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Current Clinical Practice
Series Editor: Tommy Koonce
PeterWinn PamelaA.Fenstemacher RichardG.Stefanacci R.ScottDeLongEditors
Post-Acute and Long-Term Care Medicine
AGuide forPractitioners
ThirdEdition
Current Clinical Practice
Current Clinical Practice provides an array of practical resources for primary care clinicians. Designed for internists, family physicians, physician assistants, and nurse practitioners, the Current Clinical Practice series offers evidence-based, easy­to- read titles covering a broad range of disorders commonly presented in the primary care setting. Series editor Tommy Koonce, MD, is an Associate Professor of family medicine and Vice Chair of education at UNC School of Medicine in Chapel Hill, North Carolina.
Peter Winn • Pamela A. Fenstemacher Richard G. Stefanacci • R. Scott DeLong
Editors
Post-Acute and Long-Term Care Medicine
A Guide forPractitioners
Third Edition
Editors
Peter Winn Family and Preventive Medicine OU Health Science Center Oklahoma City, OK, USA
Richard G. Stefanacci Thomas Jefferson University Philadelphia, PA, USA
Pamela A. Fenstemacher The University of Pennsylvania Jenkintown, PA, USA
R. Scott DeLong Department of Geriatrics, Penn Medicine Lancaster General Health Lancaster, PA, USA
ISSN 2364-1150 ISSN 2364-1169 (electronic) Current Clinical Practice ISBN 978-3-031-28627-8 ISBN 978-3-031-28628-5 (eBook)
https://doi.org/10.1007/978-3-031-28628-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2011, 2016, 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Humana imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface
Whether practitioners are still in training, recently graduated, or deciding to change the direction or focus of their career path, by either choice or necessity, many may nd themselves immersed in the long-term care (LTC) arena. Any practitioner can be overwhelmed when confronted by an LTC system that is both complex and highly regulated, let alone taking care of patients and residents who can challenge even the most experienced among us. These patients are challenging, due to not only multiple chronic medical conditions (multimorbidities) and extensive and complicated medication regimens, but also advanced age and increasing frailty. As experienced clinicians, educators, and medical directors in LTC, the chapter authors have written this guide for practitioners with the overarching goal of improving the quality of care provided throughout the LTC continuum by updating the current knowledge in this eld with the expertise they have acquired over many years of practice.
Both the Society for Post-Acute and Long-Term Care Medicine (AMDA) and its state chapters continue to work tirelessly to meet the needs of practitioners. Even the most experienced practitioners who have taken AMDA’s course on medical direction have commented on how much of the information on LTC care presented in the course is neither readily available nor frequently taught. The content of this guide is aimed at lling this void. The chapters of this guide address the varied components of the LTC system as well as how to care for the patients and residents living within it.
Since the rst and second editions of this guide were published, post-acute and long-term care have continued to evolve, further evident by the impact of the COVID-19 pandemic, the incorporation of zoom meetings by the interprofessional team, and the expanded use of telehealth/telemedicine. Indeed, the practice in post­acute and long-term care has itself developed into a subspecialty. The Centers for Medicare and Medicaid Services (CMS) has promulgated its Triple Aim as to the need to improve patient outcomes, to improve patient satisfaction, and to lower the cost to the healthcare system. Others have proposed a Fourth Aim (to improve healthcare workers’ satisfaction and lessen burnout) and a Fifth Aim to ensure patient equitable access to health care. Accountable Care Organization (ACOs) and
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vi
Preface
Population Health Management are ongoing CMS initiatives that focus on the pre­vention and the early treatment of chronic medical illness.
As practitioners, we are all challenged by an ever-changing healthcare environ­ment that entails bundling of healthcare services, value-based purchasing, transi­tions in care, medication reconciliation (including the CMS Quality Prescribing Initiative), HIPAA compliance (and possible audits), different electronic medical records at different healthcare settings, and EMR meaningful use. As editors of this guide, we hope that these challenges will become less daunting with the information provided in this guide.
For this third edition, the 19 chapters of the second edition have been updated and a chapter is added on COVID-19 given its impact on practice in post-acute and long-term care. The editors of this guide were approached by Springer publishing to write this third edition before the COVID-19 pandemic emerged. As such, our chap­ter authors became overwhelmed with providing patient care on the front lines in nursing and assisted living facilities. The editors appreciate their perseverance in updating all the chapters, several of whom are new authors. Thus, this guide update became a 2-year endeavor!
The authors are passionate about LTC with many having worked within the Society to develop AMDA’s clinical practice guidelines, present at conferences, write AMDA white papers, and develop the Certied Medical Director course. We hope that you nd Post-Acute and Long-Term Care Medicine as an invaluable resource to complement your endeavors to optimize the care and living experience of patients and residents in LTC and to enhance patient-centered care as well as patient choice, well-being, dignity, and an improved quality of life.
This guide is dedicated to Chris Laxton, Executive Director, and the ofce staff of the Society for Post-Acute and Long-Term Care Medicine and its cadre of profes­sional volunteers who represent many healthcare disciplines. We also welcome two additional co-editors, Dr. Richard Stefanacci and Dr. Scott DeLong. The editors wish to acknowledge Crystal Pearson for the long hours, dedication and patience in supporting our editors in updating and editing the chapters of this guide.
Jenkintown, PA, USA PamelaA.Fenstemacher Oklahoma City, OK, USA PeterWinn Philadelphia, PA, USA RichardG.Stefanacci Lancaster, PA, USA R.ScottDeLong
Contents
Post-Acute Care and Long-Term Services: Evolution to
Value-Based Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Richard G. Stefanacci and Mitchell A. Kaminski
Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Robert C. Salinas
Assisted Living and Residential Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Debra Dobbs, Carlyn E. Vogel, Daniel Haimowitz, and Sheryl Zimmerman
PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Verna Sellers and Laura Trice
Department of Veterans Affairs Options for Long-Term Care . . . . . . . . . . 71
Deborah Way
The Role of Practitioners and the Medical Director . . . . . . . . . . . . . . . . . . 77
Steven A. Levenson
Team-Based Care: Nurse Practitioners, Clinical Nurse Specialists,
and Physician Assistants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Robert C. Salinas and Peter Winn
Common Clinical Conditions in Post-Acute and Long-Term Care . . . . . . 101
Naushira Pandya
Preventing Hospital Admissions and Readmissions . . . . . . . . . . . . . . . . . . 165
R. Scott DeLong
Goals of Care and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Cynthia Kuttner
Integrating Palliative Care into Long-Term Care . . . . . . . . . . . . . . . . . . . . 197
Peter Winn
vii
viii
Contents
Weight and Nutrition in Post-Acute and Long-Term Care . . . . . . . . . . . . . 229
Todd H. Goldberg and Joel A. Levien
Wound Assessment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Richard G. Stefanacci
Dementia, Delirium, and Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Pamela A. Fenstemacher, Brandon Cantazaro, Daniela Hernandez, Andres Suarez, Krishna Suri, and Andrew Dentino
Ethical and Legal Issues in Post-Acute and Long-Term Care . . . . . . . . . . 293
David A. Smith and Randall D. Huss
Working with Families and Person- Centered Care . . . . . . . . . . . . . . . . . . . 311
David Brechtelsbauer
Documentation and Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Peter Winn and Leonard Gelman
Medication Management in Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . 341
Keith A. Swanson, Raghuveer Vedala, and Peter Winn
Rehabilitation and Maximizing Function in Long-Term Care . . . . . . . . . . 369
Thomas Lawrence
COVID-19 in Post-Acute and Long-Term Care: Challenges and
Opportunities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Naushira Pandya, Elizabeth Hames, and Peter Winn
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Contributors
David Brechtelsbauer University of South Dakota Sanford SOM, Sioux
Falls, SD, USA
BrandonCantazaro University of Texas Rio Grande Valley School of Medicine,
Edinburg, TX, USA
R. Scott DeLong, MD, CMD Geriatrics at Home Program, Penn Medicine Lancaster General Health/Penn Medicine Geriatric Fellowship, Lancaster, PA, USA
Andrew Dentino Rio Grande Valley Graduate Medical Education Consortium,
Edinburg, TX, USA
Debra Dobbs School of Aging Studies, College of Behavioral and Community
Sciences, University of South Florida, Tampa, FL, USA
PamelaA.Fenstemacher The University of Pennsylvania, Jenkintown, PA, USA
LeonardGelman Community Care, Ballston Spa, NY, USA
Todd H. Goldberg Department of Internal Medicine/Geriatrics, Jefferson
Abington Hospital, Abington, PA, USA
DanielHaimowitz Levittown, PA, USA
ElizabethHames UnitedHealth Group, Minnetonka, MN, USA
DanielaHernandez University of Texas Rio Grande Valley School of Medicine,
Edinburg, TX, USA
RandallD.Huss Department of Family Medicine and Geriatrics, Mercy Clinic,
Rolla, MO, USA
Mitchell A. Kaminski Thomas Jefferson University, Jefferson College of
Population Health, Philadelphia, PA, USA
ix