Physician Perspectives on Medical Care Delivery in Assisted Living Sloane PD, Zimmerman S, et al: The Journal of the American Geriatric Society, 2011; 59 (December): 2326-2331
OBJECTIVES: To describe the provision of medical care in assisted living (AL) as provided by physicians who are especially active in providing care to older adults and AL residents; to identify characteristics associated with physician confidence in AL staff; and to ask physicians a variety of questions about their experience providing care to AL residents and how it compares with providing care in the nursing home and home care settings.
DESIGN: Cross-sectional descriptive study.
SETTING: AL communities in 27 states.
PARTICIPANTS: One hundred sixty-five physicians and administrators of 125 AL settings in which they had patients.
MEASUREMENTS: Interviews and questionnaires containing open- and close-ended questions regarding demographics, care arrangements, attitudes, and behaviors in managing medical problems.
RESULTS: Most respondents were certified in internal medicine (46%) or family medicine (47%); 32% were certified in geriatrics and 30% in medical directorship. In this select sample, 48% visited the AL setting once a year or less, and 19% visited once a week or more. Mean physician confidence in AL staff was 3.3 (somewhat confident), with greater confidence associated with smaller AL community size, nursing presence, and the physician being the medical director. Qualitative analyses identified differences between settings including lack of vital sign assessment in the home setting, concern about the ability of AL staff to assess and monitor problems, and greater administrative and regulatory requirements in AL than in the other settings.
CONCLUSION: Providing medical care for AL residents presents unique challenges and opportunities for physicians. Nursing presence and physician oversight and familiarity and communicating with AL staff that are highly familiar with a given resident and can monitor care may facilitate care.
Kevin’s Comments: AL is the fastest growing segment of elder care. AL communities currently number over 30,000 and provide housing to nearly a million residents (Source: National Center for Health Statistics, December 2011). AL provides housing and support services to persons who cannot live independently, but who do not usually require the skilled level of care provided in nursing homes. Many residents in AL have multiple medical problems and research has shown that more than 50% have some degree of cognitive impairment.
Physicians often find providing medical care for AL residents challenging, as size, staffing, and staff training vary considerably. In addition, policies affecting AL vary considerably as states, rather than the federal government, are responsible for their regulation. Only 26 states require a licensed nurse on staff; eight of these do not specify whether the nurse be an RN or LPN. Many states have now passed regulations that allow persons to remain in AL who previously would have been required to transfer to a skilled nursing facility.
Challenges create opportunities. This study showed that the presence of a nurse in the AL community as well as staff and physicians familiar with the residents can facilitate care. Subtle changes in condition can be detected more readily by staff who know the residents well. Communication can be improved when nurses are trained to use available tools (e.g., SBAR). Health reform will encourage health care providers to avoid unnecessary emergency room visits and reduce hospitalizations. The training of staff and the availability of nursing and medical services onsite in assisted living will help meet these objectives and provide more timely and appropriate care for AL residents.
Key Points: Medical Care Delivery in Brookdale Assisted Living Communities. As the fastest growing segment of elder care, assisted living creates opportunities for physicians, nurses, social workers, and other providers.
All Brookdale assisted living communities have a nurse on staff. Brookdale helped pilot the Caregiver Communication Guide recently published by the American Medical Directors Association.
This provides guidelines for caregivers (including non-clinical staff such as housekeepers and dining services staff) in assisted living to report changes in a resident’s condition. The guide can be ordered at www.amda.com
Preventing Pressure Ulcers in Long-termCare: ACost-effectiveness Analysis Pham B, Stern A, et al. The Archivesof the Internal Medicine 2011: 171(20): 1839-1847
BACKGROUND: Pressure ulcers are common in many care settings, with adverse health outcomes and high treatment costs. We evaluated the cost-effectiveness of evidence-based strategies to improve current prevention practice in long-term care facilities.
METHODS: We used a validated Markov model to compare current prevention practice with the following 4 quality improvement strategies: (1) pressure redistribution mattresses for all residents, (2) oral nutritional supplements for high-risk residents with recent weight loss, (3) skin emollients for high-risk residents with dry skin, and (4) foam cleansing for high-risk residents requiring incontinence care. Primary outcomes included lifetime risk of stage 2 to 4 pressure ulcers, quality-adjusted life-years (QALYs), and lifetime costs, calculated according to a single health care payer’s perspective and expressed in 2009 Canadian dollars (Can$1 = US$0.84).
RESULTS: Strategies cost on average $11.66 per resident per week. They reduced lifetime risk; the associated number needed to treat was 45 (strategy 1), 63 (strategy 4), 158 (strategy 3), and 333 (strategy 2). Strategy 1 and 4 minimally improved QALYs and reduced the mean lifetime cost by $115 and $179 per resident, respectively. The cost per QALY gained was approximately $78 000 for strategy 3 and $7.8 million for strategy 2. If decision makers are willing to pay up to $50 000 for 1 QALY gained, the probability that improving prevention is cost-effective is 94% (strategy 4), 82% (strategy 1), 43% (strategy 3), and 1% (strategy 2).
CONCLUSIONS: The clinical and economic evidence supports pressure redistribution mattresses for all long-term care residents. Improving prevention with perineal foam cleansers and dry skin emollients appears to be cost-effective, but firm conclusions are limited by the available clinical evidence.
Kevin’s Comments: Pressure ulcers are common in many health care settings. Persons who are bed bound or wheelchair bound and those who cannot reposition themselves are at high risk for pressure ulcers. The cost of treatment in the United States is over $3 billion annually. In addition to the financial costs, pressure ulcers can have a profound adverse impact on health and quality of life. Many experts believe that pressure ulcers can be prevented. Although pressure applied to the skin over bony prominences such as the hips and heels is a key causative factor, other contributing forces include friction, moisture, and shear. The best strategy in managing pressure ulcers is to prevent them in the first place with interventions aimed at the causative factors. This study showed that clinical and financial evidence supports pressure redistribution mattresses for all residents in long-term care.
Key Points: Preventing Pressure Ulcers in Brookdale Long-term Care Environments. Pressure ulcer prevention is a high priority for all Brookdale clinical staff. Brookdale’s Movement is Medicine program encourages all residents to engage in a regular physical activity program. Movement in Medicine classes are conducted in all Brookdale communities.
For frail older adults, Brookdale’s nurses and staff are trained in proper techniques to avoid excessive pressure over bony prominences, to minimize shear forces when a resident is repositioned or transferred, to use moisture barriers for those with incontinence, and to use skin emollients for those with dry skin.
Improving Decision-Making for Feeding Options in Advanced Dementia: A Randomized, Controlled Trial Hanson LC, Carey TS, et al. The Journal of the American Geriatrics Society 2011; 59 (November): 2009-2016
OBJECTIVES: To test whether a decision aid improves quality of decision-making about feeding options in advanced dementia.
DESIGN: Cluster randomized controlled trial.
SETTING: Twenty-four nursing homes in North Carolina.
PARTICIPANTS: Residents with advanced dementia and feeding problems and their surrogates.
INTERVENTION: Intervention surrogates received an audio or print decision aid on feeding options in advanced dementia. Controls received usual care.
MEASUREMENTS: Primary outcome was the Decisional Conflict Scale (range: 1–5) measured at 3 months; other main outcomes were surrogate knowledge, frequency of communication with providers, and feeding treatment use.
RESULTS: Two hundred fifty-six residents and surrogate decision-makers were recruited. Residents’ average age was 85; 67% were Caucasian, and 79% were women. Surrogates’ average age was 59; 67% were Caucasian, and 70% were residents’ children. The intervention improved knowledge scores (16.8 vs 15.1, P < .001). After 3 months, intervention surrogates had lower Decisional Conflict Scale scores than controls (1.65 vs 1.90, P < .001) and more often discussed feeding options with a healthcare provider (46% vs 33%, P = .04). Residents in the intervention group were more likely to receive a dysphagia diet (89% vs 76%, P = .04) and showed a trend toward greater staff eating assistance (20% vs 10%, P = .08). Tube feeding was rare in both groups even after 9 months (1 intervention vs 3 control, P = .34).
CONCLUSION: A decision aid about feeding options in advanced dementia reduced decisional conflict for surrogates and increased their knowledge and communication about feeding options with providers.
Kevin’s Comments: Advanced dementia has a prognosis as poor as terminal cancer, yet many persons with advanced dementia are subjected to intrusive and burdensome interventions, such as feeding tubes, which may adversely affect quality of life and unfavorably affect the course of the illness. Family caregivers often find making decisions about feeding options emotionally difficult. This study demonstrated that a decision aid given to health care surrogates reduced their emotional conflict related to feeding decisions and improved their knowledge and enhanced their communication with health care providers. |