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Current Clinical Practice
Series Editor: Tommy Koonce
PeterWinn
PamelaA.Fenstemacher
RichardG.Stefanacci
R.ScottDeLongEditors
Post-Acute
and Long-Term
Care Medicine
AGuide forPractitioners
ThirdEdition

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 forPractitioners
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, specically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microlms 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 specic 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 afliations.
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
v

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 Certied 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 ofce 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 PamelaA.Fenstemacher
Oklahoma City, OK, USA PeterWinn
Philadelphia, PA, USA RichardG.Stefanacci
Lancaster, PA, USA R.ScottDeLong

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
BrandonCantazaro 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
PamelaA.Fenstemacher The University of Pennsylvania, Jenkintown, PA, USA
LeonardGelman Community Care, Ballston Spa, NY, USA
Todd H. Goldberg Department of Internal Medicine/Geriatrics, Jefferson
Abington Hospital, Abington, PA, USA
DanielHaimowitz Levittown, PA, USA
ElizabethHames UnitedHealth Group, Minnetonka, MN, USA
DanielaHernandez University of Texas Rio Grande Valley School of Medicine,
Edinburg, TX, USA
RandallD.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
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