Delivered Excellent Learning for Post Acute Teams
CALTCM’s Education Committee, chaired by Dr. Rebecca Ferrini, held the 49th annual meeting of CALTCM early this month at Universal City, CA.
This year’s conference benefited physicians, advanced practice nurses, pharmacists, licensed nurses, administrators, behavioral health specialists, and other members of the interdisciplinary team and administrative leadership who care for patients and residents of the post-acute and long-term care (PALTC). In particular, the program provided resources, information, and guidance for advanced person-centered care. Moreover, the event updated all concerned, on regulatory and legal dynamics faced by post-acute care practitioners, in accordance with the California state policies and best practices to avoid litigation.
We are pleased to offer a summary of a few key points.
Conflict Management Improves Teamwork
Conflict management skills are key to outstanding teamwork. Organizational researchers have long used various style models to help people identify their conflict management preferences. People naturally tend towards more or less collaboration and more or less direct styles. Conflict arises naturally in the workplace whether about the Task, Process, Relationship, or Status. By understanding where you fall on the continuum and where your colleagues fall, you can manage your interactions to manage conflicts productively. One conflict style model describes the variety of styles using animal analogies:
“Sharks” are very aggressive and not very collaborative and thus come across as competitive.
“Turtles” demonstrate little collaboration and are unassertive and have an avoiding style.
“Teddy Bears” are the most accomodating and least aggressive.
“Owls” rate the highest in cooperation and assertiveness and thus are recognized for collaborating.
“Fox” types tend to balance the dimensions and are seen as compromising.
By understanding where you fall on the continuum and where your colleagues fall, you can manage your conflict effectively. This awareness allows you to customize your approach, whether it’s through open communication, compromise, or seeking consensus.
Behavioral & Pharmacological Interventions for Psychosis in People with Dementia
Human beings can experience severe mental conditions. Where rational thought processes and even mundane sentiments go askew with the factual world, it is called psychosis. It can happen at any age; it can occur at an early age like late teens but as a person grows older, it exposes them more to cognitive diseases. In plain English, a psychotic person is delusional and/or hallucinating (i.e., experiencing false vision, hearing, touch, and even false conceptions towards people or incidents).
For People Over Age 60, 60% of Psychosis is Due to Cerebrovascular Issues
Delirium, Dementia, Drugs/illicit substances/toxins, Medical conditions including autoimmune conditions, paraneoplastic syndromes, endocrine disorders, etc. are secondary causes for psychosis in older people of 60 years of age, whereas 60% of primary etiology is a clinical diagnosis of cerebrovascular risk factors.
The possibility of dementia in Very Late Onset Schizophrenia Psychosis VLOSLP varies in individuals. It depends on many factors, like genetic predisposition, health, and lifestyle.
But if a person, less than 40 years of age has the onset symptoms of schizophrenia, they can have a progressive cognitive decline in his/her older age.
Differences Between Dementia Etiologies
Various types of dementia result in different etiologies. In fact, studies show delusions are more common in Alzheimer’s Disease, while hallucinations frequently occur in diffuse Lewy Body dementia, and there is less risk of psychotic symptoms in frontotemporal dementia (FTD)
There is an estimated risk of 61% heritability of Alzheimer’s disease, compared to 81% for schizophrenia and 50–60% for Alzheimer’s Disease itself.
A Complete Medical Work Up Is Vital
Case studies have proven time and again that when a patient is admitted to the hospital with psychotic symptoms, a complete medical work-up with the family’s feedback can help determine the best treatment. Several common delusions are often encountered in the older adult population:
- Charles Bonnet Syndrome CBS-“visual hallucinations associated with vision loss”
- Fregoli Delusion-“a rare disorder where the patient thinks that multiple persons are in fact a single person”
- Capgras Syndrome-“imposter syndrome, where a patient thinks that someone is masquerading as a known person and is not “real”
- Not Being Home Delusion-“patient does not recognize their own home”
- Cotard’s Syndrome-“Patients consider themselves to be dead or believe they lost their organs”
The Accuracy Of Diagnosis
By fully identifying the patient’s problem, healthcare teams stand a better chance of treating the patient effectively.
Nonpharmacologic treatment can take the edge off the misery of the patient. So a behavioral approach like listening, calming, and accepting rather than negating the patient brings positive outcomes. Often patients experiencing delusions can be upset and anxious, so speaking gently and using a calming touch can relieve their discomfort significantly.
There are antipsychotic medicines for Alzheimer’s and Parkinson’s diseases but they are not FDA-approved as trials have not shown any significant positive and long-term results.
Aging With Grace
‘Prevention is better than cure’ has altogether a new meaning when we talk about growing old and cognitive degeneration.
Resilience & Resistance
All the cognitive stimulants, like a healthy lifestyle, social engagements, diet, exercise, education, and highly demanding jobs, and all the socio-economic factors can delay if not completely prevent, and slow the process of brain diseases that can come naturally with growing old.
Early Diagnosis Early Intervention
Keeping an eye on the biomarkers and getting pathological processes with deep investigations can alert you to any brain disorder or erosion at the very earliest. This allows for early intervention to prevent the onset of cognitive decline and diseases.
The fact is documented that 1 in 3 seniors dies with Alzheimer’s or other dementia. Thus, Alzheimer’s Disease and related dementia [ADRD] are the healthcare tsunamis of the 21st century.
Medicare spends nearly 4 times as much for people with dementia than for people without ADRD. This is also proving to be a great burden both on finances and on our social [family] structure as well. While we are talking about finances, it’s said that ‘time is money’ but when we talk about human life and quality of life at that, time is not just money, it’s invaluable to providing better care. Join Hucu and save time and energy communicating while you are making life better for older adults. Nothing can beat the timely and safe connectivity among caregivers that Hucu provides with Person-centered HIPAA compliance.
So let’s work on ‘Aging With Grace’ and give our elderly quality of life.
Organizational Discipline is the Best Defense to Avoid Litigation
Organizational discipline is the most significant factor in avoiding litigation. A Nursing Home or a Long Term Care Facility must secure not only its hard-working staff but also its reputation as a facility and that can only be done with the following action plan:
A. Draft a comprehensive policy. The terms and conditions should be clear without any ambiguity so the chances of litigation can be avoided in the future.
B. Perform a Risk Assessment of each resident and his/her family’s possible risk of litigation
C. Methodically research past cases and add the clauses in the policy in foresight
D. Incessantly brainstorm theories to avoid litigation, keeping in mind realistic expectations.
E. Maintain vigilance in recording the resident’s care plan and its execution
F. Follow four vital steps before taking in a resident/patient
1. Initial Assessment
2. Care Plan
3. Identify known Risks
4. Treatment Plan
G. Stay alert of any lapses at any stage
H. The staff must always be on the top of their game
- Make sure the Nursing Home always and promptly notifies the resident’s doctor and family of any change in their condition
Two factual cases were discussed at the Summit for key learnings.
Case study 1
An element of negligence in documenting the care plan was found.
The essentials of negligence have been proven by the plaintiff and thus they are entitled to compensation.
Oral consent/contract is not admissible in a court of law, so nursing homes must be vigilant on written documentation.
The care plan [medication, hygiene, diet] should be minutely detailed and documented and must have the consent of the family.
This particular case shows the risk factor is twofold against the defendants and the plaintiff gets the benefit of the doubt.
Case study 2
The patient/resident was suffering from multiple health issues and in this case, it cannot be determined what triggered the collapse. Also, the consent for treatment was not from an authorized person.
The Nursing Home’s proper medical charting and data is a prudent standard.
Take a look
Certain protocols must be followed. Such as
Timely and accurate care plan entries as audit trails can sink a defense case.
Fall prevention is possible despite the absence of large population-based research studies and should be considered judiciously.
Individual supervision is necessary in acute cases.
Avoid conflicting documentation rather than having to go back and document it at a later stage the factual substance.
Care plan goals should be set realistically based on medical facts.
And last but not least, pose a united front as much as ethically possible.
Primary Legal Culpabilities Under California Statute
Recklessness (CACI 3113) – deliberately ignoring the acute risk of injury.
Malice (CACI 3114) – intent to cause injury or unreasonable/cruel behavior despite knowing the negative consequence
Oppression (CACI 3115) –distasteful manner and imposing harsh and unfair difficulties on the victim
Fraud (CACI 3116) – Deliberate distortion, dishonesty, or the act of hiding information with the sole purpose of depriving someone of their rights or causing harm
AN Update ON Reforms And Amendments Regarding Pre-Death Pain and Suffering [MICRA]
The introduction of CCP 377.34 in 2022 states that in cases brought by the personal representative or successor in interest of a deceased individual, seeking damages for the decedent’s cause of action, recoverable damages may now encompass compensation for pain, suffering, or disfigurement if the legal action was initiated on or after January 1, 2022.
For Living Plaintiffs And Survivorship Claims – $250,000 to $350,000 in 2023 and goes up $40,000 per year.
In Wrongful Death Actions – $250,000 to $500,000 in 2023, goes up $50,000 per year.
Pre-Death Pain And Suffering Elder Abuse Statute – MICRA cap referenced even in cases against RCFEs, so it matters.
AI Will Raise the Floor for Quality Healthcare
Artificial Intelligence in healthcare is revolutionizing automating tasks, processing large data sets, improving medical imaging, and more.
The most important leverage AI can provide is the advanced predictive analytics of a patient’s health that ensures timely intervention thus, saving them from further deterioration and suffering.
All the modern technologies and research won’t serve the purpose fully without the element of ethical considerations, particularly in healthcare, which AI brings, like fairness, transparency, and accountability.
Large data based on genetics and lifestyle will be a great help to doctors in making an accurate diagnosis. Moreover, virtual biopsies will replace the need for tissue sampling as deep learning algorithms can discern intricate patterns in imaging data. Artificial intelligence, have indeed intelligent bots that can analyze scientific literature and statistical data enabling precise diagnosis
System For Supporting Clinical Decisions
The algorithms not only help in the accuracy of diagnosis but also give input for the medicine dosage and the reactions or allergies.
1. Personal Devices
On a lighter note, patients can have their own talking or tech conscience leading them to healthy choices and reminders for time for medications. Also, the wearable device can collect data to advance treatment.
2. Administrative Documentation
AI will be giving the clinical staff much-needed breathing space by documenting all the administrative data leaving them more time and energy to give care to their residents.
Nursing homes: an institution or an actual person-centered facility
A very interesting but practical point was also discussed in the Summit about how and why a Nursing Home works better if it is deinstitutionalized into a person-centered facility. A place where the residents have a home-like atmosphere with a very casual and routine lifestyle can enjoy. Keeping the safety and of course the dignity of the residents intact with the help of the Artificial Intelligence of VSTAlert. All the activities are planned and monitored according to the resident’s physical and cognitive ability.
Interdisciplinary Teams Leverage Tenets of Osteopathic Medicine
In 1874, Doctor Andrew Taylor Still was disgruntled with the usefulness of medicine and believed many interventions to be more harmful than helpful. So he developed a unique discipline of medical care, called Osteopathic medicine. It is important to note that an Osteopathic Doctor can diagnose and prescribe and even can do surgery just like an MD, Medical Doctor. But an OD, an Osteopathic Doctor has a different approach because of the Tenets of Osteopathic Medicine.
Tenets Of Osteopathic Medicine
A human being is a unit of mind, body, and spirit. It is simply amazing that nature has made the human body capable of self-regulating, healing, and maintaining health.
The body’s structure and function are interrelated and thus reciprocal. Last but not least, is that symptoms are not to be treated partially, a holistic approach is more effective for the well-being and prevention of diseases. A rational approach to diagnosis syncs with the body’s natural ability to self-heal and enhance the process of recovering from diseases.
Unity of Mind, Body and Spirit
This basic tenet of OMT leads to a holistic approach while diagnosing. The physician must consider the aging process that brings in the factors of musculoskeletal and osseous, along with the soft tissue change as well, such as facial sheaths and muscle atrophy (sarcopenia). Also, changes in spinal curvatures, degenerative arthritis (osteoarthritis), rheumatoid arthritis, osteoporosis and an increased risk of falling is part of aging.
Physiologic changes due to slowing in the production and circulation of neurotransmitters, and a slowing of axoplasmic flow results in clinical problems such as sleep disturbance, depression, changes in balance and coordination, decline in mental sharpness, and mood changes.
The point is if your body is healthy, it keeps you relaxed mentally, if a person is mentally disturbed for some period of time it brings physiological issues. If the spirit is not centered, it affects negatively on the whole. So, if one problem shows up, the doctor has to heal the whole unit.
OMT and Self Regulation- Secrets of Healthy Aging
To boost recovery and prevent disease OMT encourages the following steps
- Nutrition and weight control
- Posture and exercise
- Healthy lifestyle
- Reduction of emotional stress
- Prevention of illness and injury
But the most important intervention is to educate and stress the importance of all the above steps.
Osteopathic Doctors Often See Benefits in Common Areas of Concern
- Respiratory infections (prevention and treatment)
- Prevention of DVT and PE
- In collaboration with PT and OT
- Fall prevention
- Recovery from surgery
- Enhancing immune system responses
Structure And Function – Interdependence
Again, we go back to basics. A body is a unit of three so it’s natural that the body, mind, and spirit are all interconnected. If one is slowing down or gets some disease the other two are affected. Same as the reaction to the medication or any kind of treatment that is viable.
Age or acute diseases react differently to the treatment, whether it’s pharmaceutical agents, rehabilitative measures, or osteopathic manipulation.
So the physician has to be mindful of all the elements.
The impaired or altered function of related components is called Somatic Dysfunction. This concept is particularly associated with osteopathic medicine and is used to describe abnormalities or imbalances in the musculoskeletal system. Somatic dysfunction manifests in nearly every condition that impacts a patient. It emerges in response to trauma or disease affecting the musculoskeletal system. Intricate neurological connections contribute to the presence of somatic dysfunction in musculoskeletal segments related to internal organ or system dysfunction.
Identifying somatic dysfunction provides the physician with crucial insights that can assist in determining the specific factors causing the disease. This information is valuable in refining both diagnostic and treatment plans.
Goals And Other Considerations
The use of Osteopathic Medicine aims to bring a person his/her dignity by returning him to physical and emotional independence as much as possible, regarding the age and disease dynamic. Foremost is to increase the patient’s sense of health and contentment:
- Prevent multisystem diseases.
- Stretch tight facial sheaths and restore autonomic balance.
- Improve and mobilize fluids and digestion
- Pain management along with maintenance care and palliation.
We can gauge the success of OMT by seeing a patient’s level of resuming a normal life or by finding a palliative patient with peace of mind and comfort.
But let us not forget that the factors of age bracket and the acuteness of disease may dictate the time duration and effectiveness of the treatment.
Innovative Organizations Break Down Barriers
Innovation is essential for Long Term Care and Skilled Nursing Facilities to thrive in a dynamic and challenging healthcare environment. It can improve the quality of care, enhance efficiency, and ensure the long-term sustainability of these institutions.
Barriers To Innovation
Time has laid out a few following hurdles that stop organizations from innovating like:
- Time, money, Power, risk, priority, Low margins
- Lack of knowledge/expertise about technology
- Slow to adapt/integrate what we have while the innovations are changing more quickly
- low Medicaid payments and fragmented financing system
- Incentives are wrong—if we save hospitalizations or Medicare, this results in lesser reimbursement
- Privacy or security concerns.
Sample Of Innovative Tools
It is an amazing list consisting of tools and approach that helps in healing as well as preventive measures. Here are a few
- Electronic health records
- Wearable devices
- Assistive robots (cleaning, dispending medications, supervising, companions)
- Fall detection systems
- Smart sensors
- New mechanisms to release drugs or diagnose illness
- Biometric access control
- Simulations, virtual reality, and online learning platforms for training
- Data management and prediction
- Dementia-friendly design, sensory rooms, and outdoor spaces
- Virtual, augmented, and mixed reality
- Intelligent homes
- Voice-activated devices
- Self-driving vehicles or equipment
There’s more in clinical innovation. Take a look
Monitoring And Response
It changes the dynamics visibly. The LEAF uses wireless, wearable technology to substantiate turn quality, notifying nursing staff of patient position, activity, and mobility data directly at the point of care.
Infrared monitoring cameras for fall detection strike a balance between respect for privacy and monitoring individuals at risk of falls. These cameras provide timely alerts and vocal reminders, like ‘a nurse is on the way to you’, to proactively prevent falls.
Cell Phone Apps
Accelerometer – assess both measures of activity and sleep.
There are Mobile Apps that trail disease motion, electronic peak flow meters, constant glucose checks, blood pressure and heart rhythm monitoring, and remote cough measurement devices.
An App for wound care that evaluates and calculates changes or progress since the previous examination while also capturing photos.
Human Resource Innovation
Raises in salaries, bonuses, and other perks like housing and meals are the means to retain skilled nursing staff.
Hiring managerial staff to take the burden off nurses’ paperwork
Offering complimentary C.N.A. training and advanced education, that can boost their career opportunities, for the training of C.N.A. staff or Dwyer’s scholars.
In short, investing in manpower in every sense of the word can ensure maintaining the quality of care and a good name for the facility.
We actually do have innovation in person per se –
Time to think big;
A, Emphasizing the strategy of growing larger in the industry
B, The expansion into additional ancillary services not only strengthens operators’ control over SNF but also provides adaptability during challenging periods.
C, More sophisticated care specialty programs in SNF will make them more like hospitals
Set up a board tasked with identifying, reviewing, and testing ideas for addressing facility-wide concerns. The board comprises personnel who are proficient in research, decision-makers with consent authority, and analytical minds capable of evaluating proposed solutions. The process begins by pointing out a precise problem and developing a business case, detailing the potential cost savings related to implementing a solution.
Pros and Cons of Anti-psychotics in Senior Living
Recognizing the symptoms or signs that might merit the prescription of antipsychotic medications is a must. Not only the present symptoms but also the differential diagnosis of similar diseases like Schizophrenia, Bipolar, Dementia, and NOS should also be taken into account while determining the disease.
Antipsychotic medications are often effective in lessening the gravity of psychotic symptoms such as delusions, hallucinations, and disorganized thinking.
Constant use of antipsychotic helps in preventing the recurrence of psychotic episodes and decrease the risk of setback.
Characterize diagnostic criteria for Bipolar, Schizophrenia, Psychosis NOS, and Dementia-Associated Behavioral disturbance.
Many antipsychotic medications can cause weight gain and metabolic side effects, which can trigger long-term health issues.
Also, the antipsychotic medication can cause movement disorders such as tremors, rigidity, and tardive dyskinesia.
A basic factor of diagnosing psychosis is that while taking a history of the patient [talking to the patient directly in the first sitting] the following aspects must be observed keenly
Mood: is the patient depressed or irritable
Speech: is the patient’s speech easy to understand and patient talk slowly or fast
Thoughts: is the patient’s perceptions towards himself and others are negative. Presence of Hallucinations or Delusions.
Cognitive: Aware of the current year but not fully oriented to the month and day; Able to register three out of three items but recalls only two out of three items
The selection of an appropriate drug and its dosage varies throughout each stage of a disease.
Treating Substance Use Disorders in Nursing Homes
Substance Use Disorder (SUD) is diagnosed based on specific criteria charted in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The intensity of SUD is categorized as mild, moderate, or severe based on the number of criteria met. Addressing substance use disorders (SUD) in nursing homes presents distinctive difficulties due to the intricate healthcare requirements of elderly residents.
NH Responsibility For Diagnosis And Treatment Of Residents With SUD
Assess Prevalence Of Substance Use -Screening And Assessment –
Determine Substance Use Disorder By DSM-5 Standards: Apply the diagnostic criteria outlined in the DSM-5 to ascertain whether a patient meets the criteria for a SUD.
Assess Medical History: Check the medical history to identify any primary health conditions or factors that may influence substance use.
Assess Psychosocial Supports: Look for family, friends, or community resources that can be of help in managing their SUD.
Assess Substance Use History And Current Substance Use: Use pattern of past, if any, SUD and current substance.
Assess Treatment History: if applicable, check for the patient’s history of treatment for past SUDs
Assess Addiction Severity: Withdrawal symptoms, cravings, and the impact of substance use on daily functioning can determine the severity of SUD.
Assess Pain: The intensity of pain can influence both the development and continuation of addictive behaviors.
Facts To Remember For Effective Treatment
· SUD is treatable
· Customized approach
· Effective treatment addresses multiple needs
· Remaining in the program for a sufficient period of time
· Both behavioral and medications can be used
· Treatment and care plan must be assessed constantly
· First comes – Medically assisted detoxification
· Monitor drug use
Motivational Interviewing (MI) is a joint and person-centered approach designed to draw out and develop the patient’s motivation for change. It is an empathetic and supportive counseling that fosters the necessary element for personal reform. MI practitioners consciously steer clear of arguments and confrontation, as these can trigger resistance in the individual.
MI Helps In..
Knowing the patient’s awareness of their disease and willingness to be healed.
Assure the patient for the disease to be treatable
Time To Use MI And Techniques
MI is best to use at the early stage but it helps in the middle of the treatment to assess the patient and the recovery level.
MI techniques are known as OARS
Forming reflective statements
New Drugs for Older Adults
Let’s start with the medication that is used for Central Nervous System CNS
RELYVRIO: is given for Amyotrophoc Lateral Sclerosis [ALS]
It helps in preventing or slowing the decline of motor neurons.
Dosage: in 250ml water once sache, twice a day for three weeks.
Adverse drug reaction ADR: stomachache, nausea, and advisable not to use it on patients who are intolerant to sodium.
LECANEMAB: is used for Alzheimer’s and Dementia mild cognitive impairment. The medicine works against the proteins that gather in the brain cells that cause these two diseases. It works as an antibody. Amyloid beta must be confirmed before starting this medicine.
Dosage: Twice a week in injection.
ADR: Hypersensitivity reaction, brain edema,
Zavegepant (Zavzpret) Nasal Spray: is used for migraines. The spray is to be used in only one/any nostril
Dosage: Once in twenty-four hours.
ADR: Gastrointestinal and Respiratory
Brixadi injection: For Opioid addicts,
It does the degradation of substances from the body
Dosage: Once a week
ADR: Dizziness, drowsiness, hypotension, constipation. And the skin might sport bruise where the medicine is injected. Blurred vision
OPVEE Nazal Spray and NALOXONE SPRAY:
Is used to combat overdosing on Opioid
ADR: Gastrointestinal hypotension and vomiting
Brenzavvy (Bexagliflozin): Prescribed for type two diabetes. it stops the insulin going directly to the blood from the kidney. Prevents chronic kidney diseases.
Dosage: once daily
Adverse drug reaction: can drop the sugar level all of a sudden. Access to urination, skin reactions. Cardiovascular deaths
Farxiga: Helps in preventing cardiovascular deaths and chronic kidney diseases in diabetic patients. It is used in diabetic one.
ADR: Skin, GI, Cardiovascular
Inpefa (Sotagliflozin): it prevents the elements [glucose, sodium] that cause heart diseases.
Dosage: 200mg an hour before meal, once daily. It can be increased to 400mg after two weeks.
ADR: Urinary tract infection, low sugar level, diarrhea, fungal infection in UTI.
Agents For Eye Disorder
SYFOVRE: is prescribed for Macular Degeneration.
Injected once every 25 to 60 days in the affected eye, builds a tear that prevents the dryness in the eye.
Perfluorhexyloctane (Miebo): prescribed for dry eyes.
ADR: Blur vision and redness in the white of the eye [Conjunctival]
Abrysvo, Arexvy, And Beyfortus: For the prevention of Respiratory Syncytial virus. It is an active immunization that is administered directly. It contains antibodies that effects directly. Especially used for 60-plus elders.
Dosage: powder form used in 0.5ml water. A single dose.
ADR: pain, fatigue
Vaccine For COVID19
Nirmatrelvir and ritonavir (Paxlovid) Tablets to be taken orally..
Dosage: twice a day for five days. Must start the dosage within 5 days of the appearance of the symptoms.
Fezolinetant (Veozah) it lessens the symptoms of menopause,
Dosage: 45mg once daily
ADR: headaches, diarrhea, body pains, lack of sleep, increased liver enzymes.
Ritlecitinib (Litfulo): used for patchy hair loss.
Dosage: 50mg once daily
ADR: headaches, dermatitis, diarrhea, stomachaches, dizziness, body aches
Xacduro: is a combination of two agents, prescribed for acquired bacterial pneumonia and ventilator-associated bacterial pneumonia
Dosage: One gram for six hours for 7 days. Dosage must be determined according to the creatinine levels.
ADR: liver function disturbance, diarrhea, anemia, decrease in blood cells, going into shock
Prescribed to combat anemia caused by acute kidney diseases. Especially for the patients on dialysis. It encourages the development of erythropoietin.
ADR: Cardiovascular, GI, hypersensitivity