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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана
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D. Dobbs et al.
• Safely reducing hospital readmissions
• Reducing the off-label use of antipsychotics
• Increasing staff stability and
• Increasing customer satisfaction
Measurement tools and demonstrative cases can be downloaded from the NCAL
website (NCAL.gov). ALCs are encouraged to use these tools to measure and track
progress related to each core area. Practitioner leadership can greatly assist these
initiatives.
By way of example, INTERACT (Interventions to Reduce Acute Care
Transfers), a quality improvement program that was developed for nursing homes,
has also been adapted for AL.INTERACT focuses on the management of acute
change in a resident’s condition. It includes validated clinical and educational
tools and strategies for use in daily practice to improve the early identication,
management, documentation, and communication of acute changes in resident
condition, with the goal to prevent avoidable hospitalizations. The program has
expanded to include tools specically for AL providers and tested through support
of a CMS Innovation Grant. Pilot communities assessed and provided feedback on
the four categories of INTERACT tools (quality improvement, communication,
decision support, and advance care planning) to help nalize the Assisted Living
Version 1.0 tools, now publicly available at the INTERACT website http://inter-
act2.net.
Clinical Suggestions forPractitioners
This section provides suggestions for healthcare providers aimed at optimizing their
practice in AL.Some of the suggestions may be easier to accomplish if a Medical
Director position has been established.
Adapt Already Established andEvidence-Based Policies
andProcedures forAL
Many healthcare practitioners familiar with the workings of nursing homes also
take care of AL residents. Nursing home residents are required to be seen at a minimum of every 60days, and with the increasing acuity and frailty of ALC residents,
it behooves clinicians to establish regular on-site visits for AL residents at least
quarterly and more often if medically necessary. Pertinent guidelines can be adapted
for use in ALCs, such as falls prevention, notication protocols, and reduction of
antipsychotic medication. Use of a consultant pharmacist for monthly or quarterly
medication reviews is encouraged. Suggestions for efcient time management in
LTC are also applicable to clinician care in AL (Table6) [42].
Assisted Living andResidential Care
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Table 6 Time management guidelines
• Limit practice to only 1–2 ALCs you know well
• Use a midlevel practitioner for management of routine problems
• Have a regular day for seeing residents at a particular community
• See the sickest patients rst
• Develop protocols for common problems such as constipation, weight loss, falls, behavioral
problems, and fever
• Train staff to limit after-hour telephone calls to urgent problems and provide mechanisms for
staff to address nonurgent problems (such as daily telephone calls, regularly checked
message lines or e-mails, and regular rounds by the healthcare practitioner)
• Speak with residents and families about advance directives shortly after admission and with
major status changes; document these discussions clearly
• Anticipate future events and discuss expectations with the family in advance to aid in
decision-making and the adjustment process
• Learn as much as possible about family dynamics to eliminate any surprises when healthcare
decisions need to be made; communicate your expectations through discussions with staff,
standing orders, and in-service programs
• Educate yourself about assisted living regulations, especially those affecting provision of
medical and nursing services
• Work as a partner with the staff and care providers
Meet Regularly withtheALC Administrator
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Getting buy-in from the administrator is an important strategy that can help improve
resident care. The clinician may initiate topics for discussion and ask the administrator how clinician involvement can help with state survey compliance and ALC
marketing. Improvement in mutual communication and medical documentation is
generally an area of concern. Scheduled meetings can vary, from monthly to less
often. Minutes from previous meetings should be kept, and it is recommended that
the focus on an identied area of concern be continued until the problem is resolved,
prior to addressing another area. If the administrator is unable to attend meetings,
clinicians should at least keep in regular contact with whoever in the AL is the liaison for medical care. A clinician could also have opportunity to participate as a
member of an “advisory committee” for overseeing the care being provided to residents by the rehabilitation, hospice, and home healthcare agencies that visit the
facility.
Provide In-Service Training toStaff, Residents, andFamily Members
A well-educated staff is a critical component to providing high quality care. For
example, a clinician or a mid-level practitioner can present educational sessions to
frontline staff on such topics as geriatric principles, medication administration and
adverse drug effects, best practices in communication, the Choosing Wisely
campaign(s), and common illnesses in older adults (e.g., dementia, hypertension,
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D. Dobbs et al.
diabetes, stroke, mental health disorders). There are AL-specic articles in nursing
journals that can benet staff. In addition, residents and families are often eager to
learn about common geriatric conditions, advance directives, and medication issues.
Some ALCs have “family nights” at which clinician-led “Q and A” or “Ask the
Doc” sessions can be invaluable. Many communities have resident and/or family
councils. Clinician attendance at these councils can be of great value to improve
education and communication and to help to identify other issues of concern within
the community.
Ensure Effective Communication
Clinicians can help communities establish a process for timely notication when
there is a change in patient status, a medication error, or a questionable treatment
ordered by a consultant. The community should convey timely and accurate
information whenever a resident leaves the community to see a different clinician
(Table7), and during an urgent or emergency transfer. It is vitally important to
include the current medication regimen and copies of any advance directives for
healthcare. As such, clinicians can help ALCs develop a packet of information
for each resident that would be available in an emergency, including copies of
items such as insurance information, family contact numbers, activity, diet, and
treatment orders as well as past medical history, pertinent consultant reports, and
lab results. Developing relationships and communicating with local emergency
department providers and emergency medical services can be helpful, as inappropriate use of these resources can lead to unnecessary transfers, hospitalizations, patient/family stress, and excess costs [43]. In addition, transferred
residents should be clearly identied that they reside in an ALC (and not a nursing home).
If an ALC does not have a resident medical chart, clinicians can share their ofce
chart with the ALC.Use of a communication book can be useful to leave messages
for and from the ALC staff. If there is a chart, the clinician should request a separate
section for medical progress notes. Copying or scanning the ALC note into the
ofce EMR or faxing the ALC note to the medical ofce can keep ofce records
updated.
Providers have a responsibility to return telephone calls promptly and
professionally. A major concern is the poor response time from primary care
providers. Providers should establish a protocol so that the ALC knows how to
contact their ofce for nonurgent and emergent calls. Having a system to contact the
Table 7 Standard information recommended for AL transfer/communication forms
Community name and phone and fax numbers Attending physician name and information
Reason for transfer/consultation Patient Name, DOB
Up-to-date medication list Family contact information
Relevant H&P/progress notes/labs/X-rays
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ALC is essential, as well as identication of the point person to contact. Consider
calling regularly at a specic time of day. Returning a call during the same staff shift
can help limit miscommunication between shifts at the assisted living.
Communication with families on a regular basis is important and can prevent
problems and misunderstanding and improve resident, family, and staff satisfaction.
Family should be contacted whenever there is a change in resident status and when
a resident is transferred out of the ALC.Discussing family expectations upon resident admission can help identify any that are unrealistic. Medication issues and
medication costs are a frequent resident/family concern and should be addressed
with the family at appropriate intervals.
Focus onHigh-Risk Medications andMedical Problems
Common geriatric disease states are often conducive to risk reduction strategies. As
in nursing homes, special attention must be given to the prevention of falls and
decubitus ulcers, diabetes management (especially hypoglycemia), and resident
elopement. Some medications have more potential for signicant harm than others,
such as anticoagulants (e.g., warfarin), diabetic drugs (both oral and injectable),
opioids, and antipsychotics. Many of the materials related to the CMS National
Partnership to Improve Dementia Care and the reduction of antipsychotic use are
applicable to AL (and referred in the 2015 GAO report “Antipsychotic Drug Use:
HHS Initiatives to Reduce Use in Older Adults in Nursing Homes, but Should
Expand Efforts to Other Settings”). The AMDA Medicine Quality Prescribing
Campaign (based on an IOM report to prevent medication errors and promote safe
prescribing) and more recently the AMDA “Drive to Deprescribe” initiative, offer
additional information and guidance.
Initiate Discussions onAdvance Directives forHealthcare
Many ALC residents either have no advance healthcare directive or have one that
will not be applicable in an emergency situation. The importance of this was evident
during the COVID-19 pandemic. Encouraging their use, as well as resident and staff
education, can be instrumental in clarifying residents’ preferences for care and for
life. It is recommended that tools such as the POLST (Physician Orders for Life
Sustaining Treatment) be used. The format of the POLST may differ from one state
to another.
Encourage Preventive Medicine andPerson-Centered Care
The importance of health promotion, disease prevention, and wellness services for
AL residents is well recognized. ALCs present opportunities for treatment and
management of chronic conditions, with potential resident benet [27]. Examples
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include screening for cancer, Alzheimer’s disease, hypercholesterolemia, and
osteoporosis, as well as using immunization protocols and promoting exercise
programs.
Person-centered care has been recognized as an important component of quality
of life for AL residents, yet measures have only been developed recently to
describe, quantify, and ultimately improve person-centered care. The PersonCentered Practices in AL (PC-PAL) has developed questionnaires to improve
person- centeredness by measuring care from the perspectives of residents and
staff, and is supported by multiple national organizations [44]. Medical leadership
can help bring this material to the attention of ALC administration and encourage
its use.
Urge Hiring ofaMedical Director
The ALC administration or corporation may be unaware of the advantages of
contracting a clinician as a Medical Director and may be concerned about its extra
nancial cost. It is important to recognize that appropriate medical direction may
improve resident care, communication and marketing, lower liability risk, and prevent avoidable ER transfers and hospitalization.
As most ALCs do not have written policies or procedures for quality improvement
related to medication management, drug regimen review, and monitoring for adverse
drug events [45], such an initiative would be an opportune focus for Medical
Director leadership. AMDA’s Position Statement on Assisted Living lists some
potential roles and responsibilities of an AL Medical Director (see Table8). The
challenge to the clinician is conveying the signicant benets this position can provide. There is evidence that having a full-time clinician at the ALC by itself can
improve care, as one study showed a statistically signicant decrease in hospitalizations and hospital days, and a suggestion of a decrease in falls [46]. ALCs might
consider having a Medical Director on retainer, not as a dedicated position, but as
Table 8 Potential roles and responsibilities of AL medical director
Practitioner services
• Assist the ALC in ensuring that residents have appropriate physician coverage and ensure
the provision of physician and healthcare practitioner services
• Assist the ALC in developing a process for reviewing physician and healthcare
practitioners’ credentials
• Provide specic guidance for physician and healthcare practitioner performance
expectations
• Assist the ALC in ensuring that a system is in place for monitoring the performance of
healthcare practitioners
• Facilitate feedback to physicians and other healthcare practitioners on performance and
practices
• Assist the ALC with resident assessment and development of the clinical component of the
service plan, when necessary
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Table 8 (continued)
Clinical care
• Participate in administrative decision making and the development of policies and
procedures related to resident care and medication management
• Participate in administrative decision making on stafng levels, coverage, licensing, and
training requirements for resident-care staff
• Assist in developing, approving, and implementing specic clinical practices for the ALC
to incorporate into care-related policies and procedures, including areas required by laws
and regulations
• Review, respond to, and participate in federal, state, local, and other external inspections
• Assist in reviewing policies and procedures regarding the adequate protection of residents’
rights, advance care planning, and other ethical issues
Quality of care
• Assist the ALC in establishing systems and methods for reviewing the quality and
appropriateness of clinical care, medication management, and other health-related services
and provide appropriate feedback
• Participate in the ALC’s quality improvement process
• Advise on infection control issues and approve specic infection control policies to be
incorporated into ALC policies and procedures
• Assist the ALC in providing a safe and caring environment with optimal levels of family
and community involvement
• Assist in the promotion of employee health and safety
• Assist in the development and implementation of employee health policies and programs
Education, information, and communication
• Promote a learning culture within the community by educating, informing, and
communicating
• Assist the ALC in developing medical information and communication systems with staff,
residents, families, and others
• Assist in establishing appropriate relationships with other healthcare professionals
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an administrative position to be available as needed. As some ALCs may have a
clinician who sees a majority of their residents, he/she may become a sort of “de
facto” Medical Director or consultant. Although, as such, this position does not
provide coverage for administrative liability, the provider may be empowered to
suggest or enact changes benecial for resident care.
Guide Families andColleagues toAvailable Resources
Clinicians often play an important role when older adults are no longer able to be
cared for at home. Several organizations offer information and guides to choosing
an ALC (e.g., National Center for Assisted Living, AARP, Assisted Living
Federation of America). Hospital case managers may not be aware of these
resources, including CEAL and AL consumer groups. Some areas of the country
have literature available to families that list housing options including AL, such as
SourceBook: Guide to Retirement Living for several eastern states.
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D. Dobbs et al.
Champion State “Mini-AL Workgroups”
One of the recommendations from the national AL Workgroup was to establish
state-level public meetings to review its recommendations. Virginia has already convened such a meeting. Wisconsin has developed an innovative collaborative called
the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL),
which includes regulatory and public funding agencies, the state ombudsman’s program, as well as state AL and residential care provider associations. This
Collaborative has developed performance measures and satisfaction surveys that
can be voluntarily used by Wisconsin AL providers as quality improvement tools. A
clinician interested and involved in AL may have the opportunity to spearhead a
“mini-AL Workgroup” or similar collaborative in their state.
Clinical Leadership inQuality Assurance/Performance
Improvement (QAPI)
As data collection and analysis to improve resident outcomes is increasingly
important, QAPI meetings are occurring more frequently in ALCs. The basic
elements of QAPI are Design and Scope; Governance and Leadership; Feedback,
Data Systems and Monitoring; Performance Improvement Projects (PIPs); and
Systematic Analysis and Systemic Action. Data to assist ALCs in their relationships
with ACOs can be tracked and evaluated through the QAPI process. The AHCA/
NCAL Quality Initiative for AL also features QAPI principles. QAPI is mandated in
nursing homes, and physician leadership should ideally take the lead to guide AL
communities in adopting similar initiatives.
Summary
Physicians, nurse practitioners, and physician assistants play an essential role in the
treatment of residents who live in ALCs. The trend of increasing resident medical
acuity and recognition of the importance of healthcare providers in AL makes this
an exciting time to practice in AL.Once understanding the capabilities of the ALC,
the potential for clinician collaboration in establishing seamless community-based
care, promotion of preventive care and wellness, early identication of sentinel
events, and contribution to quality-of-life outcomes shows great promise [47].
Ideally, the clinician can be a “middle man” advocating for resident care and helping to establish a safety net for patient care [27] while understanding ALC concerns
and striving to maintain affordability for residents and their families.
Pearls for the Practitioner
• ALCs are regulated by state agencies, which leads to signicant state-to-state
variability in rules, requirements, and terminology.
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• ALCs vary signicantly in size, resident characteristics, philosophy, staff, and
resident care capabilities.
• Staff number, availability, training, and capabilities can vary greatly by state and
location, leading to potential challenges with communication, medication management, and overall resident care.
• Treating residents in the ALC has benets for residents, families, the staff, the
faculty and practitioners.
• Many barriers to quality care may be addressed by increased clinician involvement
in ALC.Promote the position of a physician consultant or medical director.
• In the wake of COVID-19, and future epidemics/pandemics, the need for
oversight in infection control is pivotal.
Acknowledgments We want to acknowledge Kathryn Hyer, who made immense contributions to
the eld of assisted living before her untimely death in January 2021.
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