying to achieve basic Wi-Fi capability, and others are investing in electronic health record systems.

Mr. Smith of Direct Supply said he expects the passive monitoring market to quickly evolve, given the current attention to fine-tuning the software and decreasing the cost of the systems. “The hardware is ready to go,” he said. “And in the long term, costs may be lower in the scheme of things because the system doesn’t necessarily change with the turnover of a room [or living space].”

Ms. Jensen, in the meantime, pre-dicted that skilled nursing facilities will increasingly see the potential of

the evolving market. “SNF providers are now following the resident after discharge to home with the hope of avoiding their return to the hospital, but many of their processes are staff intensive, like follow-up phone calls or visits,” she said. “I think we’ll see more SNFs invest in technology that supports this process, but questions of who will pay for it remain.” LeadingAge has been advocating that the Centers for Medicare & Medicaid Services ensure that the SNFs using remote monitoring

technologies can support their costs related to infrastructure, hardware, software, and staff training, Dr. Alwan noted.

As monitoring technology evolves and is adopted by more facilities and systems, Ms. Jensen said, it is impor-tant that caregivers and clinicians con-tinue to appreciate their roles. Sensor technology “is not replacing who they are — it’s giving them more informa-tion to make a good decision. Their role is still to be a good critical thinker,” she pointed out. “But it’s also to be an advocate for the resident. The applica-tion of these sensors will create new issues related to privacy and data secu-rity . . . and clinicians will probably find themselves being asked by a daughter, for instance, ‘Is this camera or sensor a good idea to put in place for my mom?’” Clinicians will “need to be able to understand what the technology can give [their patients],” Ms. Jensen said. They must know “what they can expect to get out of it,” and they need to listen to and respect their patient’s concerns.

christine Kilgore is a freelance writer in Falls church, Va.

Continued from previous page

Communication. It’s something ev-eryone does every day. But some-

times what is said and what is heard are two different things. “Clinicians get frus-trated because they think they’re commu-nicating well, but people don’t seem to understand what they trying to say,” said Bob Arnold, MD, one of the founders of VitalTalk. Practitioners, he said, often talk to each in “shorthand and words we have a common understanding of, but patients don’t share this understanding.” He added, “It’s hard to shift gears from talking to colleagues to talking to patients and families.” One solution is to help practitioners develop and use different skill sets — such as acting and improvi-sation — to be better communicators.

Practice Makes PerfectSome programs give practitioners an opportunity to tap into their inner actor to be better communicators. For instance, Megan Cole, a stage and screen actor, offers workshops and courses for practitioners on “Balancing Engagement and Objectivity” and “Literature and Medicine.” In her programs, Ms. Cole shares some of her acting skills with participants, such as being aware of the context and subtext of what people are saying and doing. She helps people understand how to break events into goals, actions, and obstacles. Ultimately,

she said, the course is about ways of looking beyond a patient’s condition to see the person inside. It is about finding a balance that allows the practitioner to engage with the patient without becom-ing personally lost. This balance is essen-tial, she noted, explaining, “We have to learn to trust ourselves and how to balance engagement and detachment.”

Acting is about behaving “as if,” said Ms. Cole. “It’s another way of imagining yourself in the shoes of your character.

If I were this person, how would I feel? How would I behave?” This isn’t so dif-ferent from what practitioners need to do to communicate effectively with patients and family members, she suggested.

Ms. Cole encourages practitioners to watch movies and plays where actors portray someone struggling with a seri-ous illness or with aging. She said, “If the performer is doing his or her work right and well, [viewers] will get the experi-ence by proxy. They will be drawn into

the situation and feel with the person. They will learn what it’s like to be that person and to have that particular illness. This gives them a safe place to reflect.”

She also encourages practitioners to read literature that addresses aging and illness. She said, “Literature teaches us eternal truths in entertaining ways and reminds us that there is always more than one way to interpret any human experience.” She added, “Literature shows us again and again that different people have a different experience and perspective of the same event.” Reading, she offered, helps us understand and even internalize some of these different views.

From Improv to InfoActor Alan Alda came to a realization several years ago that improvisation could help researchers and other practi-tioners effectively communicate techni-cal scientific information to lay people. As a result, he developed the Alan Alda Center for Communicating Science as part of the Stony Brook University School of Journalism. “Real listening is the willingness to let the other person change you,” Mr. Alda said. The Alda Method taught in his programs uses the improvisational theater techniques

Performers Put Practitioner communication in the FootlightsJoanne Kaldy

See PERFORMERS • page 20

Megan cole helps practitioners find balance between engagement and detachment in communicating with patients.

“SNF providers are now following the resident home after discharge with the hope of avoiding their return to the hospital. I think we’ll see more SNFs invest in technology that supports this process, but who will ultimately pay for it remains the question.”— Liz Jensen

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14 carING FOr ThE aGES March 2019

Did your mother ever equate learn-ing to your brain being a cookie

jar, with each new bit of information we learned like a cookie being stored in that jar? My wife, Cheryl, used that anal-ogy to her son as a positive incentive to learning, and it worked until the study cramming session when Aaron declared, “Mom, my cookie jar is full! I can’t learn anything else new unless I throw out some old cookies that are in there now.” Sometimes the wisdom of children trumps even the wisdom of mothers — but as mothers always do, Cheryl had captured the essence of truth with the cookie jar analogy.

That perspective is being proven by research on how people process informa-tion to make decisions, what improves the decision-making process, and what degrades those choices. A key feature, of course, is the amount and presentation of the information. Data input affects our choices in a bell curve fashion: some information is good, and more informa-tion is better for correct decisions — but only up to a point. Beyond this optimal amount of information, the more input we receive, the worse our choices become.

Take a restaurant menu: the more appetizers, entrees, salads, and desserts I see, the more likely I am to give up and order the last thing I looked at when the server demands my dinner selection. Invariably, I will hate my dinner selec-tion — and all this is just as decision science would have predicted. In fact, decision science has become a legitimate subject not only for university courses but also for college majors and even established institutes.

Our information overload world of Twitter, Facebook, Snapchat, YouTube, and other electronic media blasts along with 24-hour newscasts resulted in the term “information fatigue” being added to the Oxford English Dictionary in 2009. The physiology of this con-dition is being researched by Angelika Dimoka, PhD, the director of the Center for Neural Decision Making at Temple University. Dr. Dimoka has studied vol-unteers who were exposed to increasingly complex sets of information then asked to make theoretical choices while their brain activity was measured by func-tional magnetic resonance imaging. The result was that activity in the dorsolat-eral prefrontal cortex (PFC), an area of the brain responsible for decision mak-ing and emotion control, became more and more active — until abruptly it fell off, when the information burden (the cookie overload) became overwhelming. At that point, the participants began to

make errors and poor choices, followed by frustration, as the brain emotion regions, previously held in check by the dorsolateral PFC, cut loose. Ultimately, the participants just stopped making any decisions at all.

This brings us to care transitions and how the information fatigue phenom-enon affects our patients. We now have a neurophysiologic explanation for why a patient might not carry out the instruc-tions on changing medications, follow-ing up with a physician, or obtaining a follow-up computed tomography scan or other discharge items we may feel are both critical and obvious. I submit my theory: we are overwhelming our tran-sitioning patients with so much regula-tory and legalistic required information, much of it having little relevance to that particular patient, that the key informa-tion is lost.

I can support my thinking with some anecdotal personal experience. I had the pleasure of being part of a project that implemented an inter-rater reliability method to ensure accuracy and con-sistency in the Beneficiary and Family Centered-Care Quality Improvement Organization’s (BFCC-QIO) case review process. After reviewing randomly selected charts, I noted a number of patterns:

1.The charts were never less than 100 to 200 pages, and frequently they were over 400 pages. (These were for a hospital stays that were, by definition, less than 48 hours.)

2.The discharge instructions were regularly in excess of 40 pages.

3.All the instructions were in English.

4.Even with a medical degree, I often found the instructions dense and difficult to follow.

5.The instructions were definitely not patient-centered to the indi-viduals being transitioned.

Among the boilerplate sets of discharge instructions in the charts I reviewed, I found these gems:

• A patient was given a set of simi-lar — only slightly different — in-structions to those already provided less than a week before when the same patient was discharged from the same hospital.

• A 92-year-old man was given in-structions to not take his discharge medications with birth control pills.

• Patients who had already received flu and pneumonia vaccines were given information about obtaining both.

• A patient whose admission history and physical indicated he spoke

no English received instructions in English.

• A patient whose history and physi-cal stated “Patient is blind” was given written instructions.

Nor did the instructions generally make any reference to the patients’ socioeconomic conditions — such as whether they were infirm, blind, or cog-nitively impaired, whether they needed to obtain the medications themselves or were being cared for at home, or whether they could drive or even afford the medications.

Other data overload problems are in play with discharge instructions. First, as decision science advocates have noted, in a data overload situation people will tend to recall the most recent data received, irrespective of its source. Thus, after the typical lineup of clinicians have presented their hospital discharge infor-mation (the hospitalist, pulmonologist, cardiologist, dietician, discharge plan-ner, and others), the memory a patient will internalize will be the last person’s instructions — regardless of licensure, professional discipline or specialty, con-tent, or relative importance for out-comes. Second, the more information showered upon us, the poorer our deci-sions become. Third, overwhelming data dumps do not cause us to do the wrong thing — rather, they prompt us to do nothing at all.

At the beginning of my involvement in care transitions, I believed clinicians were providing too little information to transi-tioning patients and their families. Now I contend we provide too much informa-tion — by too many members of the clin-ical care team, in an uncoordinated and rapid-fire way, without tailoring it to the needs of the transitioning patients. After we have asked our patients to attempt to drink from a firehose of information, we provide them with a 40-page set of dis-charge directions to ensure compliance, with no regard to their language, reading or visual ability, or health literacy.

I believe the answer is to assess our patients to determine their level of ability to understand and implement discharge instructions, as proposed by Jackie Vance, RNC, BSN, my friend, colleague, and former staffer with AMDA — The Society for Post-Acute and Long-Term Care Medicine. Doing so allows the dis-charging entity to determine the best avenue to effectively craft a discharge plan that is not only appropriate but can actually be implemented by the patient.

What would such an evaluation look for? Here are some thoughts:

• Is any sensory impairment present (inability to hear, see, speak, etc.)?

• Can the patient read?• What is the patient’s health literacy

level?• Does the patient use English as a

second language?• Does the patient have cognition,

memory, or judgment issues? (This would include such problems as de-menting disease, delirium, mental health issues, and substance abuse.)

• Can the patient provide self-care? If not, how is care to be provided?

• Does the patient have the financial resources to purchase medications and medical equipment or meet other discharge medical needs?

• In any transitioning patient with the type of concerns listed here, will family or a caregiver be present at the time the instructions are pro-vided?

• Can the discharge instructions be provided by a single person, sum-mating all instructions?

Part of the discharge/transition pro-cess should always include an assessment of the patient’s (or surrogate’s) under-standing of the instructions. Preferably this assessment should include a teach-back or similar aspect to ensure that the patient or surrogate can articulate the critical elements of the instructions.

Informed, engaged patients and fami-lies are at the heart of good transitions. So let us consider not only the number and type of cookies we provide to our transitioning patients but also the size and characteristics of the cookie jar we use as our discharge instructions.

Dr. Lett is a Society past president, past chair of the Society’s Transitions of care committee, and previous editor of this column. Dr. Saltsman (pictured above) is the section chief of geriatrics and transi-tional care for Lahey health, Burlington, Ma. he is the chair of the Society’s Transitions of care committee.

carING TraNSITIONSJames E. Lett, II, MD, cMD, with Wayne Saltsman, MD, PhD, cMD

Too Many cookies

Clinicians provide too much information to transitioning patients. Overwhelming dump of discharge instructions lowers our decision-making capacity, causing patients to do nothing at all.

carINGFOrThEaGES.cOM carING FOr ThE aGES 15

The role of the post-acute and long-term care (PALTC) medical director

has evolved over the years. However, talk to any member of AMDA — The Society for Post-Acute and Long-Term Care Medicine who fills this role and you will hear passion, commitment, and energy. You will hear a love for their pa-tients and their work, and loyalty to their teams. Yet the role of a facility’s medical director is often a better kept secret than Superman’s identity. If you were to ask a resident or family member to name the medical director, you often would get a blank stare. In 2006 the Society established the Medical Director of the Year (MDOY) Award to help showcase the medical director as the facility’s clini-cal leader and to recognize outstanding physicians who are innovative, visionary, and set high standards for quality care.

As always, this year’s MDOY nomi-nees are among the most innovative, inspiring practitioners in the field.

Charles A. Crecelius, MD, PhD, CMD St. Louis, MODr. Crecelius is everyone’s go-to for edu-cation, information, advice, guidance, insight, and more. He is committed to promoting PALTC, and as a clini-cal instructor of medicine and geriat-rics at Washington University School of Medicine, he exposes fellows to the man-agement of common geriatric medical problems and related issues. In conjunc-tion with the Sinclair School of Nursing, he initiated and helped coordinate a Healthcare Decisions Day at Delmar Gardens, where he has been the medical director for 20 years. He recently helped establish the PAC/LTC Consortium, a collaborative effort among post-acute care representatives from local hospitals and accountable care organizations, rep-resentatives from local skilled nursing and rehabilitation facilities, and other stakeholders. The consortium pro-vides a forum for professionals across the care continuum to share views and develop universal clinical care pathways. Dr. Crecelius is a past president of the Society and the Missouri state chapter. He has chaired and served on numerous committees, and he is a frequent and highly knowledgeable speaker on legisla-tive and regulatory issues (and other top-ics) at the Society’s annual conference.

Fred Feinsod, MD, CMDColorado Springs, CODr. Feinsod, in addition to being a strong team leader, has been a passion-ate advocate for his patients. He initi-ated conversations in Colorado about distributive justice, concerning the lack of available specialist support for resi-dents with complex medical needs. He chaired a forum in Colorado Springs that involved several long-term care communities’ councils and federal, state,

and local-level bipartisan candidates. He chairs and co-chairs ethics committees, and he provides numerous in-service programs and informal consultations on best practices or emerging thoughts through articles and presentations on topics ranging from falls to antibiotic stewardship. He is a proud practitioner serving rural communities and often travels hundreds of miles each week to see patients and work with facilities in remote areas. He frequently presents on topics related to rural medicine at the Society’s annual conference. Dr. Feinsod also plays in the Grand Army of the Republic Band, using a mountain dul-cimer he made himself.

Tsewang Ngodup, MD, CMDMinneapolis, MNDr. Ngodup is passionate about edu-cation and has led countless programs on topics ranging from substance use disorders and immunizations to hearing loss in older adults and residents’ right to refuse care. Dr. Ngodup implemented an antibiotic stewardship program that led to a decrease in urine tests and improved documentation regarding urinary tract infections and other infection-related issues, which has contributed to quality care and outcomes. He targeted poly-pharmacy, and his efforts have led to decreased antipsychotic prescribing, lower rates of narcotics use, and bet-ter medication reconciliation. He has served as president and board member of the Tibetan American Foundation of Minnesota and has been active in the Asian Pacific Endowment and the Council on Asian-Pacific Minnesotans. He has volunteered as a physician for community events in the United States and abroad in India and elsewhere.

Zachary J. Palace, MD, FACP, CMDBronx, NYDr. Palace embraces change and meets both challenges and opportunities head on. He aided in the development of a groundbreaking Domestic Violence Prevention and Assistance Program that educated staff and senior manage-ment across the care continuum in his region about the signs, symptoms, and prevention of domestic violence. He won the Society Foundation’s Quality Improvement Award for his innovative project, “Development of an Outpatient Transfusion Program to Reduce Avoidable Hospitalizations,” which not only kept patients out of the hospital but also had a positive impact on quality of life and costs. Most recently, he and his team established an innovative program regarding medical cannabis in his facil-ity. This program not only enables the use of this therapy to improve pain and symptom management (as well as quality of life), it also ensures compliance with federal and state laws. He described the

program in an article in the January issue of JAMDA. He is a frequent speaker at the Society’s annual conference and other regional and national programs.

Jennifer Riedinger, MD, CMDCatonsville, MDDr. Riedinger is a team leader in the tru-est sense possible. She created a robust and meaningful training program for advanced practice providers, and she has mentored several physicians, all of whom have gone on to pursue their Certified Medical Director designation. She works with staff on establishing best practices, educates them on a wide array of topics, and shares her expert-level knowledge on the Merit-Based Incentive Payment System (MIPS) and other regulatory issues. Dr. Riedinger established a forum for medical direc-tors to offer support and discuss best practices. Additionally, she created a urinary tract infection protocol and other clinical learning tools to stan-dardize care, and she developed a clinical documentation tool to review readmissions and contributing factors to rehospitalization and monitor anti-biotic stewardship. She led an inte-grated medicine program connecting hospitalist and post-acute care teams to enhance continuity of care. To maxi-mize quality and the patient experience, Dr. Riedinger created and implemented an effective patient satisfaction survey.

James Rider, DO, CMDValley Falls, KSDr. Rider is a natural educator whose presentations on Clostridium difficile, antipsychotic use, and opioids have informed and empowered practitio-ners, caregivers, and other stakeholders

throughout his state and beyond. He is a wound-care certified physician who uses his skills to help others. He also has been a leading advocate for palliative care programs. Dr. Rider developed an innovative pediatric palliative care pro-gram and was instrumental in creating a wound-care coalition that involves quar-terly meetings with local wound-care nurses to mentor and educate others. He has provided wound-care education to hospice and nursing home staff, and he offers monthly staff in-service train-ing on a wide variety of topics. He also worked to set up the McGeer criteria in his facilities to help prevent unnecessary treatment of asymptomatic bacteriuria. Dr. Rider is an expert resource for sur-veyors, and he is always happy to share his insights and knowledge with medical, advanced practice nursing, and other students. In addition to his commitment to his work and his patients, he is a com-munity leader who is active in the Rotary Club and his local church.

Loveleen Sidhu, MD, CMDBethlehem, PA/Phillipsburg, NJDr. Sidhu is a strong communicator who holds monthly residential council meet-ings with veterans and their families, provides an introduction to hospice and palliative care to all facility employees, and conducts in-service training on a variety of issues, including sleep hygiene and noise control, nonpharmacologic pain management, and new devices for respiratory rehabilitation. Dr. Sidhu’s commitment to patients is exemplary. She provides an annual remembrance ceremony for all bereaved families, and she holds an annual fall festival and a

Medical Director of the Year Nominees, 2019Joanne Kaldy

See MEDICAL DIRECTOR • page 16

Eric hasemeier, DO, cMD, is receiving the 2018 Medical Director of the Year award from Barbara resnick, PhD, crNP. This year’s award ceremony will be held on Friday, March 8, during the opening session.

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16 carING FOr ThE aGES March 2019

What to Expect When cannabis comes to Your StateJoanne Kaldy

Support for legalization of medical cannabis is gaining speed in Missis-

sippi. Supporters have collected nearly 40,000 signatures to get the issue on the state’s 2020 ballot; they just need an-other 45,000 by September. To date, 33 states and the District of Columbia have approved the use of medical cannabis for various conditions, and the number is expected to grow. As more states are legalizing medical cannabis, more prac-titioners have to consider how this will impact their patients, their facilities, and their work moving forward.

Medical director Zachary Palace, MD, FACP, CMD, and his team at the Hebrew Home at Riverdale in Bronx, NY, developed an innovative program that affords residents the ability to par-ticipate in a state-approved medical can-nabis program while complying with federal laws. His experiences offer a use-ful path for post-acute and long-term care practitioners and their care commu-nities who are preparing for legal medical cannabis use in their states.

Buy-In From the Top and BeyondBuy-in from the top is essential, and Dr. Palace noted that he was fortunate to have this in abundance. “Our president and CEO, Daniel Reingold, saw the benefits of it with his own father. He was very excited. He came to me, and I had been thinking about it already.” The more he researched and learned about medical cannabis, the more Dr. Palace was struck by the indications for its use. “The diagnoses were so germane to the issues we see in our patient popu-lation — most specifically, neuropathy, Parkinson’s disease, and pain.”

That medical cannabis has potential benefit for some of his patients was with-out question. However, ensuring compli-ance with state and federal laws took a little more thought and planning. “No one wants to be in violation of federal or state laws or do anything to jeopar-dize Medicare or Medicaid funding,” said Dr. Palace. “The two main issues were administration and storage, and we devised a plan to address each.” This started with a policy and procedure that detailed issues such as who is eligible for the medical cannabis program, how the cannabis is obtained and stored, how it is administered and by whom, where the product can be consumed, and so on. The staff were educated on these new policies and procedures.

Each resident registered in the medi-cal cannabis program at Hebrew Home must purchase his or her own cannabis products directly from a state-certified dispensary. The cannabis must be stored by the resident securely. Each registered individual has his or her own lockbox for this purpose, and only that resident can access it. The cannabis can only be self-administered or given to the resident by his or her designated caregiver.

The nurses know which residents are registered in the cannabis program, but no nurse, other practitioner, or staff member can administer the cannabis or handle it in any capacity.

Mining the Myths, Focusing on FactsAs medical cannabis in nursing homes is still fairly uncharted territory, nurses and other staff are likely to have some questions and concerns. Dr. Palace said, “Occasionally a nurse would ask, ‘Is the patient going to get high? What effects will it have?’” Educating them can ease some of their worries. “We aren’t giv-ing any patients formulations with a significant amount of THC [tetrahydro-cannabinol], which is responsible for the feelings of euphoria and other effects of recreational marijuana use. Sharing the facts and research with staff helped ease their concerns.”

It also is helpful to share some of the background on medical cannabis with staff. The U.S. Food and Drug Administration has approved three can-nabinoids as medications: Epidiolex (cannabidiol or CBD), an oral solution for treating seizures associated with epi-lepsy; and dronabinol and nabilone to treat nausea and vomiting associated with cancer chemotherapy. Dronabinol is also approved to treat loss of appetite and weight loss in people with acquired immunodeficiency syndrome (AIDS). Dronabinol contains synthetic delta-9-THC, and nabilone involves a similar chemical structure. The FDA approved a liquid form of dronabinol in 2016.

Various professional societies have weighed in on the use of medical can-nabis. For instance, the American Academy of Neurology (AAN) issued a formal position statement that states, in part: “The AAN acknowledges inter-est in medical marijuana from patients and physicians and notes that several states have moved to legalize medical marijuana in some form. The AAN also recognizes that medical marijuana may be useful in treating neurologic disor-ders.” Elsewhere, the American Medical Association’s current policy states, “Our AMA urges that marijuana’s status as a federal schedule I controlled substance be reviewed with the goal of facilitat-ing the conduct of clinical research and development of cannabinoid-based med-icines, and alternate delivery methods. This should not be viewed as an endorse-ment of state-based medical cannabis, the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for a prescription drug product.”

AMDA — The Society for Post-Acute and Long-Term Care Medicine doesn’t currently have a formal policy about the use of medical cannabis, but JAMDA has published numerous articles dis-cussing the documented and potential

benefits of this treatment for nursing home and other PALTC patients. “The favorable side effect profile makes it a viable option for this patient popula-tion. We haven’t seen any adverse side effects,” said Dr. Palace. “We haven’t seen patients become dependent, lethar-gic, or constipated the way they some-times do with opioids.”

“A major game changer will be when the FDA recognizes that medical can-nabis shouldn’t remain as a Schedule I substance,” Dr. Palace added. While it’s difficult to speculate if and when such a change will happen, he suggested, “I would hope that as more studies come out demonstrating the therapeutic ben-efits of medical cannabis, the FDA will reconsider.”

“I Never Smoked Pot!”Educating residents and families was another top priority for Dr. Palace and his team. They kicked off the program with a town hall meeting for residents. They also distributed fact sheets to fam-ily members and held meetings for them as well. “People were concerned about the stigma of medical cannabis,” said Dr. Palace, adding, “Many people — residents and family members alike — didn’t realize that medical cannabis isn’t like smoking recreational marijuana and getting ‘high.’ In truth, it’s nothing like that. This program is very clean and structured. We know exactly what peo-ple are getting, what the standardized dose is, and the exact concentration of active ingredients.” Dr. Palace fur-ther observed, “It’s a highly regulated program, and we have a high degree of confidence in it.”

Dr. Palace noted, “I’ve had patients who are absolutely resistant to it. They say, ‘I’ve never tried marijuana in my life, and I’m certainly not going to try it now.’” Sometimes, he said, family mem-bers — such as adult children — are instrumental in convincing their parents to consider medical cannabis. They are often more open to alternative thera-pies and can influence their older family members, Dr. Palace suggested.

The Success StoriesUltimately, the patients and their out-comes tell the story. “We had one resi-dent who had pain and was withdrawn and isolated. Since he started using medical cannabis, his pain has lessened, he comes out of his room more, and his quality of life has improved,” said Dr. Palace. “Another resident on opioids for pain complained consistently. She had been active and creative at one time, and we encouraged her to get out and participate in activity programs. Instead, she stayed in her room and obsessed about when she would get her next dose of pain medication.” After the move to medical cannabis, the resident started to come out of her room and get involved

in activities such as painting. Her com-plaining has diminished.

There are many more stories like these. For instance, the New York Times pub-lished an article about Dr. Palace’s facil-ity featuring a 98-year-old resident in the medical cannabis program (Feb. 2, 2017; https://nyti.ms/2UuPhy8). She is now 100, he said, and she is still participating.

Jump In, or Dip a ToeIf medical cannabis is in your facility or in your future, said Dr. Palace, “The most important thing is to become edu-cated. There are lots of resources and numerous articles in the literature. The actual cannabinoid pathways in the brain have been thoroughly articulated. Learn about it, and understand how canna-bis is used for medical purposes.” He added, “Treat it as an alternative therapy, a complementary approach to pain and symptom relief.”

As with any medication, start low and go slow, said Dr. Palace. “See if there is a response, then increase the dose gradually as appropriate. Watch for side effects, and assess and man-age risks for problems such as falls. As with any medication, there is always a risk–benefit analysis the practitioner has to do.”

To learn more about the program, read an article authored by Dr. Palace and Mr. Reingold in the January issue of JAMDA (https://bit.ly/2SDXUdh).

spring dinner for veterans. Always con-cerned about quality of life, she started a “happy hour” for nursing home residents. She serves as a liaison with community hospice programs under a hospice–veteran partnership, and she implemented a No Veteran Dies Alone program via hospice.

An interdisciplinary panel will assess the nominees on their contributions and accomplishments in long-term care medicine — specifically, their clinical expertise, contributions to staff education, leadership, and com-munity involvement. This year’s award recipient will be announced during the Opening General Session at the Society’s annual conference on Friday, March 8. An interview with the winner will appear in the April issue of Caring for the Ages.

Senior contributing writer Joanne Kaldy is a freelance writer in harrisburg, Pa, and a communications consultant for the Society and other organizations.

Medical Directorfrom page 15

carINGFOrThEaGES.cOM carING FOr ThE aGES 17

MaryAnne’s StoryI looked at the diagnostic specialist and burst into tears. She had seen other women like me and knew what was wrong with my shoulder. Finally, after 14 months of being tossed between phy-sicians, specialists, and physical thera-pists and many misdiagnoses, I had an answer: frozen shoulder. It explained the extreme pain in my shoulder along with the stiffness and inability to move the shoulder joint. This condition takes 1 to 3 years to resolve, and there is little that can be done to relieve the pain or force the shoulder to move. It mainly affects people ages 40 to 60, and women more often than men.

Ironically, the demographic I just men-tioned also matches the demographic of the majority of family caregivers in the United States. Coincidence? I don’t think so. During my journey with this condition, one question has popped up over and over: “Are you under a lot of stress?” “No more than usual,” I would respond, thinking back on multiple decades and three of the four parents I shared with my husband experiencing dementia.

But as those 14 months had dragged on, I often thought about my mom. She was my dad’s primary caregiver for 14 years before his death in 2001. After that point her health had quickly gone downhill, and she developed new chronic conditions and old ones wors-ened. I’ve always considered caregiving the culprit.

The Caregiving JourneyIf you’re wondering, a 14-year caregiv-ing journey is not unusual: 12% to 15% of the time, caregiving lasts 10 years or longer, and the median duration is 5 years. The truth is, my frozen shoulder began after many years of stressful care-giving for my mom, which ended when she died in 2016. It didn’t take a rocket scientist to make the connection that I had been under long-term duress and it had taken a toll on me beyond just “chronic stress.”

And it’s not just women in their 50s. Consider that 10% of caregivers are aged 75 and older, about one in four are millennials, and at least 1.3 million are young caregivers aged 8 to 18. In fact, the Gates Foundation reported that 22% of high school dropouts say they left to care for a family member. Across all these groups, 15% care for more than one person.

In fact, when somber advocates and journalists talk about the negative health impacts of caregiving, they often make

urgent pleas for caregivers to “take care of yourselves.” Sadly, this conflicts with reality for many of us, who find it next to impossible to reduce the stress of provid-ing care and interface with our complex health care system — which takes a tre-mendous amount of time, energy, and financial resources, actually compounding the stress. We simply don’t have enough support.

So where does this stress come from? If you have not been a caregiver for an aging parent or grandparent, you may be surprised. Caregiving responsibilities can begin long before you are actually caring for someone in your home and continue long after they transition to a long-term care facility (for those who do). The physical burdens of caregiving are often eclipsed by the emotional roller coaster that ends in guilt.

For many of us, the guilt of having to place a parent in a nursing home is over-whelming. We know the quality of their care will not be the same, and it won’t be provided with the same loving com-passion. We feel guilty when we learn in the phone calls that inevitably come at 3 a.m. that our parent has fallen and broken an arm or ribs, and we wonder if we could have prevented it had they just been in our care.

But we’ve had to make these tough decisions. We can’t stay home to care for our parents because we have to work to feed our families and avoid bankruptcy. The stress soon becomes a tidal wave.

Stories From the Front LinesWe reached out to several current and former caregivers for a litmus test of their

health since they became caregivers. The responses were grim. They told stories of being healthy before they began caregiv-ing, only to develop multiple chronic conditions, depression, sleep depri-vation, even complicated conditions requiring surgery due to the relentless stress of caregiving.

Here are their own words:“I stayed too late at the hospital and

drove home tired. I totaled the car and didn’t tell my kids for 2 weeks for fear they wouldn’t let me stay late to watch over my husband in the long-term acute care facility.”

“In the last year of [mom’s] life and for a few years after my mom’s death, the physical, emotional, and spiritual strength I once was able to muster through caregiving devolved into full-blown panic attacks, clumsiness result-ing in multiple physical injuries, and an inability to engage effectively in simple social situations.”

“Between caring for my dad, husband, and adult sister, I had to start working a night shift. I gained weight, lost sleep, and developed atrial fibrillation.”

“[Mom] woke-up throughout the night to go to the bathroom, 30 to 40 times a night. I had to stay awake or she could fall or walk out of the house. A few days later, I was so exhausted I gave her an Ambien, hoping she would sleep through the night. I fell asleep for a few hours but was woken-up by a loud noise — my mother had fallen in the bathroom.”

“I am sure stress has taken years off my life.”

“Five years later she passed away . . . I was now single, unemployed, estranged

to many and financially strapped. My health was in shambles — uncontrolled blood sugars, high blood pressure and cholesterol, chronic depression, anxiety, arthritis.”

“I am the most optimistic person on the planet, but due to providing demen-tia care, I am on Prozac.”

The Hidden Health CrisisUnfortunately, many studies on caregiver health have been done on small groups, and some impacts are still not well stud-ied. The effects of caregiving frequently sneak up on people. Initially, caregiv-ers may be healthy, but over time they often don’t notice how they’ve neglected their own health and well-being. When a health problem occurs for them, they don’t seek help because they’re so busy with caregiving responsibilities. For example, a 2015 study found nearly one-third of dementia caregivers “frequently or occasionally” missed medication doses and nearly half did not keep their own health care appointments (West J Nurs Res 2015;37:1548–1562).

Health risk behaviors also go up: 40% of Alzheimer’s caregivers reported smok-ing, and 25% reported a recent increase in smoking. Thirty-four percent of spou-sal Alzheimer’s caregivers said they used alcohol as a coping mechanism.

Good sleep, the single most important resource for our health and well-being, often becomes a memory. Most caregiv-ers report poor sleep. To understand how little sleep caregivers often get, one study of brain tumor caregivers found they averaged less than 6 hours each night, were awakened 8.3 times per night and were awake 15% of the time (Oncol Nurs Forum 2013;40:171–179).

Family caregivers often need to move or transfer people and do other physical tasks but usually get little or no training. Even though we know this puts them at risk for injuries, there are very few data on injury rates or how this may contribute to chronic pain. In a small study done in 2014, researchers found that for caregivers who spend more than 21 hours a week helping their loved one with activities of daily living, 76% report low back pain, and 43% report knee, shoulder, or wrist pain (J Appl Gerontol 2015;34:734–760).

While caregiver depression and anxi-ety are common, caregivers are also at risk for post-traumatic stress disorder. Research conducted on family caregivers of patients in intensive care units found high rates of PTSD symptoms that can

The hidden health crisis: What Family caregivers Want You to Know

carEGIVEr’S PErSPEcTIVEMaryanne Sterling and Geri Lynn Baumblatt

CAREGIVER RESOURCES

The reality of caregiving often prohibits caregivers from taking care of themselves, but available resources may be able to alleviate some of the burden by providing information and other support.

• CareGiving.com, https://www.caregiving.com• Caregiver Action Network, https://caregiveraction.org• Family Caregiver Alliance, https://www.caregiver.org• VA Caregiver Support, https://www.caregiver.va.gov• National Alliance on Caregiving, https://www.caregiving.org/resources/gener-

al-caregiving/• AARP, “Resources Caregivers Should Know About,” AARG.org, Mar. 22,

2017, https://bit.ly/2OLa1Pt• John M. Bridgeland, John J. Dilulio Jr., and Karen Burke Morison, The Silent

Epidemic: Perspectives of High School Dropouts (Washington, DC: Civic Enterprises, 2006), https://bit.ly/2SeMThI

• Brendan Flinn, Millennials: The Emerging Generation of Family Caregivers, AARP Public Policy Institute, Mar. 22, 2018, https://bit.ly/2sdul2j

• National Academies of Sciences, Engineering, and Medicine, Families Caring for an Aging America (Washington, DC: National Academies Press, 2016), https://bit.ly/2sP0cXL

See HEALTH CRISIS • page 18

18 carING FOr ThE aGES March 2019

persist for 3 months after the intensive care experience. Researchers have found that many people still had significant risk for PTSD and borderline anxiety and depression at 3 months.

The high stress of caregiving has also been associated with a higher risk for

stroke. One study found this association was stronger in men, especially African American men with high caregiving strain (Stroke 2010;41:331).

The inescapable conclusion is that caregiving is creating a whole new health care crisis that looms in the shadows and is not getting the atten-tion it deserves. Caregivers are becom-ing the patients. We must find ways to minimize and prevent caregiver health

risks. We must make this hidden health crisis a national priority. Over 43.5 million family caregivers are counting on it.

Ms. Sterling was a caregiver and health care advocate for her parents for over 20 years. She is a renowned speaker and educator on alzheimer’s/dementia, as she and her husband have three of

four parents with the disease. She is EVP, caregiver Experience, at Livpact. Follow her on Twitter @SterlinghIT. Ms. Baumblatt is a patient engagement and health communication expert. She is the principal at articulations consulting and cofounded the Difference collab-orative to help organizations support their caregiving employees. She blogs about patient engagement and is on Twitter @GeriLynn

uneven flooring or sidewalks, poor light-ing or glare, lack of handrails, and prob-lems with assistive devices. The majority of falls occur in the resident’s room and are generally associated with physical transfers and using the toilet. There is no evidence to confirm that the number or type of nurses on duty influences falls.

Intervening to Decrease FallsBecause many factors are associated with falling, multicomponent interventions

are needed to decrease both the risk and number of falls. Physical activity — par-ticularly physical activity that is focused on improving strength and balance — can decrease the risk of falls and their incidence. Although no single exercise program or activity is currently consid-ered the gold standard for fall preven-tion, a number of studies have focused on resistance and balance exercises and others on moderate-intensity aerobic activity.

The current guidelines from the 2018 Physical Activity Guidelines Advisory Committee recommend that older adults engage in at least 150 to 300

minutes a week of moderate-intensity or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activ-ity and muscle-strengthening activities on 2 or more days a week (Scientific Report, http://bit.ly/2VLq1VN). Older adults in long-term care settings gener-ally participate in less than a minute of moderate-level physical activity; meeting the guidelines may not be realistic, so a personalized approach to physical activ-ity is recommended.

The physical activity goals for resi-dents should focus on each individual’s underlying capability and optimizing what each resident can do. For example, if a resident can come to a stand inde-pendently, doing 10 sets of sit-to-stand three times a day could strengthen her ability to transfer and stand without falling. If a resident can walk with or without an assistive device, then three 10-minute walks a day scheduled around meals or a 30-minute walk daily on an age-appropriate treadmill setting might be a good goal option.

Additional interventions to help pre-vent falls should include evaluating and managing medical problems such as degenerative joint disease to optimize gait and decrease pain. Experiencing pain when walking or transferring can alter an individual’s balance and potentially lead to a fall. Monitoring for orthostatic hypotension and adjusting medications accordingly can avoid the type of falls that occur after a drop in blood pressure with subsequent dizziness.

There is presently no consensus on the impact of psychotropic medica-tion on falls. For instance, one study found antidepressants were associated with falls but benzodiazepines were protective of falls (BMC Fam Pract 2018;19:73). In other studies, poten-tially inappropriate psychotropic medi-cations were associated with falls (Age Ageing 2018;47:68–74) as was opioid use (Drugs Aging 2018;35:925–936; Int Psychogeriatr 2018;30:941–946; Can Med Assoc J 2018;190:E500–506). The inconsistencies among the studies may be related to whether individu-als were naïve to a drug, or an opioid was combined with other psychoactive medications, or other risk factors for falls were involved such as orthostatic hypotension, vision problems, pain, or altered balance.

Management of medications for fall prevention requires an individualized approach to determine the potential risks and benefits. A resident who is so anxious that he walks to the point of fatigue or climbs on tables or chairs may benefit from an anxiolytic, which may consequently prevent a potential fall. Likewise, prophylaxis with drugs such as beta blockers should be reconsidered if they decrease perfusion and thus con-tribute to falls from hypotension. Most important is whether a drug is being used appropriately.

Environmental modifications such as removing clutter and optimizing chair and bed heights are also effective ways to decrease the risk of falls. Environment adjustments should also be personalized and match the needs of the individual. For example, the optimal chair or bed height to facilitate safe transfers allows individuals to sit on the edge of the bed or chair with their feet flat on the ground. Better lighting and reduction of glare can also be individualized.

Finally, personalized cognitive modi-fications may be needed. Individuals who cannot make safe decisions related to physical activity should not left alone

Together We Can Make a Difference

We Need Your

Support!

Your donation combined with the generosity of others will ensure that the vulnerable elderly will always have high-quality, skilled and compassionate care.

Make a donation today! www.paltcfoundation.org

health crisisfrom page 17

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FALL PREVENTION TOOLS

Listed below are just a few examples of many tools and resources on fall prevention currently available.

• AMDA Falls Clinical Practice Guide, https://paltc.org/product-store/falls-and-fall-risk-cpg

• Supakanya Wongrakpanich, et al. STOP-FALLING: A Simple Check-list Tool for Fall Prevention in a Nursing Facility (Published online December 11, 2018, JAMDA), https://bit.ly/2TNEU8M

• Ganz DA, Huang C, Saliba D, et al. Preventing falls in hospitals: a toolkit for improving quality of care (Rockville, MD: Agency for Healthcare Research and Quality, 2013), https://bit.ly/2BHjzoQ

• Lainie Van Voast Moncada and L. Glen Mire, Preventing Falls in Older Persons (Am Fam Physician 2017;96(4):240-247), https://bit.ly/2RXZlOG

carINGFOrThEaGES.cOM carING FOr ThE aGES 19

if they will try to walk alone or lean over to reach items on the floor and potentially slide out of beds or chairs. Alternatively, the environment can be adjusted to facilitate safety: using low beds or chairs can prevent unsafe trans-fers or falls.

Challenging Inaccurate BeliefsDespite the evidence that these person-alized interventions can decrease fall risks, they are not easily put into practice because of the pervasive belief among nurses, patients, and families that physi-cal activity increases the risk of residents falling. The physiological fact is that as muscles become weak with disuse, bal-ance declines. The weaker the muscles become, the more likely it is that the smallest alteration in balance will result in a fall. To motivate caregivers, staff, and residents to provide the appropriate care behaviors to prevent falls requires addressing their inaccurate ideas and strengthening their belief in the benefits of physical activity.

So another necessary intervention involves challenging the misconcep-tions, and I’ve found that the best way to help convince staff, residents, and families of the benefits of exercise is by example. I worked with a resident with prior history of multiple falls who could not ambulate independently due to balance changes resulting from multi-infarct dementia. Her physical activity program included walking daily for a few hours in a Merry Walker. One day she got up from her bed, walked across the room (approximately 20 feet) by herself, grabbed the door, and called out for help. Afterward, everyone was confident that her Merry Walker activ-ity, which had strengthened her sig-nificantly, prevented this incident from resulting in another fall.

Creating MotivationMotivating residents to engage in phys-ical activity is the second major chal-lenge. Walking can seem hard when you feel fatigued, in pain, or afraid of falling. These unpleasant sensations need to be addressed and alleviated, if possible. Sometimes just acknowledg-ing that the resident is in pain or seems to be fearful of falling can be sufficient. Use of localized pain treatments, oral medications, ice, heat, or positioning can help with the pain. Reassurance can help the fear, as can breaking down a task into smaller components: stand by the bed the first day, march in place the next day, and take one step the third day. Making a physical activity fun and ensuring it has a recognized benefit or outcome — such as an eas-ier transfer to the toilet after a few weeks of sit-to-stand exercises — are essential motivational tactics as well. Dance, physical activity bingo, or walk-to-dine programs are all fun ways to get more physical activity into the lives of residents.

Motivating staff is equally important. Everyone needs to believe in the benefit of engaging residents in physical activ-ity to make it happen. Show the staff the benefits by continuing to highlight successful examples. Provide positive reinforcement to the staff members who walk residents to the dining room. Arrange ongoing education and new and fun ways to integrate physical activity into the daily lives of residents. The Function Focused Care webpage (www.functionfocusedcare.org) has over 100 tidbits to help staff increase physical activity among residents.

Working TogetherSo why can’t we just decrease the inci-dence of falls? There is no magic pill, no single intervention, no best exercise program. Residents and caregivers need to work together to develop person-centered approaches to fall prevention. Individually tailored interventions are the best way to manage the multiple factors that influence fall risks and inci-dences among residents. The next time you see a resident trying to get up from his or her chair, I encourage nurses and others in long-term care to stop yourself from saying, “Don’t get up! You might fall!” Instead help the resident take a walk, or put on some music and encour-age a few minutes of sit-to-stand exer-cises or dancing. Not only will this help decrease that resident’s risk of falling but it will also bring a few moments of fun to both your lives. And after the activity, once the resident is fatigued and happy to sit and rest, you’ll both feel more at peace.

Dr. resnick is the Sonya Ziporkin Gershowitz chair in Gerontology at the University of Maryland School of Nurs-ing in Baltimore. She is also a member of the Caring for the Ages Editorial advisory Board.

A study of falls, published in the Feb-ruary 2018 issue of JAMDA, won

the 2018 Mather LifeWays Innovative Research on Aging Gold Award (2018; 19:130–135, https://bit.ly/2TmfqyX). The award is given to the article that is felt to have the greatest potential to improve aging services. A runner-up article, “Use of a Robotic Seal as a Therapeutic Tool to Improve De-mentia Symptoms: A Cluster-Ran-domized Controlled Trial,” was from the September 2017 issue of JAMDA (2017;18:766–773).

The winning article, “Sex Differences in the Circumstances Leading to Falls: Evidence From Real-Life Falls Captured on Video in Long-Term Care,” by Yijian Yang, MD, PhD, and colleagues examined factors associated with falls in two long-term care communities over a 9-year period. More than 500 residents

with an average age of 83 participated in the study. The authors found that walking — the most common activity associated with a fall — was more likely to occur in women (40.3%) than men (29.2%). They recommended offering customized, gender-specific exercise programs based on these results.

“The fact that JAMDA won this award — which recognizes applied research with important implications for the care of older adults — underscores that the work published in JAMDA is of the highest quality and of relevance to post-acute and long-term care, and gaining the attention of provider organizations,” said co-editors-in-chief Philip Sloane, MD, MPH, and Sheryl Zimmerman, PhD.

Congratulations to the editorial team of JAMDA and the authors for receiv-ing this prestigious award.

The Society is pleased to release a new product – Teaching Slides. The PowerPoint presentations are an educational and teaching resource on common issues in PA/LTC. They include up-to-date information for the interdisciplinary team including practitioners, nurses, and other healthcare members.

TEACHING SLIDES

Presentations are available on:

ANNOUNCING:

For more information or to order, visit https://paltc.org/product-store/teaching-slides

• Diabetes Management in the Post-Acute and Long-Term Care Setting

• Heart Failure Management in the Post-Acute and Long-Term Care Setting

• Pressure Ulcers in the Post-Acute and Long-Term Care Setting

Continued from previous pageJAMDA article on Falls Wins National award

The physical activity goals for resi-dents should focus on what each resident can do.

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20 carING FOr ThE aGES March 2019

pioneered by acting coach Viola Spolin and her son Paul Sills to train scientists to pay dynamic attention to the needs of

their listeners and spontaneously adjust to those needs.

Laura Lindenfeld, PhD, executive direc-tor of the Alan Alda Center, explained that the Alda Method encourages profession-als to emerge from the narrowly defined traditional roles and boundaries that are

sometimes required in their professional environment. They learn to relate to oth-ers by listening, observing, and being willing to make spontaneous adjust-ments. This, she said, helps physicians to rediscover their passion for their work and inspires them to “share that energy

and take on even greater communication challenges.” Susmita Pati, MD, MPH, division chief at Stony Brook Children’s Hospital, added, “Going through impro-visational exercises helps physicians tap into their feelings. They learn to pay attention to nonverbal cues and respond to them in the moment.”

The program also has a curriculum focusing on teamwork because commu-nicating across settings and disciplines is so much a part of health care in today’s world of value-based medicine. “The meaning in work is closely tied to the team you work with. We can help people connect with their teams to reengineer processes and share burdens so that we can maximize physician face-time,” said Dr. Lindenfeld. Being able to connect with your team is key, as Arif Nazir, MD, CMD, the chief medical officer of Signature HealthCare and the president-elect of AMDA – The Society for Post-Acute and Long-Term Care Medicine, learned early in his career. He said, “My director of nursing made me realize that unless I deliberately disrupt the hierarchy between myself as the medical director of a facility and the front-line staff, my title and my white coat will always be in the way of a friendly and relaxed relationship. If staff don’t feel comfortable with you, they may hold back key information.”

Dr. Nazir observed, “One simple means I found to connect with patients, family, and staff is to share your family photos, particularly the ones where you appear to be not a physician but just another human being. I remember once I took on the role of a Pakistani bride in a community play and shared my pictures from the play with several patients for weeks. I can’t say that I’ve found a better strategy to quickly con-nect with my patients and their families!”

Few practitioners understand the value of improvisation and humor more than Dr. Nazir, who has said that he would be a comedian if he weren’t a physician. His comedic instincts, for the most part, have served him well in his current pro-fession. He said, “During medical school in Pakistan and also in my residency, I got in trouble for ‘not being serious enough’ during rounds. Very early in my resi-dency, I once put a funny but very benign comment in the medical note which was not appreciated. Of course, I quickly learned that I was going too far, but it did not take away my drive to make sure that I always inserted opportunities for light humor during my time as a faculty mem-ber. I always found that learners woke up after such an interaction and paid more attention to the content. I always believe that less content delivered with tact and humor is better than sharing too much content with utmost seriousness.”

Back to the BasicsDr. Arnold and his team at VitalTalk offer interactive, evidence-based clinician and faculty development courses to improve these skills on both the individual and institutional levels. Their instructors are

You can’t turn on the TV or open a newspaper without hearing about the “opioid epidemic.” If you or a loved one is in a post-acute or long-term care facility and has pain, knowing the facts about opioids — as well as oth-er treatment options — will help ensure that you and your practitioner make safe, effective decisions.

Your practitioner will work with you to assess your or your loved one’s pain, determine what is causing it, and consider how it might best be addressed. Sometimes opioids (also called narcotics or opiates) — strong pre-scription medications used to manage severe pain — may be considered as a treatment option. It’s impor-tant to understand that no pain medication gets rid of all pain, and there are a lot of options to reduce pain and help people live with it.

Although opioids have been proven effective for se-vere pain management, they have risks. Perhaps the most serious are addiction and overdose. If you have a personal or family history of drug or alcohol abuse or addiction or you take medications for a mental health problem, you need to tell your practitioner up front so that he or she can choose an alternative therapy. If opioids are the best option, your practitioner will work to monitor your dosage and response carefully for any problems or signs of dependence. It is important to un-derstand the difference between physical dependence and addiction. Dependence means when you stop us-ing the opioid suddenly, you will feel sick or bad be-cause of a physical habit that is normal for people who take these medications regularly. Addiction means you are obsessed with getting and taking the drug, and it is causing problems for you.

When opioids are prescribed, it is important to take them as directed. Never take more or less than your prescription says, and don’t crush tablets or capsules unless your prescriber or pharmacist tells you to. Don’t stop taking your medications suddenly. If you experi-ence uncomfortable side effects (such as constipation, nausea, or dizziness) or your pain gets better, talk to your practitioner. He or she will take you off the medi-cation slowly and safely and find other treatment choic-es. Side effects from opioids are more common and severe in older patients.

Never take more medication than prescribed or mix it with other painkillers or sedatives, including aspirin, sleeping pills or other over-the-counter products, except on the advice of your practitioner or pharmacist. Never give your opioid medication to someone else for their use.

If you or your loved one is in an assisted living facility or other setting where you manage your own medications, store your opioid medications in a safe, secure place. Keep track of the number of pills or capsules, and alert your practitioner immediately if you notice any missing.

The opioid medication will only be used for as long as is necessary. The practitioner also will look for non-drug treat-ments — such as massage therapy, exercise, aromathera-py, meditation, acupuncture, cognitive behavioral therapy, or breathing exercises — that might help manage pain.

Questions to Ask Your Practitioner•How much pain is too much pain? How do I know if my

or my loved one’s pain is bad enough to merit opioids?•Are there other drugs besides opioids to manage pain?•What about alternative treatments such as medical

cannabis?•What are the signs of opioid dependence?•Do non-drug treatments really have any value?

What You Can Do•Make sure you or your loved one takes all medica-

tions as directed.•Talk to your practitioner before taking less or more

medication. Don’t “self-treat” with over-the-counter products — again, talk to your practitioner.

•Be honest with your practitioner about pain. Don’t try to be brave. Don’t ignore it.

•Tell your practitioner if you have family members or friends with substance use problems.

For More Information•Steven A. King, “Opioid Analgesics: The Myths—and

the Facts,” Psychiatric Times, Jan. 27, 2017, http://bit.ly/2RWUke0

•Adriane Fugh-Berman, Anna Lembke, and Christina Prather, “Myths and Facts about Opioids,” PowerPoint Presentation (Department of Health, Government of the District of Columbia, 2016), http://bit.ly/2DIt0Y6

Partner With Providers to reduce Opioid risk

Editor-in-Chief of caring for the ages, Karl Steinberg, MD, CMD, HMDC, sorts out the facts and myths about the dangers of opioids.

Caring for the Ages is the official newspaper of AMDA – The Society for Post-Acute and Long-Term Care Medicine and provides post-acute and long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care. Content for Caring for the Ages is provided by writers, reporters, columnists, and Editorial Advisory Board members under the editorial direction of Elsevier and AMDA.

The ideas and opinions expressed in Caring for the Ages do not necessarily reflect those of the Society or the Publisher. AMDA – The Society for Post-Acute and Long-Term Care Medicine and Elsevier Inc., will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.

©2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine.

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carINGFOrThEaGES.cOM carING FOr ThE aGES 21

clinicians who practice what they teach, using verbal tools to empower clinicians to communicate about serious illnesses empathetically and effectively. They also seek to enable practitioners to feel less stressed and burned out in the process.

The key to effective communication, Dr. Arnold said, is “to ask before you tell.” He observed, “Make sure you understand what people know and build on that information. Realize that patients and families get information from many sources. Explore how open they are to new information.”

It takes extra time to counter wrong information, Dr. Arnold said. He sug-gested asking questions to determine why someone is attached to misinfor-mation, misunderstandings, or myths. For instance, he observed, “sometimes a patient is insistent that he or she needs antibiotics when the practitioner knows that this is not the right treat-ment choice.” By asking some carefully worded questions, Dr. Arnold suggested, the clinician may determine that the patient just doesn’t want to be sick.” In this case, the practitioner can direct the conversation away from the how (antibi-otics) to the what (feeling better).

From improv to acting, talking to lis-tening, studying to practicing, every day presents an opportunity to be a better communicator. “If you want to get better at communication, it requires intentional practice,” Dr. Arnold said. “This means thinking about it, watching others, and practicing every chance you get.” And as clinicians practice communicating, they get better and more confident at it.

Megan Cole will present the Anne-Marie Filkin Lecture at the Society’s 2019 annual conference in Atlanta, GA, on Sunday, March 10. In her presentation, “Elder Voices: How Literature Can Help Us Understand Aging,” she will read from select works of literature that vividly describe what it’s like to age and be elderly, and she will talk about how these help us understand aging.

Senior contributing writer Joanne Kaldy is a freelance writer in harrisburg, Pa, and a communications consultant for the Society and other organizations.

Congratulations to Our newest Rising Stars!

GAPNA is proud to salute our newest Rising Stars! It's with great pleasure that we recognize outstanding members who are up and coming in their specialty and in leadership. Rising Stars are the future of our organization. Thank you for your excellent work and commitment to the care of older adults!

Helen Burns MSN, ANP-BC, AGN-BC, AOCNP

Kanah May Lewallen DNP, AGPCNP-BC, GNP-BC

Patti Parker PhD, APRN, CNS, AGNP, BC, GS-C

Melissa Kramps DNP, GNP-BC, NP-C

New this year, the Society’s annual conference will offer a mobile app!

Downloading the conference app to your smartphone or tablet will provide the most up-to-date meeting informa-tion at your fingertips. Getting the app is easy: Search for the free eventScribe

app in the Apple App Store or Google Play Store. Install and open the app, then select the event: 2019 AMDA An-nual Conference. Click on the icon to launch your app, then select “Create Account” and type in your name and email address.

The app lets you browse the entire con-ference schedule, check out the exhibitor list and the exhibit hall floor plan, access and download handouts, review the lists of speakers and attendees, and much more. It truly is the best way to make the most of your conference experience.

Download the New app to Make the Most of Your conference Experience

Learning to relate to others by listening, observing, and being willing to make spontaneous adjustments helps physicians to rediscover their passion for their work and inspires them to share that energy and take on even greater communication challenges.

Continued from previous page

22 carING FOr ThE aGES March 2019

JOUrNaL hIGhLIGhTS

Journal Highlights From the March Issue of JAMDA

Editor in Chief Karl Steinberg, MD, CMD, HMDC

Editorial Advisory BoardChair: Karl Steinberg, MD, CMD, HMDC, California

Robin Arnicar, RN, West Virginia

Nicole Brandt, PharmD, CGP, BCPP, FASCP,

Maryland

Ian L. Cordes, MBA, Florida

Jonathan Evans, MD, CMD, Virginia

Phyllis Famularo, DCN, RD, New Jersey

Janet Feldkamp, RN, JD, BSN, Ohio

Nina Flanagan, PhD, GNP-PC, APMH-BC, New York

Robert M. Gibson, PhD, JD, California

Daniel Haimowitz, MD, FACP, CMD, Pennsylvania

Paige Hector, LMSW, Arizona

Jeanne Manzi, PharmD, CGP, FASCP, New York

Jeffrey Nichols, MD, New York

Dan Osterweil, MD, CMD, California

Barbara Resnick, PhD, CRNP, FAAN, FAANP,

Maryland

Caring for the Ages is the official newspaper of AMDA – The Society for Post-Acute and Long-Term Care Medicine and provides long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care. Content for Caring for the Ages is provided by the Society and by Elsevier Inc.

The ideas and opinions expressed in Caring for the Ages do not necessarily reflect those of the Society or the Publisher. The Society and Elsevier Inc., will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.

©2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine

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Opioid Use After FracturesOlder individuals who did not regularly use opioids before sustaining fragility fractures are more likely to remain on the medications one year after the frac-ture occurs, especially those who undergo surgery, according to a population-based cohort study from Dartmouth-Hitchcock Medical Center in Lebanon, NH.

Led by Michael T. Torchia, MD, researchers sought to characterize the patterns and duration of opioid use, including regional variations, in patients who experienced fragility fractures in the hip and arm.

“Our group had recently published work that analyzed prescription drug use in the elderly both before and after fragil-ity fractures of the hip, distal radius and proximal humerus,” Dr. Torchia said in an email. “We did look at opioid use in that study, but it wasn’t the primary focus. Given the ongoing conversation in health care about opioids, we thought examin-ing opioid use in the year following these three common fractures in the geriatric population would be particularly timely, relevant, and clinically actionable.”

For this study, the researchers used pharmacy data for Medicare beneficiaries who had sustained a fracture of the hip, proximal humerus or distal radius; had no opioid prescription fills in the four months prior to fracture; and underwent surgery.

Of 91,749 patients, 61.1% were treated surgically. The researchers reported three major findings:

Individuals who sustained hip frac-tures (6.4%) had the highest rate of opioid use 12 months later, followed by individuals who sustained fractures of the proximal humerus (5.7%) and the distal radius (3.7%).

Surgical treatment of distal radius and proximal humerus fractures resulted in a statistically significant increase in the proportion of patients using opioids in the first six months compared with patients managed without surgery.

There was variation by state in prescrip-tion opioid use, ranging from 7.5% to 18.2%. States with the highest use were in the Southeast and Northwest regions.

Dr. Torchia considers this study to be a “stepping stone for further inves-tigation,” as there are not many stud-ies of opioid use in the 65-and-older demographic. “On a broader level, our results demonstrate that a proportion of opioid-naive geriatric patients will be consuming opioids one year after three of the most common fractures sustained in this age group, a significant finding considering that this group of patients was not taking any opioids prior to their

injury,” he said. “Finally, the significant state-level variation in opioid use indi-cates the potential for quality-improve-ment projects to reduce any unwarranted variation in opioid consumption among this demographic at a national level.”

Although this study did not compare the rate of opioid addiction in the elderly population vs. the general population, the elderly population has a higher risk of side effects from opioids. “For exam-ple, even a relatively ‘benign’ side-effect of opioid medications, such as consti-pation, can result in profound disabil-ity in geriatric patients who may have underlying autonomic dysfunction,” Dr. Torchia said. “More relevant to the manuscript, opioid medications can precipitate delirium among hospitalized geriatric patients, leading to worse out-comes. Finally, opioid pain medications can predispose elderly patients to falls, potentially leading to fragility fractures.”

The good news is that there are many options for pain relief after fracture and/or fracture surgery that don’t involve opioid use. “Regional and spinal anes-thesia are effective non-pharmacologic methods to manage pain,” Dr. Torchia said. “Additionally, intraoperative local anesthesia injections around the surgical site can help alleviate acute postopera-tive pain and the need for opioid pain management.”Source: Torchia MT, et al. Patterns of Opioid Use In the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study. J Am Med Dir Assoc. Manuscript number: JAMDA-D-18-00338R2

Perceptions of DeathSatisfaction with care and decision-making may determine whether family members of individuals with dementia perceive them as having a peaceful death, according to a study in The Netherlands.

Sascha Rianne Bolt, of Maastricht University, and colleagues performed a secondary data analysis using data from the Dutch End of Life in Dementia (DEOLD) study, which looked at fami-lies’ and physicians’ perceptions of the quality of dying experienced by nursing home residents with dementia from 34 facilities.

Of 252 families of nursing home residents with dementia who died, the researchers found:

Forty-two (17.0%) reported one or more unpleasant experiences with care during the last week of their relative’s life.

Thirty-four (13.5%) reported neglect, namely negligence in providing tailored care for their relative and providing information about their relative’s disease.

Sixteen (6.3%) reported lack of respect, such as insensitivity by health care staff, privacy violations and non-compliance with agreements about care and treatment.

Slightly more than half the family members believed their relative died peacefully.

Families that reported unpleasant expe-riences were more likely to believe that their relative did not die peacefully, the researchers said.Source: Bolt SR, et al. Families’ experi-ences with end-of-life care in nursing homes and associations with dying peacefully with dementia [published online ahead of print February 1, 2019]. J Am Med Dir Assoc. doi: https://doi.org/10.1016/j.jamda.2018.12.001

Antipsychotics and MortalityUse of atypical and typical antipsychotic drugs increased the risk of death in indi-viduals who have dementia, according to a registry-based cohort study conducted in Sweden.

Led by Emilia Anna Schwertner, of the Karolinska Institutet, researchers studied 58,037patients diagnosed with dementia and registered in SveDem, the Swedish Dementia Registry, which was established in 2007 to improve the quality of care of patients with dementia.

Individuals who used antipsychotic drugs at the time they were diagnosed with dementia had a 40% greater risk of dying, the researchers found. Stratification by the type of dementia confirmed increased risks among people with Alzheimer’s disease as well as dementia of the mixed, unspecified, and vascular types.

Individuals with Alzheimer’s disease who used typical antipsychotic drugs had a lower risk of death than those who used atypical antipsychotics.

“It should be emphasized that this is an observation study using registry data,” the researchers said. “Therefore, we can-not assume causal relationship between antipsychotic drugs and mortality or obtain a conclusive and unambiguous result. Designs of this type, however, may lead to generation of new hypotheses and give solid fundaments for further studies.”Source: Schwertner EA, et al. Antipsychotic treatment associated with increased mor-tality risk in patients with dementia. A registry-based observational cohort study. J Am Med Dir Assoc. Manuscript number: JAMDA-D-18-00472R3

Jeffrey S. Eisenberg, a freelance writer in the Philadelphia area, compiled this report.

carINGFOrThEaGES.cOM carING FOr ThE aGES 23

NEWS FrOM ThE SOcIETY

Practice Management Sessions Offer Map for Navigating challenges

March 12, 2019Registration Deadline for Online Core Winter SessionWebsite: https://paltc.org/core-curriculum-medical-direction-post-acute-and-long-term-careContact: RegistrarPhone: 410-992-3116Email: registration@paltc.org

April 4–6, 2019California Association of Long-Term Care Medicine Annual MeetingLos Angeles, CAWebsite: http://www.caltcm.org Contact: Barbara HulzEmail: bhulz@caltcm.org

April 10, 2019North Central Society for PALTC Medicine Annual SeminarSioux Falls, SD Website: http://www.sdhca.org/index.php/medical-directorsPhone: 605-339-2071

April 27, 2019Greater New England Society for Post-Acute and Long-Term CareWaltham, MAContact: Nathan Strunk Phone: 781-434-7329Email: nstrunk@mma.org

May 7–July 16, 2019Online Core Spring SessionWebsite: https://paltc.org/core-curriculum-medical-direction-post-acute-and-long-term-careContact: RegistrarPhone: 410-992-3116Email: registration@paltc.org

July 25–28, 2019Alabama Medical Directors Association Annual MeetingWebsite: https://almda.org/page/upcoming-events-1

July 19–21, 2019Core Synthesis WeekendSt. Louis, MO

Website: https://paltc.org/core Contact: RegistrarPhone: 410-992-3116Email: registration@paltc.org

August 6–November 17, 2019Online Core Fall SessionWebsite: https://paltc.org/core-curriculum-medical-direction-post-acute-and-long-term-careContact: RegistrarPhone: 410-992-3116Email: registration@paltc.org

September 21, 2019Greater New England Society for Post-Acute and Long-Term CareWorcester, MAContact: Nathan Strunk Phone: 781-434-7329Email: nstrunk@mma.org

October 11–12, 2019Michigan Society for PALTC Medicine Annual ConferenceTraverse City, MI Phone: 517-449-7384Email: michiganmda@gmail.com

October 11–12, 2019Wisconsin Society for Post-Acute and Long-Term Care Medicine Fall Conference Madison, WIWebsite: http://www.wamd.org

November 15–17, 2019Core Synthesis WeekendSan Antonio, TXWebsite: https://paltc.org/core Contact: RegistrarPhone: 410-992-3116Email: registration@paltc.org

April 2–5, 2020AMDA Annual Conference 2020Chicago, ILContact: RegistrarPhone: 800-876-2632Email: registration@paltc.org

DON’T MISS ThESE EVENTS

The practice management sessions at the Society’s 2019 annual con-

ference are like “a map,” said Tom Haithcoat, chief operating officer for CareConnectMD and incoming chair of the Practice Group Network (PGN). This map will help participants navigate challenges, opportunities, new develop-ments, and other issues so they can keep up and enjoy success in the constantly evolving value-based medicine environ-ment.

“The bridge from volume- to value-driven care is complex and not easy to navigate alone,” said Mr. Haithcoat. “We’ve worked closely with our Practice Group Network members to develop a comprehensive program covering the financial and regulatory challenges post-acute practices face while on the volume-to-value bridge.”

There are a number of practice manage-ment sessions at the conference. Topics include: On-Call Strategies and Provider Burnout; Impact of MIPS, MCRA, APMs, VBP, and PDPM on PALTC Physicians; Engaging Clinicians and Healthcare Team Members for Higher Performance in Value-Based Systems;

Standards and Experts: Telemedicine in PALTC; and Operationalizing Frailty: The Next Frontier in PALTC.

These specialized sessions will help practice managers and others prepare their organizations to tackle value-based medicine programs such as the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-based Incentive Payment System (MIPS). Participants also will learn how to develop and use tools, including health information tech-nology, to improve and stabilize work-flow and optimize revenue from patient visits. Additionally, the program will provide exclusive opportunities for idea exchanges and networking with peers.

Participants may come to these pro-grams with questions and confusion. However, Mr. Haithcoat noted, “They will quickly see a clearer path to change. They will be able to choose a way for-ward and feel confident when facing practice challenges. Our measuring stick for the success of the conference pro-grams will be that participants go home with resources they need and a network of colleagues that they didn’t have com-ing in.”

A special JAMDA workshop at the an-nual conference is a must for practi-

tioners interested in writing or reviewing for the journal, as well as anyone who wants to effectively analyze and translate research into practice. “How to Read and Review Research Papers” is set for Friday, March 8, at 1:30 PM. JAMDA co-edi-tors-in-chief Sheryl Zimmerman, PhD, and Philip Sloane, MD, MPH, along with Foundation past-chair Paul Katz, MD, CMD, will provide a hands-on op-portunity to learn how to critically write,

read, and review scientific literature. Participants will work in small groups

facilitated by JAMDA editors and edi-torial board members, discussing and critiquing a paper that was recently submitted to the journal. You should download the paper from the annual conference website (https://paltc.org/annual-conference) and read it before-hand. This is a great interactive learn-ing experience. You don’t have to be a researcher or expert going in, but you will be much closer afterwards.

Information, opportunities, and a chance to give back await you at the

Society’s Foundation booth during the annual conference in Atlanta. Stop by the booth to:

• Donate to the Wall of Caring, where every dollar goes to support a competent, compassionate, in-formed workforce. (All donations received at the Wall will support the Futures Program.) You also can write and post a tribute to some-one who has inspired you in your career.

• Participate in an on-site auction for items that will make your work and/or life easier and better.

• Contribute to the Foundation’s many initiatives by purchasing 50/50 raffle tickets—have a little fun that also con-tributes to the future of quality post-acute and long-term care medicine.

Elsewhere, don’t forget the Founda-tion’s session, Quality Improvement: How to Achieve Better Outcomes in Your Facility (Foundation’s QI Awards and Expert Panel Discussion), Saturday, March 9, at 11:00 AM.

JAMDA Wants You: hone research analysis Skills at Special Workshop

Take the challenge: connect in atlanta

Michele Bellantoni, MD, CMD, chair of the Annual Conference

Program Planning Subcommittee, chal-lenges conference attendees to engage, connect, and interact during their time in Atlanta, both in and out of the meet-ing rooms. She said, “I’d like everyone to commit to leaving with a new friend, a colleague in the field, and have contact

information they can use to follow up.”In addition to coffee and meal breaks,

the program offers many opportunities to socialize and engage, including con-venient exhibit hours (with food and beverages often available in the hall), a welcome reception, state chapter meet-ings and events, and the Saturday night President’s Dessert Reception.

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