Current Clinical Practice Series editor Neil S. Skolnik More information about this series at http://www.springer.com/series/7633
Pamela A. Fenstemacher Peter Winn Editors Post-Acute and Long-Term Medicine A Pocket Guide Second Edition
Editors Pamela A. Fenstemacher, MD, CMD, FAAFP Chief Medical Officer Living Independently for Elders (LIFE) University of Pennsylvania School of Nursing Philadelphia, PA, USA Peter Winn, MD, CMD Department of Family and Preventive Medicine Geriatric Assessment Clinic University of Oklahoma OUHSC Family Medicine Center Oklahoma City, OK, USA Current Clinical Practice ISBN 978-3-319-16978-1 DOI 10.1007/978-3-319-16979-8 ISBN 978-3-319-16979-8 (ebook) Library of Congress Control Number: 2015953500 Springer Cham Heidelberg New York Dordrecht London Springer International Publishing Switzerland 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms 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 specific 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, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Humana Press is a brand of Springer Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com)
Preface Whether practitioners are still in training, recently graduated, or deciding to change the direction or focus of their career paths, either by choice or necessity, they can find themselves immersed in the long-term care (LTC) arena. Any practitioner of LTC can be overwhelmed when confronted by an LTC system that is both complex and highly regulated, let alone taking care of patients that are challenging even to the most experienced among us. These patients are challenging not only because they have numerous chronic medical conditions and extensive and complicated medication regimens but also because of advanced age and frailty. As experienced clinicians, educators, and medical directors in LTC, we have written this guide for practitioners in hopes of continuing to improve the quality of care provided throughout the LTC continuum by imparting to practitioners the current knowledge in this field as well as the experience our chapter authors have acquired over many years working in LTC. Both The Society for Post-Acute and Long-Term Care Medicine (AMDA) and its state chapters continue to work tirelessly to meet the LTC practitioner s needs. 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 for practitioners is aimed at filling this void. The chapters of this guide address the varied components of the LTC system as well as how to take care of the patients and residents living within it. Since the first edition of the guide was written, the LTC system has continued to evolve. The Center for Medicare and Medicaid Services (CMS) is promoting highquality cost-effective care through initiatives that encourage the use of innovation, technology, and collaboration to improve quality. Accountable Care Organizations (ACOs) and Population Health Management are two examples of CMS innovation, focusing on prevention and early treatment of chronic medical illness. Chapters on PACE, Nurse Practitioners, Clinical Nurse Specialists and Physician Assistants, and the Department of Veteran Affairs Options were added to reflect the increase in community-based care that is being offered to our elders. The focus of some chapters was shifted as well. The first edition s chapter on Acute Change in Condition v
vi Preface was changed to reflect the increasing focus on Preventing Hospital Admissions and Readmissions that is seen in LTC today. All of the chapters were updated to include the latest innovations such as INTERACT II. 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 recent CMS Quality Prescribing Initiative), PQRS reporting, HIPAA compliance (and possible audits), different electronic medical records at different healthcare settings, and EMR meaningful use. As editors of this guide, we hope these challenges will be less daunting with the information provided in this guide. The contributors to this guide are passionate about LTC and many have worked within AMDA to create and disseminate a knowledge base for practitioners through varied means such as AMDA s clinical practice guidelines, conferences, and white papers, all of which have served as resources to this guide. We hope that you find Post-Acute and Long-Term Care Medicine an invaluable resource to complement your quest to optimize the care and living experience of your patients in LTC that supports patient-centered care as well as patient choice, well-being, dignity, and an improved quality of life. This guide is dedicated to Chris Laxton and the AMDA staff, and all our AMDA colleagues who have mentored both of us over the years, many of whom have written chapters for this guide. Philadelphia, PA Oklahoma City, OK Pamela A. Fenstemacher Peter Winn
Series Editor Introduction There is no better time for an update of Long-Term Care Medicine. Individuals over 65 represent the fastest-growing portion of the population in the United States, consume the highest proportion of the country s healthcare dollars, and often live in long-term care facilities or receive intensive outpatient home-based management for the latter portion of their lives. The editors, Drs. Fenstemacher and Winn, have extensive academic and practical experience in long-term care and have been involved in leadership positions with the American Medical Directors Association, which is the professional association for long-term care physicians. From this vantage point, they have selected authors who have both an academic and practical perspective on issues most relevant to the patients we take care of in long-term care facilities. The book s emphasis is on giving the practicing physician an accessible guide to understand and better manage the issues that come up in taking care of frail elderly patients. The book goes over the changing environment and regulations of long-term care. It does so by providing an expansive general overview of places and processes of care as well as details of care including chapters on wound care, dementia, delirium, rehabilitation, and many more. The book is readable, practical, interesting, and relevant. For this the editors and authors are owed our thanks. Neil Skolnik, MD Professor of Family and Community Medicine Temple University School of Medicine Associate Director Family Medicine Residency Program Abington Memorial Hospital vii
Contents Home Health Care... 1 Robert C. Salinas and Stefani D. Madison Assisted Living and Residential Care... 13 Daniel Haimowitz PACE... 37 Laura Trice Department of Veteran Affairs Options for LTC... 47 Deborah Way Behind the Scenes at Nursing Facilities... 51 Richard G. Stefanacci, George Brown, and Shelley Reich The Role of Practitioners and the Medical Director... 73 Steven A. Levenson Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants... 91 Pamela Z. Cacchione and Reshma Shah Common Clinical Conditions in Long-Term Care... 99 Naushira Pandya Preventing Hospital Admissions and Readmissions... 145 J. Kenneth Brubaker Goals of Care and Prevention... 165 Cynthia Kuttner Integrating Palliative Care into Practice... 177 Peter Winn and Deborah Way Weight and Nutrition... 203 Todd H. Goldberg and Joel A. Levien ix
x Contents Wound Care... 217 Ganesh Merugu and Andrew Rosenzweig Dementia, Delirium, and Depression... 235 Andrew Neal Dentino, Pamela A. Fenstemacher, and Kourtney Harrington Ethical and Legal Issues... 261 David A. Smith and Randall D. Huss Caring for Families... 279 David Brechtelsbauer Documentation and Coding... 291 Alva S. Baker and Leonard Gelman Medication Management in Long-Term Care... 307 Susan T. Marcolina and Peter Winn Rehabilitation and Maximizing Function... 327 Thomas Lawrence Index... 339
Contributors Alva S. Baker CMDR, HMDC, Hagerstown, MD, USA David Brechtelsbauer Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA George Brown Director of Clinical Services, The Access Group, Berkeley Heights, NJ, USA J. Kenneth Brubaker Masonic Villages, Elizabethtown, PA, USA Geriatric Associates, Suburban Outpatient Pavilion, Lancaster General Health, Lancaster, PA, USA Pamela Z. Cacchione Department of Family and Community Health, University of Pennsylvania, Philadelphia, PA, USA Andrew Neal Dentino Donald W. Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA Leonard Gelman Capital Care Family Medicine, Ballston Spa, NY, USA Todd H. Goldberg Department of Internal Medicine, West Virginia University Health Sciences Center, Charleston, WV, USA Daniel Haimowitz Multi-facility Medical Director, Levittown, PA, USA Kourtney Harrington Donald W. Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma, OK, USA Randall D. Huss Department of Family Medicine and Geriatrics, Mercy Clinic, Rolla, MO, USA Cynthia Kuttner Department Chair and Assistant Professor, Department of Geriatrics and Gerontology, Ohio University Heritage College of Osteopathic Medicine, Ohio, USA xi
xii Contributors Thomas Lawrence Department of Geriatric Medicine and Long Term Care, Main Line Health System, Main Line Health Center, Newtown Square, PA, USA Steven A. Levenson Genesis Healthcare, Baltimore, MD, USA Joel A. Levien Department of Gastroenterology, Jackson Madison County General Hospital, Jackson, TN, USA Stefani D. Madison Donald W. Reynolds Department of Geriatric Medicine, Hospice and Palliative Care Fellow, Oklahoma University Medicine Senior Health Center, Oklahoma City, OK, USA Susan T. Marcolina Public Health Seattle and King County, Seattle, WA, USA Eastgate Public Health Center, Bellevue, WA, USA Ganesh Merugu Department of Geriatric Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA Naushira Pandya Department of Geriatrics, Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL, USA Shelley Reich The Access Group, Berkeley Heights, NJ, USA Andrew Rosenzweig Department of Geriatric Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA Robert C. Salinas Family and Preventive Medicine, OU Medical Center, Oklahoma City, OK, USA Reshma Shah Living Independently For Elders (LIFE), University of Pennsylvania, Philadelphia, PA, USA David A. Smith Geriatric Consultants of Central Texas, Brownwood TX, USA Richard G. Stefanacci Chief Medical Office, The Access Group, Berkeley Heights, NJ, USA Thomas Jefferson University, College of Population Health, MercyLIFE Philadelphia, PA, USA Laura Trice Physician Hospital Organization, TriHealth, Cincinnati, OH, USA Deborah Way Department of Palliative Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA Pamela A. Fenstmacher Living Independently for Elders (LIFE), University of Pennsylvania School of Nursing, Philadelphia, PA, USA Peter Winn Department of Family and Preventive Medicine, Geriatric Assessment Clinic, OUHSC Family Medicine Center, University of Oklahoma, Oklahoma, OK, USA